Leisure Glen Post Acute Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 32, Resident 71, Resident 91) in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered by failing to ensure: 1. Resident 32 who receives intradialytic parenteral nutrition [IDPN - nutrition that is given through the dialysis machine while receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed)] was addressed to determine interventions and monitoring needed while receiving the nutritional therapy 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify with resident's physician when one of three sampled residents (Resident 91) with depression (a mental illness resulting in feeling severe hopelessness, sadness affecting their daily life) had a significant change in condition, was found crying and verbalized to the facility staff that he wanted to end everything and wanted to die, in accordance with the facility's policy and procedure titled Change in a Resident's Condition or Status and the resident's care plan. This deficient practice resulted in delayed emotional and mental health care and treatment of Resident 1 that could result in worsening depression, suicide the action of killing oneself intentionally) and self-inflicted injury that could lead to hospitalization and death.

Inspectors wroteBased on interview and record review the facility failed to update the Minimum Data Set (MDS - a resident assessment tool) to accurately reflect resident's behaviors in the MDS for 1 of 3 sampled resident (Resident 50), who had a pattern of refusing prescribed medications and laboratory blood draws (a simple procedure where a healthcare professional uses a tiny needle to collect a small blood sample) which are behaviors identified in the resident's clinical record. This deficient practice had the potential to resulted in an inaccurate inappropriate care planning, identify and implement interventions necessary to address the Resident 50's refusal or medications and behavioral needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and care in accordance with professional standards of practice (established guidelines or requirements for safe and accountable practice, protecting both the public and the profession's reputation) for one of three sampled residents (Resident 16), who had a change of condition and was diagnosed with acute respiratory failure (a sudden, life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received treatment, care and services for 2 of 3 sampled residents (Resident 8 and 58) in accordance with professional standards of practice, resident's care plan, physician's order and facility' s policy and procedures. 1. For Resident 8, who has MASD (Moisture-Associated Skin Damage, a broad term for skin inflammation, irritation, or sores caused by prolonged exposure to moisture [such as urine, sweat, wound fluids, or saliva]), and receiving lactulose (a prescription medication to treat constipation and certain liver diseases) with frequent loose stool, by failing to: a. Ensure TXN 1 developed an individualized repositioning schedule for Resident 8 in accordance with the care plan. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 90) with an indwelling catheter (a flexible plastic tube inserted into the bladder [an organ that collected and stored urine until it was expelled from the body] that remains there to provide continuous urinary drainage) received proper care and services in accordance to the facility's policy and procedures titled Catheter Care, Urinary, by failing to: 1. Ensure Treatment Nurse (TXN) 1 accurately assess Resident 90's urine for sediments (urine appears cloudy or contain visible particles - such as cells, minerals, or bacteria [germs])) that settle at the bottom of a urine sample) in the indwelling catheter tubing and follow the physician's order to flush the catheter on 7/2/2026. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 71) who received Continuous Positive Airway Pressure (CPAP - medical device and therapy that pumps steady, mild stream of pressurized air through a hose and face mask into the airway) was provided care in accordance with the facility's policy and procedure to ensure resident had nothing by mouth two hours before using a full-face mask, monitor the oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) of the resident, general assessment (including vital signs, oxygen saturation, respiratory prior to procedure. titled CPAP/BiPAP (Bilevel Positive Airway Pressure a type of non-invasive ventilator that helps keep airways open and makes breathing easier) Support. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat one of two sampled resident (Resident 1) in a manner that promoted respect and dignity, when the Certified Nurse Assistant (CNA) 1 was rough and loud to Resident 1 who spoke and understand a foreign language during care. CNA1 yelled and pushed Resident 1 to turn to the side when changing the resident's wet clothing and asked the resident why she was wearing a long gown that was hard to remove. This deficient practice resulted in Resident 1 to experienced fear and anxiety (fear of the unknown) towards CNA 1 during interactions. Resident 1 to immediately contacted Family Member 1 (FM 1) while crying to inform her about what had occurred. Resident 1 began to frequently calling FM 1 to contact facility staff to assist such as when turning and repositioning.

