Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ledgecrest Health Care Center during CMS and state inspections, most recent first.
Failure to care plan Legionella exposure and language needs. Three residents' care plans did not identify a potential Legionella exposure despite the facility testing positive, and a fourth resident's baseline care plan did not identify that the resident spoke only Spanish and needed a translator or other communication supports. The resident assessments showed varying levels of cognitive impairment and dependence, and staff acknowledged the communication need was known but not documented in the chart.
A dependent, Spanish‑speaking resident with recent surgery, pain, moderate cognitive impairment, and mixed continence required substantial assistance with ADLs and toileting. While assisting with translation, an NA, who was not assigned to the resident, told the resident that if they did not want to get up due to pain, they could void in the incontinent product they were wearing, and did not report the resident’s pain to a nurse. A family member later reported that staff had told the resident to void in bed. The DON’s review of the NA’s written statement confirmed the NA had instructed the resident to void in the brief, which the DON and regional nurse deemed inappropriate and inconsistent with the resident’s right to dignified care and respect for toileting preferences.
A resident with dementia and a history of traumatic brain injury became physically aggressive toward a nurse aide after being confronted for taking another resident’s food, throwing an item at the aide and attempting to stab the aide with a pencil. An RN asked an LPN to deescalate the situation and escort the resident back to their room, but after doing so, the LPN left the resident unattended and resumed medication pass, and no staff remained with the resident despite recent violent behavior. Approximately 10–15 minutes later, the resident left the room and again attacked the same aide near the nurse’s station, resulting in injuries to both the resident and the aide. Review of video and facility policy showed that staff did not provide the required continuous 1:1 supervision or ongoing monitoring during this psychiatric emergency, contrary to the facility’s Emergency Care policy.
Failure to provide individualized activity preferences for two residents. One resident with paraplegia, anxiety, and depression had a care plan for self-chosen activities, but records showed only limited 1:1 recreation visits and no documentation that preferred activities such as pets, news, or going outside were offered. Another resident with muscle weakness, DM, depression, and anxiety reported boredom and said preferred activities like photography and sign language were not provided; the care plans did not include individualized recreation preferences, and the Recreation Director said she did not know she was responsible for adding them.
Missing CWC Reviews and Incomplete Positioning Plan: A resident with paraplegia, OA, and muscle weakness was dependent on staff for transfers and ADLs and used a custom wheelchair with a mechanical lift. The resident’s 24-hour positioning plan did not include specific times or time frames for wheelchair use or bed positioning, and the record lacked required quarterly rehab reviews and multiple monthly nursing reviews for the CWC despite physician orders.
Expired controlled meds remained in emergency stock and were administered to residents after the labeled expiration date. Staff counted the narcotics at shift change but did not verify expiration dates, and expired hydrocodone/APAP and alprazolam were found in stock. The expired alprazolam was given 15 times to four residents, while the RN, DON, and pharmacist each described shared responsibility for removing expired meds.
Failure to disinfect a multi-use glucometer per manufacturer guidelines was identified during blood glucose checks for two residents with diabetes. An LPN used alcohol prep pads to clean the meter between residents and stated this was facility policy, while the DON confirmed the facility policy required EPA-registered disinfectant wipes and the glucometer user guide required CaviWipes or similar wipes before use and between each patient.
Failure to Address Urinary Incontinence in Care Plan: A resident with dementia and BPH was admitted as incontinent of bowel and bladder, but the care plan only addressed skin protection with barrier cream and did not include a specific incontinence plan. MDS data showed poor memory recall, extensive assist for toileting, limited assist with transfers, and ongoing urine and bowel incontinence. Bladder documentation showed repeated urine incontinence and missing shift charting, and the resident later attempted to toilet unassisted and fell. The Corporate Nurse confirmed the only incontinence-related intervention was under the skin breakdown plan.
