Leisure Village Health Care Center

Inspectors wroteBased on observation, interview, facility document and policy review, and U.S. [United States] Food and Drug Administration 2022 Food Code, guidelines, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, daily log documentation was lacking for the dish machine sanitation test strip levels and rinse temperature levels. Additionally, dietary staff did not perform hand hygiene during meal service. Additionally, food was not labeled and dated appropriately in facility refrigerators. These deficiencies had the potential to affect all residents in the facility.

Inspectors wroteBased on facility policy review, record review, interview, a review of a Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH) publication, observation, and a review of a glucometer's manufacturer instructions, the facility failed to develop/implement a comprehensive infection control program when they failed to do the following:- Complete annual fit testing for N95 respirators for staff, which had the potential to affect all residents in the building.- Properly utilize a barrier when placing a glucometer and insulin pens on surfaces, ensure staff wore gloves when handling a used glucometer, and failed to properly disinfect a glucometer, which affected 2 (Resident #66 and Resident #83) of 8 residents reviewed for the medication administration task.- Ensure staff did not touch medications with their bare hands during medication [...]

Inspectors wroteBased on interview, record review, facility policy review, the facility failed to notify the physician when ordered medication was not administered for 1 (Resident #41) of 2 residents reviewed for dialysis. Specifically, the facility failed to notify the physician that Resident #41's hydroxyzine (a medication used to treat anxiety) medication was scheduled to be given at a time when the resident was gone for dialysis and was not routinely administered per physician's order for approximately five months.

Inspectors wroteBased on interview and facility document and policy review, the facility failed to ensure nutritional nighttime snacks were provided to the residents on 1 (South Hall) of 3 facility halls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that 3 (Residents #7, #44, and #77) of 5 sampled residents reviewed for immunizations were offered the pneumococcal vaccination.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that 3 (Residents #7, #14, and #44) of 5 sampled residents reviewed for immunizations were offered the Coronovirus-19 (COVID-19) vaccination.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a dignified dining experience for 3 (Residents #80, #13, and #77) sampled residents during 2 of 2 meal observations. Specifically, on 06/08/2026, 23 minutes after being served, Resident #13 had finished their meal and Resident #77 and Resident #80, who were seated at the same table, had not been served their meal. On 06/11/2026, the residents were seated at the same table again and staff had not served Resident #13 and Resident #77's meals when Resident #80 had consumed 75% of their meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary, orderly, and comfortable environment for 1 (Resident #88) of 2 residents who utilized a wheelchair. Specifically, observation revealed Resident #88 had damaged wheelchair armrests, and there was no documented evidence that efforts to repair the damage had been made, despite the Maintenance Director being aware of the issue.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident #14) of 3 residents reviewed for respiratory care. Specifically, Resident #14 received oxygen therapy without a physician's order, the resident's nebulizer mask was observed stored improperly, and a physician ordered oxygen humidifier bottle was not provided for the resident.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that dialysis services were consistent with professional standards of practice for 1 (Resident #58) of 2 residents reviewed for dialysis. Specifically, the facility failed to ensure Resident #58 had a physician order and care plan for dialysis treatment and for care/monitoring of the resident's hemodialysis (a process in which blood is pulled from a dialysis access, such as a catheter, circulated outside the body through a dialysis machine, then pumped back into the blood stream) catheter/catheter site. The facility also failed to ensure staff completed an ongoing assessment of the resident's condition and monitored for complications after hemodialysis treatments.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure their medication rate was below 5% for 1 (Resident #83) of 8 residents observed for medication administration. Specifically, staff did not perform an insulin pen safety check before insulin administration which resulted in 2 medication errors of 27 opportunities. The facility's overall medication error rate was 7.41%.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure comfortable water temperatures were maintained for 5 of 5 shower rooms. The DON identified 79 residents received showers.

