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
🏥 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
View recent deficiencies (5 shown)
- Tag 0658 Severity DEnsure services provided by the nursing facility meet professional standards of quality.Apr 28, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0578 Severity EHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, andFeb 25, 2025 · Resident Rights Deficiencies
- Tag 0655 Severity ECreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedFeb 25, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0689 Severity EEnsure 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 EProvide 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
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