Leisure Homestead at Stafford

Inspectors wroteThe facility reported a census of 35 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for foodborne bacteria. This placed the residents at risk of food-borne illnesses.

Inspectors wroteThe facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)1 who had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). The facility failed to follow adequate hand hygiene and infection control practices related to catheter bags and tubing as well as sanitary storage of nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs). This deficient practice placed the residents at increased risk for infections.

Inspectors wroteThe facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record review, and observation, the facility failed to ensure residents had safe and properly maintained resident care equipment. This deficient practice placed the residents at risk for infection and decreased comfort.

Inspectors wroteThe facility reported a census of 35 residents, the sample included 12 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 29 and/or his representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment.

Inspectors wroteThe facility reported a census of 35 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 38 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital and failed to provide a written notification to the resident and/or his representative for the reason of the resident's transfer to the hospital in a language easy to understand. This placed the resident at risk of not understanding bed hold policy or the reason of the transfer.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide weekly wound assessments for Resident (R) 1. This deficient practice placed the resident at risk for developing pressure injuries and delayed wound healing.

Inspectors wroteThe facility reported a census of 35 residents. The sample included 12 residents, which included one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide necessary supervision and assistance required for safe ambulation for Resident (R) 6. This placed R6 at risk for falls and fall-related injuries.

Inspectors wroteThe facility reported a census of 35 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, daily, for the 35 residents who resided in the facility.

Inspectors wroteThe facility reported a census of 33 residents. Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent cross contamination and the spread of infection in the laundry and throughout the facility. Furthermore, the facility failed to perform required hand hygiene between residents during the delivery of clean linen and passing ice water. Additionally, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection for three residents (R)9, R31, and R7.

Inspectors wroteThe facility reported a census of 33 residents with a sample of 12 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan with relevant interventions following falls to prevent further falls for four sampled residents (R)16, R10, R32, and failed to revise the care plan for R21, related to compression stockings.

Inspectors wroteThe facility reported a census of 33 residents with a sample of 12 residents which included four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough investigation to determine contributing factors and causes of falls to implement appropriate immediate new interventions following falls for Resident (R)16, R10, R7, and R32.

Inspectors wroteThe facility reported a census of 33 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set MDS for one sampled resident, Resident (R)7, with a CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [OSA - a condition in which a person cannot maintain an open airway while sleeping]). This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 33 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to apply TED hose (thrombo-embolic-deterrent - specialized compression stockings designed to help manage swelling of the feet/legs) every morning and remove them every night for Resident (R) 21. This deficient practice had the potential to place R21 at an increased risk for development of additional medical problems.

Inspectors wroteThe facility reported a census of 33 residents with 12 residents sampled, including four residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean and store the nebulizer (a device for administering inhaled medications) for Resident (R)9 and R31 in accordance with the standards of care. In addition, the facility failed to disassemble and clean the CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [OSA - a condition in which a person cannot maintain an open airway while sleeping]) and to correctly store distilled water used for humidification in the CPAP for R7.

Inspectors wroteThe facility reported a census of 37 residents with one main kitchen, which prepared and served food for all residents. Based on observation, interview, and record review the facility failed to handle and store food in accordance with professional standards for food service safety when dietary staff did not prepare food for storage or date and store foods in a sanitary manner.

Inspectors wroteThe facility reported a census of 37 with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure staff administered Tylenol (pain medication) as ordered by the physician for Resident (R)12.

Inspectors wrote- R12's signed physician orders dated 09/10/21 revealed the diagnosis of hypertension (HTN, elevated blood pressure). The Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The resident required one staff assistance with Activities of Daily Living (ADL). The resident received antipsychotic and antidepressant medications 7 days of the 7-day observation period. A gradual dose reduction attempted on 02/04/21. The 09/27/21 Quarterly MDS revealed no significant changes since the 03/27/21 MDS. [...]

Inspectors wroteThe facility census totaled 37 residents, with 12 in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the efficacy of blood pressure medications for Resident (12), when stafff failed to administer the medicaiton as ordered, and failed to document why the staff did not administer the medication as ordered.

Inspectors wroteThe facility had a census of 37 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Resident (R)22's did not receive unnecessary medications when staff admnistered an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication from an order dated 10/12/20 (almost 14 months prior and without a duration for use) and the staff continued to administer the PRN psychotropic medication. The medical record lacked a physician rationale for the continued adminsitration of the PRN psychotropic medication, Ativan, for R22.

Inspectors wroteThe facility reported a census of 37 residents. Based on observation, interview, and record review the facility failed to ensure staff used Personal Protective Equipment (PPE) appropriately, during toileting cares observation for Resident (R)22.