Leisure Glen Post Acute Care Center

In the surveyor’s words

From the most serious findings on record at Leisure Glen Post Acute Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Jul 2, 2026

  Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 32, Resident 71, Resident 91) in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered by failing to ensure: 1. Resident 32 who receives intradialytic parenteral nutrition [IDPN - nutrition that is given through the dialysis machine while receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed)] was addressed to determine interventions and monitoring needed while receiving the nutritional therapy 2. […]

• No harm, potential for more than minimal, patternF689Jun 27, 2025

  Based on observation, interview, and record review, the facility failed to provide safe and hazard free environment and interventions for safety and supervision for four of four sampled residents (Residents 7,69,102, and 79) the facility failed to: 1.Ensure Resident 7's bed alarm was in the working condition. 2.Provide adequate supervision and safety measures to ensure safety to Residents 69 and 102 who are at risk for elopement (leaving the facility without permission) keeping the patio gate closed and not kept opened with a wire. […]

• No harm, potential for more than minimal, patternF695Jun 27, 2025

  Based on observation, interview, and record review, the facility to failed to provide respiratory care to ensure four of 4 sampled residents (Resident 15, 99, 75, and 213) who were receiving oxygen therapy were provided care in accordance with the professional standard of practice and facility's policy and procedure by failing to: 1.Ensure Resident 99 was monitored to ensure the resident wears the nasal cannula (a tube inserted into the nostril used to deliver oxygen into the lungs) to received continuous oxygen as ordered by the physician ordered for oxygen administration. 2.Ensure Resident 15's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was placed in designated plastic bag when not in use. 3. […]

• No harm, potential for more than minimal, patternF880Jun 27, 2025

  Based on observation, interview, and record review, the facility failed to enforce the facility's policy and procedure to ensure a visitor was monitored and instructed not obtain the cups, spoons, juice and water pitchers from medication cart for 1 of 3 sampled resident (Resident 15). This deficiency has the potential to result in cross contamination (the process by which bacteria or other microorganism unintentionally transfer from one object to another with harmful effect) and spread of infection in the facility. […]

• No harm, potential for more than minimal, patternF730Jun 13, 2024

  Based on interview, and record review, the facility failed to complete a performance review by completing the Annual Core Clinical Competencies (ACCC, an assessment and training on the Certified Nurse Assistant(s) (CNA) the ability to perform clinical nursing care). In addition, the facility did not have a system in place to keep track of the CNA's performance evaluation to ensure three of five CNAs (CNA 1, CNA 2 and CNA 3) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. […]