Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lee Healthcare during CMS and state inspections, most recent first.
A resident with moderate vascular dementia, mood disturbance, and a history of agitation had a care plan calling for identification of triggers and use of de-escalation strategies. While the resident was seated at the nurses’ station, a CNA briefly touched the resident’s hat, and the resident immediately yelled and objected, causing that CNA to stop. Another CNA, despite witnessing this clear objection, then touched the hat, and after the resident loudly demanded that the CNA stop, touched it a second time. This taunting behavior provoked escalating agitation, with the resident becoming verbally abusive and physically destructive toward facility property, demonstrating a failure to treat the resident with dignity and to respect personal possessions.
The facility failed to maintain sanitary conditions in two unit kitchenettes, with crumb-laden toasters presenting a fire risk. Observations showed crumbs in toasters, and interviews revealed uncertainty about cleaning responsibilities. The Director of Housekeeping and Food Service Director were unsure who should clean the toasters, while the Regional Nurse suggested kitchen staff should maintain them.
A facility failed to maintain a clean environment in a resident's room, where surveyors observed brown, dried drip marks on the wall and windowsill over several days. Despite cleaning policies requiring regular cleaning, these marks remained visible to the resident, who was lying in bed facing the wall. The Director of Housekeeping acknowledged the oversight, noting that the room was scheduled for a deep clean and that such issues should have been addressed during routine cleaning.
A facility failed to complete a PASRR Level I Screening before admitting a resident with SMI, including PTSD and a later diagnosis of Borderline Personality Disorder. The Social Worker responsible was unavailable, and no other staff were trained to conduct the screening, leading to a delay in appropriate care evaluation.
A resident's wound dressing was not properly monitored or documented, as staff failed to obtain a physician's order and did not conduct ongoing assessments. The dressing, applied to the resident's elbow, was left unchanged for an extended period, leading to potential risks. The facility's protocol for weekly skin observations was not followed, resulting in the dressing being overlooked.
A resident with Parkinson's Disease and a femur fracture was discharged without a complete discharge summary or proper communication with follow-up care providers. The facility failed to ensure a comprehensive discharge plan, including necessary VNA services, leading to a delay in post-discharge care. Interviews revealed a lack of coordination among staff, with incomplete evaluations from Therapy and Social Work departments.
A facility failed to create a Trauma Informed Care Plan for a resident with PTSD, despite recommendations from a Social Services Evaluation. The resident's Comprehensive Care Plan lacked documentation of such a plan, and the Social Worker confirmed that it should have been developed but was not.
A facility failed to ensure complete CNA documentation for a resident with significant weight loss and nutritional risk. Despite a care plan requiring meal intake monitoring, records for June and July showed incomplete documentation. Interviews revealed that CNAs were expected to document each shift, but this was not consistently done, impacting the Dietician's ability to adjust dietary needs.
A facility failed to issue a Notice of Medicare Non-Coverage and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to a resident's guardian. The facility did not successfully contact the guardian or provide evidence of sending a certified letter, leaving the guardian uninformed about the end of Medicare Part A coverage and potential financial liabilities.
A facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative when the resident was transferred to the hospital. The resident's medical record lacked documentation of the notice, and interviews with staff revealed confusion about responsibility for issuing the notice. The Infection Preventionist confirmed that no education had been provided to nursing staff regarding this requirement.
Failure to Respect Resident’s Personal Possessions and Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions. The facility’s policy on Resident Rights and Responsibilities, revised January 2024, requires employees to treat all residents with kindness, respect, and dignity. Resident #1, admitted in August 2023, had diagnoses including moderate vascular dementia with mood disturbance and an anxiety disorder. A Quarterly MDS dated 09/30/25 documented moderate cognitive impairment with a BIMS score of 9/15. The resident’s Mood and Behavioral Care Plan, reviewed 12/03/25, noted vascular dementia with mood disturbance and agitation, with a history of hitting, kicking, grabbing, spitting, screaming, or threatening others, and identified interventions such as assessing triggers for aggression or agitation and providing de-escalation strategies including a quiet environment and reassurance. On 12/20/25, an altercation occurred between Certified Nurse Aide (CNA) #1 and Resident #1 at the nurses’ station. According to the facility’s investigation report and staff interviews, Nurse #1 was on the phone addressing a medical emergency while Resident #1 sat in a wheelchair at the nurses’ station, with CNA #1 and CNA #2 nearby. CNA #2 leaned forward to speak with the resident and briefly touched the top of the resident’s hat. Resident #1 immediately yelled and verbally objected, stating that the hat should not be touched, and CNA #2 stopped touching the hat after the objection. Despite having witnessed this objection, CNA #1 then approached and touched the resident’s hat. Nurse #1 and CNA #2 reported that Resident #1 loudly objected to CNA #1 touching the hat, demanded that CNA #1 stop, and that CNA #1 nevertheless touched the hat a second time. Nurse #1 stated that after the second touch, the resident’s agitation escalated, leading him to separate CNA #1 from the resident. When Nurse #1 returned to the nurses’ station area about 15 minutes later, Resident #1 remained very agitated, cursing and kicking a medication cart. CNA #1 acknowledged in a telephone interview that she touched the resident’s hat despite having seen the resident loudly object to CNA #2 doing so. The Director of Social Services later observed that the resident was “a bit revved up,” consistent with behavioral presentations that occurred at times for this resident, and the DON confirmed that CNA #1 had teased and provoked the resident by touching the hat despite the resident’s objections.
