Heritage Hall-Leesburg

Based on staff interview, clinical record review, and facility document review, staff interview, the facility staff failed to maintain a resident free of unnecessary medications for one of 44 residents in the survey sample, Resident #97 (R97). The findings include: For (R97), facility staff failed to administer a prn (as needed) the pain medication Oxycodone (1) within the physician ordered pain level parameters. (R97) was admitted to the facility with a diagnosis that included but was not limited to back pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/22/2025, R97 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R15) was cognitively intact for making daily decisions. The physician's order for R97 documented in part, oxycodone (pain medication) HCl (hydrochloride) Oral Tablet 5 (five) MG Milligrams). Give 1 (one) tablet by mouth every 6 (six) hours as needed for pain as needed for pain rate >6/10 (greater than six out of ten). Order Date: 11/26/2024. The eMAR (electronic medication…

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, resident interview, staff interview and clinical record review, the facility staff failed to provide accommodations of resident needs by ensuring the call bell (a device with a button that can be pushed to alert staff when assistance is needed) was within reach for two of 44 residents in the survey sample, Residents #19, (R19) and R67. The findings include: 1. For R19, the facility staff failed to keep the call bell within reach. R19 was admitted to the facility with a diagnosis that included by not limited to difficulty breathing. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/07/2024, R19 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R19 was moderately impaired of cognition for making daily decisions. On 01/27/25 at approximately 7:44 p.m. an observation revealed R19 lying in bed. When asked to locate the call bell R19 was unable to find it and stated she did not know where 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.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care and services for one of 44 residents in the survey sample, Resident #32 (R32). The findings include: For R32, facility staff failed to store the incentive spirometer (1) in a sanitary manner. R32 was admitted to the facility with a diagnosis that included by not limited to generalized muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2024, R32 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R32 was cognitively intact for making daily decisions. On 01/28/25 at approximately 8:18 a.m., an observed revealed R32 lying in bed. Observation of an incentive spirometer laying on top of the bedside table inside a plastic bag. Further observation revealed the mouthpiece of the incentive spirometer hanging outside of the bag resting on the bedside table. On 01/28/25 at approximately 11:20 a.m., an…

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, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of three residents observed during the medication administration observation, Resident #23. During the medication administration observation, two errors out of 29 opportunities occurred, resulting in a 6.9 percent medication error rate. The findings include: For Resident #23 (R23), LPN (licensed practical nurse) #1 failed to administer gabapentin and Breo Ellipta per physician's orders. A review of R23's clinical record revealed a physician's order dated 1/29/24 for gabapentin 100 mg (milligrams)- one capsule by mouth in the morning for pain and a physician's order dated 5/2/24 for Breo Ellipta 100/25 mcg (micrograms)- one inhalation in the morning for chronic obstructive pulmonary disease (lung disease), rinse mouth with water post use. On 1/28/25 at 7:38 a.m., an observation of LPN #1 preparing and administering medications to R23 was conducted. LPN #1 administered two capsules (instead 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.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 9/20/22 at 12:15 PM, a tour of the facility kitchen was conducted with OSM #1 (Other Staff Member) the Dietary Manager. In the walk-in freezer, a box of dinner rolls was noted to have been opened, and the bag inside with the dinner rolls was left open to air, exposing the rolls to the freezer environment. When asked if the box should be left open, OSM #1 stated that it should be closed and sealed. He removed the box and discarded it. The facility policy, Cost Containment - Food Storage: General was reviewed. This policy documented, 6. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area. On 9/21/22 at 1:05 PM, ASM #1 (Administrative Staff Member) was made aware of the findings. No further information was provided by the end of the survey.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to conduct a review of the advance directive for one of 40 residents in the survey sample, Resident # 44 (R44). The findings include: For (R44) the facility staff failed to evidence documentation of a discussion regarding advance directives for Resident # 44. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Review of the facility's Advance Directive Acknowledgement for (R44) dated 08/24/2020 revealed that (R44) executed an advance directive and provided the facility with a copy of the advance directive. The facility's social service note for (R44) dated 02/05/2022 documented in part, Resident will remain a DNR code status. Further review of the social service note failed to evidence discussion of an advance directive. The POS…

