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Public Record

Ledgewood Manor

Nursing HomeWindham, MECMS 205137
58 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
60

*CMS

Avg. residents per day
45.7

*CMS

Inspection record

On record from CMS

Citations on record
58

*CMS

Inspections on file
8

*CMS

Last inspection
2025-04-29

*CMS

Citations

58 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0342Generalpotential for harm

    Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0578Generalpotential for harm

    Honor 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.

  • 0623Generalno actual harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0655Generalpotential for harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0637Generalno actual harm

    Assess the resident when there is a significant change in condition

  • 0025Generalpotential for harm

    Create arrangements with other facilities to receive patients.

  • 0037Generalpotential for harm

    Establish staff and initial training requirements.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0625Generalno actual harm

    Notify 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.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0584Generalpotential for harm

    Honor 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.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0868Generalno actual harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0882Generalpotential for harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0886Generalpotential for harm

    Perform COVID19 testing on residents and staff.

  • 0887Generalpotential for harm

    Educate 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.

  • 0947Generalpotential for harm

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 0567Generalno actual harm

    Honor the resident's right to manage his or her financial affairs.

  • 0341Generalpotential for harm

    Install a fire alarm system that can be heard throughout the facility.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0916Generalpotential for harm

    Have a battery powered remote alarm panel in a location accessible by operating personnel.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0689Seriousimmediate jeopardy

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0661Generalpotential for harm

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0623Generalno actual harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0761Generalpotential for harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0015Generalpotential for harm

    Address subsistence needs for staff and patients.

  • 0020Generalpotential for harm

    Establish policies and procedures including evacuation.

  • 0025Generalpotential for harm

    Create arrangements with other facilities to receive patients.

  • 0231Generalpotential for harm

    Provide large enough exits.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0838Generalpotential for harm

    Conduct 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.

  • 0730Generalno actual harm

    Observe each nurse aide's job performance and give regular training.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Ledgewood Manor?
Ledgewood Manor is a Medicare- and Medicaid-certified nursing home in Windham, ME, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 205137.
What is the CMS rating for Ledgewood Manor?
Ledgewood Manor has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Ledgewood Manor have?
Ledgewood Manor is certified for 60 beds. It serves an average of 45.7 residents per day.
How many citations does Ledgewood Manor have?
Ledgewood Manor has 58 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Ledgewood Manor last inspected?
Ledgewood Manor was last inspected on April 29, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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