Ledgewood Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Ledgewood Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686May 5, 2022

  Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions, resulting in the development of a pressure ulcer, for 1 Resident (#47) out of a total sample of 26 residents. Findings include: Review of facility policy titled 'Wound and Skin Care Protocols/ Definitions', reviewed 9/21, indicated the following: *Purpose: -To prevent pressure ulcer/ injury formation by identifying those residents who are at risk for pressure injuries/ ulcers and to develop appropriate interventions. *Definitions: -A pressure injury/ulcer is defined as any lesion caused by unrelieved pressure resulting in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are staged to classify the degree of tissue damage observed. […]

• Actual harm, isolatedF692May 5, 2022

  Based on observation, record reviews and interviews, the facility failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain usual body weight and prevent significant weight loss or gain, for 2 Residents (#2, and #57) out of a total sample of 26 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, undated, indicated the following: *Any weight change in 5 pounds or more over 1 month will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. *The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. […]

• No harm, potential for more than minimal, patternF812Aug 1, 2024

  Based on observations and interviews, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: The surveyor made the following observations during the initial kitchen walkthrough on 7/30/24 at 7:10 A.M.: - In the walk-in refrigerator, a container of unlabeled, undated sliced meat. - In the walk-in refrigerator, a container labeled as mushrooms with a use by date of 7/29 written on it. The container was partially open. - In the walk-in refrigerator, an opened bottle of Gatorade belonging to a staff member was stored with resident food. - In the walk-in freezer, numerous boxes containing resident food were stored directly on the ground. […]

• No harm, potential for more than minimal, patternF812May 5, 2022

  Based on observation, interview and facility policy review, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: Review of the facility policy titled, Preventing Foodborne Illnesses-Employee Hygiene and Sanitary Practices indicated the follow: Policy Statement: -Food and Nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent spread of foodborne illnesses. Policy Interpretation and Implementations: Employees must wash hands: *Before coming in contact with any food surfaces. *After handing soiled equipment or utensils. […]

• No harm, potential for more than minimal, isolatedF550Jul 9, 2026

  Based on observation, record review and interview, the facility failed to ensure residents were treated with dignity on one resident care unit, out of three units. Specifically, three Certified Nursing Assistants (CNAs) wore earbuds (a small headphone worn inside the ear) while providing care to residents. Findings include: Review of the facility policy titled 'Quality of Life-Dignity,' version 9/2025, indicates: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be treated with dignity and respect at all times. On 7/8/26 the surveyor made the following observations on the Farms Unit: -At 6:56 A.M., Certified Nursing Assistant (CNA) #4 exited a room occupied by two residents. […]