Every finding on record at Ledgewood Manor

Based on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 1 2026 (October 1, 2025 - December 31, 2025). This has the potential to affect all residents (47 Residents).Findings: Review of the facility's payroll based journal report, titled PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) 1705D FY (Fiscal Year) Quarter 1, 2026 (October 1 - December 31) stated that the facility Failed to Submit Data for the Quarter was triggered. Triggered' was defined as no data submitted for quarter. A facility document titled Daily Census, printed 5/26/26, documented there were 47 residents living in the facility. On 5/26/26 at 9:30 a.m., in an interview with a surveyor, the Administrator stated there were 47 residents living in the facility. The Administrator revealed that the facility had not submitted the PBJ data for the 1st quarter (10/1/25 - 12/31/25) due to staff's inability to log in to the CMS website. The most recent quarter had been submitted. On 5/27/26 at 1:00 p.m., in an interview with a surveyor, the Human Resources/Nursing Scheduler and MDS Support staff, stated at the time of submission, she had difficulty with accessing the CMS website. She contacted the CMS IT (information technology) site and was given a ticket number. The staff stated the period to submit information is up to 45 days after the end of the quarter (2/14/26). She had not tried to submit the data earlier during this time and waited until the last day it was due, then was unable to gain access. The staff stated she did not have a copy of any communications with the CMS IT department or other information addressing her efforts to submit the data when it was due.

Based on observation and interview, the facility failed to adequately provide maintenance and housekeeping services necessary to maintain the physical environment in good repair and in a clean, sanitary condition. This was evidenced by the widespread use of heavy adhesive tape (duct tape) to patch and repair damaged floors, sinks, and handrails across multiple resident rooms and common areas, creating un-cleanable surfaces. In addition, the facility failed to maintain floors and ceiling tiles in good structural repair, and failed to clean patient care equipment. An environmental tour conducted by two (2) surveyors on May 28, 2026, starting at 9:37 AM, revealed the following environmental deficiencies throughout the facility: Surveyors observed widespread use of heavy adhesive tape used as a permanent repair method and as a room-dividing barrier, creating sticky, frayed, and un-cleanable surfaces in the following locations: 1. Tape was observed on the floors or room entries of Rooms 101, 102, 104, 105, 106, 109, 111, 112, 113, 114, 115, 116, 119, 121, and 129.- Tape was affixed to the floor at the entry to Wing 2, the area between rooms [ROOM NUMBERS], the floor outside room [ROOM NUMBER], and the entry area/floor around the Nurses' Station, including the Nurses' Station restroom entryway.- The floor at the end of the corridor outside room [ROOM NUMBER] had two white X marks made of tape that was heavily soiled and fraying upward.- Tape was used to repair the end caps and surfaces of handrails outside Rooms 103, 105, 109, and 113.- room [ROOM NUMBER]'s bathroom and bedroom floors contained tape, and tape was utilized on a broken sink fixture.- Dining Room-the rear door had tape affixed to the floor 2. The corridor floor outside rooms [ROOM NUMBERS] was chipped down to the bare, exposed concrete.- The hallway area outside rooms [ROOM NUMBERS] exhibited large areas of entirely missing flooring.- The rear door in the Dining Room had chipped paint.- Two (2) water-stained, wet ceiling times were sagging outside of the Laundry area. 3. Whirlpool Room-the shower area exhibited accumulated black grout and a heavily soiled floor surface.- A sit-to-stand mechanical lift parked in the corridor outside room [ROOM NUMBER] was covered in visible dirt and debris. On May 29, 2026, the entire list of the environmental findings was compiled and emailed directly to the Administrator at his request.

Based on interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to present evidence that the required members attended 3 of 5 quarterly committee meetings provided from April 2025 through April 2026. Finding: On 5/28/26, a surveyor reviewed the facility's QAPI program and attendance sheets for the previous year. The attendance sheets lacked evidence that the facility's Medical Director attended quarterly committee meetings held on 10/15/25, 1/14/26, and 4/9/26. On 5/28/26 at 1:45 p.m., in an interview with a surveyor, the Administrator and Director of Nursing confirmed the finding and stated that future meetings have been rescheduled to allow for the Medical Director's attendance. Review of the facility's Nursing Quality Assurance & Performance Improvement Policy and Procedure, with an effective date of 3/10/26, stated Policy 9.1: QAPI Program Structure and Oversight . QAPI Committee Structure, 1. The facility shall maintain a QAPI Committee chaired by the Administrator or designee. 2. Membership shall include, at a minimum: Administrator, Director of Nursing, Medical Director (as applicable), Infection Preventionist, Department Leadership (e.g., dietary, therapy, environmental services.

