LeTort Spring Nursing and Rehab LLC

In the surveyor’s words

From the most serious findings on record at LeTort Spring Nursing and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 24, 2025

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found approximately one half mile from the facility approximately 17.5 hours following his elopement with injury to his forehead. […]

• Actual harm, isolatedF684Jan 29, 2026

  Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of three residents reviewed (Residents 1, 2, and 3) which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled IIA2. Medication Administration-General Guidelines, undated, revealed, in part, Medications are administered in accordance with written orders of the attending physician. […]

• Actual harm, isolatedF755Jan 29, 2026

  Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for two of three residents reviewed (Residents 1 and 2), which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).Findings include:Review of facility policy, titled IC4: Ordering and Receiving Controlled Medications, undated, revealed, in part, Schedule II controlled medications prescribed for a specific resident are delivered to the facility only if a faxed or original written prescription has been received by the pharmacy. […]

• Actual harm, isolatedF692Feb 6, 2025

  Based on facility policy review, clinical record review, and staff and resident representative interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for three of six residents reviewed for nutrition or hydration (Residents 17, 28, and 58). This failure resulted in harm for Resident 17, as evidenced by significant weight loss. Findings include: Review of facility policy, titled Weight Monitoring, last reviewed January 17, 2025, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents… […]

• Actual harm, isolatedF692Mar 21, 2024

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45). Findings include: Review of facility policy, titled Weight Monitoring, dated October 2022, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical… […]