Inspection Reports for
Laurel Ridge Health Care Center
642 Danbury Rd, Ridgefield, CT 06877, CT, 06877
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
90% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to report a change of condition for Resident #1 on two occasions, as required by facility policy.
Complaint Details
The investigation was complaint-driven, focusing on whether the facility properly reported changes in Resident #1's condition. The complaint was substantiated as the facility failed to notify the provider timely, leading to delayed care and hospital admission.
Findings
The facility failed to notify the provider of Resident #1's lethargy and change in activity level following a fall on 4/1/25, resulting in delayed evaluation and hospital admission. Interviews and documentation confirmed that staff did not properly report significant changes in Resident #1's condition as required by policy.
Deficiencies (1)
F 0684: The facility failed to ensure a change of condition was reported to the provider on two occasions for Resident #1, including lethargy on 3/31/25 and decreased activity after a fall on 4/1/25. This failure delayed appropriate evaluation and treatment.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to inform provider of Resident #1's lethargy and change in condition. |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding lack of notification about Resident #1's condition changes and ordered labs after fall. |
| RN #1 | Registered Nurse | Completed Change of Condition Evaluation after Resident #1's fall. |
| LPN #2 | Licensed Practical Nurse | Did not inform provider of Resident #1's change in condition after fall. |
| SW #1 | Social Worker | Returned call voicing concerns about Resident #1's health and informed Administrator and Director of Nurses. |
| Director of Nurses | Interviewed about standard practice for change of condition notification. |
Inspection Report
Renewal
Census: 113
Capacity: 126
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
The inspection was conducted as a licensing inspection with a focus on renewal and included a complaint investigation related to complaint numbers 43429, 43705, 43743, and 43762.
Complaint Details
Complaint investigation was conducted for complaint numbers 43429, 43705, 43743, and 43762. No substantiation status or further details are provided.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. Specific details of violations or deficiencies are not provided in the visible portion of the report.
Report Facts
Licensed Bed Capacity: 126
Census: 113
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 8, 2025
Visit Reason
Annual inspection of Laurel Ridge Center for Health & Rehabilitation to assess compliance with regulatory requirements including resident care, abuse prevention, wound care, staffing, and food service.
Findings
The facility failed to prevent resident-to-resident altercations, ensure timely incontinent care for several residents, report injuries and abuse allegations timely to the state agency, conduct complete investigations for injuries of unknown origin, and provide appropriate care plans and activities for residents. Additionally, the facility failed to maintain proper air mattress settings, provide palatable food at safe temperatures, ensure snacks were offered as scheduled, and submit accurate staffing data to CMS.
Deficiencies (11)
F0600: The facility failed to prevent resident-to-resident altercations and ensure timely incontinent care for multiple residents on 3/8/2025 during the 7 AM to 3 PM shift.
F0609: The facility failed to timely report injuries of unknown origin, resident-to-resident altercations, and allegations of abuse to the state agency.
F0610: The facility failed to conduct a complete investigation for a resident with an injury of unknown origin by not obtaining investigative statements from staff and the resident.
F0644: The facility failed to refer a resident for a Level II PASRR evaluation after identifying a new mental disorder.
F0656: The facility failed to develop a comprehensive care plan addressing a resident's activity needs and preferences.
F0679: The facility failed to provide activities that met a resident's interests and preferences, including music therapy, fresh air breaks, and pet therapy.
F0684: The facility failed to ensure air mattresses were set at appropriate settings based on resident weight and failed to initiate timely treatments for a non-pressure skin condition.
F0725: The facility failed to provide adequate nursing staff for Quarter 2 of 2024, including licensed nursing coverage and weekend staffing.
F0804: The facility failed to ensure food temperatures were maintained at safe and palatable levels, with repeated resident complaints of cold food.
F0809: The facility failed to ensure snacks were consistently offered to residents at scheduled times and residents had to request snacks.