Based on observations, interviews, record reviews, and policy review, the facility failed to develop and implement an Infection Control Program designed to prevent the transmission of infection related to linen handling for 1 of 3 days of survey, and Enhanced Barrier Precautions (EBP) for 5 of 8 residents reviewed for indwelling foley catheters (R2, R8, R17, R44, and R45).Findings: 1. On 5/26/26 at 10:55 a.m. a surveyor observed a rack in the hallway with clothing items hanging on it and not covered. On 5/26/26 at 10:56 in an interview with a surveyor, the Director of Housekeeping and Laundry confirmed that the rack had clean, unidentified items on it for staff and residents to identify any items that might be a resident's missing clothing item, confirming it was not covered, and that they would cover it. 2. On 5/27/26 at 12:18, two surveyors interviewed the Director of Nursing (DON) expressing concerns with no EBP signage for residents with catheters. The DON stated that the Infection Preventionist (IP) and herself had looked into EBP stating, this is a newer thing, we have been doing a lot of research and consulted with the medical director. The DON stated the medical director had told them to continue doing what they were doing and only do EBP with active infections. The DON stated that they had tried to educate staff, but they do not like change, and that they planned on doing an in-service for EBP in June. They also stated they had drafted a policy in February. The DON stated that the facility only had 5 cases of influenza when asked if there had been any widespread infections in the facility. On 5/28/26 at 11:00 a.m. a surveyor reviewed the facilities Infection and Prevention policy which was last reviewed 7/9/25 and did not include EBP policies or procedures. 3. On 5/26/26 at 9:55 a.m., a surveyor observed R17's catheter drainage bag sitting on the floor. Further observation shows no Personal Protective Equipment (PPE) or Enhanced Barrier Precaution (EBP) signage upon entering the R17's room. On 5/6/26 at 10:05 a.m., the above information was observed and confirmed with RN1 (Registered Nurse). 4. On 5/27/26 at 7:20 a.m., during an interview with CNA1 (Certified Nursing Assistant), who stated that when he/she provides catheter care to residents, he/she only wears gloves. 5. On 5/27/26 at 7:23 a.m., during an interview with CNA2, who stated that when he/she provides catheter care, he/she just wears gloves. 6. On 5/27/26 at 7:27 a.m., during an interview with CNA3, who stated that CNA's are the ones who typically provide catheter care. When asked what kind of PPE he/she wears when providing catheter care, CNA3 stated that he/she only wears gloves. However, he/she will wear a gown, goggles, and gloves when there is a precaution sign up or if the resident has anything in his/her urine. 7. On 5/27/26 at 7:30 a.m., during an interview with CNA-M1, who stated that when he/she provides catheter care, he/she will only wear gloves. However, if the resident is colonized with something, he/she will wear PPE as directed by signage. 8. On 5/27/26 at 7:52 a.m., during an interview with CNA4 regarding precaution types, he/she is unsure what EBP are. 9. On 5/27/26 at 7:54 a.m., during an interview with CNA3 regarding precaution types, he/she is unsure what EBP is and what it is used for. 10. On 5/27/26 at 8:00 a.m., during an interview with LPN1 regarding precautions, specifically EBP he/she stated, I have never heard of that. 11. On 5/27/26 at 8:05 a.m., in an interview with CNA6, who stated he/she has never heard of EBP before and has been a CNA for a long time. 12. On 5/27/26 at 8:08 a.m., during an interview with RN1, who stated he/she just heard about EBP yesterday from another surveyor but never knew about it before then. 13. On 5/26/26 at 10:36 a.m. during an interview with R45, it was observed that he/she had a catheter and stated that he/she has had it for about 6 months. When ask how the staff clean it, R45 stated that staff put on gloves and then clean it. Surveyor observation that there was no sign on the door for EBP, nor was there any PPE available outside of resident's room. 14. On 5/26/26 at 1:05p.m during an interview with R44, it was observed that he/she had a catheter. R44 stated he/she had just returned from the hospital. When asked about the catheter R44 stated that he/she had it prior to going to the hospital and that the staff take good care of it and clean it well. When asked what staff wear when they clean the catheter, R44 stated that staff wear gloves. Surveyor observation that there was no sign on the door for EBP nor was there any PPE available outside of resident's room. 15. On 5/26/2026 at approximately 11:00 a.m., in an interview with a surveyor, R2 confirmed he/she had an indwelling urinary catheter. The surveyor asked if staff wear any special precautions when providing care for the catheter, and R2 stated staff only use gloves, no gown or other PPE. On 5/26/26 at approximately 11:30 a.m., surveyor noted no signage outside of R2's room indicating the need for special precautions and no PPE station was present. 16. On 5/26/25 at 11:35 a.m., surveyor interviewed CNA4 and asked if R2 required any special precautions when receiving care. CNA4 stated not that he/she was aware of. Surveyor asked how CNA would know if the resident required special precautions, and CNA4 stated a sign would be posted outside the room and a PPE station would be set up. 17. On 5/26/2026 at 1:16 p.m., in an interview with a surveyor, R8 stated he/she has an indwelling urinary catheter and was being treated for a urinary tract infection. Surveyor asked what type of PPE staff use when providing catheter care. R8 stated staff only wear gloves. Surveyor noted no signage was posted outside of R8's room indicating the need for special precautions and no PPE station was present. A review of R8's clinical record noted a history of urinary tract infections with multidrug resistant organisms (MDRO's). A urine culture dated 2/27/26, noted an infection with E. Coli/ESBL (extended spectrum beta lactamase), an MDRO. Most recently, a hospital Discharge summary, dated [DATE], stated R8 was treated for polymicrobial UTI (urinary tract infection). A urine culture dated 4/26/26 resulted in E. Coli resistant to tetracycline (an antibiotic). On 5/28/26 at 10:30 a.m., a surveyor discussed the findings with the Director of Nursing.

