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.

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Last standard health inspection on record

May 28, 2026

Showing 1 to 25 of 27 citations

No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 26, 2026).
No harm, with potential for more than minimal harm
Establish roles under a Waiver declared by secretary.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 1, 2026).
No harm, with potential for more than minimal harm
Establish staff and initial training requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 26, 2026).
No harm, with potential for more than minimal harm
Conduct testing and exercise requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Have properly located and lighted "Exit" signs.
Widespread (many residents). CMS level F.
Fire safety citation K-0293, Egress Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Create arrangements with other facilities to receive patients.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0025, Emergency Preparedness Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 6, 2025).
No harm, with potential for more than minimal harm
Establish staff and initial training requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 21, 2025).
No harm, with potential for more than minimal harm
Conduct testing and exercise requirements.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 5, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 27, 2025).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Widespread (many residents). CMS level F.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 6, 2025).
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 February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 19, 2025).
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).
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).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0211, Egress Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 12, 2026).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (July 2, 2026).
No harm, with potential for more than minimal harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0222, Egress Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 1, 2026).
No harm, with potential for more than minimal harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0232, Egress Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 26, 2026).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 10, 2026).
No harm, with potential for more than minimal harm
Provide properly sized and located linen or trash receptacles.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0754, Miscellaneous Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (June 1, 2026).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 28, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 29, 2026).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0291, Egress Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 4, 2025).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 12, 2025).
No harm, with potential for more than minimal harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0342, Smoke Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 12, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 14, 2025).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of February 26, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 7, 2025).

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.