Medford Leas

In the surveyor’s words

From the most serious findings on record at Medford Leas, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 25, 2025

  Based on observation, interview and document review, it was determined that the facility failed to to maintain the kitchen environment and equipment in a sanitary manner and ensure all staff performed hand hygiene appropriately to prevent potential contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 02/20/25 at 12:01 PM, the surveyor conducted an initial tour of the kitchen with the Executive Chef (EC), Director of Dining (DD), and the Dining Manager (DM) and observed debris affixed to the ceiling tiles in the pot washing area. […]

• No harm, potential for more than minimal, patternF761Feb 25, 2025

  Based on observation, interview and document review, it was determined that the facility failed to: a) ensure controlled drugs (narcotics) were stored in a permanently affixed compartment, and b) have a system in place to ensure that the emergency crash cart (a portable wheeled cabinet that contained emergency medical supplies and drugs) did not contain expired emergency supplies. This deficient practice was identified for 1 of 1 medication storage room, and for 1 of 1 emergency crash carts (ECC) reviewed for medication storage. The deficient practice was evidenced by the following: 1. […]

• No harm, potential for more than minimal, patternF838Feb 25, 2025

  Based on observation, interview and document review, it was determined that the facility did not address the resident population, identify the specific care related to the type of diseases or conditions that were present in the resident population and did not identify the staff competencies and skill sets that were necessary to provide care for the specific resident population to the specific resident population and was evidenced by the following: On 02/20/25 at 1:30 PM, the facility provided the survey team with a copy of the Facility Assessment (FA), Updated 2/2024. The surveyor reviewed the FA which revealed: Facility Assessment and Overview: . There are three healthcare buildings . containing nursing care. […]

• No harm, potential for more than minimal, patternF865Feb 25, 2025

  Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to identify and consistently implement an effective Quality Assurance and Performance Improvement (QAPI) program to: a)ensure medication carts and emergency carts for identified and monitored for expired supplies and medications, b) ensure secure storage of all narcotic medications, and c) ensure that competencies required for all staff who worked in resident care areas were identified and addressed. This deficient practice was evidenced by the following: 1. […]

• No harm, potential for more than minimal, patternF867Feb 25, 2025

  Based on observation, interview and document review, it was determined that the facility failed to ensure a system was in place, and consistently followed to incorporate feedback from all departments and direct care staff for their Quality Assurance Performance Improvement (QAPI) program. Refer to 761E, 812F This deficient practice was evidenced by the following: On [DATE] at 12:54 PM, during entrance conference the facility provided documentation which included their QAPI plan and three months of attendance sheets. A review of the attendance sheets documented no direct care staff or maintenance staff. […]