Based on record reviews and interviews, the facility failed to develop and implement a resident's care plan in the area of Enhanced Barrier Precautions (EBP) for Multi-drug Resistant Organisms (MDRO's) for 1 of 8 residents reviewed with indwelling urinary catheters (R8).Findings: A review of the clinical record revealed Resident #8 was admitted in June, 2023, and had diagnoses which included neurogenic bladder and a history of urinary calculi (stones) and multi-drug resistant urinary tract infections. Resident #8 required an indwelling (Foley) catheter for urinary elimination. In February, 2026, a urine culture revealed ESBL (extended spectrum beta lactamase) - a drug resistant organism, for which R8 was treated. In April, 2026, R8 was hospitalized for urosepsis. The hospital Discharge summary, dated [DATE], noted R8 was admitted for polymicrobial urinary tract infection, with the organisms Proteus mirabilis, Citrobacter freundii, ESBL Escherichia coli requiring a 7-day course of intravenous antibiotics. Upon discharge, a urine culture obtained on 4/26/26, noted the presence of Enterococcus faecalis, resistant to tetracycline (an antibiotic) and R8 was discharged with an antibiotic the organism was sensitive to. A review of Resident #8's care plan included a problem area of Indwelling Catheter. Interventions included: Catheter bag changed weekly on Sundays for infection prevention. Monitor and document intake and output as per facility policy. Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Position catheter bag and tubing below the level of the bladder and away from entrance room door. (R8) frequently puts head lower than foley - remind to keep head higher so foley can drain. On 5/28/26 at 10:30 a.m., in an interview with the Director of Nursing, the surveyor discussed R8's history of recurrent MDRO's associated with the urinary catheter was not included in the resident's care plan, which should include the need for staff to use Enhanced Barrier Precautions whenever providing direct care to avoid transmission of resistant organisms.

Based on observation and interview, the facility failed to ensure that medications were stored properly as evidenced by unattended medication left at a resident's bedside, allowing residents and unauthorized persons access to the medication on 1 of 2 units (Wing 2). Finding: On 5/26/26 at approximately 11:00 a.m., during an interview with Resident #26, a surveyor observed a cup containing medication on the resident's overbed table. After the interview, at approximately 11:30 a.m., the surveyor asked RN#2 if he/she was aware of the meds left at the bedside. RN#2 observed the medication and stated he/she thought the resident had taken them. On 5/26/26 at 4:00 p.m., the finding was discussed with the Director of Nursing.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 6 residents whose Medication Administration Records (MAR) and Treatment Administration Records (TAR) were reviewed. (R17)Findings:On 5/28/26 a surveyor reviewed R17's clinical record which showed an active physician order for Trazodone HCL with instructions to give 50 milligrams by mouth at bedtime. A review of his/her MAR/TAR for the month of May lacked evidence that the medication was given on 5/4/26, 5/15/26, 5/21/26, 5/22/26, 5/25/26. Additionally, the clinical record showed active physician orders to remove TED stockings every night, apply Miconazole powder to the groin/peri area for redness two times a day for skin integrity, and apply Biofreeze Cool the Pain External Gel 4% to both shoulders and neck three times a day. A review of his/her MAR/TAR for the month of May lacked evidence that the treatments were given on 5/10/26.On 5/28/26 at 10:10 a.m., the above information was reviewed and confirmed with the Director of Nursing.