Inspectors wroteBased on observation and interview, the facility failed to ensure there were qualified dietary staff to meet the needs of the residents for 2 of 3 dietary staff reviewed for qualifications. The DON identified 81 residents received nutrition from the kitchen. The DM identified 11 staff members who worked in the dietary department.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff performed their duties in a manner that would ensure clean and proper sanitation of dishes during 2 of 2 kitchen observations. The DON identified 81 residents received nutrition from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#4 and #9) of 4 sampled residents reviewed for change in condition. The DON reported the census in the facility was 80.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#1) of 3 sampled residents whose care plans were reviewed. The DON identified 75 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from abuse for one (#3) of three sampled residents for abuse. The DON identified 81 residents who resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less during medication administration. A total of 25 opportunities were observed with three medication errors. The medication error rate was 12%. The DON identified 78 residents who resided in the facility who received medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were labeled and dated when opened for four (north hall medication cart, east hall treatment cart, south hall medication cart, and south hall treatment cart) of four medication/treatment carts observed. The DON identified eight medication/treatment carts in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a resident's dignity, by using a privacy bag over an indwelling catheter bag, for one (#7) of two residents reviewed for dignity. The administrator reported a facility census of 78. A Quality of Life Dignity Policy dated 03/2017, documented in part, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered if Resident wants . [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure range of motion services were provided to one (#21) of one sampled residents who were reviewed for range of motion. The DON identified 18 residents who had contractures.

Inspectors wroteBased on observation and interview, the facility failed to ensure the urinary drainage bag was properly positioned for one (#59) of one resident observed for urinary catheter. The Resident Matrix, documented six residents who had a urinary catheter.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food items were labeled, dated, and stored according to facility policy. The administrator identified 77 residents received services from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure enhanced barrier precautions were used for one (#13) of one resident observed for peg tube care. The administrator identified one resident with a peg tube.

Inspectors wroteBased on record review and interview, the facility failed to ensure the required number of staff were present when the mechanical lift was operated for one (#3) of one resident reviewed for mechanical lift use. The DON identified 79 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the dignity of a resident was maintained during and following perineal care for one (#1) of five sampled residents reviewed for abuse. A midnight census report, dated 07/01/24, documented 75 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure a CNA provided perineal care in accordance with accepted standards of care for one (#1) of five sampled resident reviewed for abuse. A midnight census report, dated 07/01/24, documented 75 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide showers for two (#5 and #6) of two sampled residents reviewed for assistance with activities of daily living. The administrator identified 76 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to answer call lights in a timely manner for three (#2, #3 and #4) of three residents reviewed for sufficient staff to meet the needs of residents. The administrator identified 76 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were followed during the administration of medication. The administrator identified 76 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation for one (#5) of three residents reviewed for allegations of abuse. The DON identified 10 allegations of abuse since August of 2023.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure timely incontinent care for one (#4) and failed to maintain infection control during incontinent care for one (#10) of four sampled residents reviewed for incontinent care. The DON identified 55 residents who were incontinent.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent misappropriation of a controlled substance for one (#70) of one sampled resident reviewed for misappropriation of property. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide assistance for activities of daily living (bathing, incontinent care, and nail care) for three (#35, 59 and #28) of five sampled residents reviewed for ADL care. The Resident Census and Condition of Residents report, dated 07/19/23, documented 15 residents were dependent for bathing, census was 78.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide proper cleaning and storage of a suction machine for one (#37) of one resident reviewed for cleaning and storage of a suction machine. The Resident Census and Condition of Residents report, dated 07/19/23, documented 78 residents resided in the facility and no Residents required suction.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a care plan intervention (low air loss mattress) was in place for pressure ulcer prevention for one (#35) of four residents reviewed for pressure ulcers. The Resident Census and Condition of Residents report, dated 07/19/23, documented eight residents had pressure ulcers. The census was 78.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staffing ratios were met to provide supervision and assistance as needed for one (#73) of six residents reviewed for staffing. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 27 residents were dependent on staff for toileting and transfers, 34 residents required assistance of one or more staff for transfers, and 44 residents required assistance of one or more staff for toileting. The census was 78.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication was available to administer as ordered by the physician for one (#132) of five sampled residents reviewed during medication pass observation. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to monitor for side effects related to the use of psychotropic medications for four (#42, 54, 61, and #78) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 07/19/23, documented 24 residents received antianxiety medications, and 51 residents received antidepressant medications. The census was 78.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication pass was less than five percent error rate for two (#132 and #16) of five residents reviewed during the medication pass observation. The medication pass error rate was 11.11%. The Resident Census and Conditions of Residents report, dated 07/19/23, documented 78 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to serve a mechanically altered diet for one (#42) of three sampled residents reviewed for diets. A Resident Census and Condition of Residents report, dated 07/19/23, documented 24 residents received mechanically altered diets for pureed/chopped and census was 78.