A list of the most recent deficiencies for Leisure Glen Post Acute Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-18 | 2024-02-02 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-01 | 2023-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2022-12-16 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-11-17 | 2021-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-18 | 2021-12-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-18 | 2021-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2021-12-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-18 | 2021-12-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-11-18 | 2021-12-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-18 | 2021-12-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-18 | 2021-12-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-18 | 2021-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-02-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-09 | 2020-02-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-09 | 2020-02-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2020-01-09 | 2020-02-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-09 | 2020-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-09 | 2020-02-04 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-09 | 2020-02-04 | N |
| Post nurse staffing information every day. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-02-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-09 | 2020-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-04 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-04 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-01-09 | 2020-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-10 | 2020-02-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-02 | 2019-04-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-01-02 | 2019-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-02 | 2019-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-02 | 2019-04-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-12-31 | 2019-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-31 | 2019-02-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-31 | 2019-02-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-31 | 2019-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-31 | 2019-02-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-31 | 2019-02-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-12-31 | 2019-02-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-31 | 2019-02-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-31 | 2019-02-11 | N |
| Post nurse staffing information every day. | Health | 2018-12-31 | 2019-02-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-31 | 2019-02-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-31 | 2019-02-11 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-12-31 | 2019-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-31 | 2019-02-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-12-31 | 2019-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-31 | 2019-02-11 | N |