Based on record review and interviews, the facility failed to ensure a valid physician's order was obtained before administering an antibiotic to 1 of 1 residents reviewed for dialysis care (R2).Findings: On 5/26/26 at approximately 11:00 a.m., during an interview with a surveyor, R2 stated he/she goes to the local Veterans Administration (VA) every month for catheter changes. R2 stated recently the VA prescribed an antibiotic for a urinary tract infection (UTI). A review of the clinical record for R2 noted admission in September, 2025. Diagnoses included Chronic Kidney Disease, stage 5, with dependence on hemodialysis, and chronic urinary retention requiring an indwelling foley catheter. The electronic medical record noted an order dated 5/26/26 for the antibiotic Sulfamethoxazole-Trimethoprim 400-80 mg. (milligrams), give 1 tablet by mouth at bedtime for UTI for 6 days. This order was unsigned by a licensed medical provider. Further review of the electronic and hard copy medical record lacked evidence that a provider's evaluation had been completed or an authorized and signed prescription had been obtained. A nursing progress note, dated 5/25/26, stated R2 noted what he/she described as intense pain and burning around the catheter and into his/her bladder. He/she expressed desire for immediate relief. Discussed with [family] about if the VA or dialysis could help. The [family] decided to take R2 to urgent care where they diagnosed him/her with a UTI and provided new orders. R2 is currently at dialysis but will return with new orders and the medication. On 5/26/26, the facility's physician evaluated R2 and noted the presence of urinary retention but did not refer to a new urinary tract infection or treatment with an antibiotic. The physician did not sign the electronic order for the antibiotic. There was no evidence that a urine culture had been obtained prior to initiating an antibiotic. A review of R2's medication and treatment administration record noted staff had administered the antibiotic on 5/26/26 and 5/27/26. On 5/28/26 at 9:30 a.m., in an interview with a surveyor, RN1 stated on 5/25/26, R2's family had transported him/her to dialysis and took R2 to an urgent care clinic. R2 stated the clinic diagnosed R2 with a UTI and ordered an antibiotic. RN1 stated he/she did not think the clinic had examined the resident or obtained a urine culture. RN1 stated he/she did not know if a written order was obtained and stated the family did not bring back an after-care summary from the clinic. On 5/28/26 at 10:30 a.m., the surveyor discussed the above concerns with the Director of Nursing (DON), who stated the family frequently takes R2 to appointments but does not communicate with the facility. The DON stated she has discussed this with the family. The DON stated she did not think R2 was receiving an antibiotic at this time. On 5/28/26 at 11:00 a.m., the surveyor met with RN1, R2 and his/her daughter. The surveyor asked if R2 was receiving an antibiotic right now. RN1 confirmed R2 was receiving the medication at this time and confirmed no order had been received from the prescriber at the urgent care clinic. The [family member] confirmed that [he/she] had filled the prescription at a local pharmacy and brought the bottle of pills in when [he/she] returned R2 to the facility. The surveyor discussed that when the resident is taken to an outside provider, paperwork including doctor's signed orders must be given to the facility if staff are going to be administering medications/treatments. The [family member] asked if the instructions which stated what was done and ordered (after care summary) were enough, and the surveyor explained these were not signed physician orders. The [family member] stated [he/she] would go to the pharmacy and obtain a copy of the prescription and bring it back. On 5/28/2026 at 12:45 p.m., the DON and facility's Infection Preventionist (IP) provided a copy of the final report from the 5/25/26 visit to the urgent care clinic with a copy of the antibiotic prescription attached. The IP stated R2's daughter brought the clinic paperwork to staff on the morning of 5/26/26 and the first dose of the antibiotic was administered by dialysis. On 5/28/26 at 1:00 p.m. in an interview with a surveyor, RN1 stated R2's [family member] brought in a copy of the prescription after speaking with the surveyor earlier that morning.

Based on record review and interview, the facility failed to monitor side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (R6).Findings:On 5/27/26 review of Resident #6's (R6) active orders revealed an order for risperidone oral tablet 0.25 mg, give 0.25 mg by mouth two times a day for anxiety/agitation with start date of 9/19/25.On 5/27/26 review of R6's care plan states, (R6) is/has potential to be verbally aggressive (threatening, agitation, anxiety, anger/frustration) r/t Severe Dementia with Agitation & Behaviors, Ineffective coping skills, PTSD, defensive behavior d/t childhood physical & sexual abuse. Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness.Review of R6's Medication Administration Record and Treatment Administration Record dated May 2026 lacked evidence they were being monitored for side effects of the medication listed above.On 5/27/26 at 1:57 p.m. in an interview with a surveyor the Director of Nursing confirmed there is no documentation for assessment of the psychotropic side effects for this resident.

Based on record reviews and interviews, the facility failed to complete a Minimum Data Set (MDS) upon a resident's discharge (R40). Additionally, the facility failed to adequately capture the presence of a resident's wounds on the MDS for 1 of 2 residents reviewed for pressure ulcers (R8). Findings: 1.Review of R40's clinical record revealed he/she discharged from the facility in April of 2026. Review of R40's Minimum Data Set (MDS) lacked evidence that a MDS was completed upon his/her discharge. During an interview on 5/28/26 at 12:38p.m., the Director of Nursing reviewed R40's clinical record and confirmed that an MDS was not completed after the resident was discharged . 2. A review of R8's clinical record revealed diagnoses which included stroke and paraplegia. Physican orders indicated R8 was receiving treatment for deep tissue injuries (DTI's) of the toes. A review of the quarterly MDS assessment, dated 4/6/26, section M: Skin Conditions, noted no pressure ulcers or other skin conditions. On 5/28/2026 at 10:30 a.m., in an interview with the Director of Nursing, a surveyor discussed that R8's quarterly MDS did not include DTI's for which he/she was receiving treatment.