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 staff interview, clinical record review, and facility document review, it was determined the facility staff failed to accurately code an MDS (Minimum Data Set) assessment for two of 40 residents, Resident #2 and Resident #433. The facility staff failed to code an MDS (minimum data set) discharge assessment for Resident #2 and Resident #433. The findings include: 1. Resident #2 was admitted to the facility on [DATE] and discharged home on 4/27/22. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 4/27/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Further review of Resident #2's MDS dated [DATE], the last MDS done for this resident revealed Section A0310 Type of Assessment: F: Entry/Discharge Reporting: revealed coding of 99 (none of the above). MDS Section A2000 discharge date : revealed no discharge date entered. 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 observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the comprehensive care plan for one of 40 residents in the survey sample; Resident #6. The findings include: For Resident #6, the facility staff failed to implement the comprehensive care plan for administering oxygen at the ordered rate. Resident #6 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily decisions. The resident was coded as being on oxygen therapy. On 9/20/22 at 12:30 PM and 9/21/22 at 8:05 AM, Resident #6 was observed in bed, wearing the nasal cannula for the oxygen. The oxygen concentrator was set for 2.5 liters per minute. A review of the comprehensive care plan revealed one dated 3/5/20 for At risk for respiratory/cardiac complications This care plan included an intervention dated 12/12/21 for O2 per…

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, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer oxygen at the physician ordered rate for 1 of 40 residents in the survey sample; Resident #6. The findings include: For Resident #6, the facility staff failed to administer oxygen at the physician ordered rate. Resident #6 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily decisions. The resident was coded as being on oxygen therapy. A review of the clinical record revealed a physician's order dated 12/21/21 for O2 (oxygen) on 2L (two liters) via NC (nasal cannula) cont (continuous). On 9/20/22 at 12:30 PM and 9/21/22 at 8:05 AM, Resident #6 was observed in bed, wearing the nasal cannula for the oxygen. The oxygen concentrator was set for 2.5 liters per minute. On 9/21/22 at 8:10 AM an interview was conducted with…

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 resident interview, observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a clean and homelike environment for one of four shower rooms observed in the facility, (Unit two shower room). The facility staff failed to maintain the shower room on Unit two in a sanitary manner. The findings include: On 5/4/2021 at approximately 4:40 p.m., an interview was conducted with Resident #108. Resident #108 stated that the care they received at the facility was excellent and the staff were wonderful however there was always visible mold in the shower room when they took a shower. Resident #108 stated that they were a former housekeeper and noticed things like that. Resident #108 was admitted to the facility with diagnoses that included but were not limited to heart failure (1) and diabetes (2). Resident #108's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/19/21, coded the resident as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15,…

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, staff interview, and facility document review it was determined facility staff failed to discard food items past their use-by date in one of three pantry/nourishment rooms observed, (Unit one pantry room). The facility staff failed to discard four bottles of Ensure (nutritional supplement drink) that were past their use-by date and available for resident use in the Unit one pantry/nourishment room in the facility. The findings include: On 5/4/2021 at approximately 9:45 a.m., an observation was made of the refrigerator located in the pantry/nourishment room on Unit one at the facility. Observations revealed two Ensure French Vanilla flavored 11 fl. oz. (fluid ounce) bottles labeled with a resident name and room number. The two bottles were observed with a manufacturer's use-by date of 1JAN2021 (1/1/2021). Additional observations revealed another Ensure French Vanilla flavored 11 fl. oz. bottle labeled with a resident name and room number with a manufacturer use-by date of 1OCT2020 (10/1/2020). Further observation of the Unit one refrigerator revealed one Ensure…

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.