St Leonard HCC

In the surveyor’s words

From the most serious findings on record at St Leonard HCC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 28, 2022

  Based on medical record review, observations, interview with staff, residents and family, review of hospital records, review of the facility's Self-Reported Incidents (SRI), review of staff statements, review of facility maps, review of a weather report, and review of facility policy, the facility failed to accurately assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors, and level of supervision for Resident #85, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy with the potential for serious life-threatening harm, injuries, and/or death on [DATE] at approximately 6:15 P.M. when Resident #85 eloped from the facility without staff knowledge. […]

• Actual harm, isolatedF686Jul 18, 2024

  Based on record review, observations, interviews, review of the information from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure timely treatments and interventions were done for a resident's pressure ulcer. This resulted in actual harm when Resident #95's pressure ulcer to his left heel deteriorated in condition and developed osteomyelitis from the delay in treatment. This affected one (Resident #95) of two residents reviewed for pressure wounds. The facility census was 112. Findings include: Review of the medical record for Resident #95 revealed an admitted [DATE]. […]

• Actual harm, isolatedF686Oct 16, 2023

  Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure interventions and treatment orders were in place for a resident admitted to the facility with a stage three pressure ulcer to the coccyx. This resulted in the Actual Harm when Resident #10's stage three pressure ulcer, present upon admission, did not receive timely treatment and there was deterioration of the pressure ulcer to a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. […]

• No harm, potential for more than minimal, patternF677Apr 2, 2026

  Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received bathing services as scheduled. This affected four (Residents #7, #56, #114, and #130) of five residents reviewed for bathing. The facility census was 124 residents.Findings include: 1.Review of the medical record for Resident #7 revealed an admission date of 12/19/25 with diagnoses including myelodysplastic syndrome, hypokalemia, and iron deficiency anemia. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 02/10/26 revealed the resident had severe cognitive impairment and required assistance with activities of daily living (ADLs), including bathing and dressing. […]

• No harm, potential for more than minimal, patternF550Jul 7, 2022

  Based on observation, staff interviews, resident interviews, review of Resident Council Meeting Minutes, and review of employee handbook, the facility failed to ensure residents were able to identify names and credentials of facility staff. The facility identified 64 residents (Residents #1, #2, #4, #5, #14, #16, #17, #18, #19, #20, #21, #29, #30, #31, #34, #36, #40, #42, #44, #45, #48, #51, #56, #61, #69, #70, #73, #76, #77, #78, #80, #81, #82, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #120, #121, #122, #123, #124, #125, #126, #127, #128, and #129) with intact to moderately impaired cognition and adequate vision with the potential to be affected. […]