Leisure Village Health Care Center

In the surveyor’s words

From the most serious findings on record at Leisure Village Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 12, 2026

  Based on observation, interview, facility document and policy review, and U.S. [United States] Food and Drug Administration 2022 Food Code, guidelines, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, daily log documentation was lacking for the dish machine sanitation test strip levels and rinse temperature levels. Additionally, dietary staff did not perform hand hygiene during meal service. Additionally, food was not labeled and dated appropriately in facility refrigerators.These deficiencies had the potential to affect all residents in the facility.Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF880Jun 12, 2026

  Based on facility policy review, record review, interview, a review of a Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH) publication, observation, and a review of a glucometer's manufacturer instructions, the facility failed to develop/implement a comprehensive infection control program when they failed to do the following:- Complete annual fit testing for N95 respirators for staff, which had the potential to affect all residents in the building.- Properly utilize a barrier when placing a glucometer and insulin pens on surfaces, ensure staff wore gloves when handling a used glucometer, and failed to properly disinfect a glucometer, which affected 2 (Resident #66 and Resident #83) of 8 residents reviewed for the medication… […]

• No harm, potential for more than minimal, widespreadF584Jan 28, 2026

  Based on observation, record review, and interview, the facility failed to ensure comfortable water temperatures were maintained for 5 of 5 shower rooms. The DON identified 79 residents received showers. Finding:On 01/27/26 at 3:23 p.m., an observation of the large South shower showed an initial temperature of the water flow out of the shower head to be 100.4 degrees F. Within 11 minutes the water temperature was observed to be 77.4 degrees F.On 01/28/26 at 8:42 a.m., an observation of the small East shower showed an initial temperature of the water flow out of the shower head to be 107.4 degrees F. […]

• No harm, potential for more than minimal, patternF584Aug 3, 2026

  Based on observation, record review, and interview, the facility failed to maintain an indoor temperature of less than 81 degrees Fahrenheit for 1 (South hall) of 3 sampled halls reviewed for environment.The regional nurse manager identified 33 residents resided on South hall.Findings:On 07/30/26 at 3:00 p.m., the temperature on South hall in front of room [ROOM NUMBER] was observed to be 81.5 degrees F.On 07/30/26 at 3:05 p.m., the temperature inside of room [ROOM NUMBER] measured at ground level was observed to be 82.5 degrees F.On 07/31/26 at 2:35 p.m., the temperature in the south hallway outside of room [ROOM NUMBER] measured at ground level was observed to be 81.6 degrees F.On 07/31/26 at 2:40 p.m., the temperature measured at ground level in room [ROOM NUMBER] was observed to be… […]

• No harm, potential for more than minimal, patternF580Jun 12, 2026

  Based on interview, record review, facility policy review, the facility failed to notify the physician when ordered medication was not administered for 1 (Resident #41) of 2 residents reviewed for dialysis. Specifically, the facility failed to notify the physician that Resident #41's hydroxyzine (a medication used to treat anxiety) medication was scheduled to be given at a time when the resident was gone for dialysis and was not routinely administered per physician's order for approximately five months.Findings included: A facility policy titled, Medication Administration and General Guidelines, dated 01/2026, revealed, 2. Medications are administered in accordance with written orders of the attending physician. The policy also revealed, 10. […]