Failure to document PRN pain medication administration and follow-up occurred for a resident with cancer and lumbar radiculopathy who had frequent pain rated 7/10. Although oxycodone was recorded on the narcotic sheet and the RN stated she gave it and later checked on the resident, the MAR did not show the dose was administered or whether it was effective. Facility policy required PRN meds, pain assessments, interventions, and resident responses to be documented in the medical record.
A resident with a history of falls and moderate cognitive impairment was found on the floor with visible head and possible spinal injuries after an unwitnessed fall. Despite clear signs of trauma, staff, including an RN and nursing assistants, moved the resident back to bed using a mechanical lift before EMS arrived, contrary to best practices for suspected head and spinal injuries. The resident was later diagnosed with multiple traumatic injuries and expired after hospital admission. Staff interviews revealed uncertainty about proper procedures in such situations.
A resident with Alzheimer's disease, experiencing severe cognitive impairment, mistakenly believed his roommate instructed a nurse aide to remove his belongings, leading to an altercation where he hit the roommate with a plate cover. The incident resulted in a bruise on the roommate's arm, highlighting a lapse in communication and supervision by the facility staff.
A facility failed to manage the use of offloading boots for a resident with a Stage 3 pressure ulcer, despite a physician's recommendation to discontinue their use. The resident, who was severely cognitively impaired and at risk for skin breakdown, had worsening wounds potentially due to the boots. Staff interviews revealed a lack of communication and awareness about the physician's recommendation, and there was no documented physician's order for the boots. The facility lacked policies for the use of offloading boots, contrary to their wound care protocols.
A resident with urinary retention was catheterized, and more than the facility's policy limit of 1000 cc of urine was removed on two occasions. The RN involved was unaware of the policy limit, believing the procedure should continue until the bladder was empty. The DNS confirmed the policy and identified the non-compliance.
The facility failed to monitor weights and notify the dietician for two residents, leading to deficiencies in care. One resident with severe malnutrition and a pressure ulcer was not reweighed despite significant weight changes, and the dietician was not informed. Another resident with dysphagia and multiple sclerosis experienced a 25-pound weight loss without reweighing or dietician notification. Facility policies for weight monitoring and communication were not followed, resulting in a lack of timely intervention.
A facility failed to conduct monthly Medication Regimen Reviews (MRR) for a resident on psychotropic medications. The resident, diagnosed with anxiety disorder and dementia, was prescribed Lorazepam for anxiety and combativeness. Despite the requirement, MRRs were not completed for two months. The resident was cognitively impaired and required full assistance with daily activities.
Failure to Care Plan Legionella Exposure and Spanish Language Communication Needs
Penalty
Summary
The facility failed to include a potential exposure to Legionella in the comprehensive Resident Care Plans for three sampled residents. The facility tested positive for Legionella on 12/29/25. Resident #3 had diagnoses including high blood pressure, seizure disorder, paraplegia, muscle weakness, and depression, and the quarterly MDS identified the resident as cognitively intact and requiring assistance with eating and maximum assistance with bathing, mobility, and self-care. Resident #15 had diagnoses including dementia, high cholesterol, anemia, high blood pressure, and depression, and the quarterly MDS identified severe cognitive impairment with maximum assistance needed for personal hygiene and bathing. Resident #33 had diagnoses including high blood pressure, dementia, Alzheimer's disease, and depression, and the quarterly MDS identified severe cognitive impairment with independence in eating, bathing, personal care, and mobility. Their Resident Care Plans dated 3/18/26, 3/19/26, and 2/3/26, respectively, failed to identify the potential for Legionella exposure. The Infection Prevention Nurse stated staff were aware of the potential exposure and were mitigating risk by using bottled water, but acknowledged that new or agency staff might not be aware of the exposure if it was not documented in the residents' charts. The facility also failed to develop a baseline Resident Care Plan within 48 hours of admission for Resident #47 that identified the need for a translator. Resident #47 had diagnoses including sepsis, calculus of the gallbladder with chronic cholecystitis without obstruction, and generalized anxiety. The admission nursing assessment identified a BIMS score of 8, indicating moderate cognitive impairment, and showed the resident required substantial maximal assistance with bed mobility, dressing, and personal hygiene, and was dependent on staff for toileting. The admission nursing assessment, baseline Resident Care Plan, OT and PT evaluations, and SLP screen all failed to identify that the resident spoke only Spanish, required a translator to communicate, or had alternate communication methods such as a picture board or translator availability. The Social Worker stated the resident spoke only Spanish and that communication had occurred through a family member or a Spanish-speaking staff member when available, and stated the resident should have had a communication Resident Care Plan.
