A list of the most recent deficiencies for Ledgecrest Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-15 | 2023-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-15 | 2023-10-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-10 | 2022-11-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-07 | 2022-09-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-07 | 2022-09-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-11 | 2022-08-22 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-08 | 2022-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-08 | 2022-07-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-08 | 2022-07-20 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-08 | 2022-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-08 | 2022-07-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-08 | 2022-07-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-06-08 | 2022-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-08 | 2022-07-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-08 | 2022-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-06 | 2022-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-06 | 2022-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-14 | 2021-10-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-26 | 2019-11-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-26 | 2019-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-11-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-26 | 2019-11-07 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-26 | 2019-11-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Develop a communication plan. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-04 | 2018-11-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-09-07 | 2018-10-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-09-07 | 2018-10-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-07 | 2018-10-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-07 | 2018-10-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-07 | 2018-10-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-09-07 | 2018-10-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-07 | 2018-10-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-07 | 2018-09-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-07 | 2018-09-30 | N |
