Leslie Lakes Retirement Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the current care plan revealed Resident #11 was at risk for bruising and bleeding related to anticoagulant therapy. Further review of the care plan revealed approaches included to observe resident for signs and symptoms of bleeding. Review of the February 2026 physician orders revealed an order dated 12/02/2025 for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility staff failed to implement standard precautions as evidenced by: 1) failure to perform hand hygiene and don gloves during medication administration, 2) failure to doff PPE prior to exiting resident room, and 3) failure to clean and disinfect a whirlpool bath.Findings: #1. Review of the facility's Infection Control Guidelines for All Nursing Procedures policy dated 01/15/2026 revealed: General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 4. In most situations, the preferred method of hand hygiene is with alcohol-based hand rub. If…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure residents have a right to a clean, comfortable and homelike environment by having unsanitary items for resident use for 1 (#1) of 2 residents reviewed for environment. Findings:Observations of resident #1's room on 02/23/2026 at 10:00 a.m., 02/24/2026 at 9:00 a.m., and 02/25/2026 at 8:30 a.m. revealed a spilled substance on the bedside table and tube feeding pole. Further review revealed a black substance and grime on the resident's air condition unit. During an interview on 02/25/2026 at 8:38 a.m., S6Housekeeper confirmed there were spills and splatters on the bedside table and tube feeding pole. During an interview on 02/25/2026 at 8:42 a.m., S7Maintenance confirmed there was a black substance and grime on the air condition unit, and the air filter needed to be changed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services, in accordance to the professional standards of practice, for 2 (#31, #78) of 2 residents reviewed for respiratory care. The facility failed to 1) properly store the nebulizer mask when not in use and change nebulizer tubing for Resident #31, and 2) change the oxygen tubing weekly for Resident #78. Findings: Review of facility's Oxygen administration policy dated 01/15/2026 revealed in part: Oxygen shall only be administered by physician order, except in an emergency. Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and prn. All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly in a zip lock bag. Resident #31 Review of the medical record for Resident #31 revealed an admission date of 08/08/2025. Resident #31 had diagnoses including pneumonia, reflux, anxiety, and dementia. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the pharmacist identified irregularities related to adequate monitoring of prescribed medications 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 that included 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.Review of the current care plan revealed Resident #11 was at risk for bruising and bleeding related to anticoagulant therapy. Further review of the care plan revealed approaches included observe resident for signs and symptoms of bleeding.Review of the February 2026 physician orders revealed an order dated 12/02/2025 for Eliquis (anticoagulant) 2.5 mg, give 1 tablet by mouth two times a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to conduct a MDS (Minimum Data Set) admission assessment timely for 1 (#238) of 6 (#37, #62, #66, #69, #77, #238) residents reviewed for accidents out of a total sample of 26 residents. Findings: Review of Resident #238's medical record revealed an admit date of 11/15/2024. Review of Resident #238's admission MDS dated [DATE] revealed a status of still in progress. During an interview on 12/11/2024 at 1: 45 p.m. S3 MDS Coordinator reviewed the MDS assessment for Resident #238 and confirmed the admission assessment due by 12/06/2024, had not been completed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner after the resident's admission to the facility. During an interview on 12/11/2024 at 5:45 p.m. S1 DON (Director of Nursing) reviewed and reported the admission MDS assessment was due to be completed and transmitted by 12/06/2024 and was not.

Based on observations and interviews the facility failed to accommodate the needs of 1 (#8) of 2 (#4, #8) residents reviewed for environment by failing to ensure Resident #8's bed control was in working order. Findings: Review of Resident #8's medical record revealed an admission date of 07/22/2013 with diagnoses that included, in part, major depressive disorder, hereditary and idiopathic neuropathy unspecified, morbid (severe) obesity due to excess calories, venous insufficiency (chronic) (Peripheral), polyosteoarthritis unspecified, and essential hypertension. During an interview on 11/14/2023 at 8:23 a.m. Resident #8 reported his bed control had not worked for 8 years and he could not adjust the head of the bed or the feet. Resident #8 also confirmed CNAs (Certified Nursing Assistant) were aware the bed controls did not work. Observation on 11/14/2023 at 8:23 a.m. revealed Resident #8's bed control was on floor at head of Resident #8's bed. During an interview on 11/14/2023 at 10:58 a.m. S7 CNA was in Resident #8's room and reported Resident #8's bed control did not work and had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews the facility failed to provide services that met professional standards during medication administration for 1 (#90) of 33 sampled residents. The facility failed to follow policies and procedures to ensure safe medication administration practices. Findings: Review of facility's Administering Oral Medications policy revealed in part: Purpose - The purpose of this procedure is to provide guidelines for the safe administration of oral medications. 16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace. 21. Remain with the resident until all medications have been taken. Resident #90 was admitted to the facility on [DATE] with diagnoses including in part chronic pain and chronic kidney disease. Review of Resident #90's Quarterly MDS (Minimum Data Set) dated 10/03/2023 revealed a BIMS (Brief Interview for Mental Status) Summary Score of 15, indicating intact cognition. Review of Resident #90's MAR (Medication Administration Record)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to ensure residents who had indwelling catheters received appropriate care and treatment according to standards of professional practice and the facility's policy to prevent urinary tract infections (uti) for 3 (#12, #38, #78) of 4 (#12, #38, #78, #246) residents reviewed for urinary catheter and uti. The facility failed to ensure: 1. Resident #12, Resident #38 and Resident #78's catheter bags were kept above the floor. 2. Resident #12, who had a catheter in place, had an order for a catheter. 3. Resident #12's urine quality was being monitored and documented as per facility policy. Findings: Review of facility's Catheter Care, Urinary policy with a revision date of September 2014 revealed in part: Purpose - The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines . Infection Control: . b. Be sure the catheter tubing and drainage bag are kept off the floor. Changing Catheters: 1. Changing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observation and interviews the facility failed to ensure provision of necessary care and services consistent with professional standards of practice and the facility's policy for 1 (#12) of 2 (#12, #19) residents reviewed for Respiratory Care. The facility failed to ensure: 1) Resident #12's oxygen tubing and humidification bottle were labeled with date they were changed. 2) There was a physician order for Resident #12 who was receiving oxygen. Findings: Review of Oxygen Administration Policy revealed: POLICY: Oxygen shall only be administered by physician order, except in an emergency. In an emergency situation, oxygen can be administered without physician order, but the order must be obtained immediately after the crisis is under control. All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Humidifier bottles will be changed as needed. Nasal cannulas will be changed every week and prn. Review of Resident #12's medical record revealed an original admission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure dietary services were provided in a sanitary environment for the 83 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure food was properly dated and not expired. Findings: Review of the facility's Food Receiving and Storage Policy Statement revealed: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observation of the kitchen on 11/13/2023 at 8:30 a.m. revealed the following: 1. 3 packages of coconut flakes with an expiration date of 01/06/2022. 2. 1 package of vanilla wafers opened, not sealed without opened dated on the package. 3. 1 package of graham pie crust opened, without opened date. 4. 1 gallon of pickle relish opened in the walk-in refrigerator with an expiration date of 03/24/2023 and an opened date of 07/03/2023. 5. 1 package of American cheese single slice opened, without an opened date in the walk-in refrigerator. During an interview on 11/13/2023 at 9:00 a.m., S9Dietary Manager was in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.