Cycle 1
Health 2025-02-26 · Fire 2025-02-26
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Windham, ME
Ledgewood Manor
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
200 Route 115, Windham, ME
(207) 892-2261
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.71
Licensed practical nurse staffing
Aide hours / resident day
2.88
Nurse aide staffing
Weekend hours
3.84
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.1% |
90.7%
21.6 pts worse
|
93.4%
24.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 58.7% |
95.5%
36.8 pts worse
|
95.5%
36.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
4.3%
1.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.6% |
10.7%
1.9 pts worse
|
11.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.5%
4.8 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
17.0%
1.8 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
21.0%
4.9 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.0% |
29.6%
6.6 pts better
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.4% |
25.7%
5.7 pts worse
|
14.9%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
1.3%
2.6 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.7%
2.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
29.8%
2.6 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.4%
2.3 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 6.0% |
71.2%
65.2 pts worse
|
81.7%
75.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-14 · Fire 2022-06-14
13 health deficiencies
Top issue: Infection Control (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-02-26
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-27
F · Potential for more than minimal harm
2025-02-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-02-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-26
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-07
F · Potential for more than minimal harm
2022-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-02
F · Potential for more than minimal harm
2022-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-02
D · Potential for more than minimal harm
2022-06-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-02
D · Potential for more than minimal harm
2022-06-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-08-17
F · Potential for more than minimal harm
2019-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-10-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-10-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-02-26
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-11
B · Minimal harm
2025-02-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-11
B · Minimal harm
2025-02-26
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-11
B · Minimal harm
2025-02-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-10-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-14
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-14
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-14
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-06-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-06-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-06-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-06-14
F887 · Infection Control Deficiencies
Health
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.
Corrected 2022-06-29
C · Minimal harm
2022-06-14
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-06-29
B · Minimal harm
2022-06-14
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-06-29
K · Immediate jeopardy
2019-10-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
F838 · Administration Deficiencies
Health
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.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-12-31
B · Minimal harm
2019-10-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-31
B · Minimal harm
2019-10-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-12-31
Penalties and ownership
What sits behind the stars
Ownership
Bennett, Edison
5% Or Greater Direct Ownership Interest · Individual
Bennett, Jean
5% Or Greater Direct Ownership Interest · Individual
Bennett, Edison
Operational/Managerial Control · Individual
Bennett, Nathaniel
Operational/Managerial Control · Individual
Bennett, Nathaniel
Corporate Director · Individual
Brown, Jessica
Operational/Managerial Control · Individual
Brown, Jessica
Corporate Director · Individual
Cadigan, Catharine
Operational/Managerial Control · Individual
Preferred Therapy Outpatient Services Of Me, LLC
Operational/Managerial Control · Organization
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#2
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Fallbrook Commons
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2-star overall rating with 2-star inspections with 19 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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