LEDGEWOOD MANOR - WINDHAM, ME

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Address

200 ROUTE 115, PO BOX 760
WINDHAM, ME, 04062

Phone (make sure to verify first before calling): (207) 892-2261

Number of Certified Beds: 60
Total Number of Residents: 52
Percent of Occupied Beds: 87%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: For profit - Corporation
Located Within a Hospital?: No
Multi Nursing Home Ownership?: No
Resident and Family Councils: Resident
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 4 Stars
Health Inspections Star Rating: 3 Stars
Nurse Staffing Star Rating: 4 Stars
Quality Measures Star Rating: 4 Stars
RN Only Star Rating: 4 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 3.43
Administrative Staff - Part Time: 0.69
Certified Nurse Aides - Full Time: 15.31
Certified Nurse Aides - Part Time: 14.66
Dietitians - Under Contract: 0.09
Food Service Personnel - Full Time: 4.34
Food Service Personnel - Part Time: 5.43
Housekeeping Personnel - Full Time: 2.41
Licensed Practical/ Vocational Nurses - Full Time: 3.31
Licensed Practical/ Vocational Nurses - Part Time: 0.80
Medical Directors - Under Contract: 0.06
Nurses With Administrative Duties - Full Time: 2.29
Physical Therapists - Under Contract: 0.43
Rn Director Of Nursing - Full Time: 1.14
Activities Professionals - Full Time: 1.14
Occupational Therapists - Under Contract: 0.60
Pharmacists - Under Contract: 0.11
Registered Nurses - Part Time: 2.60
Social Workers - Part Time: 0.91
Housekeeping Personnel - Part Time: 2.49
Certified Nurse Aides - Under Contract: 0.34
Medication Aides/ Technicians - Part Time: 2.89
Medication Aides/ Technicians - Full Time: 3.43
Medication Aides/ Technicians - Under Contract: 0.11

Provided Services

Activities Services Are Provided Onsite To Residents
Clinical Laboratory Services Are Provided Onsite To Residents
Dental Services Are Provided Onsite To Residents
Diagnostic Xray Services Are Provided Onsite To Residents
Dietary Services Are Provided Onsite To Residents
Housekeeping Services Are Provided Onsite To Residents
Nursing Services Are Provided Onsite To Residents
Occupational Therapy Services Are Provided Onsite To Residents
Pharmacy Services Are Provided Onsite To Residents
Physical Therapy Services Are Provided Onsite To Residents
Physician Services Are Provided Onsite To Residents
Podiatry Services Are Provided Onsite To Residents
Social Work Services Are Provided Onsite To Residents

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.630
Maine:	1.053

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	0.370
State:	0.440

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	0.990
Maine:	1.485

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.290
Maine:	6.410

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.290
Maine:	0.132

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	16.2%
Maine:	13.7%

Percent of long-stay residents who self-report moderate to severe pain

Here:	3.4%
Maine:	12.6%

Percent of long-stay residents who lose too much weight

Here:	3.8%
Maine:	8.0%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	2.0%
State:	4.2%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	5.8%
Maine:	7.0%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	30.8%
State:	10.8%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	1.9%
Maine:	3.7%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
Maine:	97.5%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	100.0%
State:	94.6%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	38.5%
State:	26.6%

Complaint Deficiency

Record of quarterly fire drills for each shift under varying conditions: Many (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Many (Potential for minimal harm)

Other fire safety features required by fire safety codes: Many (Potential for minimal harm)

A properly installed master alarm panel: Many (Minimal harm or potential for actual harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Many (Potential for minimal harm)

Allow the resident the right to participate in the planning or revision of the resident's care plan: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Some (Minimal harm or potential for actual harm)

Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function: Some (Minimal harm or potential for actual harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Some (Minimal harm or potential for actual harm)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Many (Minimal harm or potential for actual harm)

Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public: Many (Minimal harm or potential for actual harm)

Give or get quality lab services/tests in a timely manner to meet the needs of residents: Some (Minimal harm or potential for actual harm)

A fire alarm system that can be heard throughout the facility: Many (Potential for minimal harm)

An approved automatic sprinkler system connected to the fire alarm system: Many (Potential for minimal harm)

Send and promptly deliver unopened mail to residents: Many (Potential for minimal harm)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Minimal harm or potential for actual harm)

1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being: Few (Minimal harm or potential for actual harm)

Make sure medically necessary lab services/tests are ordered by the attending physician: Few (Minimal harm or potential for actual harm)

Provide care by qualified persons according to each resident's written plan of care: Few (Minimal harm or potential for actual harm)

Develop policies and procedures for influenza and pneumococcal immunizations: Some (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Many (Actual harm)

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