Sanitation and Safety Deficiency in Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary and safe conditions in two unit kitchenettes, specifically regarding the cleanliness of toasters. On July 24, 2024, observations revealed a crumb-laden toaster in Unit Two and crumbs lining the top and inside of the toaster slots in Unit One. These conditions presented a potential fire risk and were not in accordance with professional standards for food storage, preparation, distribution, and service. Interviews conducted on July 25, 2024, with the Director of Housekeeping and the Food Service Director revealed uncertainty about which department was responsible for cleaning the toasters. The Director of Housekeeping acknowledged the potential bacteria and fire risks associated with the crumb buildup. The Regional Nurse indicated that kitchenettes are cleaned twice monthly and as needed, suggesting that kitchen staff should maintain the toasters during restocking or fridge temperature checks. However, the lack of clarity in responsibility led to the observed deficiencies.
Failure to Maintain Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its units, specifically in a resident's room. Observations made by the surveyor on multiple occasions revealed multiple brown, dried drip marks on the wall and windowsill directly to the right of the resident's bed. These marks were visible to the resident, who was observed lying in bed facing the wall with the marks. The facility's cleaning policies, including the Complete Room Cleaning list and the Daily Patient Room Cleaning guidelines, require walls to be wiped as needed and vertical surfaces to be spot cleaned with a cloth and disinfectant. Despite these policies, the room in question was not adequately cleaned, as evidenced by the persistent presence of the drip marks over several days. The Director of Housekeeping confirmed that resident rooms are cleaned daily and deep cleaned monthly, and acknowledged that the room was scheduled for a deep clean prior to the surveyor's observations. The Director also stated that such drippings should have been addressed during both daily and deep cleaning routines, indicating a failure to adhere to the facility's cleaning protocols.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I Screening was completed prior to the admission of a resident diagnosed with serious mental illness (SMI). Specifically, the resident was admitted with diagnoses of Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder, and Anxiety Disorder, but the Level I Screening was conducted nine days after admission. Additionally, the screening did not include the resident's new diagnosis of Borderline Personality Disorder, which was identified after admission. The Social Worker responsible for completing the Preadmission Screenings was unavailable at the time of the resident's admission, and no other staff member was trained to perform this task. Consequently, the necessary screenings were not completed as required. The Social Worker was also unaware of the resident's PTSD diagnosis and the subsequent diagnosis of Borderline Personality Disorder, which would have necessitated a Post Admission Level I Screening and a Resident Review. This lack of awareness and communication among staff led to a delay in the evaluation and determination of appropriate care and services for the resident.
Failure to Monitor and Document Wound Dressing
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice concerning the application and monitoring of a wound dressing for a resident. The staff did not accurately assess the resident's skin, obtain a physician's order for a dressing applied to the resident's left elbow, or provide ongoing assessment of the area. This resulted in the dressing not being changed in a timely manner, putting the resident at risk for worsening wound status and infection. The resident was admitted with a diagnosis of a displaced intertrochanteric fracture of the right femur and had a care plan that included weekly skin condition checks and the application of barrier cream to certain areas. Observations revealed that a foam dressing applied to the resident's left elbow was not documented in the physician's orders or the treatment administration record. The dressing, dated ten days prior, was observed to be intact but later found to be lifted at the edges with dry tan drainage. Interviews with the nurse who applied the dressing and the infection preventionist/unit manager indicated a lack of awareness and documentation regarding the dressing. The facility's protocol for weekly full-body skin observations was not followed, as the dressing was not identified in the non-pressure ulcer evaluation.
