St. Leonard HCC

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received bathing services as scheduled. This affected four (Residents #7, #56, #114, and #130) of five residents reviewed for bathing. The facility census was 124 residents.

Inspectors wroteBased on medical record review, review of a facility (self-reported incident), observations, staff interview and facility policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#205) out of three residents reviewed for elopement risk. The facility census was 116.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to administer medications as ordered to be free from errors not five (5) percent (%) or greater. There were two medication errors observed out of 27 opportunities for a medication error rate of 7.41%, This affected two (#66 and #71) of two residents observed during medication administration. The facility census was 110. Findings Included: 1. Review of Resident #71's medical record revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Review of a physician order dated 04/25/25 revealed Resident #71 was ordered supplemental calcium 600 milligrams (mg) to be given once daily. Observation on 05/28/25 at 6:40 A.M. [...]

Inspectors wroteBased on medical record review, staff interview, review of electronic mail (email) documents, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#112 and #113) of four residents reviewed for medications. The facility census was 110. Findings Included: 1. Review of Resident #112's medical record revealed an admission date of 04/16/25. Diagnoses included depression, hyperkalemia, fluid overload, thrombocytopenia, peripheral vascular disease, protein-calorie malnutrition, chronic obstructive pulmonary disease, acute diastolic heart failure, and congestive heart failure. The resident was discharged on 04/24/25. Review of Resident #112's physician orders revealed an order dated 04/20/25 for the diuretic furosemide 20 milligrams (mg) with instructions to take two tablets by mouth once a day for hypertension. [...]

Inspectors wroteBased on medical record review, review of laboratory results, review of a facsimile (fax) document, staff interview, and review of a facility policy, the facility failed to notify the physician of critical laboratory values in a timely manner. This affected one (#112) of three residents reviewed for laboratory services. The facility census was 110. Findings Included: Review of Resident #112's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, hyperkalemia, fluid overload, thrombocytopenia, peripheral vascular disease, protein-calorie malnutrition, chronic obstructive pulmonary disease, acute diastolic heart failure, and congestive heart failure. The resident was discharged on 04/24/25. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to notify family/Power of Attorney (POA) of an appointment scheduled for the resident and the facility sent the resident, who has Alzheimer's disease, to the appointment alone. This affected one (Resident #110) of three residents reviewed for appointments. The facility census was 123.

Inspectors wroteBased on record review, observations, interviews, review of the information from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure timely treatments and interventions were done for a resident's pressure ulcer. This resulted in actual harm when Resident #95's pressure ulcer to his left heel deteriorated in condition and developed osteomyelitis from the delay in treatment. This affected one (Resident #95) of two residents reviewed for pressure wounds. The facility census was 112.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to ensure the comprehensive care plan included a vision and hearing plan for Resident #107 and a indwelling urinary catheter for Resident #95. This affected two (Resident #95 and #107) of six residents reviewed for care plans. The facility census was 112.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure fall interventions were timely added to the care plan. This affected one (#66) of five residents reviewed for falls. The facility census was 112.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the physician treatment orders were followed and implemented timely for the residents. This affected two (Residents #60 and #108) of two residents reviewed for un-pressure related skin conditions. The facility census was 112.

Inspectors wroteBased on record review, observations, staff interview, and policy review, the facility failed to ensure physician orders for oxygen administration were followed. This affected one (Resident #7) of one resident reviewed for respiratory care. The facility census was 112.

Inspectors wroteBased on record review, resident and staff interviews, and policy review, the facility failed to schedule dental services for teeth extractions per physician orders for a resident. This affected one (Resident# 54) of one resident reviewed for dental services. The facility census was 112.

Inspectors wrote2. Review of the medical record for Resident #26 revealed an admission date of 11/27/22 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the physician orders revealed an order for Artificial Tears one drop in each eye daily. Observation on 07/17/24 at 8:46 A.M. revealed Licensed Practical Nurse (LPN) #110 administered Resident #26's Artificial Tears one drop in each eye without wearing gloves. Interview on 07/17/24 at 8:54 A.M. with LPN #110 confirmed she did not use gloves to administer Resident #26's Artificial Tears one drop in each eye. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure proper enhanced barrier precautions (EBP) were followed for Resident #60 and the facility failed to ensure gloves were worn when administering eye drops for Resident #26. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure influenza and pneumococcal immunizations were offered to residents. This affected four (#19, #51, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure COVID-19 immunizations were offered to residents. This affected three (#19, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to act in a timely manner to protect residents from abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility staff failed to report allegations of abuse in a timely manner. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to investigate allegations of abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102.

