Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Ledgewood Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and other complex needs, who required two-person assistance for all Hoyer lift transfers, was transferred multiple times by individual CNAs without a second staff member present, despite both staff knowing the facility's policy and the resident's care plan requirements.
A CNA assisted with Hoyer Lift transfers for residents without having completed the required competency training or documentation, including operating the lift controls while under 18 and after turning 18, contrary to facility policy and federal guidelines. The CNA's personnel file lacked evidence of proper training or competency sign-off, and interviews confirmed the CNA had not received formal instruction on the device.
A resident who was fully dependent on staff for ADL care, including incontinence care, did not receive timely assistance after requesting help during the evening and night shifts. Due to staff shortages and lack of communication, the resident remained without necessary care for approximately nine hours until the day shift provided assistance, despite repeated requests.
The facility was found to have improper food storage practices, including unlabeled and undated food items, staff members' drinks stored with resident food, and food stored directly on the ground. The Food Service Director acknowledged that all food should be labeled, dated, and discarded appropriately, and staff drinks should not be stored with resident food.
The facility failed to create individualized care plans for two residents, one with dementia and another requiring nutritional care. A resident with dementia did not have a care plan addressing their condition, despite requiring assistance with daily activities. Another resident, with severe cognitive impairment, lacked a nutritional care plan due to a missed assessment by the RD. The DON confirmed the absence of these essential care plans.
The facility failed to document care as ordered for two residents, including the external length of a PICC line, urine output from a Foley catheter, and drainage from NPWT. The DON was unaware of these lapses until the surveyor's review.
A nurse failed to follow infection control practices while administering IV medication to a resident with a PICC line. The nurse did not perform hand hygiene, donned gloves without a gown, and potentially contaminated the IV tubing and insertion site by handling the IV solution bag improperly. The facility's policy required enhanced barrier precautions, including gown and glove use, for residents with indwelling medical devices.
Failure to Follow Two-Person Hoyer Lift Transfer Protocol
Penalty
Summary
Staff failed to consistently implement and follow a resident's comprehensive care plan, which required two staff members to assist with all Hoyer lift transfers. Despite clear documentation in the resident's care plan and care card, as well as facility policy mandating two-person assistance for mechanical lift transfers, two CNAs independently transferred the resident using the Hoyer lift without assistance on multiple occasions. Both CNAs acknowledged awareness of the policy and the resident's care requirements but proceeded to perform transfers alone. The resident involved had diagnoses including dementia, anxiety, and adult failure to thrive, and was assessed as needing full mechanical lift transfers with two-person assistance. The deficiency was identified through review of records, interviews with the CNAs, and confirmation from facility leadership that the required procedures were not followed. The failure to adhere to the care plan and facility policy was confirmed during interviews and documentation review.
CNA Assisted with Hoyer Lift Transfers Without Required Competency Training
Penalty
Summary
Certified Nurse Aide (CNA) #1 was found to have assisted with Hoyer Lift transfers for residents without having completed the required competency training for the use of the device. At the time of her orientation and during her employment, CNA #1 was under 18 years of age and her competency checklist for the Hoyer Lift was not signed off, with only a line drawn in the relevant section. There was no documentation in her personnel file indicating that she had received further training or demonstrated competency in the use of the Hoyer Lift, either as an assistant or as an operator after turning 18. CNA #1 confirmed in an interview that she had regularly assisted with Hoyer Lift transfers and had used the controls, despite not being formally trained or signed off as competent. Facility policy required that at least two trained nursing assistants be present for mechanical lift transfers and that all staff demonstrate competency in the use of such devices. The Assistant Director of Nurses (ADON) stated that CNA #1, being under 18, should not have operated the Hoyer Lift controls and should have been signed off as competent for assisting with transfers, with additional competency required upon turning 18. However, these steps were not completed, and CNA #1 continued to participate in resident transfers without the necessary training or documentation of competency.
Failure to Provide Timely ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for activities of daily living (ADL) did not receive timely care as required by the facility's policy and the resident's care plan. The resident, who had diagnoses including morbid obesity, Type 2 Diabetes with polyneuropathy, and an acquired absence of the right leg below the knee, was nonambulatory and required a two-person assist with a mechanical lift for transfers, as well as total assistance for bathing, grooming, positioning, and toileting. On the evening in question, the resident requested care after being incontinent, but staff did not provide the necessary assistance until the following morning. Interviews and record reviews revealed that the resident requested care around 11:00 P.M. after an episode of incontinence. The assigned CNA informed the resident that he could not provide care alone and needed to wait for another staff member. The nurse on duty was aware of the request but did not ensure care was provided before the end of her shift, nor did she assist or seek help from another nurse. During the night shift, only one CNA was present instead of the scheduled two, and the CNA continued to wait for assistance that did not arrive until approximately 5:00 A.M. Despite the resident's repeated requests, care was not provided until the day shift arrived. When the day shift nurse and CNA responded to the resident's call light around 8:00 A.M., they found the resident had a bowel movement that appeared to have been present for many hours. The Director of Nursing confirmed that staff should have clarified the resident's needs and provided timely care in accordance with the care plan. The lack of communication and failure to provide necessary assistance resulted in the resident remaining without incontinence care for approximately nine hours.