F0851: The facility failed to submit accurate Payroll Based Journal staffing data for Quarter 1 of 2025 and Quarter 2 of 2024.
Report Facts
Deficiencies cited: 11
Resident weight: 202
Resident weight: 114
Resident weight: 87
Food temperature: 124
Food temperature: 127
Food temperature: 136
Food temperature: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Assessed Resident #59 after altercation and involved in notification of APRN. |
| LPN #3 | Licensed Practical Nurse | Notified APRN of Resident #9's injury and involved in care and reporting. |
| RN #2 | Nursing Supervisor | Responsible for assessing and reporting Resident #9's injury and investigation. |
| DNS | Director of Nursing Services | Interviewed regarding multiple findings including reporting delays and care failures. |
| FSD | Food Service Director | Interviewed regarding food temperature and snack service issues. |
| LPN #6 | Licensed Practical Nurse, Infection Preventionist | Interviewed regarding air mattress settings and resident care. |
| RN #4 | Registered Nurse | Interviewed regarding hospice air mattress management. |
| LPN #4 | Licensed Practical Nurse | Responsible for checking air mattress settings for Resident #102. |
| RN #5 | Registered Nurse | Interviewed regarding air mattress settings and adjustments. |
| Administrator | Interviewed regarding staffing and snack service policies. | |
| NA #4 | Nurse Aide | Interviewed regarding snack distribution responsibilities. |
| NA #5 | Nurse Aide | Interviewed regarding snack distribution and resident requests. |
| Vendor #2 | Interviewed regarding air mattress settings and manufacturer instructions. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 8, 2025
Visit Reason
Unannounced visits were made to Laurel Ridge Center For Health & Rehabilitation, concluding on April 8, 2025, for the purpose of conducting a recertification and a complaint investigation survey.
Complaint Details
The complaint investigation was substantiated for neglect related to failure to provide incontinent care and failure to report resident-to-resident altercations and injuries timely to the State Agency.
Findings
The investigation identified multiple violations including resident-to-resident altercations, failure to report injuries and abuse timely, neglect in providing incontinent care, incomplete nursing assessments, inadequate staffing, failure to maintain food temperatures, and incomplete medical records documentation. Several residents were involved in incidents of aggression and neglect was substantiated.
Deficiencies (6)
Failure to provide timely incontinent care to residents #27, #40, #62, and #99.
Failure to report resident-to-resident altercations and injuries to the State Agency timely.
Failure to complete nursing assessments and documentation timely for residents involved in incidents.
Failure to maintain adequate staffing levels during Quarter 2 of 2024.
Failure to ensure food temperatures were palatable and snacks were provided as needed.
Failure to maintain complete and accurate medical records including timely documentation of APRN visits.
Report Facts
Complaints referenced: 3
Resident count for social work staffing: 120
Required social work hours: 64
Staffing quarter: 2
Weight of Resident #40: 202
Weight of Resident #45: 114
Weight of Resident #102: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed the initial notice letter regarding the inspection and violations. |
| LPN #1 | Identified for failure to provide timely incontinent care and failure to complete nursing assessments. | |
| LPN #2 | Involved in assessment and reporting of resident altercations and injuries. | |
| LPN #3 | Notified of resident injury and responsible for reporting to nursing supervisor and APRN. | |
| RN #1 | Day Shift Supervisor | Notified about missed care and failed to complete assessments timely. |
| RN #2 | Nursing Supervisor | Responsible for oversight of nursing assessments and reporting; identified failures in documentation and reporting. |
| RN #4 | Identified issues with air mattress settings and hospice coordination. | |
| RN #5 | Observed air mattress settings and ensured proper documentation. | |
| Director of Nursing Services (DNS) | Interviewed regarding reporting delays and investigation findings. | |
| Administrator | Interviewed regarding staffing and snack provision. | |
| Food Service Director (FSD) | Interviewed regarding food temperature and meal service issues. | |
| Recreation Director | Responsible for plan of correction related to recreational activities. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 8, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident to resident altercations, neglect in providing timely incontinent care, failure to report injuries and abuse promptly, and incomplete medical record documentation.
