De Leon Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food stored in the kitchen was sealed and/or labeled properly in the facility's freezers #1 and #2. This failure could place residents that eat out of the kitchen at risk for contamination and food borne illnesses.During an observation on 9/23/25 at 9:45 AM, the facility kitchen revealed Freezer #1:1 bag of chicken legs was unsealed and opened to air.,1 bar of butter was unsealed/not dated and open to air. Freezer #2:1 bag of hushpuppies was unsealed and open to air.1 bag of corn nuggets was unsealed and opened in the air.1 bag of chicken thighs was unsealed and open to air.1 box of burritos was unsealed and opened to air.A sheet tray of red velvet chocolate chip cookies was open to the air. During an observation and interview on 9/23/25 at 9:45 AM, of freezers #1 and #2 revealed opened box of food, the DM stated that she would not…

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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. The facility failed to provide paper towels at the kitchen hand washing sink. The facility failed to label stored foods with a description and/or open date. The facility failed to store foods with lids that covered the food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 08/18/2024 between 02:10 PM and 2:30 of the kitchen revealed: 1. The hand washing sink in the kitchen did not have paper towels available to dry hands. 2. An opened container of cake frosting was sitting in a sealed see through bag with no opened date in 1 of 1 dry storage. 3. An opened bag of cream soup base was in a sealed see through bag with no opened date in 1 of 1 dry storage. 4. A circular frozen breaded product was in a sealed see through bag in 1 of 2 freezers with no description or…

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 interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 14 residents (Resident #5, Resident #12, and Resident #37) reviewed for PASRR. The facility failed to follow up with the LA for PASRR Level II determination when Resident #5, Resident #12, and Resident #37s PASRR Level 1 Screening reflected they were positive for mental illness. This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services. Findings included: Resident #5 Record review of Resident #5's electronic face sheet dated 08/20/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #5 had diagnoses of psychosis with onset date of 01/22/2021 and diagnosis of major depressive disorder added…

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 observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 (Resident # 6 and Resident #17) reviewed for oxygen therapy. The facility failed to ensure that oxygen tubing and nasal cannula were placed in plastic bag for 2 of 2 residents (Resident #6 and Resident #17) when not in use. These failures placed residents of the facility at risk for respiratory illnesses. Findings included: During an observation on 08/18/2024 at 2:25 PM RM [ROOM NUMBER] revealed Oxygen tubing with nasal cannula on bedside table and not in a plastic bag. Resident #6 was not in the room at the time. Resident #6 During a review of Resident #6 's electronic face sheet revealed: [AGE] year-old female admitted on [DATE] with diagnoses of Anorexia (eating disorder), Dysphagia (difficulty swallowing), Cognitive…

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 observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #22) reviewed for meals. The facility failed to ensure that Resident #22 was served a pureed bowl of melon, instead of a bowl of regular melon. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: Record review of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnoses include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), and Abnormal weight loss. Record review of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns Resident #22 had a BIMS score of 00 indicating had severe cognitive impairment; Section K- Swallowing/Nutritional Status Resident #22 was on mechanically altered diet. Record review of Resident #22's Care plan dated 08/18/2024 revealed:…

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 interviews, and record reviews, the facility failed to ensure professional staff was certified in accordance with applicable State laws for 1 (NA B) of 15 personnel reviewed for licensed nursing. The facility failed to ensure NA B had become a Certified Nurse Aide by passing her certification test. These failures could place residents at risk of being provided care by staff who are not qualified per state law. Findings included: Record review of NA B's employee file revealed a hire date of 08/30/2022 and no evidence of CNA certification. During an interview on 08/20/24 at 3:21 PM the DON stated that NA B was a NA and not a CNA. The DON stated NA B was currently enrolled in an online course. The DON stated NA B had failed the CNA certification exam twice before and had one more attempt. The DON stated her expectation was for her to complete the online course and pass her test in a timely manner. The DON did not think there was an effect on residents because NA B always worked with a CNA (who was certified). The DON stated what led to failure of NA not being certified was she…