Improper Food Storage Practices in Facility
Penalty
Summary
The facility failed to properly store food items in accordance with professional standards for food service safety, as observed during a survey. During an initial kitchen walkthrough, the surveyor noted several deficiencies: a container of unlabeled and undated sliced meat, a container labeled as mushrooms with a use-by date of the previous day that was partially open, and an opened bottle of Gatorade belonging to a staff member stored with resident food in the walk-in refrigerator. Additionally, numerous boxes containing resident food were stored directly on the ground in the walk-in freezer. During a revisit, further issues were observed, including another opened bottle of Gatorade and an opened bottle of water with a staff member's name stored with resident food. Interviews with the Food Service Director confirmed that all food should be labeled, dated, and discarded after three days or as per the label, and that staff members' drinks should not be stored with resident food.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered care plans for two residents, leading to deficiencies in their care. Resident #1, who was admitted with diagnoses including unspecified dementia with agitation and adult failure to thrive, did not have a care plan addressing their dementia. Despite having a Brief Interview for Mental Status score indicating intact cognition, the resident required assistance with all activities of daily living. Interviews with Nurse #2 and the Director of Nursing (DON) confirmed the absence of a dementia care plan, which was expected for residents with such a diagnosis. Resident #104, admitted with diagnoses including urinary tract infection, hyperlipidemia, and unspecified dementia, also lacked an individualized care plan, specifically related to nutritional care. The resident's Minimum Data Set Assessment indicated severe cognitive impairment. The Registered Dietitian (RD) admitted to missing the initial nutrition assessment and care plan development for this resident. The DON acknowledged that a nutritional care plan should have been developed upon the resident's admission, highlighting a lapse in the facility's care planning process.
Documentation Failures in Catheter and Wound Therapy Management
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care documentation. For one resident, the staff did not document the external length of a peripherally inserted central catheter (PICC) line as required, nor did they record the urine output from the resident's Foley catheter on multiple occasions throughout July 2024. This resident, who was admitted with diagnoses including bacteremia and urinary retention, showed moderate cognitive impairment and required assistance with daily activities. The Director of Nursing (DON) was unaware of these documentation lapses until the surveyor's review. Another resident, admitted for surgical aftercare and with chronic pulmonary disease, also experienced a lack of documentation regarding their negative pressure wound therapy (NPWT). The staff failed to record the drainage amount from the wound vac as ordered by the physician on several shifts in July 2024. This resident was cognitively intact and required assistance with personal care. The DON, upon reviewing the records with the surveyor, acknowledged the oversight in documenting the NPWT drainage.
Infection Control Breach During IV Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff adhered to infection control practices during the administration of intravenous (IV) medication for a resident. The resident, who was admitted with diagnoses including bacteremia, chronic obstructive pulmonary disease, and urinary retention, was receiving IV antibiotics through a peripherally inserted central catheter (PICC) line. The facility's Enhanced Barrier Precautions policy required staff to use gowns and gloves during high-contact care activities for residents with indwelling medical devices. However, during an observation, a nurse administered IV antibiotics to the resident without performing hand hygiene, donning a gown, or following proper glove protocol, potentially contaminating the IV tubing and PICC line insertion site. The nurse was observed exiting the medication room, gathering supplies, and donning gloves without first performing hand hygiene. She then entered the resident's room, adjusted the privacy curtain with her gloved hands, and set the infusion rate on the IV pump. The nurse removed an IV solution bag from her pocket, potentially contaminating her gloves, and connected the IV bag to the resident's PICC line while still wearing the same gloves. During an interview, the nurse acknowledged that staff were required to wear a gown when providing care to the resident but incorrectly believed it was unnecessary for medication administration. The Director of Nursing confirmed that the nurse should have worn a gown, performed hand hygiene, and not kept the IV solution bag in her pocket.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 977 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blueberry Hill Rehabilitation And Healthcare Ctr | 0.2 mi | ★★★★★ | 12 | 0 |
| Care One At Essex Park | 0.7 mi | ★★★★★ | 1 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 2.4 mi | ★★★★★ | 6 | 0 |
| New England Homes For The Deaf, Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| Twin Oaks Center | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ledgewood Rehabilitation And Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.