Leisure Village Health Care Center

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 2 (#4 and #9) of 4 sampled residents reviewed for change in condition.The DON reported the census in the facility was 80.

Findings: A facility policy titled Notification of Change in Condition, revised 02/06/25, read in part, The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in resident's condition, per standards of practice and federal and/or state regulations.1. An admission record, dated 10/23/20, showed Res #4 had diagnoses which included congestive heart failure and obstructive sleep apnea.A nurse note, dated 12/05/24, showed Res #4 had complained of nausea and the physician had been notified and ordered Zofran 4mg (a medication used to prevent nausea) every four hours as needed.

The note did not show the resident's representative had been notified of the new medication.A nurse note, dated 01/21/25, showed Res #4 had an elevated A1C level (a test that measures average blood sugar levels).

The note showed the physician was notified and the physician ordered metformin 500mg (an antihyperglycemic medication) twice a day by mouth for a new diagnosis of type II diabetes mellitus.

The note did not show the resident's representative had been notified of the abnormal laboratory value, the new medication, or the new diagnosis.An annual assessment, dated 06/18/25, showed Res #4 had a brief interview for mental status score of 15 which was indicative of intact cognition.On 09/09/25 at 11:30 a.m., Res #4's representative stated they had been contacted by the facility once since admission on [DATE].2.

An admission record dated 02/28/25, showed Res #9 had diagnoses which included diabetes mellitus and muscle weakness.A nurse note, dated 05/02/25, showed Res #9 fell from the bed onto a fall mat.

The note showed the physician, the DON and Res #9's family member were notified.On 09/09/25 at 10:55 a.m., Res #9's family member stated the facility did not notify them of the fall that occurred on 05/02/25.On 09/09/25 at 11:40 a.m., LPN #1 stated that resident representatives should be notified of any significant change to a resident's condition. LPN #1 stated if the resident was cognitively intact, they did not always have to notify family. On 09/09/25 at 11:45 a.m., LPN #2 stated representatives should be notified whenever a resident was sent to the hospital, had a medication change, or any other significant event.On 09/09/25 at 11:55 a.m., the DON stated representatives should be notified of significant changes, but it was not always necessary to notify the representatives of cognitively intact residents unless the representative requested to be notified.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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