Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LEDGEWOOD REHABILITATION AND NURSING CENTER
BEVERLY, MA · 123 certified beds · Last Life Safety survey August 14, 2025
CMS Certification Number 225309 · first certified March 1988
Ownership
Operated by BANECARE MANAGEMENT · For profit - Corporation
- Ownership changed June 1, 2021 (change of ownership)to LEDGEWOOD REHABILITATION AND SKILLED NURSING CENTER from LEDGEWOOD HEALTHCARE CORPORATION
Position within MA
9 citations — more than 39% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was August 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 9 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 9 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 15, 2023 | 4 |
| August 1, 2024 | 4 |
| August 14, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-08-14 |
| E-0041 | Implement emergency and standby power systems. | 2 | 2024-08-01 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-08-01 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2023-06-15 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-08-01 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Emergency Preparedness Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 14, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2025) |
August 1, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 30, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 30, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 30, 2024) |
June 15, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 25, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 25, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 25, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 25, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.