De Leon Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food stored in the kitchen was sealed and/or labeled properly in the facility's freezers #1 and #2. This failure could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. During an observation on 9/23/25 at 9:45 AM, the facility kitchen revealed Freezer #1:1 bag of chicken legs was unsealed and opened to air.,1 bar of butter was unsealed/not dated and open to air. Freezer #2:1 bag of hushpuppies was unsealed and open to air.1 bag of corn nuggets was unsealed and opened in the air.1 bag of chicken thighs was unsealed and open to air.1 box of burritos was unsealed and opened to air. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. The facility failed to provide paper towels at the kitchen hand washing sink. The facility failed to label stored foods with a description and/or open date. The facility failed to store foods with lids that covered the food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 14 residents (Resident #5, Resident #12, and Resident #37) reviewed for PASRR. The facility failed to follow up with the LA for PASRR Level II determination when Resident #5, Resident #12, and Resident #37s PASRR Level 1 Screening reflected they were positive for mental illness. This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 (Resident # 6 and Resident #17) reviewed for oxygen therapy. The facility failed to ensure that oxygen tubing and nasal cannula were placed in plastic bag for 2 of 2 residents (Resident #6 and Resident #17) when not in use. These failures placed residents of the facility at risk for respiratory illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #22) reviewed for meals. The facility failed to ensure that Resident #22 was served a pureed bowl of melon, instead of a bowl of regular melon. This deficient practice could affect residents by placing them at risk for choking and weight loss.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure professional staff was certified in accordance with applicable State laws for 1 (NA B) of 15 personnel reviewed for licensed nursing. The facility failed to ensure NA B had become a Certified Nurse Aide by passing her certification test. These failures could place residents at risk of being provided care by staff who are not qualified per state law.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents LVN A feeding 1of 1 residents (Resident #22) did not perform hand hygiene after touching resident and wiping resident mouth. The facility failed to ensure proper hand hygiene when feeding a resident (Resident #22). These failures placed residents of the facility at risk of infections from respiratory care and dining.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 2 of 3 days reviewed for nursing services and postings. The facility failed to ensure daily staffing information was posted in a prominent place on 08/18/2024 and 08/19/2024. This failure places residents, their families, and visitors at risk of not having access to information regarding staffing and facility census.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid for 2 of 14 residents (Resident #8 and Resident #30) reviewed for resident rights. The facility failed to ensure Residents #8 and Resident #30 were given a paper copy of the NOMNC (notice of Medicare non coverage) with information on how to appeal the decision when residents were discharged from skilled services at the facility prior to covered days being exhausted. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for infection control related to COVID-19 (a virus that is spread from person to person causing mild to severe respiratory symptoms) for 16 of 18 residents reviewed. Multiple asymptomatic residents tested positive for COVID-19 after dietary staff tested positive for COVID-19, by not taking preventative measures. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff practiced proper hand hygiene. This deficient practice could place residents at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurate for 2 of 3 residents (Resident #36 and Resident #149) reviewed for resident records. The facility failed to document the verification of placement of a wanderguard each shift, and the function of resident's device daily for Resident #36 and Resident #149. This failure could place residents at risk of residents having errors in care and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #199) reviewed for accidents and supervision. The facility failed to ensure there was adequate supervision while Resident #199 was smoking. This failure could place residents at risk for injury due to the lack of supervision provided by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for one of two medication carts reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when the medication cart was left unlocked and unattended. This failure could result in access to medications by unauthorized staff or residents leading to possible harm or drug diversion. The findings Included: During an observation on 06/26/23 at 02:09 p.m., a medication cart was observed to be unlocked and unattended outside the nurse's station near Hall 3. Residents were observed passing by the cart. Review of the content of the medication cart revealed the cart contained the following: [...]