Ledgecrest Health Care Center

In the surveyor’s words

From the most serious findings on record at Ledgecrest Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Jun 8, 2022

  Based on review of the facility Infection Control program, review of facility documentation, review of facility policy and interviews, the facility failed to designate one or more individual(s) as the Infection Preventionist (IP) on a full time basis. The findings include: Interview with the interim DNS on 6/7/22 at 10:30 AM identified the previous IP (RN #4) took the position of DNS on 1/16/22 until 4/10/22, when she then went out on a medical leave of absence. RN #4 had not returned to the role of DNS as of currently, but the Interim DNS (Corporate Nurse) identified she was returning by next week. Additionally, the Interim DNS identified the facility had not had an official IP RN since RN #4 left the role as an Infection Control RN in January 2022. […]

• No harm, potential for more than minimal, patternF655Apr 20, 2026

  Based on review of the clinical record, facility documentation, and facility policy for 3 of 4 sampled residents (Resident #3, #15, #33) reviewed for the facility Water Management Plan, the facility failed to ensure a comprehensive Resident Care Plan that included a potential exposure to Legionella (a bacteria that causes Legionnaires Disease) and for the only sampled resident (Resident #47) reviewed for communication, the facility failed to develop a baseline Resident Care Plan identifying the need for a translator. […]

• No harm, potential for more than minimal, patternF657Jun 8, 2022

  Based on observation, review of the clinical record, facility documentation, and interviews for 1 of 2 residents (Resident #17) reviewed for pressure ulcers, the facility failed to revise the care plan to meet the needs of the resident. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 10/22/21 indicated Resident #17 required staff assistance with activities of daily living. […]

• No harm, potential for more than minimal, patternF660Jun 8, 2022

  Based on review of the clinical record, facility documentation, facility policy and interviews for one of 3 residents (Resident #44) reviewed for discharge, the facility failed to develop and implement a comprehensive plan of care with interventions to address the resident's discharge needs and failed to ensure application to community housing was completed in a complete and accurate manner. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS assessment dated [DATE] identified Resident #44 was cognitively intact and independent for most activities of daily living. a. […]

• No harm, potential for more than minimal, isolatedF689Aug 27, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for wandering behaviors and elopement risk, the facility failed to adequately identify, assess, care plan, implement necessary interventions, and provide effective supervision and functional safety systems to prevent elopement for a resident with known cognitive impairment, wandering behaviors and fall risk. These failures resulted in Resident #1 eloping from the facility unsupervised and unrecognized by staff. […]