Inspection visit
Fire Safety inspection
Citations
10 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0015GeneralS&S Dpotential for harm
Address subsistence needs for staff and patients.
- 0020GeneralS&S Dpotential for harm
Establish policies and procedures including evacuation.
- 0025GeneralS&S Dpotential for harm
Create arrangements with other facilities to receive patients.
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Dpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0231GeneralS&S Dpotential for harm
Provide large enough exits.
FAQ · About this visit
Common questions about this visit
What happened during the October 31, 2019 survey of Ledgewood Manor?
This was a inspection survey of Ledgewood Manor on October 31, 2019. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Ledgewood Manor on October 31, 2019?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address subsistence needs for staff and patients."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.