Failure to Provide Dignified Toileting Assistance to Dependent Resident
Penalty
Summary
The deficiency involves a failure to provide toileting in a dignified manner for a dependent, Spanish‑speaking resident who required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and was dependent on staff for toileting, with episodes of both continence and incontinence. The resident had diagnoses including sepsis, gallbladder disease with chronic cholecystitis, and generalized anxiety, and was moderately cognitively impaired. The care plan called for assistance with ADLs, including toileting and incontinent care per policy. A family member reported to the social worker that staff had told the resident to stay in bed for voiding and later that staff had told the resident to void in bed. The resident’s rights policy stated that residents have the right to be treated with consideration and respect and to receive care with reasonable accommodation of individual needs and preferences. According to a written statement, one NA who was not assigned to the resident but was asked to translate for the Spanish‑speaking resident asked if the resident needed anything or wanted to use the bathroom. The resident declined, citing recent surgery and pain. The NA then reassured the resident that if they needed to, they could use the incontinent product they were wearing, and explained the use of the call bell, stating staff would assist and change the resident as needed. The DON’s investigation noted that this NA had written that she instructed the resident to void in the incontinent product, and the DON and regional nurse stated that instructing the resident to void in a diaper was not appropriate. Additionally, the NA did not notify a nurse that the resident was experiencing pain, which was the reason the resident did not want to get up to use the bathroom. The facility was unable to substantiate neglect but acknowledged that telling the resident to void in the brief was inappropriate and not consistent with resident dignity and rights.
Failure to Provide 1:1 Supervision After Violent Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of required interventions for a resident with known agitation and violent behavior following an initial physical altercation. The resident had vascular dementia, a history of traumatic brain injury, chronic kidney disease, and was care planned for anxiety, dementia, and risk for mood changes, with interventions such as relaxation techniques, simple communication, support, and reporting changes in mental status. A quarterly MDS showed moderately impaired cognition with independence in mobility and transfers. On the evening in question, a nurse aide observed the resident taking food from another resident; when the aide intervened, the resident became upset and threw a croissant at the aide’s face and then attempted to stab the aide with a pencil, prompting staff to call the police. Following this initial altercation, the charge LPN was called by the RN supervisor to help deescalate the situation and escort the resident back to their room. During the escort, the resident repeatedly stated they were not a thief. The LPN left the resident alone in the room and returned to medication pass, while the RN supervisor remained on the unit but did not direct the LPN or other staff to stay with the resident. The resident was left unattended for approximately 10–15 minutes despite the recent violent behavior and ongoing agitation related to being accused of theft. During this time, the aide involved in the first incident was near the nurse’s station and bathroom area, tending to her own injuries and discussing calling the police. Within that period of unsupervised time, the resident exited the room and re-engaged with the same aide in front of the nurse’s station, grabbing the aide by the shirt collar and striking her, while the aide attempted to protect herself. Staff, including the LPN and another aide, intervened to separate them, and the police arrived to prevent further altercation. The resident sustained a scrape to the head and wrist and broken glasses, and the aide sustained a cut to the forehead. Review of video footage by the ADON confirmed that no staff member remained with the resident after the initial hallway altercation. The facility’s Emergency Care policy required the nursing supervisor or designee to ensure scene safety with ongoing monitoring and, for psychiatric emergencies with acute disturbance, to provide 1:1 supervision and remove harmful objects. The ADON acknowledged that staff did not stay with the resident and that the facility failed to follow its Emergency Policy.
