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Inspection visit

complaint

LEISURE GARDEN SENIOR ASSISTED LIVING FACILITYLicense 1976100321 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

(Continued from LIC9099) LPA's review of Unusual Incident Report submitted by administrator to Community Care Licensing (CCL) revealed R1 had a change in condition and now requires assistance with incontinent care. LPM observed one (1) staff on duty in the designated memory care unit which houses twenty-five (25) residents, of which fifteen (15) have cognitive impairment according to the administrator. Staff #1(S1) had to call another staff not already in the memory care unit for assistance. LPM interview with S1 revealed S1 is a med-tech and a caregiver. At the time of the interview S1 was working in the capacity of a med-tech and not as a caregiver. In addition, LPM observed resident #2 (R2) in room #109 calling out for assistance requesting assistance with incontinent care. LPA's review of Unusual Incident Report submitted by administrator revealed R2 had a change in condition and now requires assistance with incontinent care. LPA Rios interview with administrator Jessica at approximately 11:50 a.m. revealed staff are expected to log the times they assist residents with bathing. According to Jessica residents that require assistance with bathing, are bathed twice a week. According to Jessica, staff have been known to not document consistently when they assist residents with hygiene. The facility uses an electronic database Caring Data to log hygiene assistance provided to residents. Based on observation, record review and interviews conducted, the above allegation is found to be SUBSTANTIATED at this time. Deficiencies cited (refer to 9099-D). Exit interview was conducted with administrator. A copy of the report and appeal rights provided.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87307(a)(3)(C)Type A

    (a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: based on LPAs obervation the facility failed to provide hygine items to residents.

  • 87309(a)Type A

    Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by:

  • 87705(k)(2)Type A

    87705(k)(2)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of delayed egress devices. This requirement has not been met as evidence by LPA's observation. Facility failed to notify CCLD and provide a complete LIC 200 form within the appropriate time frame

  • 87411(a)Type A

    Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) and (R2) who required incontinant care and S1 was the only staff observed in the memory care unit to provide assistance which poses an immediate safety risk to this resident in care.

  • 87705(f)(2)Type A

    87705(f)(2) Care of persons with Dementia Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observation chemicals used for cleaning where left unattended in a hallway in the designated memory care unit accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 27, 2023 inspection of LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY?

This was a complaint inspection of LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY on October 27, 2023. 1 citation were issued: 1 Type A (serious).

Were any citations issued to LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY on October 27, 2023?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall appl..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.