Leeway, Inc

In the surveyor’s words

From the most serious findings on record at Leeway, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Dec 30, 2025

  Based on observations, clinical record reviews, facility documentation, facility policy and interviews for 4 of 12 residents (Resident # 10, Resident #15, Resident #22, and Resident # 23 reviewed for smoking, the facility failed to revise the care plan to indicate smoking privileges, concerns or restrictions. The findings included: 1. Resident #10 's diagnoses included necrotizing fasciitis, Fournier gangrene and anxiety disorder.The Resident Care Plan dated 11/24/2025 failed to identify smoking in the care plan. […]

• No harm, potential for more than minimal, patternF711Jun 6, 2024

  Based on clinical record review, and interviews for one sample resident (Resident #22) who was admitted to the facility within the past six months, the facility failed to ensure physician's orders were signed and dated in a timely manner The findings include: Resident #22's diagnoses included Kaposi's sarcoma, malnutrition, neoplasm related pain, anemia, and depression. The admission MDS assessment dated [DATE] identified Resident #22 was admitted to the facility on [DATE], was without cognitive deficits, required extensive assistance with bed mobility, toileting, hygiene, transfers and was non-ambulatory. Review of the physician's orders from January/2024 through 6/4/24 identified the physician's orders were not signed and/or dated for that period of time. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  Based on observations, review of facility policy and interviews, the facility failed to ensure foods were dated and labeled appropriately, discard expired foods, and utilize hygienic practices during the handling of prepared food. The findings include: Observations with the Food Service Manager on [DATE] at 2:45 PM identified the reach-in refrigerator contained the following food items that were covered in plastic wrap but were undated and unlabeled: Two peanut butter and jelly sandwiches A round dough like substance A salami sandwich Three eggs in a bowl A plate containing chicken and roasted potatoes A chicken salad sandwich A pan containing mixed vegetables and ground beef A metal bin containing yellow colored rice in a metal bin Scrambled eggs in a white bowl Shredded… […]

• No harm, potential for more than minimal, patternF578Mar 17, 2022

  Based on review of clinical records, review of facility policy and interviews for 4 of 5 sampled residents (Residents #5, #9, #29, & #631), reviewed for Advanced Directives the facility failed to establish advanced directives related to code status and other life sustaining treatments with newly admitted and readmitted residents. The findings include: 1. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-day MDS assessment dated [DATE] identified Resident #5 was readmitted from the hospital on [DATE]. The assessment further noted that Resident #5 was cognitively intact, required total assistance with bed mobility and transfers, was independent with eating and did not ambulate. […]

• No harm, potential for more than minimal, isolatedF628Dec 30, 2025

  Based on clinical record reviews, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #34) reviewed for discharges, the facility failed to ensure the Ombudsman was notified of a hospitalization and a discharge to community and for ( Resident #7) reviewed for discharge, the facility failed to provide written notification to the resident's conservator explaining why the resident was being transferred to the hospital The findings included: 1 a. Resident #34 was admitted to the facility in [DATE] with diagnoses that included chronic hepatitis, and cardiomyopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 had moderately impaired cognition. […]