Failure to Provide Individualized Activity Preferences
Penalty
Summary
The facility failed to ensure individualized activity preferences were provided for 2 of 2 sampled residents reviewed for activities. Resident #3 had diagnoses including generalized muscle weakness, paraplegia, anxiety, and depression, and an annual recreation assessment identified that it was very important for the resident to do favorite activities, be around animals such as pets, keep up with the news, and get some fresh air. The quarterly MDS showed intact cognition and the care plan stated the resident would engage in activities of their own choosing, with interventions to offer a calendar, encourage attendance at chosen activities, offer in-room materials, and provide a weekly 1:1 visit. However, the resident stated the only activity engaged in was self-propelling around the facility in a wheelchair, and that there were no activities of interest for younger residents. Recreation participation records from 3/1/26 to 4/14/26 showed participation in only 3 of 45 recreational opportunities, all of which were weekly 1:1 visits with the Recreation Director, with 2 of 5 expected visits missing and no documentation that the resident’s identified preferences for animals, news, or going outside were attempted or provided during the remaining days. Resident #31 had diagnoses including muscle weakness, overactive bladder, diabetes, depression, and anxiety, and the quarterly MDS showed intact cognition with independence for dressing and oral hygiene and set-up assistance for eating. The care plan stated the resident needed leisure and diversional activities to adjust to the new environment, with interventions to offer a calendar, encourage attendance at chosen activities, offer in-room materials, and provide a weekly 1:1 visit to determine interests and offer support and encouragement. The resident stated the facility did not provide activities of interest such as photography and sign language courses, and that the resident was bored; the resident also reported that a tablet provided by the facility had so many blocks that it was difficult to use. The annual recreation assessment identified that it was very important for the resident to do favorite activities, be around animals such as pets, keep up with the news, do things with groups of people, and get some fresh air. Review of the care plans for both residents did not identify individualized recreational preferences, and the Recreation Director stated she was unaware it was her responsibility to individualize the care plans to include preferred recreational activities.
Missing CWC Reviews and Incomplete 24-Hour Positioning Plan
Penalty
Summary
The facility failed to ensure a custom wheelchair was regularly reviewed for a resident with paraplegia, generalized osteoarthritis, and muscle weakness. The resident’s quarterly MDS identified total dependence on staff for dressing, toileting, bed mobility, and transfers, use of a wheelchair independently, and risk for pressure ulcer development. The care plan directed staff assistance with ADLs, use of a wheelchair with a total mechanical lift, and other interventions related to toileting, incontinent care, side rails, and transfers. Physician orders directed transfer from bed to a motorized wheelchair with a mechanical lift, offering transfer out of bed after morning care and back to bed after lunch or by request, with the schedule subject to resident tolerance, a 24-hour positioning plan, and a monthly custom wheelchair nursing review on the 15th of each month. Observations during the survey showed the resident in the custom wheelchair on multiple days. The 24-hour positioning plan stated the resident should be offered transfer to the custom wheelchair after morning care and back to bed after lunch or by request, but it did not identify specific times or time frames for being out of bed, returning to bed, or specific positions in or out of bed. The clinical record also lacked required quarterly rehabilitation reviews for the custom wheelchair for multiple quarters, and the monthly nursing reviews were missing documentation for several months despite the physician order. The annual rehab review dated 2/6/26 stated there were no health issues related to the custom wheelchair and that it remained appropriate without recommendations or modifications. During interview, the Director of Rehabilitation stated the positioning plan was based on the resident’s preferences, that the resident knew how to tilt and reposition in the wheelchair, and that rehabilitation was responsible for quarterly reviews while nursing was to complete monthly reviews, though nurses often missed documentation.
