SNF
Ledgewood Manor
CCN: 205137 · WINDHAM, ME 04062 · Cumberland County
Overview
- Address
- 200 ROUTE 115, WINDHAM, ME 04062
- Phone
- 2078922261
- Certified beds
- 60
- Avg daily residents
- 44 (73% of beds filled)
- Ownership
- For-profit (individual owner)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1993-01-01
- Setting
- Urban
3 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 4.11 | 3.52 | 4.51 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.52 | 0.62 | 0.57 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.71 | 0.78 | 0.78 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.88 | 2.12 | 3.16 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.23 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.00 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.84
hrs / resident / day
RN (weekend)
0.34
hrs / resident / day
Total nurse (adjusted, weekend)
4.21
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
53.1%
annual
RN turnover
57.1%
annual
Administrators departed
1
last 12 months
Resident acuity
Nursing Case-Mix Index
1.25
higher acuity than avg
Case-Mix Index Ratio
0.90
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-02-26 | 11 | 10 | 1 | 52 | 1 | 52 |
| Cycle 2/3 (prior) | 2022-06-14 | 13 | 12 | 1 | 92 | 1 | 92 |
Total weighted health score
62.0
lower is better
Deficiencies (33)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
7 A/B/C No actual harm — minor
25 D/E/F Actual harm — potential for minor
1 J/K/L Immediate jeopardy
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | 2025-04-29 | 2025-04-24 |
| 0578 | 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. | E | 2025-02-26 | 2025-04-11 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | 2025-02-26 | 2025-04-11 |
| 0625 | 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. | B | 2025-02-26 | 2025-04-11 |
| 0637 | Assess the resident when there is a significant change in condition | B | 2025-02-26 | 2025-04-11 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | 2025-02-26 | 2025-04-11 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-02-26 | 2025-04-11 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | 2025-02-26 | 2025-04-11 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2025-02-26 | 2025-04-11 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | 2025-02-26 | 2025-04-11 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2025-02-26 | 2025-04-11 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2024-10-08 | 2024-11-08 |
| 0567 | Honor the resident's right to manage his or her financial affairs. | C | 2022-06-14 | 2022-06-29 |
| 0584 | 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. | D | 2022-06-14 | 2022-06-29 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2022-06-14 | 2022-06-29 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | 2022-06-14 | 2022-06-29 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2022-06-14 | 2022-06-29 |
| 0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | B | 2022-06-14 | 2022-06-29 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2022-06-14 | 2022-06-29 |
| 0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F | 2022-06-14 | 2022-06-29 |
| 0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | 2022-06-14 | 2022-06-29 |
| 0886 | Perform COVID19 testing on residents and staff. | F | 2022-06-14 | 2022-06-29 |
| 0887 | 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. | D | 2022-06-14 | 2022-06-29 |
| 0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | 2022-06-14 | 2022-06-29 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | 2019-10-31 | 2019-12-31 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2019-10-31 | 2019-12-31 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | 2019-10-31 | 2019-12-31 |
| 0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D | 2019-10-31 | 2019-12-31 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K | 2019-10-31 | 2019-12-31 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2019-10-31 | 2019-12-31 |
| 0730 | Observe each nurse aide's job performance and give regular training. | B | 2019-10-31 | 2019-12-31 |
| 0838 | 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. | D | 2019-10-31 | 2019-12-31 |
| 0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | 2019-10-31 | 2019-12-31 |
Ownership & Corporate Structure
Owner / manager organizations (1)
| Organization | Role | Association |
|---|---|---|
| PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLC | OPERATIONAL/MANAGERIAL CONTROL | since 12/03/2018 |
Owner / manager individuals (8)
| Name | Role | Association |
|---|---|---|
| BENNETT, EDISON | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 02/11/1980 |
| BENNETT, JEAN | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 02/11/1980 |
| BENNETT, EDISON | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/1980 |
| BENNETT, NATHANIEL | OPERATIONAL/MANAGERIAL CONTROL | since 02/22/2015 |
| BROWN, JESSICA | OPERATIONAL/MANAGERIAL CONTROL | since 05/31/2021 |
| CADIGAN, CATHARINE | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2024 |
| BENNETT, NATHANIEL | CORPORATE DIRECTOR | since 02/22/2015 |
| BROWN, JESSICA | CORPORATE DIRECTOR | since 05/31/2021 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 99 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.77760 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 3.16079 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.56866 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 4.50706 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 4.21408 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 44.0 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.78048 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.12117 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.61519 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.51684 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.09972 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | WINDHAM | City/Town |
| Provider Information | CMS Certification Number (CCN) | 205137 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Cumberland | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1993-01-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 3 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 43.8368 | Latitude |
| Provider Information | Legal Business Name | LEDGEWOOD MANOR INC | Legal Business Name |
| Provider Information | Location | 200 ROUTE 115,WINDHAM,ME,04062 | Location |
| Provider Information | Long-Stay QM Rating | 3 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -70.426 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 60 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.24586 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.90434 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 3 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Individual | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 200 ROUTE 115 | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Ledgewood Manor | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 020 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 3 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 52 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 1 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 10 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-02-26 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 52 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 11 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 12 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2022-06-14 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 92 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 1 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 92 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 13 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.34370 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 57.1 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.22629 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.70830 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.87910 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.00000 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.51798 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 4.10539 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | — | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | 2 | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 4 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | ME | State |
| Provider Information | Telephone Number | 2078922261 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.83852 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 53.1 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 62.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 04062 | ZIP Code |