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 observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents LVN A feeding 1of 1 residents (Resident #22) did not perform hand hygiene after touching resident and wiping resident mouth. The facility failed to ensure proper hand hygiene when feeding a resident (Resident #22). These failures placed residents of the facility at risk of infections from respiratory care and dining. Findings included: During a record review on 08/20/2024 of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnosis include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Abnormal weight loss. During a record review on 08/20/2024 of Resident #22's Physician Orders dated 08/01/2024 revealed: Fortified/Enhanced…

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 interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for infection control related to COVID-19 (a virus that is spread from person to person causing mild to severe respiratory symptoms) for 16 of 18 residents reviewed. Multiple asymptomatic residents tested positive for COVID-19 after dietary staff tested positive for COVID-19, by not taking preventative measures. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: Record review of Resident #1's face sheet dated 10/15/23 revealed an admission date of 6/14/23 with a BIMS of 6 and diagnoses which included: Dementia, kidney disease, and hypertension. Record review of Resident #2's face sheet dated 10/15/23 revealed an admission date of 1/28/22 with a BIMS of 5 and diagnoses which included: heat disease, kidney disease,…

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 observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff practiced proper hand hygiene. This deficient practice could place residents at risk for food borne illness and cross-contamination. Findings include: During an observation on 06/26/2023 at 11:20 AM, DA B exited the kitchen without removing gloves. DA B then reentered the kitchen with gloves on hands while holding a bowl of pudding. DA B did not wash her hands or change gloves. DA B then opened the refrigerator with gloved hands, placed the bowl of pudding into the refrigerator. DA B then scratched her head underneath her hair net then rubbed her nose with the same gloved hands. DA B then reached into her pocket with her gloved hand, pulled out a pen, wrote on a label, and placed the label onto another bowl of pudding before placing it into the refrigerator. DA B then grabbed a cup from a rack with the same…

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 observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurate for 2 of 3 residents (Resident #36 and Resident #149) reviewed for resident records. The facility failed to document the verification of placement of a wanderguard each shift, and the function of resident's device daily for Resident #36 and Resident #149. This failure could place residents at risk of residents having errors in care and treatment. Findings include: Review of Resident #36's face sheet, dated 06/28/2023, revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Dementia. review of Resident # 36's Quarterly MDS, dated [DATE], revealed: Section C- Cognitive Behavior a BIMS score of 8 meant he had moderate cognitive impairment. Review of Resident #36's electronic medical record revealed no evidence of documentation of verification of placement of a wanderguard documented each…

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 observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #199) reviewed for accidents and supervision. The facility failed to ensure there was adequate supervision while Resident #199 was smoking. This failure could place residents at risk for injury due to the lack of supervision provided by the facility. Findings include: Record review of Resident #199's electronic face sheet revealed Resident #199 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #199 had diagnoses which included Dementia, Alzheimer's and Depression. Record review of Resident #199 Comprehensive assessment, dated 06/09/2023, revealed a BIMS of 09, which indicated moderately impaired cognition. Resident #199 was a tobacco user. Record review of Resident #199 Comprehensive Care Plan,…

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 observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for one of two medication carts reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when the medication cart was left unlocked and unattended. This failure could result in access to medications by unauthorized staff or residents leading to possible harm or drug diversion. The findings Included: During an observation on 06/26/23 at 02:09 p.m., a medication cart was observed to be unlocked and unattended outside the nurse's station near Hall 3. Residents were observed passing by the cart. Review of the content of the medication cart revealed the cart contained the following: analgesics (non-narcotic and narcotic pain relievers), antacids (relieve heartburn), antianxiety drugs (have a calming effect and relax muscles), antiarrhythmics (controls irregular heartbeats), antibiotics (for infections), anticoagulants and thrombolytics (prevent blood clots),…

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.