Facility profile · CCN 205137
Ledgewood Manor
33 federal citations on record , including 1 at the Immediate Jeopardy level.
Record summary
Federal record · Q1 202633
Total citations
12
Last 3 years
1
Actual harm+
0
Federal penalties
$0
Total fines
3
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
33 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Apr 29, 2025 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint |
| Feb 26, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Feb 26, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Standard |
| Feb 26, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Feb 26, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard |
| Feb 26, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Feb 26, 2025 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | Standard |
| Feb 26, 2025 | F637 | Assess the resident when there is a significant change in condition | B | Standard |
| Feb 26, 2025 | F625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | B | Standard |
| Feb 26, 2025 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | Standard |
| Feb 26, 2025 | F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E | Standard |
| Oct 8, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Jun 14, 2022 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | Standard |
| Jun 14, 2022 | F887 | 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. | D | Standard |
| Jun 14, 2022 | F886 | Perform COVID19 testing on residents and staff. | F | Standard |
| Jun 14, 2022 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Jun 14, 2022 | F882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F | Standard |
| Jun 14, 2022 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Jun 14, 2022 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | B | Standard |
| Jun 14, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Jun 14, 2022 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Jun 14, 2022 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Jun 14, 2022 | F584 | 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. | D | Standard |
| Jun 14, 2022 | F567 | Honor the resident's right to manage his or her financial affairs. | C | Standard |
| Oct 31, 2019 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Oct 31, 2019 | F838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | D | Standard |
| Oct 31, 2019 | F730 | Observe each nurse aide's job performance and give regular training. | B | Standard |
| Oct 31, 2019 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Oct 31, 2019 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K | Standard |
| Oct 31, 2019 | F661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D | Standard |
| Oct 31, 2019 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Oct 31, 2019 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Oct 31, 2019 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | Standard |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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