Complaint Details
The complaint investigation involved allegations of resident to resident altercations, neglect in providing timely incontinent care, failure to report injuries and abuse promptly to the state agency, and incomplete medical record documentation. The facility investigation substantiated neglect related to incontinent care delays. The facility failed to report injuries and abuse within required timeframes and failed to complete timely RN assessments and APRN documentation.
Findings
The facility failed to prevent resident to resident altercations, ensure timely incontinent care for several residents, report injuries and abuse to the state agency in a timely manner, and complete timely RN assessments and documentation including APRN visit notes. Multiple residents experienced delayed care and the facility's investigation substantiated neglect. The facility also failed to notify the state agency within required timeframes for abuse and neglect incidents.
Deficiencies (4)
F 0600: The facility failed to protect residents from abuse and neglect, including resident to resident altercations and delayed incontinent care for multiple residents on 3/8/2025 during the 7 AM to 3 PM shift.
F 0609: The facility failed to timely report suspected abuse, neglect, or injury of unknown origin to the proper authorities for multiple residents, including a resident to resident altercation and injury of unknown origin.
F 0658: The facility failed to ensure Registered Nurse assessments were completed timely following incidents of abuse and neglect for multiple residents, and failed to complete timely APRN documentation for a resident's skin injury.
F 0842: The facility failed to maintain complete and accurate medical records, including timely documentation of an APRN visit for a resident with a skin injury.
Report Facts
Delay in incontinent care: 10
Delay in incontinent care: 6.95
Delay in incontinent care: 10.75
Delay in incontinent care: 7.2
Delay in reporting: 17.5
Delay in reporting: 46.5
Delay in APRN note entry: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Assessed Resident #59 after altercation and redirected Resident #81; involved in resident to resident altercation incident. |
| RN #2 | Nursing Supervisor | Responsible for RN assessments on 11/29/24 for Resident #9's injury; failed to complete and document assessment. |
| LPN #1 | Licensed Practical Nurse | Notified RN #1 of residents not receiving timely incontinent care on 3/8/2025. |
| RN #1 | Registered Nurse Supervisor | Notified late of neglect incident and failed to notify DNS immediately or complete RN assessments. |
| APRN #1 | Advanced Practice Registered Nurse | Saw Resident #40 on 3/10/2025 but delayed documentation of visit until 3/27/2025. |
| DNS | Director of Nursing Services | Interviewed regarding failures in reporting, assessments, and investigations. |
Inspection Report
Renewal
Census: 113
Capacity: 126
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations numbered 43429, 43705, 43743, and 43762.
Complaint Details
Complaint investigations referenced by numbers 43429, 43705, 43743, and 43762 were reviewed during this inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 5/9/25.
Report Facts
Licensed Bed Capacity: 126
Census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Cannavaro | Administrator | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to an allegation of resident-to-resident physical abuse involving two roommates in the facility.
Complaint Details
The complaint involved an allegation of resident-to-resident abuse where Resident #1 was reported to have attempted to choke Resident #2. The Director of Nursing did not substantiate abuse, considering the incident behavioral due to Resident #1's cognitive impairment. Both residents were evaluated with no injuries noted. Resident #1 was transferred for psychiatric treatment and returned with increased monitoring.
Findings
The facility failed to ensure a resident was free from physical abuse when Resident #1 attempted to choke Resident #2. The incident was investigated, and although no injuries were found, the facility implemented increased monitoring and transferred Resident #1 for psychiatric evaluation and treatment.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse, including physical abuse, as Resident #1 attempted to choke Resident #2. The facility did not substantiate abuse due to cognitive impairment but took corrective actions including hospital transfer and increased monitoring.
