Leisure Court Nursing Center

In the surveyor’s words

From the most serious findings on record at Leisure Court Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Jun 18, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for four of five sampled residents (Residents 4, 7, 38, and 52) reviewed for unnecessary medication, two of 22 final sampled residents (Residents 9 and 10), and two nonsampled residents (Residents 80 and 83). * The facility failed to ensure Resident 38's orthostatic blood pressure was accurately monitored, as ordered by the physician, for the use of the quetiapine (antipsychotic) medication. In addition, the facility failed to ensure non-pharmacological interventions were implemented for the documented observed behaviors. […]

• No harm, potential for more than minimal, patternF695Jun 18, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 67) and two nonsampled residents (Residents 41 and 109) reviewed for respiratory care were provided with the appropriate respiratory care and services. * The facility failed to ensure Resident 41's nasal cannula tubing and storage bag were changed every seven days. * The facility failed to ensure Resident 67 was administered with the oxygen therapy as ordered by the physician; and failed to ensure Resident 67's nasal cannula tubing was dated and labeled. In addition, the facility failed to ensure a sign to show oxygen in use was posted outside the resident's room. […]

• No harm, potential for more than minimal, patternF812Jun 18, 2026

  Based on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the food in the walk-in refrigerator was thrown out after the use by date. These failures had the potential to cause foodborne illnesses for the 97 residents who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Texture dated 6/15/26, showed 97 of 105 residents were receiving food prepared in the kitchen. 1. […]

• No harm, potential for more than minimal, patternF880Jun 18, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P.* The facility failed to maintain an accurate infection control surveillance program for January 2026 through May 2026 and failed to ensure the Surveillance Data was accurate to determine whether the residents' infection met McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria for true infection for Residents 2, 21, 37, 52, 71, 93, and 112.* The facility failed to ensure the water management plan was available which addressed and identified where… […]

• No harm, potential for more than minimal, patternF881Jun 18, 2026

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics for two final sampled resident (Residents 2 and 52) and three nonsampled residents (Residents 21, 37, and 112) reviewed for antibiotic stewardship. * Residents 2, 21, 37, 52, and 112 who did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, increasing the risk of adverse drug reactions and the development of antibiotic resistant organisms. […]