Leonard Florence Center for Living

In the surveyor’s words

From the most serious findings on record at Leonard Florence Center for Living, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF759Aug 24, 2022

  Based on observation, interview and record review, the facility failed to ensure that they were free from a medication error rate of 5% or greater. There were 2 errors in 29 opportunities for a medication error rate of 6.9%, during observations made on 2 of 4 houses with 2 of 4 nurses (#3 and #4); 2 residents (#48 and #72) were involved. Findings include: 1. On 8/23/22 at 8:21 A.M., the surveyor observed Nurse #3, on the [NAME] house, administer medications to Resident #48, including [MEDICATION(S)] 240 milligram(mg) tablet, 1 tablet. Review of Resident #48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/23/22 at 8:25 A.M., Nurse #3 said that he thought the tablets were 400 mg tablets. […]

• No harm, potential for more than minimal, isolatedF842Jul 14, 2026

  Based on records reviewed and interviews, for one of six sampled residents (Resident #1), who experienced an acute change in medical status, the Facility failed to ensure they maintained an accurate and complete medical record that included nursing documentation related to the life saving measures initiated and provided by staff.Findings include:The Facility Policy, titled Charting and Documentation, undated, indicated all observations, medications administered, services performed, incidents, accidents, and changes in the resident's condition would be documented in the resident's clinical record. Resident #1 was admitted to the Facility in [DATE], diagnoses included irritable bowel syndrome, aortic valve insufficiency, and history of stroke. […]

• No harm, potential for more than minimal, isolatedF759Nov 20, 2025

  Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one Nurse observed made 4 errors out of 38 opportunities, resulting in a medication error rate of 10.53 %. Those errors impacted two Residents (#102 and #98), out of 3 residents observed.Findings include: Review of the facility policy titled, Administering Medications, undated, indicated: Medications shall be administered in a safe and timely manner, and as prescribed.4. Medications must be administered in accordance with the orders, including any required time frame.5. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).7. […]

• No harm, potential for more than minimal, isolatedF761Nov 20, 2025

  Based on observations, and interviews, the facility failed to ensure medications were labeled, and dated once opened, according to manufacturer's guidelines on one out of five units. Findings include:Review of the facility policy titled, Storage of Medications, undated, indicated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. Expired medications cannot be stored or kept in the medication or treatment carts. Expired medications may be kept in the medication room before being destroyed.7. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.11. […]

• No harm, potential for more than minimal, isolatedF557Jun 25, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented and able to make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner by staff, when on 06/02/25 a staff member witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a rude, disrespectfully manner, which included CNA #1 yelling at Resident #1 to shut up. Findings include: The Facility's Policy titled, Resident Rights, undated, indicated that employees shall treat all residents with kindness, respect, and dignity. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. […]