A list of the most recent deficiencies for Leisure Court Nursing 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-24 | 2024-02-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-24 | 2023-11-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-19 | 2022-08-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-19 | 2022-08-17 | Y |
| 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 | 2022-04-22 | 2022-05-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-22 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-22 | 2022-05-20 | 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 | 2022-04-22 | 2022-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-22 | 2022-05-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-22 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-22 | 2022-05-20 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-04-22 | 2022-05-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-25 | 2022-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-25 | 2022-05-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-25 | 2022-05-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-25 | 2022-05-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-19 | 2020-01-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-19 | 2020-01-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-20 | 2020-01-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-12-20 | 2020-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-20 | 2020-01-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-20 | 2020-01-17 | 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 | 2019-12-20 | 2020-01-17 | 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 | 2019-12-20 | 2020-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-20 | 2020-01-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-13 | 2019-03-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-01-09 | 2019-02-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-09 | 2019-02-07 | 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 | 2019-01-09 | 2019-02-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-09 | 2019-02-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-01-09 | 2019-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-09 | 2019-02-07 | N |
