LEDGEWOOD MANOR
Address
200 ROUTE 115, PO BOX 760
WINDHAM, ME 04062
(207) 892-2261
Nursing Home Ratings
| Health Inspections | |
| Quality Measures | |
| Nursing Staff | |
| R.N. Staff Only | |
| Overall Rating | |
Percent of Beds Occupied
98%Number of Residents and Certified Beds
- Residents: 59
- Certified Beds: 60
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Individual
- Offers Only Resident Counseling
- This Facility is Not Part of a Chain or Franchise
Rating Details For Ledgewood Manor
Nursing Staff - 
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
| Nursing Hours Per Resident Per Day | Reported | Expected |
| Registered Nurse (RN) Hours | 40 Minutes | 1 Hour and 4 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 20 Minutes | 44 Minutes |
| Certified Nursing Assistant (CNA) Hours | 3 Hours and 39 Minutes | 2 Hours and 52 Minutes |
| Total Licensed Nurse Hours | 59 Minutes | 1 Hour and 49 Minutes |
| Total Nurse Hours | 4 Hours and 38 Minutes | 4 Hours and 41 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Maine are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
| This Facility | Maine Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 89% |
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 92% |
Long-Term Stay Deficiencies
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 3% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 25% | 15% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 5% | 6% |
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 40% | 32% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 6% | 8% |
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 63% | 71% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 15% | 15% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 10% | 8% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 13% | 8% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 6% | 6% |
| Percent of Long-Stay Residents Who Were Physically Restrained | - | 3% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 86% |
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 84% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Have Pressure Sores | 7% | 10% |
| Percent of Short-Stay Residents Who Have Delirium | - | 2% |
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 14% | 25% |
Health Inspection Details - 
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 05/07/2010.
Degree of Harm
- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health
Residents Affected
- Isolated
- Some Residents
- Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Administration
Give or Get Lab Tests to Meet the Needs of Residents.
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Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Be Designed, Built, Equipped, or Well Kept to Protect the Health and Safety of Residents, Workers, and the Public.
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Mistreatment
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Quality Care
Give Professional Services That Meet a Professional Standard of Quality.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Each Resident's Nutritional Needs Were Met.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Resident Rights
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey.
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Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Ledgewood Manor, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Formal Complaints | Degree of Harm | Residents Affected |
Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
| | |
Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Resident Rights
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Ledgewood Manor had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 05/05/2010.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Corridor Walls and Doors
Signs That State That Exit Doors Are to Be Kept Closed.
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Emergency Plans and Fire Drills
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Exits That Are Free from Obstructions and Can Be Used at All Times.
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Medical Gases and Anesthetizing Areas
A Properly Installed Master Alarm Panel.
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Miscellaneous
Fire Safety Features Required by Current Fire Safety Codes.
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Smoke Compartmentation and Control
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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