Ledgewood Manor

Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive for 2 of 5 residents (Residents #24, #38), and failed to ensure a physician's order included the resident's preference for resuscitation (Resident #17). Findings: 1. Resident #24 was admitted in August of 2023. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #38 was admitted in September of 2024. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 3. Resident # 17 was admitted in December of 2024. A review of the electronic medical record revealed that provider orders did not designate the resident's preferred…

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 review, the facility failed to complete a baseline care plan, as required, within 48 hours of admission to the facility for 5 of 16 residents sampled. (Resident #38, Resident #39, Resident #242, Resident #243 and Resident #244). Finding: Resident #38 was admitted to the facility in mid September of 2024. The care plan for Resident #38, located in the Electronic Medical Record (EMR), was initiated on 10/2/24. Resident #39 was admitted to the facility in early December of 2024. The care plan for Resident #39, located in the EMR, was initiated on 12/11/24. Resident #243 was admitted to the facility in mid February of 2025. The care plan for Resident #243 located in the EMR, was initiated on 2/20/25. Resident #242 was admitted to the facility in mid February of 2025. The care plan for Resident #242, located in the EMR, was initiated on 2/24/25. Resident #244 was admitted to the facility in mid February of 2025. On 2/25/25 a surveyor was unable to locate a care plan in the EMR for Resident #244. On 2/25/25 at 12:50 p.m. a surveyor met with the charge nurse…

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, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals and over-the-counter medications for 1 of 3 survey days. (2/24/25) Findings: On 2/24/25 at 9:08 a.m. a surveyor observed a storage room door propped open, cupboards in the room were unlocked and contained the facility's of supply of over-the-counter medications. The administrator was immediately made aware. On 2/24/25 at 9:14 a.m. a surveyor observed a whirlpool #1 room with a door propped open that had a closet door inside with a key in the door. The closet contained a supply of G2-2100 bottles used for surface cleaning and Simoniz hospital disinfecting deodorant. CNA #1 was immediately made aware. On 2/25/25 at 10:00 a.m. a surveyor observed Whirlpool #2 room with a door propped open and found a bottle of G2-2100 on a shelf unsecured next to the sink. A closet door inside Whirlpool #2 was observed with a key in the lock. The closet contained a supply of G2-2100 and Simoniz…

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 facility policy and clinical record reviews, observations and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed. Findings: A review of the facility's policy, Controlled Drug Policy and Procedure, dated 10/4/24, stated Controlled drugs, as determined by the facility, are counted every shift by the nurse/med tech reporting on duty with the nurse/med tech reporting off-duty. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count. On 2/24/25 at 11:45 a.m., a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications coming…

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, interviews and record review, the facility failed to ensure the facility was maintained in a clean and sanitary manner for the kitchen counter, fans, ceiling vents and floors. In addition, the facility failed to ensure the kitchen ice machine and food preparation sink were plumbed in accordance with code requirements to prevent food contamination. Further, the facility lacked evidence that the sanitizing bucket and sanitizing sink solutions, dishwashing temperatures were documented and within the appropriate range for 3 of 3 days of survey. Findings: Initial Kitchen Tour: 1. On 2/24/25 from 9:23 a.m. to 9:45 a.m. a surveyor completed a tour of the kitchen with the Food Service Director [FSD] in which the following findings were observed: -The countertop near the food preperation sink had several gauged areas on the surface creating an uncleanable surface. -Two floor fans in the dish room had chipped paint on the front grille and base of fan. -The ceiling vent in the dishwashing room had dust/debris. -The floor in the dishwashing room was soiled and had missing…

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 develop a comprehensive care plan that addressed the use of psychotropic drug use and nutrition for 1 of 5 residents reviewed for unnecessary medications. (#21). Finding: Resident #21's February 2025 Medication Administration Record (MAR) indicated that the resident had received the antidepressants Fluoxetine 40 milligrams (mg) once daily since 10/8/24 and Trazodone 100 mg once daily at bedtime since 5/8/24. Resident #21's Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE], under Care Area Assessment Summary, noted Resident #21 would be care planned for Psychotropic Drug use and Nutrition. As of 2/26/25, Resident #21's medical record lacked evidence of a comprehensive care plan in the area of psychotropic drug use and Nutrition. The surveyor confirmed this lack of care plan for psychotropic drug use and in the care area of nutrition in an interview with the Director of Nursing, on 2/26/25 at 11:15 a.m.