Based on record review and interviews, the facility failed to ensure professional standards of quality were met for controlled medication administration for 1 of 1 resident reviewed. Finding: Record review revealed Resident #1 was admitted in 2019 with diagnoses to include dementia. Resident #1 was admitted to Hospice services on 1/10/25. Review of Resident #1's active physician orders revealed the following: -Order with a start date of 4/9/25 for, Morphine Sulfate (Concentrate) Solution 20 MG/ML [milligrams per milliliter] *Controlled Drug* Give 5 mg by mouth every 30 minutes as needed for PAIN / DISCOMFORT . - Order with a start date of 3/19/25 for, LORazepam Intensol Concentrate 2 MG/ML (LORazepam) *Controlled Drug* Give 0.5 mg by mouth every 15 minutes as needed for ANXIETY . Review of facility-reported incident, dated 4/12/25, states, . [Resident #1's] family members informed nursing staff that the night shift charge nurse .informed the family that she did not have time to give [Resident #1] his/her PRN [as needed] medications as often as they were requesting them. She then drew up a dose of Morphine and a dose of Ativan (Lorazepam) into syringes and gave them to the family to administer themselves. On 5/2/25 at 9:48 a.m., during a phone interview, the Registered Nurse (RN) stated that at 5:00 a.m. she gave Resident #1 a dose or lorazepam and morphine and then asked Resident #1's [family member] to give the next dose at 5:30 a.m. because the RN was too busy and proceeded to give Resident #1's [family member] a pre-drawn oral syringe of morphine and a pre-drawn oral syringe of lorazepam to administer at 5:30 a.m. At this time, the RN stated she knows she is not supposed to leave medications at the bedside table for family to administer. On 4/29/25 at approximately 11:00 a.m., the Director of Nursing (DON) stated the RN was sent home as soon as the incident was reported to the DON, and the RN's employment was terminated once the facility determined the RN had given medications to the family to administer to Resident #1. As a result of the facility's investigation the following correction actions were immediately taken: -On 4/14/25 a report of the incident was submitted to the Department of Licensing and Certification (DLC) -The Registered Nurse was terminated -The Maine State Board of Nursing was notified -On 4/24/25 a Licensed Nursing Meeting included the Narcotic Incident Review which instructed licensed staff that under no circumstances are they to give medications to family to administer.

Based on facility policy and clinical record reviews, observations and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed. Findings: A review of the facility's policy, Controlled Drug Policy and Procedure, dated 10/4/24, stated Controlled drugs, as determined by the facility, are counted every shift by the nurse/med tech reporting on duty with the nurse/med tech reporting off-duty. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count. On 2/24/25 at 11:45 a.m., a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. Multiple days on both units were missing staff signatures for verification and completion of the controlled medication count on the following dates: 9/28/24, 11/28/24, 12/19/24, 1/21/25, 1/23/25, 2/3/25, 2/15/25, 2/23/25, and 2/24/25. On 2/24/25 at 4:00 p.m., the surveyor confirmed the findings with the Director of Nursing and the Administrator.