Expired Controlled Medications Remained in Emergency Stock and Were Administered
Penalty
Summary
The facility failed to ensure emergency stock controlled medications were not expired and were not administered past their labeled expiration dates. During observation and interview with the supervising RN, emergency stock controlled medications were counted at each shift change, but the process did not include checking expiration dates. Review of the emergency stock revealed 44 expired Hydrocodone Bitartrate and Acetaminophen 5/325 mg tablets with expiration dates of 6/2025 and 9/2025, and 12 Alprazolam 0.25 mg tablets with an expiration date of 11/2025. The Controlled Substance Disposition Record showed the expired Alprazolam 0.25 mg was administered 15 times after its labeled expiration date between 11/22/25 and 3/19/26 to four residents, including two administrations to one resident, six to another, six to a third, and one to a fourth. The RN stated it was the responsibility of all nurses to check expiration dates before dispensing, but could not explain why the expired medications remained in stock or were administered. The DON stated it was the responsibility of the DON, nursing staff, and pharmacy to remove expired medications, and the pharmacist stated the pharmacy checked expiration dates before delivery, after which nursing staff were responsible for checking before dispensing.
Failure to Disinfect Multi-Use Glucometer per Manufacturer Guidelines
Penalty
Summary
The facility failed to follow the manufacturer’s guidelines for disinfecting and cleaning a multi-use glucometer used for blood glucose monitoring for 2 of 2 sampled residents reviewed for the infection control program. Resident #6 had diagnoses including type 2 diabetes mellitus, depression, and hypertension, and had physician orders for blood sugar checks every Tuesday and Friday at 6:30 AM. Resident #22 had diagnoses including type 2 diabetes mellitus, congestive heart failure, and end stage renal disease, and had an order for Insulin Lispro before meals based on blood sugar readings. Both residents were identified in care plans as having diabetes and being at risk for hyperglycemia and/or hypoglycemia, with finger sticks ordered as needed and for symptoms such as hunger, sweating, confusion, dizziness, increased thirst, nausea, vomiting, abdominal discomfort, or changes in mental status. During observation with an LPN, the glucometer was cleansed with an alcohol prep pad before obtaining Resident #6’s blood glucose level and again with a new alcohol prep pad before obtaining Resident #22’s blood glucose level. The LPN stated this was facility policy and said the alcohol prep pads were used to disinfect the glucometer between residents, with particular emphasis on the test strip port. Review of the facility cleaning and disinfecting policy with the LPN showed that CaviWipes were required per manufacturer guidelines, and the LPN stated she was unaware of this and did not know whether CaviWipes were available. The DON later confirmed that the facility policy required multi-use glucometers to be cleaned and disinfected with Medline Micro-kill One wipes, and review of the glucometer user’s guide showed that CaviWipes or other EPA-registered disinfectant wipes were required to clean and disinfect the meter before use and between each patient.
Failure to Address Urinary Incontinence in Care Plan
Penalty
Summary
Resident #2, a new admission with diagnoses including dementia and benign prostatic hyperplasia, was identified on admission as incontinent of bowel and bladder. The baseline care plan addressed skin breakdown risk with interventions to keep the skin clean and dry and apply barrier cream with incontinent care, but it did not include a specific plan to address the resident’s urinary incontinence. The quarterly MDS showed a BIMS score of 8 out of 15, poor memory recall deficits, extensive assistance needed for toilet use, limited one-person assistance with transfers, and that the resident was occasionally incontinent of urine and frequently incontinent of bowel. Bladder flowsheets from 9/10/25 through 9/30/25 showed the resident was incontinent of urine on at least one shift for 12 of 21 days, and 4 of 21 days had no documentation for the 3-11 PM shift. An A&I form dated 10/3/25 at 12:20 AM documented that the resident attempted to go to the bathroom unassisted and fell. Although the falls care plan was updated on 10/8/25 with an intervention to offer and assist with toileting at the beginning of third shift, the care plan still did not identify or address the resident’s incontinence. The Corporate Nurse confirmed on 10/9/25 that the only incontinence-related information in the care plan was under the skin breakdown plan with the intervention to apply barrier cream with incontinence episodes.
