Leslie Lakes Retirement Center

In the surveyor’s words

From the most serious findings on record at Leslie Lakes Retirement Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 7, 2022

  Based on record review, observations, and interviews, the facility failed to ensure 1 (Resident #1) of 17 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for impaired cognition with a diagnosis of Dementia or Alzheimer's Disease and the potential to elope was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 09/24/2022 at 4:20 p.m. when Resident #1 exited through the front door of the facility unsupervised. Resident #1 had a diagnosis of Dementia and a documented history of intermittent confusion and wandering behavior. The facility failed to assess Resident #1 as an elopement risk and did not supervise Resident #1 to prevent Resident #1 from eloping. […]

• Immediate jeopardy, patternF835Oct 7, 2022

  Based on record review, observations, and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1 (Resident #1) of 17 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for impaired cognition with a diagnosis of Dementia or Alzheimer's Disease and the potential to elope was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 09/24/2022 at 4:20 p.m. when Resident #1 exited through the front door of the facility unsupervised. […]

• Actual harm, isolatedF600Nov 1, 2023

  Based on record review and interviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#1) of 3(#1, #2, #3) sampled residents reviewed for abuse. This deficient practice resulted in an actual harm for resident #1 (who was cognitively impaired) when on 10/10/2023 at 7:30 a.m. resident #2 physically abused resident #1. Resident #2 (who was cognitively impaired) hit resident #1 in the face because resident #1 was in his bed. Resident #1 was sent to the hospital diagnosed with a nose bleed and a broken nose. Findings: Review of the facility's current Abuse Prevention Program policy revealed the following: As part of the resident's abuse prevention, the administration will: 1. […]

• Actual harm, isolatedF600Apr 30, 2021

  Based on observations, record review and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse was free of physical abuse by facility staff. This deficient practice resulted in an actual harm on 04/11/2021 at 3:01pm when S5LPN (Licensed Practical Nurse) and S4TNA (Temporary Nursing Assistant) physically abused Resident #1 by hitting and kicking Resident #1 in the facility. Resident #1 was sent to the hospital, treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility's Abuse and Neglect Policy revealed the following: Physical abuse is defined as hitting, slapping, pinching, kicking, etc. […]

• No harm, potential for more than minimal, patternF757Feb 25, 2026

  Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for bleeding while a resident was receiving an anticoagulant for 1 (#11) of 5 residents reviewed for unnecessary medications.Findings: Review of the medical record for Resident #11 revealed an admission date of 10/21/2025. Resident #11 had diagnoses including atrial fibrillation, hypothyroidism, hyperlipidemia, schizophrenia, dementia and depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 8 which indicated moderate cognitive impairment for daily decision making. […]