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Ledgewood Manor

Inspection Results

Nursing Homes Maine Windham Ledgewood Manor

Ledgewood Manor has been cited for a total of 50 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Ledgewood Manor.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 89 nursing homes in Maine with a total of 3,290 deficiencies resulting in an average of 36.97 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Honor the resident's right to manage his or her financial affairs.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
PASARR screening for Mental disorders or Intellectual Disabilities
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
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.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Honor the resident's right to manage his or her financial affairs.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
PASARR screening for Mental disorders or Intellectual Disabilities
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category:
Administration Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
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.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-06-14
Corrected:
2022-06-29
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-02-09
Corrected:
2021-02-19
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-02-09
Corrected:
2021-02-19
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
K
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-10-31
Corrected:
2019-12-31
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-09-12
Corrected:
2018-09-28

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Ledgewood Manor

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