C

Ledgewood Manor

200 ROUTE 115, WINDHAM, ME 04062
Score: 64 / 100

Ledgewood Manor is an average performer in CMS ratings, earning a C grade with a score of 64/100. Located in Windham, Maine, the facility meets baseline standards across most quality metrics.

Staffing at Ledgewood Manor is near the national average, with 4.11 total nursing hours per resident per day (national average: 3.8 hours).

Recent CMS inspections identified 33 deficiencies at Ledgewood Manor, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: ensure services provided by the nursing facility meet professional standards of quality..

Score Breakdown

Overall CMS Rating 24 / 40 pts
3 ★ CMS rating
Health Inspections 15 / 25 pts
3 ★ inspection rating
Staffing 16 / 20 pts
4 ★ staffing rating
Quality Measures 9 / 15 pts
3 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 4.11 3.8 Average
Registered Nurses (RN) 0.52 0.7 Below Average
Licensed Practical Nurses (LPN) 0.71 0.7 Average
Certified Nursing Assistants (CNA) 2.88 2.4 Above Average
Weekend Total Nursing 3.84 3.8 Average
Weekend RN Hours 0.34 0.7 Below Average

🔍 Inspection & Deficiency History

33
Total Deficiencies
Apr 28, 2025
Most Recent Inspection
⚪ 7 Minor 🟠 25 Moderate 🔴 1 Serious
View recent deficiencies (5 shown)
  • Tag 0658 Severity D
    Ensure services provided by the nursing facility meet professional standards of quality.
    Apr 28, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0578 Severity E
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and
    Feb 25, 2025 · Resident Rights Deficiencies
  • Tag 0655 Severity E
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    Feb 25, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0689 Severity E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Feb 25, 2025 · Quality of Life and Care Deficiencies
  • Tag 0755 Severity E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    Feb 25, 2025 · Pharmacy Service Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 2.1% 4.5% Better
Falls with major injury 3.0% 3.0% Average
On antipsychotic medication 16.1% 14.5% Worse
Urinary tract infections 0.0% 2.5% Better
ADL decline (daily activities) 31.4% 14.0% Worse
Excessive weight loss 0.7% 7.5% Better
New/worsened incontinence 32.4% 45.0% Better

How This Grade Was Calculated

This facility's grade of C is based on a score of 64 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 3★ → 24 pts (max 40)
  • Health Inspection Rating: 3★ → 15 pts (max 25)
  • Staffing Rating: 4★ → 16 pts (max 20)
  • Quality Measures Rating: 3★ → 9 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Individual
Certified Beds
60
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Feb 25, 2025
Deficiencies (Cycle 1)
11