Deficiency Records for Ledgewood Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Ledgewood Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-15 | 2023-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-15 | 2023-07-28 | 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 | 2023-06-15 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-07-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-15 | 2023-07-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-05 | 2022-06-17 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-05 | 2022-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-05 | 2022-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-05 | 2022-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-05 | 2022-06-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-05 | 2022-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-05 | 2022-06-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-09 | 2022-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-06 | 2019-10-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-11 | 2019-08-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-07-11 | 2019-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-11 | 2019-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-12 | 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 | 2019-07-11 | 2019-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-11 | 2019-08-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-07-11 | 2019-08-12 | 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 | 2019-07-11 | 2019-08-12 | N |