Based on observation, interview, clinical record and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 2 residents (Resident's #24). Finding: On 2/24/25 at 11:18 a.m., a surveyor observed a nebulizer machine on a stand next to Resident #24's bed. The face mask and attached tubing was noted to be dated 10/27, and was placed exposed on a shelf of the stand. On 2/24/25 at 11:28 a.m., a surveyor asked the treatment nurse how staff care for nebulizer equipment. The nurse stated tubing is changed weekly and other items are washed every night. The nurse stated I don't have anyone with a nebulizer right now. At this time, the surveyor showed the nurse Resident #24's nebulizer machine and face mask with tubing dated 10/27. The nurse stated he/she did not know why that was there and should have been removed as there is no order for a nebulizer. The nurse then removed the equipment. A review of Resident #24's provider orders noted an active order, dated 10/22/24,…

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 review and interviews, the facility failed to ensure that an alleged violation of resident sexual abuse was reported to the State Agency within 24 hours when an incident occurred for 1 of 6 residents reviewed for neglect/abuse (#1). Findings: A review of the facility's Resident Rights Policy Revised on 9/06, on page 2, #4. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility administrator. Or his/her designee, will notify the following persons or agencies of such incident. A. The State Licensing/certification agency responsible for surveying/licensing the facility; and on page 7, Reporting Abuse to State Agencies and Other Entities/Individuals Policy, revised on 9/13/06, page 7, under #1. A. Should an alleged/suspected violation or substantiated incident of neglect, injury of unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator, or his/her designee, will promptly notify the following person or agencies (verbally and written) of such incident: 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 record review and interview, the facility failed to establish a facility wide Infection Prevention and Control Program (IPCP) which included standards, policies and procedures that are current, based on national standards and reviewed annually for COVID-19. This has the potential to affect all residents. Finding: From 6/12/22 through 6/14/22, the annual Long-Term Care Survey Process was completed. The facility was found to be in noncompliance with F880, F882, F883, F886, and F887. The facility failed to develop written policies and procedures for an Infection Prevention and Control Program, resulting in failure to designate a qualified staff to serve as the Infection Preventionist, failure to screen and determine eligibility for resident vaccinations, and failed to implement routine COVID-19 testing of staff and residents. On 6/12/22, a surveyor requested the Director of Nursing (DON) provide copies of the facility's infection control policies and procedures, including Covid-19, testing, and…

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 designate a qualified staff member to function as the Infection Preventionist, who is responsible for the facility's Infection Control Program. This has the potential to affect all residents in the facility. Finding: On 6/13/22 at 2:30 PM, in an interview with the Director of Nursing (DON), and the Resident Coordinator, the surveyor asked who was designated as the facility's Infection Preventionist (IP). The DON stated the previous Infection Preventionist had not worked at the facility from October 2021 through March 2022. The DON stated the facility did not have a copy of the staff's infection preventionist certificate or evidence of training. The DON stated that she and the Resident Coordinator (a Certified Nursing Assistant - Medications), were presently taking the courses, but had not completed the program. The DON and Resident Coordinator confirmed the facility did not have a designated staff person who had completed specialized training in infection prevention and control.

Based on record review and interview, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines and the Center for Medicare and Medicaid Services (CMS) August 26, 2020, revised 3/10/22, Quality, Survey and Certification Group (QSO)-20-38-Nursing Home (NH) for testing of staff who are not up to date with COVID-19 vaccination. This has the potential to affect all residents at the facility (31 residents). Findings: A review of the CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities, updated 2/2/22, stated In nursing homes, Health Care Personnel (HCP) who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes in counties with substantial to high community transmission, these HCP should have a viral test twice a week. A review of the CDC website, covid.cdc.gov/covid-data-tracker, noted on 6/13/22 the county in which the facility 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 interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 3 of 17 residents whose care plans were reviewed (#11, #24, #26) Findings: 1. On 6/12/22 at 10:43 a.m., during an interview, Resident #11 stated he/she hasn't had an IDT meeting in the past several months and I was supposed to have it in Jan, that didn't happen. On review of Resident #11's clinical record, the surveyor noted an MDS Annual assessment dated [DATE]. The clinical record lacked evidence of an IDT which included the resident, and resident's representative after the 9/29/21 assessment. In addition, the MDS Quarterly assessment dated [DATE], had and IDT meeting on 2/14/22, 31 days late. 2. On review of Resident #24's clinical record, the surveyor noted a MDS Quarterly assessment dated [DATE]. The clinical record lacked evidence of 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, interview, and policy review, the facility failed to ensure that food was stored, prepared and served in a sanitary manner for 2 of 3 days of survey. Findings The facilities policies: Hood/Filters, revised 10/2010 states, All hoods/filters shall be free of soil build up. and Note: Filters shall be cleaned at least weekly. Hood shall be cleaned at least monthly. Freezer, Walk-in, revised 10/2010 states, All freezers shall be cleaned and sanitized at least once a month and as needed. Procedure #9 wash gaskets, use a brush if needed, and replace when necessary and Note: check all gasket thoroughly, check thermometer. Refrigerator, Reach-in revised 10/2010 states, All refrigerators shall be cleaned and sanitized at least once a month and as needed. #7 Scrub inside and outside, give special attention to: hinges and door frames, gaskets - may need to use a small toothbrush. Refrigerator, Walk-In revised 10/2010 states, All refrigerators shall be cleaned and sanitized at least once a month and as needed. #5 Wash inside and outside surfaces, including the door and…

