Ledgewood Manor - 3-Star Rehab Facility in Windham, ME | PlacetClinical Quality Indicators
Long-stay residents , lower is better
Antipsychotic medication use 16.07%Falls causing major injury 3.03%Pressure ulcers (high-risk) 2.14%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
Last inspected: Apr 2025 (401 days ago)🔍 Health Inspection
3/5
★★★☆☆
📊 Quality Measures
3/5
★★★☆☆
Private Pay
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 1h 3m · US avg: 41 min
Total Nurse / Resident / Day
4h 6m
State avg: 4h 21m · US avg: 3h 53m
N/A
State avg: 4 min · US avg: 4 min
53 per 100
State avg: 49 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
89%above avg
US avg: 64%
Total Nurse Weekend
4h 37m
Federal Penalties
No federal penalties in the past 3 years.
✅ No penalty records on file
Inspection Citations
Survey: April 29, 2025(3 citations)
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
Survey: February 26, 2025(30 citations)
🟡 Potential for HarmResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
Survey: October 8, 2024(3 citations)
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation DeficienciesComplaint
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation DeficienciesComplaint
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation DeficienciesComplaint
Survey: June 14, 2022(36 citations)
⚪ MinimalResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
⚪ MinimalAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
N/A
State avg: 20.5 · US avg: 23.9
N/A
State avg: 15.6 · US avg: 12.0
3.0 per 100
State avg: 4.3 · US avg: 3.3
2.1 per 100
State avg: 4.4 · US avg: 5.1
N/A
State avg: 1.4 · US avg: 1.6
N/A
State avg: 74.5 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
20/100
Incentive Payment
-1.78% penalty
Healthcare-Assoc. Infections
N/A
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
N/A
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
🟡 Potential for Harm
Quality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Rights Deficiencies
⚪ MinimalResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for Harm
Infection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
⚪ MinimalResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
⚪ MinimalAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
⚪ MinimalResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
⚪ MinimalAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
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