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Deficiency Records for Leisure Glen Post Acute Care Center

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.

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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-06-13 2024-07-08 N
Reasonably accommodate the needs and preferences of each resident. Health 2024-06-13 2024-07-08 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-06-13 2024-07-08 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 2024-06-13 2024-07-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-06-13 2024-07-08 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2024-06-13 2024-07-08 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-06-13 2024-07-08 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-06-13 2024-07-08 N
Observe each nurse aide's job performance and give regular training. Health 2024-06-13 2024-07-08 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-13 2024-07-08 N
Provide and implement an infection prevention and control program. Health 2024-06-13 2024-07-08 N
Install an approved automatic sprinkler system. Fire Safety 2024-06-17 2024-07-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-17 2024-07-08 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-06-17 2024-07-08 N
Have proper medical gas storage and administration areas. Fire Safety 2024-06-17 2024-07-08 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-04-19 2024-05-17 Y
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 2024-02-02 2024-02-16 Y
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

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