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 Facility Assessment review, in-service review, and interview, the facility failed to monitor and ensure Certified Nursing Assistants (CNA) attended the required annual in-service education which included abuse and Dementia in-services for 5 of 5 randomly selected CNA's employed greater than 1 year (#1, #2, #3, #4 & #5). Findings: Review of Page 2 of the Facility Assessment provided at survey, under Resident Profile, Part 1 Diseases/Conditions and cognitive disabilities, under the category Neurological Symptoms, revealed one of the common diagnoses is Non-Alzheimer's Dementia. On 06/13/22, a surveyor requested 5 randomly sampled Certified Nursing Assistants (CNA) annual training records from the Director of Nursing (DON). 1. CNA #1 was hired on 8/27/07. Documentation provided by the facility indicated CNA #1 attended 1.5 hours Dementia training from the facility between 2021 to 2/15/22. There was no record that Dementia training had been completed or Abuse training having been attended by CNA #1. 2. CNA #2 was hired on 8/23/17. Documentation provided by the facility…

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 provide maintenance services necessary to maintain the building in good repair and in a sanitary condition for 4 of 17 residents sampled (#17, #18, #26, #29) for 2 of 2 environmental tours. Findings: On 6/12/22 at 10:08 a.m., during the initial tour of the facility, a surveyor observed the following: 1. Resident #17's Broda chair had bilateral arm rests and footrest that were ripped/torn. The wall behind the residents bed had a circular area approximately 1.5' of marred wall with exposed sheetrock and above the headboard was another large area of marred wall with sheet rock exposed. On 6/13/22 at 11:20 a.m., during an interview with Resident #17's representative, he/she stated the marred wall has been like that quite a while. 2. Resident #18's Broda chair had bilateral arm rest that were ripped/torn the entire length of arm rests. 3. Resident #26's wheelchairs right arm rest was ripped with the plastic coating peeled off. 4. Resident #29's Broda chair had bilateral arm rests and footrest that were ripped/torn. On 6/12/22…

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 reviews, the facility failed to coordinate assessments for Pre-admission Screening and Resident Review (PASRR) Level I and Level II program for 1 of 4 records reviewed. (#12) Findings: Resident #12 was admitted to the facility on [DATE]. Resident #12's medical record indicated that he/she has a diagnosis of Down Syndrome. The medical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. On 6/13/22 at 12:50 p.m., in an interview with the surveyor the Director of Nursing he/she confirmed that there was no referral made for PASRR Level I and Level II.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to screen and determine eligibility for immunizations for 1 of 9 residents reviewed for pneumococcal and influenza vaccinations (#13). Finding: A review of the facility's Immunization Policy, with an adopted date of 1/12/08, stated The influenza and pneumonia vaccine will be offered to residents during all months recommended by the Center for Disease Control, which is usually October 1st through March 31st of each year. The dosage will be given per the physician's order. The pneumonia vaccination history of each resident will be reviewed on admission in the event that it is not current a vaccination will be offered and administered per CDC recommendations and doctor's orders. All residents will be screened on admission for pneumococcal/influenza immunization. If the status of the resident is unknown or never given the vaccine, the resident will be offered immunization. A review of Resident #13's clinical record indicated he/she was admitted on [DATE]. 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 record review and interview, the facility failed to screen and determine eligibility for immunizations for 1 of 9 residents reviewed for COVID-19 vaccinations (#13). Finding: During a review of the facility's list of residents who had refused vaccination for COVID-19, the surveyor noted Resident #13's immunization status was listed as unknown for COVID-19. A review of Resident #13's record indicated he/she was admitted on [DATE]. On 6/13/22 at approximately 3:30 pm, the Resident Coordinator stated Resident #13's immunization status had been requested by the physician several times and not yet received. The Resident Coordinator confirmed that Resident #13's record did not contain evidence of attempts made to request information from the physician, and that Resident #13 had not been screened yet for eligibility of vaccinations. On 6/14/22 at 11:10 am, in a discussion with the Administrator, Director of Nursing, and the Resident Coordinator, it was confirmed the facility did not have current policies and…

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.