Ledgewood Rehabilitation and Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]