Failure to Document PRN Pain Medication Administration and Effectiveness
Penalty
Summary
Failure to document the administration and follow-up of an as-needed pain medication occurred for one resident with malignant cancer and lumbar radiculopathy. The annual MDS identified that the resident had no memory recall deficits, received scheduled and PRN pain medication, experienced frequent pain, and rated the pain as 7 out of 10. The care plan identified the resident as at risk for pain and discomfort and directed staff to administer medications as ordered and determine the level of pain using the pain scale before giving the medications. Review of the September 2025 control drug record showed the resident received oxycodone 5 mg at 9:30 PM, but the September 2025 MAR did not document that the medication was administered at that time and did not show a follow-up response indicating whether the PRN medication was effective or ineffective. During interview, the 3-11 PM RN stated she administered the oxycodone around 9:30 PM, forgot to enter it on the MAR, and believed she followed up about an hour later when the resident was resting in bed. The corporate nurse stated narcotic sheets are not part of the resident's clinical record and that medication administration should be documented on the MAR or in a nurse's note. Facility policy required PRN medications to be documented with indication and effectiveness, and the pain management policy required all pain findings, interventions, and resident responses to be documented in the medical record.
Failure to Follow Protocol After Resident Fall with Head and Spinal Injuries
Penalty
Summary
Staff failed to follow professional standards of care after an unwitnessed fall involving a resident with multiple diagnoses, including heart failure, anxiety, and chronic pain, and a documented risk for falls. The resident, who had moderate cognitive impairment, was found face down on the floor with visible head injuries, including large lumps on the head, a cut near the eye, abrasions, and complaints of wrist pain. Despite these injuries and the potential for spinal involvement, staff, including an RN and nursing assistants, assisted the resident back into bed using a mechanical lift before the arrival of Emergency Medical Services (EMS). Facility documentation and interviews revealed that the RN assessed the resident and, despite recognizing the possibility of head and spinal injuries, directed staff to move the resident to bed to make them comfortable. The EMS run sheet confirmed that the resident had been moved prior to their arrival and subsequently placed in a cervical collar and transferred to the hospital. Hospital records documented multiple traumatic injuries, including a subdural hematoma, subarachnoid hemorrhage, facial fractures, wrist fractures, and a T8 vertebral fracture, with the resident ultimately expiring after admission. Interviews with staff, including the RN, nursing assistants, and the Director of Nursing Services (DNS), indicated uncertainty or lack of knowledge regarding the appropriate response to a resident with suspected head and spinal injuries following a fall. Facility policy directed minimizing injury after a fall, but staff actions did not align with standards for managing potential head and spinal trauma, as the resident was moved prior to EMS assessment.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #28, who has severe cognitive impairment due to Alzheimer's disease, became upset when a nurse aide cleaned out his room without informing him. This misunderstanding led Resident #28 to believe that his roommate, Resident #149, had instructed the aide to remove his belongings. In a state of confusion and agitation, Resident #28 hit Resident #149 with a plate cover, resulting in physical contact and a subsequent bruise on Resident #149's left arm. Resident #149, who has intact cognition but requires assistance with activities of daily living due to conditions such as lymphedema and morbid obesity, was lying in bed when the incident occurred. Despite the physical altercation, Resident #149 reported no pain and was emotionally stable, understanding that Resident #28's actions were due to cognitive issues. The incident was documented in the nurse's notes, and Resident #149 was moved to another room following the event. The facility's policy on abuse prevention emphasizes the right of residents to be free from all forms of abuse and the responsibility of staff to monitor and supervise care delivery. However, the incident highlights a lapse in communication and supervision, as the nurse aide did not inform Resident #28 of the room cleaning, which triggered the aggressive behavior. The facility's failure to prevent this incident resulted in a deficiency in ensuring the safety and protection of Resident #149 from physical abuse.