Inspectors wroteBased on observation, interview and record review, the facility failed implement to implement the facility's policies and procedure titled Abuse Investigation and Reporting for one of two sampled resident (Resident 1) by facility to: 1. Investigate the allegation of abuse when Family (FAM 1) reported to Licensed Vocational Nurse (LVN) 1 that Certified Nurse Assistant (CNA) 1 was loud and rough to Resident 1 when changing the resident's wet clothing. CNA 1 was yelling at Resident 1 pushing the resident while turning to the side and complained that resident should not be wearing a long gown that was hard to remove. 2. Report the allegation of abuse to the state agency, police department and the ombudsman when FAM 1 reported to LVN 1 that CNA 1 was rough and yelling at Resident during care. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and hazard free environment and interventions for safety and supervision for four of four sampled residents (Residents 7,69,102, and 79) the facility failed to: 1. Ensure Resident 7's bed alarm was in the working condition. 2. Provide adequate supervision and safety measures to ensure safety to Residents 69 and 102 who are at risk for elopement (leaving the facility without permission) keeping the patio gate closed and not kept opened with a wire. 3a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to failed to provide respiratory care to ensure four of 4 sampled residents (Resident 15, 99, 75, and 213) who were receiving oxygen therapy were provided care in accordance with the professional standard of practice and facility's policy and procedure by failing to: 1. Ensure Resident 99 was monitored to ensure the resident wears the nasal cannula (a tube inserted into the nostril used to deliver oxygen into the lungs) to received continuous oxygen as ordered by the physician ordered for oxygen administration. 2. Ensure Resident 15's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was placed in designated plastic bag when not in use. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to enforce the facility's policy and procedure to ensure a visitor was monitored and instructed not obtain the cups, spoons, juice and water pitchers from medication cart for 1 of 3 sampled resident (Resident 15). This deficiency has the potential to result in cross contamination (the process by which bacteria or other microorganism unintentionally transfer from one object to another with harmful effect) and spread of infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for one of one sampled resident (Residents 11) by not ensuring Resident 11 was provided a functional wall clock in the room. This deficient practice had the potential to cause disorientation and Resident 11 verbalizing feelings of frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a prompt response to address grievances for one of one sampled resident (Resident 5) Resident Representative (FAM 1), when FAM 1 reported missing clothing items belonging to Resident 5. This deficient practice delayed the process of investigating Resident 5's missing clothing items and violated the residents' right to have grievances addressed promptly.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federally mandated standardized assessment and care-screening tool) and Quarterly Risk Assessment was accurate for two (2) of 2 sampled residents (Resident 69 and 102) who had a diagnosis of dementia and was not evaluated for elopement risk. These deficient practices had the potential to result in Resident 69 and 102 not receiving appropriate treatment and/or services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was revised for two of two sampled residents (Resident 69 and 102) who had an active care plan for a diagnosis for dementia (a progressive brain disorder that results in a decline in memory and thought process). This deficient practice had the potential result in Resident 69 and 102 no receiving appropriate interventions and treatment and/or services.

Inspectors wroteBased on interview, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of [three] residents (Resident 94). This deficient practice had the increased potential for Resident 94 to develop new pressure ulcer or injury (skin injury due to prolonged unrelieved pressure or skin friction) and/or delay the resident's wound to heal.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two licensed nurses (Minimum Data Set Nurse [MDSN] 1 and 2) were trained and with sufficient competency to conduct and coordinate the development and completion the residents MDS assessment by failing to: Ensure MDSN 1 and MDSN 2 conducted an accurate MDS assessment of Resident 69 and 102's elopement risk. Ensure MDSN 2 had an updated competency skills to conduct annual evaluation used for MDS assessment. This deficient practice placed residents at risk for not receiving appropriate services, treatments, and unsafe level and type of care necessary for the resident population.