Report Facts
Residents Affected: 2
Frequency of monitoring: 15
Date of incident: Sep 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nursing Supervisor who received report of abuse from Resident #2 |
| LPN #1 | Licensed Practical Nurse | Charge nurse who obtained vital signs and documented Resident #1's admission of choking attempt |
| Director of Nursing | Director of Nursing | Interviewed and did not substantiate abuse, considered incident behavioral |
| APRN #1 | Psychiatric Advanced Practice Registered Nurse | Provided progress notes on Resident #1's psychiatric status |
| APRN #2 | Medical Advanced Practice Registered Nurse | Contacted for emergency evaluation of Resident #1 |
| Social Worker #1 | Social Worker | Provided one-to-one visits and evaluated Resident #2 after incident |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
The document is a Change of Ownership Pre-Licensure Consent Order for Laurel Ridge Center for Health & Rehabilitation, seeking an initial license to operate a nursing home in Connecticut. The visit and inspection were conducted to evaluate compliance with statutory and regulatory requirements for initial licensing.
Findings
The report outlines extensive requirements and conditions for licensing, including appointment of an Infection Control Nurse (INC), quality assurance programs, staffing and supervisory roles, facility maintenance, and compliance with state and federal regulations. It includes a Plan of Correction approved on August 7, 2024, with detailed corrective actions and timelines for compliance.
Report Facts
Plan of Correction submission date: 2024
Fine amount per day: 1000
Timeframe for Plan of Correction cure: 14
Timeframe for initial assessment report: 4
Retention period for documentation: 5
Frequency of Quality Assurance Committee meetings: 30
Retention period for Quality Assurance Committee minutes: 3
Timeframe for electrical and mechanical inspections: 120
Timeframe for fire safety inspections: 60
Resident room occupancy limit: 2
Resident counts by floor: 34
Resident counts by floor: 46
Resident counts by floor: 46
Shower stalls and tubs: 2
Shower rooms: 3
Days for elevator inspection report: 120
Days for roof inspection report: 60
Days for asbestos survey: 180
Days for fire safety repairs: 120
Days for kitchen suppression system inspection: 60
Days for hood ventilation system inspection: 90
Days for laundry and dietary evaluations: 180
Days for housekeeping evaluation: 180
Days for maintenance evaluation: 180
Days for dietary equipment repairs: 90
Days for fire and smoke barrier repairs: 90
Days for all other repairs: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lorraine Cullen | Branch Chief, Healthcare Quality and Safety Branch, Department of Public Health | Acting on behalf of the Department in executing the Pre-Licensure Consent Order |
| Marvin Ostreicher | Member of Laurel Ridge Acquisition Operator LLC | Member of the Licensee executing the Consent Order |
| Keith Edwards | Director of Engineering & Planning | Prepared the Plan of Correction |
Inspection Report
Routine
Deficiencies: 12
Date: Aug 11, 2022
Visit Reason
Routine state inspection survey of Laurel Ridge Center for Health & Rehabilitation to assess compliance with regulatory requirements including resident rights, abuse prevention, care planning, nutrition, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to verify resident code status with responsible parties, failure to prevent resident-to-resident physical mistreatment, failure to report injuries of unknown origin, failure to implement care plans to prevent altercations, failure to document nursing assessments properly, failure to provide timely podiatry care, failure to maintain safe wandering/elopement practices, failure to obtain timely weights and accurate intake records, failure to label and date oxygen tubing, failure to respond timely to pharmacy recommendations, failure to complete required antipsychotic monitoring, failure to maintain kitchen sanitation, and failure to enforce infection control practices such as hand hygiene and mask wearing.
Deficiencies (12)
F 0578: The facility failed to obtain and verify Resident #78's code status with the responsible party on admission, resulting in delayed DNR status confirmation.
F 0600: The facility failed to protect residents from physical mistreatment by other residents, resulting in multiple resident-to-resident altercations causing injuries.
F 0609: The facility failed to timely report an injury of unknown origin to the State Agency for Resident #56's bruise.
F 0656: The facility failed to implement the care plan to keep Resident #40 separated from Resident #262, resulting in repeated resident-to-resident altercations.
