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Deficiency Records for Ledgewood Manor
View the most recent health deficiencies and inspection results for Ledgewood Manor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Ledgewood Manor. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-04-29 | 2025-04-24 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-26 | 2025-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-02-26 | 2025-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-02-26 | 2025-04-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-02-26 | 2025-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-26 | 2025-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-02-26 | 2025-04-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-02-26 | 2025-04-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2025-02-26 | 2025-04-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2025-02-26 | 2025-04-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-02-26 | 2025-04-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2025-02-26 | 2025-04-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-02-26 | 2025-03-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-26 | 2025-03-19 | 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 | 2025-02-26 | 2025-03-12 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2025-02-26 | 2025-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-02-26 | 2025-03-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2025-02-26 | 2025-03-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-02-26 | 2025-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-02-26 | 2025-03-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-02-26 | 2025-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-26 | 2025-02-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-08 | 2024-11-08 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-14 | 2022-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-08-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-14 | 2022-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-14 | 2022-08-02 | 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 |
| 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 |
| 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 |
| PASARR screening for Mental disorders or Intellectual Disabilities | 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 |
| Honor the resident's right to manage his or her financial affairs. | 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 | 2019-10-31 | 2020-01-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-31 | 2020-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-31 | 2020-01-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Provide large enough exits. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-31 | 2020-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-31 | 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 (including nights and weekends) 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 |