Based on observations, interviews and record review, the facility failed to ensure the facility was maintained in a clean and sanitary manner for the kitchen counter, fans, ceiling vents and floors. In addition, the facility failed to ensure the kitchen ice machine and food preparation sink were plumbed in accordance with code requirements to prevent food contamination. Further, the facility lacked evidence that the sanitizing bucket and sanitizing sink solutions, dishwashing temperatures were documented and within the appropriate range for 3 of 3 days of survey. Findings: Initial Kitchen Tour: 1. On 2/24/25 from 9:23 a.m. to 9:45 a.m. a surveyor completed a tour of the kitchen with the Food Service Director [FSD] in which the following findings were observed: -The countertop near the food preperation sink had several gauged areas on the surface creating an uncleanable surface. -Two floor fans in the dish room had chipped paint on the front grille and base of fan. -The ceiling vent in the dishwashing room had dust/debris. -The floor in the dishwashing room was soiled and had missing pieces of tile. -The ceiling and walls in the dishwashing room were stained and had areas of chipped loose paint creating an uncleanable surface. The kitchen ice machine and the food preparation sink were not plumbed in accordance with the code requirement and did not have the required proper air gaps. This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 2/25/25 a.m. during an interview with the FSD. She indicated that the dishwashing final rinse temperature is not always accurate on the temperature gauge and that the facility is currently waiting for a part to repair the dishwasher. A surveyor asked if there was an alternate method of checking the final rinse temperature. The FSD confirmed that the staff had no alternative method of checking the final rinse temperature while using the dishwashing machine. Record review of the facilities monthly Dish Machine Temperatures log for October, November 2024 and February 2025 revealed that the staff recorded using the High-Temp dish washer at temperatures below the recommended range (Wash 150 F-165 F, Rinse 180 F) on various shifts and on five days including but not limited to: On the morning shift of 10/14/24 the rinse was recorded at 178 F; on the evening shift of 10/16/24, the rinse was recorded as 179 F; on the evening shift of 11/25/24, the rinse was recorded at 179 F; on the evening shift of 11/27/24, the rinse was recorded at 178 F; on the evening shift of 2/25/25, the rinse was recorded at 179 F. A review of the monthly Dish Machine Temperatures log for November 2024 and January 2025, revealed that the staff did not record dish machine temperatures for the Wash and Rinse cycles on various shifts on three days including but not limited to: Evening shift on 11/29/24 and 11/30/24; and Evening shift on 1/31/25. A review of the Dish Machine Temperature/Sanitizer Records Policy & Procedure indicates Dish machine temperatures and/or sanitizer strengths (as indicated) shall be monitored prior to each meal and recorded to prevent foodborne illness by ensuring all food contact surfaces are properly cleaned and sanitized. Special attention is required to determine if a high temperature or low temperature dish machine is being used. 1. The Dietary Manager shall train all dietary employees regarding the type of dish machine (high temperature/low temperature) and sanitation methods specific to the type being used. 2. Dish machines use either heat or chemical sanitation methods. The following are specifications according to the US Department of Health and Human Services , 7. If there is concern about the sanitizing quality due to inadequate wash or rinse temperature, inadequate sanitizer strength, or inappropriate flow pressure that cannot be resolved by the dietary employee, the ware washing shall be stopped and reported to the Dietary Manager or a designee for corrective action. 9. The Dietary Manager shall be responsible for assuring that the record of dish machine temperatures is maintained at all times. The facilities Sanitizer Bucket Strength Record Policy and Procedure revised 5/2011 indicates When sanitizing buckets are utilized as a system to sanitize food contact surfaces, the strength of the sanitizer in the buckets shall be monitored. Procedure: 1. The Dietary Manager shall train all dietary employees regarding the use of sanitizer test strips, acceptable sanitizer concentration, and the required procedure for documenting sanitizer strength in the sanitizer bucket(s). 3. Sanitizer strength in sanitizing bucket(s) shall be monitored following each meal and recorded by the dietary staff. The Sanitizer Bucket Strength Log may be utilized as a reference as needed. 5. The Dietary Manager or designee shall be responsible for posting the log in the Dietary Department to record sanitizer strength in sanitizer bucket(s). 6. The Dietary Manager shall be responsible for assuring that the record of sanitizer bucket(s) is maintained at all times. The Sanitization Buckets in the Kitchen: The facility lacked evidence that the sanitizer checks for appropriate parts per million (ppm) were monitored and documented for the following dates and times: 11/16/24 6 a.m., 9 a.m., 11 a.m., and 1 p.m., 11/20/24 and 11/21/24 3 p.m., 6 p.m., 11/23/24 and 11/24/24 6 a.m., 9, a.m., 11 a.m., 1 p.m., 3 p.m., 6 p.m., 11/25/24, 11/26/24 and 11/27/24 3 p.m., 6 p.m., 1/28/25 3 p.m., 6 p.m., 2/8/25 11 a.m. On 2/26/25 at 10:38 a.m. during an interview with a surveyor, the FSD stated that the facility started using paper and plastic during the evening meal on 2/25/25 and that the dishwasher is not currently being used. On 2/26/25 at 12:37 p.m., a surveyor discussed the above findings with the Administrator and the Director of Nursing.

Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive for 2 of 5 residents (Residents #24, #38), and failed to ensure a physician's order included the resident's preference for resuscitation (Resident #17). Findings: 1. Resident #24 was admitted in August of 2023. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #38 was admitted in September of 2024. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 3. Resident # 17 was admitted in December of 2024. A review of the electronic medical record revealed that provider orders did not designate the resident's preferred code status, meaning to resuscitate or do not resuscitate. On 2/25/25 at 12:30 p.m., in an interview with a surveyor, the Business Office Manager stated the facility's admission process includes requesting copies of an advanced directive but staff do not document if a resident is offered the opportunity to form an advanced directive or if the resident declines the offer, and stated it has not been routine practice to offer or provide assistance with formulating advanced directives. The Business Office Manager reviewed the records and confirmed that there was no advanced directive in the records of Residents #24 and #38. On 2/25/25, at approximately 3:30 p.m., the Business Office Manager reviewed Resident #17's record and confirmed the provider did not write an order indicating Resident #17's code status was to be designated as do not resuscitate.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals and over-the-counter medications for 1 of 3 survey days. (2/24/25) Findings: On 2/24/25 at 9:08 a.m. a surveyor observed a storage room door propped open, cupboards in the room were unlocked and contained the facility's of supply of over-the-counter medications. The administrator was immediately made aware. On 2/24/25 at 9:14 a.m. a surveyor observed a whirlpool #1 room with a door propped open that had a closet door inside with a key in the door. The closet contained a supply of G2-2100 bottles used for surface cleaning and Simoniz hospital disinfecting deodorant. CNA #1 was immediately made aware. On 2/25/25 at 10:00 a.m. a surveyor observed Whirlpool #2 room with a door propped open and found a bottle of G2-2100 on a shelf unsecured next to the sink. A closet door inside Whirlpool #2 was observed with a key in the lock. The closet contained a supply of G2-2100 and Simoniz hospital disinfecting deodorant. CNA #2 was immediately made aware. She/he stated that shouldn't be there and locked the door and removed the key. On 2/24/25 at 9:00 a.m. a surveyor observed Resident #11 wandering in and out of accessible areas. MDS review of Resident #11 revealed a diagnosis of Dementia with a Brief Interview for Mental Status (BIMS) score of 0 indicting severe cognitive impairment. A review of the SDS for GC-2100 with a revision date of 3/24/27 showed a GHS US classification -Serious eye damage/eye irritation Category 2B A review of the SDS for Simoniz hospital disinfectant deoderant with a revision date of 3/3/2015 showed a classification for eye irritant as Category 2A. Hazardous ingredients include Propane/n-Butane and ethyl Alcohol. On 2/24/25 at 3:12 p.m. the Director of Nursing was made aware of the above findings.