F 0658: The facility failed to ensure RN assessment and timely documentation of a bruise for Resident #56, delaying proper nursing evaluation.
F 0687: The facility failed to provide timely podiatry care to diabetic Resident #10, resulting in prolonged toenail overgrowth.
F 0689: The facility failed to follow manufacturer guidelines for Wanderguard use and failed to complete accurate wandering/elopement assessments for Residents #19 and #96.
F 0692: The facility failed to obtain timely weights for Resident #1 with a new feeding tube and failed to ensure accurate and complete fluid intake records for Resident #22 on fluid restriction.
F 0695: The facility failed to label and date oxygen tubing when changed per policy for Resident #44.
F 0756: The facility failed to ensure timely response to pharmacy recommendations for Resident #21 and failed to complete required Abnormal Involuntary Movement Scale (AIMS) assessments every 6 months for antipsychotic medication monitoring.
F 0812: The facility failed to ensure dietary staff wore beard restraints and failed to maintain kitchen cleanliness and sanitation.
F 0880: The facility failed to perform hand hygiene and enforce facial masking practices according to infection control standards.
Report Facts
Days since Resident #10 admission without podiatry care: 187
Fluid restriction: 1200
Medication shifts with incomplete intake documentation: 61
Medication shifts with incomplete intake documentation: 22
Weight in pounds: 143.6
Weight in pounds: 139.4
Weight in pounds: 135
Weight in pounds: 155.2
CBC Hemoglobin: 8.7
CBC Hematocrit: 28.9
CBC Red Blood Cell Count: 3.78
CBC Monocytes: 15.2
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 30, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, including failure to accommodate resident needs, failure to provide appropriate treatment, and failure to prevent accidents.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate resident care including accessibility of call lights, oxygen administration, accident prevention, and dental service follow-up. The complaints were substantiated with findings of deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for a resident with paraparesis, failure to administer oxygen when saturation was low, failure to prevent falls and accidents due to inadequate supervision and assistance, and failure to provide timely dental services after loss of dentures.
Deficiencies (4)
F 0558: The facility failed to ensure a call light was accessible to a resident with paraparesis, resulting in the call light being out of reach for over an hour despite staff awareness.
F 0684: The facility failed to administer oxygen to a resident with low oxygen saturation (74%), and lacked a policy for oxygen administration in hypoxic residents.
F 0689: The facility failed to prevent accidents by not following residents' plans of care and physician orders, resulting in falls and injuries for multiple residents due to inadequate assistance and supervision.
F 0791: The facility failed to ensure timely follow-up dental services after a resident's dentures were lost, and did not implement its policy regarding lost dentures.
Report Facts
Oxygen saturation level: 74
Laceration size: 5
Laceration size: 1
Skin tear size: 0.5
Skin tear size: 0.2
Time call light out of reach: 75
Date of physician order: Jul 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nursing Assistant | Named in call light placement deficiency for Resident #100 |
| LPN #2 | Licensed Practical Nurse | Identified call light placement expectations for Resident #100 |
| RN #3 | Registered Nurse | Identified failure to administer oxygen and follow-up for Resident #32 |
| RN #5 | Registered Nurse | Assessed Resident #32 with low oxygen saturation but did not administer oxygen |
| DNS | Director of Nursing Services | Provided statements on oxygen administration and accident prevention policies |
| NA #2 | Nurse Aide | Showered Resident #19 alone despite care plan requiring two staff |
| NA #5 | Nurse Aide | Involved in Resident #54 fall and unable to prevent injury |
| NA #9 | Nurse Aide | Transferred Resident #2 alone despite two-person assist order, resulting in fall |
| LPN #3 | Licensed Practical Nurse | Completed missing property form for Resident #11's lost dentures |
Report
May 6, 2025
Report
April 8, 2025
Report
April 8, 2025
Report
October 1, 2024
Report
August 11, 2022
Report
October 30, 2019
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