All citations for Ledgewood Manor

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Ledgewood Manor

Last standard health inspection on record

May 28, 2026

Showing 1 to 16 of 16 citations

  1. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  2. No harm, with potential for more than minimal harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    Widespread (many residents). CMS level F.

    Health citation F-0882, Infection Control Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  3. No harm, with potential for more than minimal harm

    Perform COVID19 testing on residents and staff.

    Widespread (many residents). CMS level F.

    Health citation F-0886, Infection Control Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  4. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 2, 2022).

  5. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 2, 2022).

  6. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  7. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  8. No harm, with potential for more than minimal harm

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0947, Nursing and Physician Services Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  9. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  10. No harm, with potential for more than minimal harm

    PASARR screening for Mental disorders or Intellectual Disabilities

    Isolated (one or a few residents). CMS level D.

    Health citation F-0645, Resident Assessment and Care Planning Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  11. No harm, with potential for more than minimal harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0883, Infection Control Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  12. No harm, with potential for more than minimal harm

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0887, Infection Control Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  13. No harm, with potential for more than minimal harm

    Install a fire alarm system that can be heard throughout the facility.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0341, Smoke Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 2, 2022).

  14. No harm, with potential for more than minimal harm

    Have a battery powered remote alarm panel in a location accessible by operating personnel.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0916, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 17, 2022).

  15. No harm, with potential for minimal harm

    Honor the resident's right to manage his or her financial affairs.

    Widespread (many residents). CMS level C.

    Health citation F-0567, Resident Rights Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

  16. No harm, with potential for minimal harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Pattern (more than a few residents). CMS level B.

    Health citation F-0868, Administration Deficiencies. Inspection of June 14, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 29, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.