Ledgewood Rehabilitation And Nursing Center

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose comprehensive plan of care indicated interventions included that he/she required two staff member assistance with use of the Hoyer lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her comprehensive plan of care, when staff transferred him/her without the assistance of another staff member.Findings include:The Facility Policy, titled Comprehensive Person-Centered Care Plan, dated as reviewed 09/2024, indicated the comprehensive, person-centered care plan would describe the services that would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being.The Facility Policy, titled Mechanical Lift, dated as reviewed 09/2024, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.A Hoyer Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is…

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 records reviewed and interviews, the Facility failed to ensure that Certified Nurse Aide (CNA) #1 had completed competency training prior to use of the Hoyer Lift for resident transfers.Findings include:The Facility Policy, titled Mechanical Lift, dated as reviewed 09/2024, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift, and staff must be trained in and demonstrate competency in the use of lift devices.A Hoyer Lift is a device that allows caregivers to safely transfer an individual between a bed, wheelchair, shower chair, or another surface. A sling lift is comprised of a base on casters, a boom, and a cradle that supports the sling.Review of The US Department of Labor Wage and Hour Division Fact Sheet #52, Hazardous Order No. 7 prohibits minors under 18 from operating or assisting in the operation of power-driven hoists, including those designed to lift and move patients. The Wage and Hour Division has, however, adopted an enforcement position…

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 and interviews, for one of three sampled residents (Resident #1), who was totally dependent on staff for his/her Activities of Daily Living (ADL) care needs, the Facility failed to ensure staff consistently provided necessary services to meet his/her ADL care needs, when on 5/16/25 Resident #1's request to nursing for care during the evening shift were not met and he/she was not provide care until the next morning. Findings include: Review of the Facility's Care and Treatment for ADL Care Policy, dated September 2024, indicated ADLs are provided in accordance with resident preference and needs. The Policy indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, oral care), mobility, and toileting. Review of Resident #1's clinical record indicated diagnoses included morbid obesity, Type 2 Diabetes with Polyneuropathy, and Acquired…

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 properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: The surveyor made the following observations during the initial kitchen walkthrough on 7/30/24 at 7:10 A.M.: - In the walk-in refrigerator, a container of unlabeled, undated sliced meat. - In the walk-in refrigerator, a container labeled as mushrooms with a use by date of 7/29 written on it. The container was partially open. - In the walk-in refrigerator, an opened bottle of Gatorade belonging to a staff member was stored with resident food. - In the walk-in freezer, numerous boxes containing resident food were stored directly on the ground. During the revisit walk-through of the kitchen on 7/31/24 at 11:27 A.M., the surveyor observed the following: - In the walk-in refrigerator, an opened bottle of Gatorade (a different bottle than the day prior) belonging to a staff member was stored with resident food. - In the reach-in refrigerator, an opened bottle of water with 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 interview, record review and observation, the facility failed to develop individualized, person-centered care plans for two Residents (#1, #104) out of a total sample of 25 residents. Specifically: 1. For Resident #1, the facility failed to develop an individualized, person-centered care plan related to dementia. 2. For Resident #104, the facility failed to develop an individualized person-centered care plan related to nutritional care. Findings include: Review of the facility policy titled Care Plan, revised and dated September 2023, indicated the following: - Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. - A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 1. Resident #1 was admitted to the facility in December 2018 with diagnoses including unspecified dementia with agitation and adult failure to thrive. Review of Resident…

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, record review and interview, the facility failed to ensure staff followed physicians' orders for two Residents (#47 and #23) out of a total of 25 sampled residents. Specifically: 1. For Resident #47, the facility failed to document the external length of a peripherally inserted central catheter (PICC) line (a long thin tube that's inserted into a vein in the arm and passed through to the larger veins near the heart) and failed to document the urine output of his/her Foley catheter, as ordered by the physician. 2. For Resident #23, the facility failed to document the output from his/her negative pressure wound therapy (NWPT; also called a wound vac, is a suction pump and tubing used to remove excess exudate and promote healing in acute or chronic wounds), as ordered by the physician. Findings include: 1. Resident #47 was admitted to the facility in July 2024 with diagnoses including bacteremia, chronic obstructive pulmonary disease, and urinary retention. Review of the Minimum Data Set…

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, policy review and interview, the facility failed to ensure nursing staff followed infection control practices during the administration of intravenous (IV) medication for one Resident (#47) out of a total of 25 sampled residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy dated 7/1/24 indicated: Purpose: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: central line; urinary catheter, feeding tube, tracheostomy/ventilator. Resident #47 was admitted to the facility in July 2024 with diagnoses including bacteremia, chronic obstructive…