Incomplete Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure a comprehensive discharge process for a resident, leading to a deficiency in the discharge summary and communication with follow-up care providers. The resident, who was moderately cognitively impaired and had been admitted with Parkinson's Disease and a femur fracture, expressed uncertainty about the discharge plan and desired a specific Visiting Nurse Agency (VNA) for post-discharge care. However, there was no documented discussion or arrangement for the resident's follow-up care, and the discharge summary was incomplete. The discharge planning process was inadequately executed, as evidenced by the lack of a completed discharge summary from the Therapy and Social Work departments. Although the nursing department completed their portion of the Discharge/Transfer Evaluation, the necessary information regarding ongoing community services, such as VNA services, was not included. The Social Worker and Director of Rehabilitation were unaware of who made the referral to the VNA, and the VNA contact confirmed that no referral had been made until after the resident's discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the discharge process. The Social Worker acknowledged that the Discharge/Transfer Evaluation should have been completed before the resident's discharge, and the Director of Rehabilitation admitted that the Therapy department failed to complete their portion of the evaluation. The Regional Nurse confirmed that the Social Work Department was responsible for making VNA referrals, which should have been done prior to discharge, but this was not completed, resulting in a delay in the resident receiving necessary post-discharge services.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident diagnosed with PTSD. The resident was admitted in May 2024, and the Social Services Evaluation conducted on 5/15/24 indicated that the resident had past experiences that were emotionally, spiritually, physically, or behaviorally upsetting. This evaluation recommended the creation of a Care Plan related to Trauma Informed Care. However, a review of the resident's Comprehensive Care Plan revealed no documentation of such a plan being developed. During an interview, the Social Worker acknowledged that a Trauma Informed Care Plan should have been created for the resident but was not.
Incomplete CNA Documentation for Meal Intake
Penalty
Summary
The facility failed to ensure complete and accurate documentation by a Certified Nurses Aide (CNA) for a resident with a history of significant weight loss and increased risk for nutritional decline. The resident, admitted in May 2022, had diagnoses of muscle wasting, atrophy, and chronic pain. A Dietician's Progress Note from June 2024 identified a significant weight loss of 7.8% over three months. The care plan, initiated in May 2022 and revised in May 2024, required monitoring and recording of meal intake every meal. However, the CNA documentation for June and July 2024 showed incomplete records, with only 58 of 90 meals in June and 36 of 73 meals in July having documented meal intake percentages. Interviews with facility staff revealed that meal intake documentation was expected to be recorded each shift. The Dietician noted that incomplete documentation hindered her ability to make necessary dietary adjustments, as she often had to seek additional information verbally from staff. The Regional Nurse confirmed that CNAs were not documenting meal intakes every shift as required, which was evident upon reviewing the resident's meal intake records for June and July 2024.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's guardian. This notice is crucial for informing the resident or their guardian about the end of Medicare Part A coverage and any potential financial liabilities for continued services. The deficiency involved a resident who was admitted in August 2023, and the facility did not successfully contact the guardian to inform them of the last covered day of Medicare Part A services, which was set for June 13, 2024. Attempts to contact the guardian on June 11, 2024, were unsuccessful, and the facility claimed to have sent a certified letter, but there was no evidence of this action. During an interview, the facility's administrator acknowledged the failure to provide the necessary documentation to the guardian. The administrator noted that the process should have included sending a certified letter and maintaining the return receipt for records, but no such receipt or evidence of mailing was found. This oversight left the resident's guardian uninformed about the termination of Medicare coverage and the potential financial responsibility for continued skilled services.
Failure to Provide Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative at the time of discharge. Specifically, the staff did not issue a Notice of Intent to Transfer and Discharge when the resident was transferred from the facility to the hospital. The resident was admitted to the facility in July 2023 and was transferred to the hospital on May 12, 2024. A review of the resident's medical record showed no documentation of the required notice being provided at the time of discharge or shortly thereafter. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of the notice. The Social Worker stated that she does not provide the notice when a resident is transferred to the hospital, indicating that it was the nursing staff's responsibility. The Infection Preventionist, who also served as the Unit Manager, confirmed that neither the resident nor their representative received the notice and acknowledged that no education had been provided to the nursing staff about this requirement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kimball Farms Nursing Care Center | 2.7 mi | — | 3 | 0 |
| Mount Carmel Care Center | 4.9 mi | — | 0 | 0 |
| Springside Rehabilitation And Skilled Care Center | 7.9 mi | — | 2 | 0 |
| Berkshire Place | 8 mi | — | 2 | 0 |
| Hillcrest Commons Nursing & Rehabilitation Center | 9.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.