Ledgewood Manor
200 Route 115, Windham, ME 04062
Ledgewood Manor is a nursing home in Windham, Maine. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (207) 892-2261
- Last standard health inspection
- May 28, 2026 (5 months ago)
- Certified beds
- 60
- Residents per day, on average
- 46.8
- Ownership type
- For profit - Individual
- Legal business name
- Ledgewood Manor INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Maine average (34 vs 31).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
10 citations
Health inspection on May 28, 2026
CMS lists this as a standard inspection.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on June 19, 2026.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 12, 2026.
CMS has cited this home for F0584 2 times since 2022.
Citation F0868. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on July 9, 2026.
CMS has cited this home for F0868 2 times since 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 9, 2026.
CMS has cited this home for F0880 2 times since 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 3, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 26, 2026.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 19, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on June 22, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 26, 2026.
Citation F0636. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on July 3, 2026.
12 citations
Fire safety inspection on May 28, 2026
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on June 26, 2026.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on June 1, 2026.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on June 26, 2026.
CMS has cited this home for E0037 2 times since 2025.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for E0039 2 times since 2025.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on July 10, 2026.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 12, 2026.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for K0712 2 times since 2022.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on June 1, 2026.
Citation K0232. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on June 26, 2026.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 10, 2026.
Citation K0754. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on June 1, 2026.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 29, 2026.
CMS has cited this home for K0918 3 times since 2022.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of May 28, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
1 citation
Health inspection on April 29, 2025
CMS lists this as a complaint inspection.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 24, 2025.
10 citations
Health inspection on February 26, 2025
CMS lists this as a standard inspection.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on April 11, 2025.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 11, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 11, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0812 2 times since 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 11, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 11, 2025.
Citation F0623. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 11, 2025.
Citation F0625. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
Citation F0637. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on April 11, 2025.
11 citations
Fire safety inspection on February 26, 2025
CMS lists this as a standard inspection.
Citation E0025. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on March 6, 2025.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on March 21, 2025.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on March 5, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 27, 2025.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on March 6, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 19, 2025.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on March 4, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 12, 2025.
Citation K0342. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on March 12, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 14, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on March 7, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
1 citation
Health inspection on October 8, 2024
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 8, 2024.
CMS update of September 26, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of December 21, 2023
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
12 citations
Health inspection on June 14, 2022
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 29, 2022.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on June 29, 2022.
Citation F0886. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Perform COVID19 testing on residents and staff.
CMS lists it as corrected on June 29, 2022.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 29, 2022.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 29, 2022.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on June 29, 2022.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 29, 2022.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on June 29, 2022.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on June 29, 2022.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 29, 2022.
Citation F0567. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on June 29, 2022.
Citation F0868. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on June 29, 2022.
4 citations
Fire safety inspection on June 14, 2022
CMS lists this as a standard inspection.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 2, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 2, 2022.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on August 2, 2022.
Citation K0916. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on August 17, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BENNETT, EDISON5% or greater direct ownership interest · 51% · since 02/11/1980
- BENNETT, JEAN5% or greater direct ownership interest · 49% · since 02/11/1980
- PREFERRED THERAPY OUTPATIENT SERVICES OF ME, LLCOperational/managerial control · not applicable · since 12/03/2018
- BENNETT, EDISONOperational/managerial control · not applicable · since 01/01/1980
- BENNETT, NATHANIELOperational/managerial control · not applicable · since 02/22/2015
- BROWN, JESSICAOperational/managerial control · not applicable · since 05/31/2021
- CADIGAN, CATHARINEOperational/managerial control · not applicable · since 10/01/2024
Questions
When was Ledgewood Manor last inspected?
CMS lists May 28, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Ledgewood Manor have?
CMS lists 34 health citations since June 14, 2022. CMS also calls these deficiencies.
Has Ledgewood Manor been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Ledgewood Manor?
Its CMS overall star rating is 3 of 5.
Is Ledgewood Manor a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.