Ledgewood Manor

Quick Facts
Address	200 ROUTE 115, PO BOX 760, WINDHAM, ME 04062
Phone	(207) 892-2261	Diriving Directions From
Beds	60
Residents	56
Occupancy	93%
Category	Participating in Medicare and Medicaid
Ownership	For profit - Individual
Within a Hospital?	No
Resident or Family Councils	Resident

Staffing Comparison
Number of Residents	This Facility: 56 State Average: 85.3 National Average: 89.94
Number of Registered Nurses hours per residents per day	This Facility: Not Available State Average: 0.63 National Average: 0.64
Number of Licensed Practical/Vocational Nurses hours per residents per day	This Facility: Not Available State Average: 0.8 National Average: 0.79
Number of Licensed Staff hours per residents per day	This Facility: Not Available State Average: 1.44 National Average :1.43
Number of Certified Nursing Assistants hours per residents per day	This Facility: Not Available State Average: 2.41 National Average: 2.34

Latest Inspection Results
Survey Date Correction Date	Scope	Level of Harm	Deficiency Type	Deficiency Category	Deficiency
02/10/2006 03/23/2006	Isolated	Minimal harm or potential for actual harm	Fire Safety	Smoke Compartmentation and Control Deficiencies	proper construction of ducts through walls designed to prevent smoke passage.
04/06/2007 05/21/2007	Pattern	Potential for minimal harm	Health	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
04/06/2007 05/21/2007	Pattern	Minimal harm or potential for actual harm	Health	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.
04/06/2007 05/21/2007	Pattern	Minimal harm or potential for actual harm	Health	Quality Care Deficiencies	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.
04/06/2007 05/21/2007	Pattern	Minimal harm or potential for actual harm	Health	Quality Care Deficiencies	offer Flu or Pneumococal vaccine to some residents.
04/06/2007 04/24/2007	Widespread	Potential for minimal harm	Health	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.
04/06/2007 05/21/2007	Pattern	Minimal harm or potential for actual harm	Health	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.
04/06/2007 05/16/2007	Isolated	Minimal harm or potential for actual harm	Health	Pharmacy Service Deficiencies	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.
04/10/2007 05/21/2007	Isolated	Minimal harm or potential for actual harm	Fire Safety	Corridor Walls and Doors Deficiencies	corridors that are separated from common areas by walls constructed to limit the passage of smoke.
04/10/2007 05/21/2007	Pattern	Potential for minimal harm	Fire Safety	Corridor Walls and Doors Deficiencies	corridor and hallway doors that block smoke.
04/10/2007 05/21/2007	Isolated	Minimal harm or potential for actual harm	Fire Safety	Corridor Walls and Doors Deficiencies	signs that state that exit doors are to be kept closed.
02/02/2006 03/03/2006	Widespread	Potential for minimal harm	Health	Resident Rights Deficiencies	Allow residents to easily see the results of the nursing home's most recent survey.
04/10/2007 05/21/2007	Pattern	Minimal harm or potential for actual harm	Fire Safety	Furnishings and Decorations Deficiencies	exits that are free from obstructions and can be used at all times.
02/02/2006 03/10/2006	Isolated	Minimal harm or potential for actual harm	Health	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.
02/02/2006 02/15/2006	Isolated	Minimal harm or potential for actual harm	Health	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.
02/02/2006 02/08/2006	Isolated	Minimal harm or potential for actual harm	Health	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.
02/10/2006 03/23/2006	Pattern	Potential for minimal harm	Fire Safety	Automatic Sprinkler Systems Deficiencies	automatic sprinkler systems that have been maintained in working order.
02/02/2006 02/07/2006	Isolated	Minimal harm or potential for actual harm	Health	Pharmacy Service Deficiencies	Properly mark drugs and other similar products.
02/02/2006 02/15/2006	Isolated	Minimal harm or potential for actual harm	Health	Environmental Deficiencies	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.
02/02/2006 03/23/2006	Widespread	Minimal harm or potential for actual harm	Health	Environmental Deficiencies	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.
02/10/2006 03/23/2006	Pattern	Potential for minimal harm	Fire Safety	Interior Finish Deficiencies	fire-resistant room wall surfaces.
02/10/2006 03/23/2006	Isolated	Minimal harm or potential for actual harm	Fire Safety	Exits and Egress Deficiencies	exits that are accessible at all times.
02/10/2006 03/23/2006	Isolated	Minimal harm or potential for actual harm	Fire Safety	Emergency Plans and Fire Drills Deficiencies	record of quarterly fire drills for each shift under varying conditions.
02/10/2006 03/23/2006	Isolated	Minimal harm or potential for actual harm	Fire Safety	Automatic Sprinkler Systems Deficiencies	an approved automatic sprinkler system connected to the fire alarm system.
02/02/2006 02/15/2006	Isolated	Minimal harm or potential for actual harm	Health	Resident Assessment Deficiencies	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.

Prior years Inspection reports and Complaints of this facility are available for only $4.95. Order now

Latest Complaints
Survey Date Correction Date	Scope	Level of Harm	Deficiency Type	Deficiency Category	Deficiency
06/13/2006 06/20/2006	Isolated	Minimal harm or potential for actual harm	Health	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.

Quality Measures
Quality Measure	Score
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores	This Facility: Not Available State Average: NaN National Average: 2.33
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder	This Facility: Not Available State Average: 69.17 National Average: 48.73
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season	This Facility: 88 State Average: 75.11 National Average: 71.44
Percent of Short-Stay Residents Who Had Moderate to Severe Pain	This Facility: Not Available State Average: 23.63 National Average: 20.65
Percent of Long-Stay Residents With a Urinary Tract Infection	This Facility: 14 State Average: 9.55 National Average: 8.83
Percent of Short-Stay Residents With Delirium	This Facility: Not Available State Average: 2.5 National Average: 2.13
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores	This Facility: 6 State Average: 9.59 National Average: 12.84
Percent of Short-Stay Residents With Pressure Sores	This Facility: Not Available State Average: 15.42 National Average: 17.47
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	This Facility: Not Available State Average: 72.55 National Average: 71.04
Percent of Long-Stay Residents Whose Need for Help With Daily Activities Has Increased	This Facility: 20 State Average: 17.97 National Average: 16.06
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season	This Facility: 90+ State Average: 86.35 National Average: 83.07
Percent of Long-Stay Residents Who are More Depressed or Anxious	This Facility: 35 State Average: 30.03 National Average: 14.43
Percent of Long-Stay Residents Who Have Moderate to Severe Pain	This Facility: 4 State Average: 3.21 National Average: 4.52
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder	This Facility: 9 State Average: 6.97 National Average: 5.88
Percent of Long-Stay Residents Who Lose Too Much Weight	This Facility: 13 State Average: 9.91 National Average: 9.09
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair	This Facility: 12 State Average: 4.52 National Average: 4.38
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	This Facility: 59 State Average: 80.91 National Average: 76.95
Percent of Long-Stay Residents Who Were Physically Restrained	This Facility: 0 State Average: 2.27 National Average: 5.63
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse	This Facility: 14 State Average: 17.54 National Average: 13.02

**Not Available: The number of residents is too small to report or the data for this measure is missing.