A list of the most recent deficiencies for Ledgewood Manor. 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? |
|---|---|---|---|---|
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-13 | 2022-08-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-13 | 2022-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-13 | 2022-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-13 | 2022-08-02 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-06-14 | 2022-06-29 | 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 | 2022-06-14 | 2022-06-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-14 | 2022-06-29 | 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 | 2022-06-14 | 2022-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-14 | 2022-06-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-14 | 2022-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-06-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-14 | 2022-06-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-14 | 2022-06-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-14 | 2022-06-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-14 | 2022-06-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-06-14 | 2022-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-29 | 2020-01-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-29 | 2020-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-29 | 2020-01-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Provide large enough exits. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-29 | 2020-01-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-31 | 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 | 2019-10-31 | 2019-12-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-31 | 2019-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-31 | 2019-12-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-31 | 2019-12-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-31 | 2019-12-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-10-31 | 2019-12-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-31 | 2019-12-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-13 | 2018-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-12 | 2018-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-12 | 2018-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-09-12 | 2018-09-28 | N |
