Ledgewood Manor
200 ROUTE 115, WINDHAM, ME 04062 · CCN 205137
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- For profit - Individual
- Certified beds
- 60
- Avg residents/day
- 44.0
- Phone
- 2078922261
Inspection history vs Maine & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Maine avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-02-26 | 11 | 11.4 | 9.5 | -0.4 better |
| 2 | 2022-06-14 | 13 | 10.8 | 9.8 | +2.2 worse |
| 3 | 2019-10-31 | 9 | 6.9 | 9.3 | +2.1 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 4 |
| Resident rights | 3 |
| Nutrition and dietary | 1 |
| Pharmacy service | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.11 | 53.1% |
| RN staffing (reported) | 0.52 | 57.1% |
| Total nurse staffing (adjusted) | 4.51 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Inspection citations (33)1 immediate jeopardy
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-04-29 · Health · corrected 2025-04-24
Potential for more than minimal harm
- EF0578Honor 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.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- BF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2025-02-26 · Health · corrected 2025-04-11
Potential for minimal harm
- BF0625Notify 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.2025-02-26 · Health · corrected 2025-04-11
Potential for minimal harm
- BF0637Assess the resident when there is a significant change in condition2025-02-26 · Health · corrected 2025-04-11
Potential for minimal harm
- EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-02-26 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-08 · Health · corrected 2024-11-08
Potential for more than minimal harm
- CF0567Honor the resident's right to manage his or her financial affairs.2022-06-14 · Health · corrected 2022-06-29
Potential for minimal harm
- DF0584Honor 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.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- EF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- BF0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly2022-06-14 · Health · corrected 2022-06-29
Potential for minimal harm
- FF0880Provide and implement an infection prevention and control program.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- FF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- FF0886Perform COVID19 testing on residents and staff.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- DF0887Educate 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.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2022-06-14 · Health · corrected 2022-06-29
Potential for more than minimal harm
- BF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2019-10-31 · Health · corrected 2019-12-31
Potential for minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
- EF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
- DF0661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
- KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2019-10-31 · Health · corrected 2019-12-31
Immediate jeopardy
- DF0692Provide enough food/fluids to maintain a resident's health.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
- BF0730Observe each nurse aide's job performance and give regular training.2019-10-31 · Health · corrected 2019-12-31
Potential for minimal harm
- DF0838Conduct 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.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2019-10-31 · Health · corrected 2019-12-31
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| BENNETT, EDISON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 51% | 1980-02-11 |
| BENNETT, JEAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 49% | 1980-02-11 |
| PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2018-12-03 |
| BENNETT, EDISON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 1980-01-01 |
| BENNETT, NATHANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2015-02-22 |
| BROWN, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-05-31 |
| CADIGAN, CATHARINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-10-01 |
| BENNETT, NATHANIEL | Individual | CORPORATE DIRECTOR | — | 2015-02-22 |
| BROWN, JESSICA | Individual | CORPORATE DIRECTOR | — | 2021-05-31 |
Other facilities in WINDHAM
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.