Failure to Manage Offloading Boot Use for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper management and communication regarding the use of offloading boot devices for a resident with a Stage 3 pressure ulcer. The resident, who was severely cognitively impaired and dependent on staff for mobility, was at risk for skin breakdown due to multiple factors including immobility and poor nutrition. Despite a wound physician's recommendation to discontinue the use of green offloading boots due to their potential contribution to the worsening of the resident's wound, the boots were observed at the resident's bedside, and staff were unclear about their usage. Interviews with nursing assistants and a charge nurse revealed a lack of awareness and communication regarding the physician's recommendation, and there was no physician's order documented for the use of the boots. Further investigation showed that the physical therapist was unaware of the physician's recommendation and that the use of the boots was implemented by nursing staff without a formal order. The Director of Nursing Services and a registered nurse acknowledged the absence of a physician's order and the lack of facility policies regarding the use of offloading boots. The medical doctor confirmed the recommendation to stop using the boots due to the resident's worsening condition, which included redness and swelling of the foot, and the initiation of antibiotic therapy for a potential bone infection. The facility's policy on wound and skin care protocols indicated that the interdisciplinary plan of care should address interventions for pressure ulcer prevention and treatment, highlighting a gap in adherence to this policy.
Failure to Adhere to Catheterization Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the maximum amount of urine to be removed during catheterization for a resident with urinary retention. The resident, who had diagnoses including retention of urine, neuromuscular dysfunction of the bladder, chronic kidney disease Stage 3A, and malignant neoplasm of the prostate, was ordered to be straight catheterized every shift. However, on two separate occasions, more than the policy-stipulated maximum of 1000 cubic centimeters (cc) of urine was removed from the resident's bladder. Specifically, 1300 cc and 1200 cc were removed during catheterization procedures on different shifts. The deficiency was identified through a review of the clinical record and interviews with facility staff. An interview with a registered nurse (RN) revealed a lack of awareness regarding the policy's limit on urine removal, as the RN believed the procedure should continue until the bladder was empty. The Director of Nursing Services (DNS) confirmed the policy and identified the instances of non-compliance. The facility's catheterization policy, which was undated, clearly directed not to remove more than 1000 cc of urine at one time, highlighting the oversight in following established protocols.
Failure in Weight Monitoring and Dietician Notification
Penalty
Summary
The facility failed to ensure proper weight monitoring and notification of the dietician for two residents, leading to deficiencies in care. Resident #31, diagnosed with Parkinson's Disease, severe protein-calorie malnutrition, failure to thrive, dementia, and a stage 3 pressure ulcer, was not reweighed despite significant weight fluctuations. A physician's order required weekly weights, but discrepancies were noted without reweighing or notifying the dietician. The facility policy required reweighing if there was a 5-pound discrepancy, but this was not followed, and the dietician was not informed of the weight changes. Similarly, Resident #44, with diagnoses including dysphagia, GERD, and Multiple Sclerosis, experienced a significant weight loss of 25 pounds in one month without a reweight or dietician notification. The facility's policy mandated weekly weights for new admissions and reweighing for discrepancies, but these procedures were not adhered to. Interviews with staff revealed a lack of communication and documentation regarding the weight changes, and the dietician was not informed during their visit, preventing timely intervention.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were completed for a resident on psychotropic medications. Resident #41, who had diagnoses including anxiety disorder, unspecified dementia with other behavioral disturbances, and type 2 diabetes mellitus, was prescribed Lorazepam for anxiety and combativeness. Despite the requirement for monthly MRRs, the pharmacy consultant did not conduct reviews for May 2024 and June 2024. The resident was identified as cognitively impaired and required full assistance with daily activities, and was receiving antipsychotic and anti-anxiety medications. An interview with the Director of Nursing Services (DNS) revealed that the MRRs for the specified months were not available, and the DNS planned to contact the pharmacist for the missing information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kensington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grandview Rehabilitation And Healthcare Center | 2.4 mi | — | 13 | 1 |
| Jerome Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Civita Care Center At Newington | 3 mi | ★★★★★ | 39 | 1 |
| Apple Rehab Cromwell | 3.4 mi | ★★★★★ | 20 | 0 |
| Monsignor Bojnowski Manor, Inc | 3.5 mi | ★★★★★ | 3 | 0 |
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