Based on interviews and record review, the facility failed to complete a baseline care plan, as required, within 48 hours of admission to the facility for 5 of 16 residents sampled. (Resident #38, Resident #39, Resident #242, Resident #243 and Resident #244). Finding: Resident #38 was admitted to the facility in mid September of 2024. The care plan for Resident #38, located in the Electronic Medical Record (EMR), was initiated on 10/2/24. Resident #39 was admitted to the facility in early December of 2024. The care plan for Resident #39, located in the EMR, was initiated on 12/11/24. Resident #243 was admitted to the facility in mid February of 2025. The care plan for Resident #243 located in the EMR, was initiated on 2/20/25. Resident #242 was admitted to the facility in mid February of 2025. The care plan for Resident #242, located in the EMR, was initiated on 2/24/25. Resident #244 was admitted to the facility in mid February of 2025. On 2/25/25 a surveyor was unable to locate a care plan in the EMR for Resident #244. On 2/25/25 at 12:50 p.m. a surveyor met with the charge nurse about Resident #249's missing care plan. The charge nurse confirmed that a baseline care plan should be in the resident's EMR and completed within 48 hours. She/he was also unable to locate a care plan for Resident #249. On 2/26/25 at 9:50 a.m. a surveyor met with the Director of Nursing to discuss the above findings.

Based on record review and interview, the facility failed to develop a comprehensive care plan that addressed the use of psychotropic drug use and nutrition for 1 of 5 residents reviewed for unnecessary medications. (#21). Finding: Resident #21's February 2025 Medication Administration Record (MAR) indicated that the resident had received the antidepressants Fluoxetine 40 milligrams (mg) once daily since 10/8/24 and Trazodone 100 mg once daily at bedtime since 5/8/24. Resident #21's Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE], under Care Area Assessment Summary, noted Resident #21 would be care planned for Psychotropic Drug use and Nutrition. As of 2/26/25, Resident #21's medical record lacked evidence of a comprehensive care plan in the area of psychotropic drug use and Nutrition. The surveyor confirmed this lack of care plan for psychotropic drug use and in the care area of nutrition in an interview with the Director of Nursing, on 2/26/25 at 11:15 a.m.

Based on observation, interview, clinical record and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 2 residents (Resident's #24). Finding: On 2/24/25 at 11:18 a.m., a surveyor observed a nebulizer machine on a stand next to Resident #24's bed. The face mask and attached tubing was noted to be dated 10/27, and was placed exposed on a shelf of the stand. On 2/24/25 at 11:28 a.m., a surveyor asked the treatment nurse how staff care for nebulizer equipment. The nurse stated tubing is changed weekly and other items are washed every night. The nurse stated I don't have anyone with a nebulizer right now. At this time, the surveyor showed the nurse Resident #24's nebulizer machine and face mask with tubing dated 10/27. The nurse stated he/she did not know why that was there and should have been removed as there is no order for a nebulizer. The nurse then removed the equipment. A review of Resident #24's provider orders noted an active order, dated 10/22/24, for DuoNeb Solution (Ipratropium-Albuterol) 0.5-2.5 mg/3 ml (milligrams per milliliter) - 3 ml inhale orally every 4 hours as needed for shortness of breath, wheezing related to chronic respiratory failure with hypoxia; panlobular emphysema. On 2/24/25 at 4:00 p.m., a surveyor discussed the finding with the Director of Nursing who confirmed Resident #24 had an active order for nebulizer treatments and that the tubing should be changed weekly. The facility's policy, Equipment Change Out, revised 10/4/24, stated Small volume nebulizers will be dated and changed out weekly.

Based on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 3 of 3 sampled residents who had been transferred to an acute care facility (#6, #21, & #40). Findings: Documentation in Resident #6's clinical record indicated that he/she transferred to an acute care hospital in early February of 2025 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. Documentation in Resident #21's clinical record indicated that he/she transferred to an acute care hospital in early December of 2024. The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 2/26/25 at 11:15 a.m., in an interview with a surveyor, the Director of Nursing (DON) confirmed that she was unable to locate evidence that the facility issued a written bed hold notice to the resident, a family member, or a legal representative upon transfer to an acute care facility for Resident #6 and Resident #21. 3. Documentation in Resident #40's clinical record indicated that he/she transferred to an acute care hospital in early January of 2025 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 2/26/25 at 8:54 a.m., During an interview the Facility Administrator confirmed that the clinical record lacked evidence that a written bed hold notice was provided in writing to Resident and/or Resident Representative.

Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 3 out 3 of of sampled residents transferred/discharged to an acute care facility.(#6, #21 & #40) Findings: 1. Documentation in Resident 6's clinical record indicated that he/she was transferred to an acute hospital in early February of 2025 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. 2. Documentation in Resident 21's clinical record indicated that he/she was transferred to an acute hospital in early December of 2024. The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. On 2/26/25 at 11:15 a.m., in an interview with a surveyor, the Director of Nursing (DON) confirmed that she was unable to locate evidence that the facility issued a written transfer/discharge notice to the resident, a family member, or a legal representative upon transfer to an acute care facility for Resident #6 and Resident #21. 3. Documentation in Resident 40's clinical record indicated that he/she was transferred to an acute hospital in early January of 2025 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. On 2/26/25 at 8:54 a.m., During an interview the Facility Administrator confirmed that the clinical record lacked evidence that a transfer/discharge notice was provided in writing to the Resident and/or Resident Representative.

Based on observations and interviews, the facility failed to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit on 2 of 2 resident wings in 5 of 7 resident rooms and 1 shower room during 1 of 4 days of survey. The failure of the facility to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit created the potential for residents to be burned by the domestic hot water. Finding: There are twenty eight (28) resident rooms and 1 whirlpool room in use at Ledgewood Manor. On 10/28/19 four surveyors measured and observed the following hot water temperatures: On Wing 2: -At 9:43 a.m., the hot water temperature in whirlpool hair-washing sink was 125.8 degrees Fahrenheit; -At 9:48 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s bathroom sink was 129.8 degrees Fahrenheit; -At 9:50 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s bathroom sink was 126.8 degrees Fahrenheit; and -At 9:54 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s bathroom sink was 125.4 degrees Fahrenheit. On Wing 1: -At approximately 9:45 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 129.6 degrees Fahrenheit. -At approximately 9:45 a.m., the hot water temperature in room [ROOM NUMBER]'s bathroom sink was 124.2 degrees Fahrenheit. On 10/28/19 at 9:45 a.m., two surveyors met with the General Manager (GM) and the Maintenance Supervisor to inform them of hot water temperatures above 120 degrees Fahrenheit in resident accessible rooms. The facility provided the surveyors with a printout titled Boiler Room Temperature Check, with entries for (MONTH) 2019. The Boiler Room Temperature Check indicated readings from gauges on Boiler #1, Boiler #2, mixer temp gauges, outgoing and incoming digital gauges. The GM explained that the outgoing and incoming digital gauges most accurately reflect the water temperatures upon leaving and reentry to the boiler room after circulating through the facility. Only 1 of the 14 readings from both outgoing and incoming was less than 120 degrees Fahrenheit. The GM stated that the printout does not reflect any adjustments made to the temperature settings. At this time, the Maintenance Supervisor stated he was new and started employment 8/16/19. He stated he was not directed to perform resident room hot water temperatures monitoring. The GM confirmed he did not direct the Maintenance Supervisor to perform this task. When the surveyor asked the GM if he was aware that monitoring of resident room hot water temperatures was necessary, he responded, Yes, I am aware. I dropped the ball. When the surveyor requested any hot water temperature monitoring prior to October, the Maintenance Supervisor responded he did not have any. On 10/28/19 at 9:54 a.m. a surveyor, the GM and the Maintenance Supervisor noted in Resident room [ROOM NUMBER] a hot water temperature of 125.4 degrees Fahrenheit and at 10:53 a.m., in Resident room [ROOM NUMBER] a hot water temperature of 128 degrees Fahrenheit. The GM used a facility digital thermometer and the surveyor used a calibrated digital thermometer. The readings were compared and matched. The surveyor confirmed the hot water temperature readings with the GM at this time. On 10/28/19 at 1:50 p.m., the Immediate Jeopardy (IJ) template was provided to the GM by the surveyor Team Leader. On 10/28/19 at 3:06 p.m., an immediate plan of correction for the unsafe hot water temperatures was provided and accepted by the survey team. The Action Plan included the following immediate interventions: Facility would immediately adjust the water temperature; staff were made aware to use caution and to observe residents closely; and the facility would be monitoring temperatures to ensure safe temperatures of 120 degrees Fahrenheit or below. Random checks throughout the building were conducted by surveyors prior to exiting the building on 10/28/19 at 3:30 p.m. No hot water temperatures exceeded 120 degrees Fahrenheit. On 10/29/19 at 8:00 a.m., random resident room's hot water temperature readings were provided to the surveyor by the Maintenance Supervisor. No hot water temperatures exceeded 120 degrees Fahrenheit. During the remainder of the survey, random resident room checks for hot water revealed no hot water temperatures in excess of 120 degrees Fahrenheit.