Inspectors wroteBased on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure interventions and treatment orders were in place for a resident admitted to the facility with a stage three pressure ulcer to the coccyx. This resulted in the Actual Harm when Resident #10's stage three pressure ulcer, present upon admission, did not receive timely treatment and there was deterioration of the pressure ulcer to a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Additionally, the facility also failed to ensure skin assessments were completed as ordered for Resident #14 who was at risk for pressure ulcer development and who developed an unavoidable pressure ulcer, this placed the resident at potential risk for more than minimal harm for Resident #14. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a residents colostomy care was completed as ordered. This affected one (#10) of three residents reviewed. The facility census was 113.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure residents received written documentation explaining the reason for transfers to hospital at the time of transfer. This affected two residents (#112 and #119) of two residents reviewed for hospital transfer requirements. The facility census was 123.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to provide written notification to the resident or resident's representative of their bed hold policy. This affected one (#119) of four reviewed for bed holds. The census was 123.

Inspectors wroteBased on medical record review, observations, staff interviews, review of the Pre-admission Screening and Resident Review (PASRR) and review of the Centers of Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set assessments were accurate. This affected two (#48 and #16) of 24 residents assessments reviewed for accuracy. The facility census was 123.

Inspectors wroteBased on record review and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission. This affected two (#33, and #119) of four residents reviewed for new admission. The census was 123.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to initiate comprehensive care plans for residents. This affected two (#48 and #66) of 24 sampled residents. The facility census was 123.

Inspectors wroteBased on record reviews, staff, resident family member and resident interviews, and policy review, the facility failed to include residents in initial and quarterly care conferences when planning the residents care. This affected three (#55, #66, and #75) of five sampled residents for care planning. The facility census was 123.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to obtain a physician order for the use of an indwelling Foley catheter and a supporting diagnosis. This affected one (#48) of 24 sampled residents. The facility identified seven residents with indwelling Foley catheters. The facility census was 123.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure residents receiving psychoactive medications were being adequately monitored for adverse side effects. This affected two (#16 and #75) of five reviewed for psychoactive medication usage. The facility census was 123. Findings Include: 1. Medical record review for Resident #16 revealed an admission date on 06/12/15 with diagnoses including unspecified intellectual disabilities, cerebral palsy, high blood pressure, anxiety, hypotension, dental caries, hypothyroidism, major depressive disorder, hearing loss, repeated falls, long term drug therapy and personal history of infectious and parasitic disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed resident was coded as rarely or never understood. [...]

Inspectors wroteBased on resident and staff interviews and review of the local post office business hours, the facility failed to ensure residents would receive mail on Saturdays, that was delivered to the facility by the post office. This affected 10 (#317, #28, #53, #15, #35, #77, #55, #3, #39 #57) of 10 residents interviewed during resident council meeting and had the potential to affect all 123 residents in the facility. Facility census was 123.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of facility pain policy, the facility failed to ensure a resident with an unstageable pressure ulcer received pain medication prior to or during a treatment. This resulted in actual harm to Resident #89 who complained of pain during a pressure ulcer treatment. This affected one Resident (#89) of two reviewed for pain. The census was 145.

Inspectors wroteBased on observation and sampling of a food test tray, review of resident council minutes and staff and resident interviews the facility failed to ensure the food was palatable and was served at the correct temperature. This affected 143 residents out of 145. The facility identified two Residents (#34 and #128) who ate nothing by mouth. The census was 145.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure items in the kitchen had expiration dates on them, failed to date items that were opened, failed to discard items that were opened and out of date, failed to change gloves in between handling food and dirty surfaces and failed to wash hands between change of gloves. This had the potential to affect 143 resident of a census of 145. The facility identified two Resident's (#34 and #128) who could have nothing by mouth.

Inspectors wroteBased on record review, staff interview, review of the Resident Assessment Instrument (RAI) and review of facility policy the facility failed to encode the Minimum Data Set (MDS) within the correct time frames. This affected four Residents (#27, #98, #107 and #345) of six reviewed for correct completion timing. The facility census was 145.

Inspectors wroteBased on medical record review, observations, resident and staff interview the facility failed to complete and implement person-centered comprehensive plans of care. This affected four Residents (#27, #52, #98, and #345) of six reviewed for patient centered care plans. The facility was 145.

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to ensure activities were provided according to resident interest for three (#27, #98 and #345) of four residents reviewed for activities. The facility census was 145.

Inspectors wroteBased on medical record review and resident's family and staff interview, the facility failed to ensure a physician order to document urinary output from an indwelling catheter was followed. This affected one Resident (#35) of two reviewed for urinary catheter. The census was 145.

Inspectors wroteBased on medical record review, observation, staff interviews and facility policy review, the facility failed to ensure fall interventions were in place for residents who sustained falls with injuries. This affected two Residents (#17 and #71) of six reviewed for accidents. The census was 145.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure non-pharmacological interventions were attempted before an as needed pain medication was administered. This affected one Resident (#71) of five reviewed for unnecessary medications. The census was 145.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure to document an assessment for pain and a treatment for a pressure ulcer. This affected one Resident (#89) of two reviewed for pain. The census was 145.