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 and interview, the facility failed to provide a dignified dining experience for the residents on the Fields Unit. The following was observed during the breakfast meal on 6/14/23: *At 8:21 A.M., 8:26 A.M. and 8:52 A.M., staff members were referring to residents who require assistance with meals as feeds in the unit hallway where residents were able to hear them. *At 8:31 A.M., a staff member was observed standing over a resident, not at eye level while feeding the resident while he/she was sitting up in bed. *At 8:52 A.M., a resident was observed with his/her tray open and untouched in front of him/her while he/she was sleeping in bed. Thirty-seven minutes later, a staff member was observed standing over the resident, not at eye level while feeding the resident, while he/she was sitting up in bed. On 6/15/23 at 12:11 P.M., a staff member was observed standing over a resident, not at eye level while feeding the resident while he/she was sitting up in bed. During an interview on 6/15/23 at 12:52 P.M., the Director of Nursing said staff should be assisting residents…

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, record review, interview and facility policy review, the facility failed to complete a restraint assessment for one Resident (#66) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Restraints reviewed and dated September 2022 indicated the following: *Prior to initiating a restraint, the interdisciplinary team must determine that alternatives to restraints have been tried and determined not to have been effective. The team will assess the resident for the least restrictive device/method. Re-assessments will be done at least quarterly. Resident #66 was admitted to the facility in November 2022 with diagnoses that include vascular dementia, anxiety disorder, history of falling and insomnia. Review of Resident #66's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further 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 observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with showers, for three Residents (#7, #29, and #57) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, reviewed and dated September 2022, indicated the following: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: Hygiene (bathing, dressing, grooming, and oral care). 1. Resident #7 was admitted to the facility in February 2022 with diagnoses that include hypertensive heart and chronic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an air mattress was at the correct setting to help prevent the development of pressure ulcers for one Resident (#66) out of a total sample of 25 residents. Findings include: Resident #66 was admitted to the facility in November 2022 with diagnoses that include vascular dementia, anxiety disorder and insomnia. Review of Resident #66's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 11 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the Resident's MDS indicated that he/she requires extensive assistance with activities of daily living and is at risk for developing pressure ulcers. During an observation on 6/13/23 at 10:53 A.M., Resident #66 was observed sleeping in bed with his/her air mattress set to 150 pounds. During an observation on 6/15/23 at 6:58 A.M., Resident #66 was observed sleeping in bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to identify and address a significant weight loss for 1 Resident (#46) out of a total of 25 sampled residents. Findings include: Review of the facility policy revised September 2022, titled Weight Assessment and Intervention, indicated the following: *Any change in weight 5 pounds or more over 1 month will be re-taken for confirmation. If the weight is verified, nursing will notify the dietitian. *The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (past weight - actual weight)/(past weight) x 100. - a. 1 month - 5% weight loss is significant; greater than 5% is severe 3 month - 7.5% weight loss is significant; greater than 7.5% is severe 6 months - 10% weight loss is significant; greater than 10% is severe *if the weight change is desirable or expected, this will be documented and no change in the care plan will be necessary. Resident #46 was admitted to 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 observations, policy review and interviews the facility failed to ensure expired medications were unavailable for administration, medications once opened were dated according to manufacturer's guidelines and medications were stored separately from food on 1 out of 2 observed medication rooms and 3 out of 4 observed medication carts. Review of the facility policy titled, Storage of Medications revision date April 2007 included the following: - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. - Medications requiring refrigeration must be stored and monitored in a refrigerator located in the drug room at the nurse's station or other secured location. Medication must be stored separately from food and must be labeled accordingly. On 6/15/23 at 8:36 A.M., [NAME] Farms Medication Cart 2 the surveyor observed the following: -Two bottles…

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, and interview the facility failed to maintain proper sanitation practices related to food labeling and storage in the kitchen. Review of the facility policy, revised September 2022, titled Food Storage and Preparation, indicated the following: *All foods will be shelved and rotated using the older foods first and based on the use-by or expiration dates. *All food items will be wrapped properly and tightly, or stored in clean, covered containers clearly marked, including the preparation date and discard date. *All temperature control for safety foods (TCS), ready-to-eat foods (RTE) or leftover foods will be labeled and dated with the date the food was prepared and the discard date. *All ready to eat salads (ex. Tuna salad, seafood salad etc.) or leftovers will be discarded within 5 Calendar days from the preparation date including day 1. During the initial kitchen walk-through on 6/13/23, at 7:05 A.M., the following observations were made: *A container of mandarin slices in the reach-in refrigerator, labeled as prepared on 5/7 and use by 5/9 *A cut tomato in 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.