Inspectors wroteBased on interview and record review, the facility failed to post the nurse staffing information of the number of Registered Nurses (RN), License Vocational Nurse (LVN)/ License Practical Nurse (LPN) and Certified Nursing Assistant (CNA)/Nursing Assistant (NA) per shift in a prominent location in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential to not inform and cause misleading information to the residents and the visitors of the nursing care provided to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to complete a performance review by completing the Annual Core Clinical Competencies (ACCC, an assessment and training on the Certified Nurse Assistant(s) (CNA) the ability to perform clinical nursing care). In addition, the facility did not have a system in place to keep track of the CNA's performance evaluation to ensure three of five CNAs (CNA 1, CNA 2 and CNA 3) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. This failure had a potential to result in the facility's resident's population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) not to receive quality care services from CNAs with insufficient skills and competencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of food service safety for residents in the facility by failing to label, date and store food in the refrigerator and freezer. Facility failed to ensure [NAME] 1 change visible soiled gloves prior to plating the residents' food. This deficient practice had the potential to place residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of one sampled resident (Resident 32) by ensuring the facility staff was observed standing over the resident while assisting during a meal. This deficient practice had the potential to affect Resident 32's self-esteem and self-worth.

Inspectors wroteBased on observation, Interview, and record review, the facility failed to ensure call light was within reach for one of eight sampled residents (Resident 11). This deficient practice has the potential to delay necessary assistance, not meeting the needs of the resident promptly. Ensuring that the call light is always within reach is crucial for the safety and well- being of resident. The delay in in meeting the resident's needs for assistance can lead to frustration, falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 46), was informed of where to find the facility's monthly and alternative, breakfast, lunch, and dinner menu. This deficient practice denied the resident the right to choose and participate in food choices, leading to feelings of helplessness and loss of autonomy, which can have negative impacts on their overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of an Advance Health Care Directives form (AHCD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) readily available for review in the medical record of one (1) of 3 sampled residents (Resident 162). This deficient practice had the potential to cause conflict in carrying out the resident's wishes regarding health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to formulate a care plan for one out of 22 total sample residents (Resident 35) who did not understand the formal language in the facility and did not have a care plan to address the resident's communication needs. This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide a communication tool for one of 22 total sample residents (Resident 35) who did not understand the formal language, was not provided a communication board (a communication device, usually a whiteboard and a marker, used to facilitate communication between resident and staff). This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 106), received care and services for urine and bowel incontinence (no control) care promptly and after each incontinent episode as indicated in the resident's care plan and the facility's policy and procedure. Resident 106 waited one hour before she was assisted to be cleaned and brief to be changed due to incontinent. This deficient practice could result in discomfort and pain due to skin breakdown that could lead to skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility provided respiratory care as indicated in the facility's policy and procedure and plan of care for one out of 22 residents (Resident 24) with a physician order to receive continuous oxygen therapy was observed with an empty oxygen tank that required a refill. This deficient practice had the potential to cause Resident 24 to suffer complications associated to inadequate oxygen intake such as shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for one of one resident (Resident 31) by ensuring the Permcath (a flexible tube inserted into the skin and into the blood vessels and used for hemodialysis [is a type of treatment that helps your body remove extra fluid and waste products from the blood when the kidneys]) dressing was not peeling off. This deficient practice placed the resident at risk for infection and accidental dislodgement (removal) of the Permacath.

Inspectors wroteBased on observation, interviews and record review, the facility failed to report an allegation of abuse to the Department and other officials immediately, but not later than two hours for one of one sampled resident (Resident 1) in accordance with the mandated Federal and State regulatory guidelines. This deficient practice had the potential for the facility to under report allegations of abuse, which could lead to failure to investigate alleged abuse in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician for 19 out of 102 residents requiring fortified diet. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread and transmission of infections for two of three sampled Resident (Resident 2 and 3) in accordance with the facility ' s policy and procedure titled Hand Hygiene revised 10/2022, Covid-19, Prevention and Control revised 9/29/2023 and infection Prevention Quality Control Plan revised 10/10/2021, by failing to: 1. Ensure the Licensed Vocational Nurse (LVN) 1 performed hand hygiene (cleaning/washing hands to prevent the spread of germs) before entering Resident 3 ' s room to administer Resident 3 ' s medication. 2. Ensure Certified Nurse Assistant (CNA) 2 perform hand hygiene before entering Resident 2s room to render personal care. [...]