Ledgewood Manor
Windham, Maine · CCN 205137
15 surveys since 2011. The first finding at harm level was recorded in 2019.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 59
- Surveys
- 15
- Harm or worse
- 1
- Immediate jeopardy
- 1
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 60
- Ownership
- For profit - Individual
- Chain
- Independent
- County
- Cumberland
- Medicare-certified since
- 1993
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 3
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 25 for-profit facilities with fewer than 66 beds in Maine.
Last survey on record
May 28, 2026
165 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.04 | 4.14 |
| Registered-nurse hours per resident day | 0.65 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K12.3% | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1841.9% | E1227.9% | F49.3% |
| No harm, potential for minimal | A— | B716.3% | C12.3% |
Most frequently cited here
In CMS’s current monthly file.
- F6563×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F5842×
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.
- F6232×
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
In the surveyor’s words
From the most serious findings on record at Ledgewood Manor, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF851May 28, 2026
Based on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 1 2026 (October 1, 2025 - December 31, 2025). This has the potential to affect all residents (47 Residents).Findings: Review of the facility's payroll based journal report, titled PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) 1705D FY (Fiscal Year) Quarter 1, 2026 (October 1 - December 31) stated that the facility Failed to Submit Data for the Quarter was triggered. Triggered' was defined as no data submitted for quarter. […]
- No harm, potential for more than minimal, widespreadF880Jun 14, 2022
Based on record review and interview, the facility failed to establish a facility wide Infection Prevention and Control Program (IPCP) which included standards, policies and procedures that are current, based on national standards and reviewed annually for COVID-19. This has the potential to affect all residents. Finding: From 6/12/22 through 6/14/22, the annual Long-Term Care Survey Process was completed. The facility was found to be in noncompliance with F880, F882, F883, F886, and F887. […]
- No harm, potential for more than minimal, widespreadF882Jun 14, 2022
Based on interview and record review, the facility failed to designate a qualified staff member to function as the Infection Preventionist, who is responsible for the facility's Infection Control Program. This has the potential to affect all residents in the facility. Finding: On 6/13/22 at 2:30 PM, in an interview with the Director of Nursing (DON), and the Resident Coordinator, the surveyor asked who was designated as the facility's Infection Preventionist (IP). The DON stated the previous Infection Preventionist had not worked at the facility from October 2021 through March 2022. The DON stated the facility did not have a copy of the staff's infection preventionist certificate or evidence of training. […]
- No harm, potential for more than minimal, widespreadF886Jun 14, 2022
Based on record review and interview, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines and the Center for Medicare and Medicaid Services (CMS) August 26, 2020, revised 3/10/22, Quality, Survey and Certification Group (QSO)-20-38-Nursing Home (NH) for testing of staff who are not up to date with COVID-19 vaccination. This has the potential to affect all residents at the facility (31 residents). Findings: A review of the CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities, updated 2/2/22, stated In nursing homes, Health Care Personnel (HCP) who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening… […]
- No harm, potential for more than minimal, patternF584May 28, 2026
Based on observation and interview, the facility failed to adequately provide maintenance and housekeeping services necessary to maintain the physical environment in good repair and in a clean, sanitary condition. This was evidenced by the widespread use of heavy adhesive tape (duct tape) to patch and repair damaged floors, sinks, and handrails across multiple resident rooms and common areas, creating un-cleanable surfaces. In addition, the facility failed to maintain floors and ceiling tiles in good structural repair, and failed to clean patient care equipment. […]
Read 21 findings in full →The most serious and the most recent: 21 of 59 on record.
Every survey on record
FindingsAt actual harm or above
- May 28, 2026Standard10 findings
- Apr 29, 2025Complaint1 finding
- Feb 26, 2025Standard10 findings
- Oct 8, 2024Complaint1 finding
- Jun 14, 2022Standard12 findings
- Feb 9, 2021Complaint1 finding
- Oct 31, 2019Standard9 findings · 1 harm
- Sep 12, 2018Standard3 findings
Show the 7 earlier surveys
- Jul 5, 2018Complaint1 finding
- Sep 28, 2017Standard1 finding
- Oct 5, 2016Standard1 finding
- Oct 23, 2014Standard1 finding
- Sep 19, 2013—1 finding
- Jul 11, 2012—3 findings
- Jun 23, 2011—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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