Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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 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 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 | — | 14 | 1 |
| Jerome Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Civita Care Center At Newington | 3 mi | ★★★★★ | 42 | 1 |
| Apple Rehab Cromwell | 3.4 mi | ★★★★★ | 20 | 0 |
| Monsignor Bojnowski Manor | 3.5 mi | ★★★★★ | 3 | 0 |
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