Inspection Reports for Ludlowe Center for Health and Rehabilitation
CT, 06825
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Inspection Report
Complaint Investigation
Census: 131
Capacity: 144
Deficiencies: 0
Sep 15, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included complaint investigations numbered 120671 and 120675.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. Specific findings or deficiencies are not detailed in the provided pages.
Complaint Details
Complaint investigations #120671 and #120675 were part of the inspection process; no substantiation status is provided.
Report Facts
Licensed Bed Capacity: 144
Census: 131
Complaint Investigation Numbers: Complaint investigation numbers 120671 and 120675 referenced
Medicare Residents: 31
Medicaid Residents: 63
Other Residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Personnel contacted during inspection |
| Barbara Stuart | Regional DNS | Personnel contacted during inspection |
| Jordanne Ellington | Survey Team Leader | Report submitted by |
| Sandra Vermont Hollo | Supervisor | Survey team supervisor |
Inspection Report
Complaint Investigation
Deficiencies: 9
Sep 15, 2025
Visit Reason
Unannounced visits were conducted at Ludlowe Center for Health and Rehabilitation to investigate multiple complaints related to resident care and facility compliance.
Findings
The investigation identified multiple violations including failure to ensure proper oxygen administration and physician orders, inadequate response to resident complaints about missing clothing, failure to prevent resident abuse, incomplete discharge documentation, insufficient care planning for indwelling catheters and skin care, failure to follow transfer protocols, inadequate supervision leading to a resident fall with fracture, and delayed response to pharmacy recommendations.
Complaint Details
This investigation was complaint-driven, involving complaints #2611071, #120675, and #120671. The report details substantiated violations related to resident care and facility compliance.
Deficiencies (9)
| Description |
|---|
| Failed to determine if Resident #98 was clinically appropriate to self-administer oxygen and lacked physician order for oxygen use as needed. |
| Failed to acknowledge and resolve Resident #44's complaint of missing clothing. |
| Failed to ensure Resident #76 was free from abuse after an incident involving another resident. |
| Failed to ensure complete discharge documentation and communication for Resident #154. |
| Failed to develop care plans for indwelling catheter (Resident #102) and noncompliance with geri sleeves (Resident #13). |
| Failed to ensure staff transferred Resident #12 with assistance of two per plan and failed to apply geri sleeves per physician order for Resident #13. |
| Failed to provide adequate supervision for Resident #12 at risk for falls, resulting in a fall with acute hip fracture and delayed reporting of pain. |
| Failed to obtain physician order for oxygen for Resident #98 using oxygen as needed and failed to date oxygen tubing when changed. |
| Failed to address pharmacy recommendations in a timely manner for Resident #4. |
Report Facts
Residents reviewed: 5
Dates of oxygen administration: Resident #98 received oxygen on 7/10/25, 7/11/25, 7/12/25, 7/13/25, 7/14/25, 7/19/25, 8/5/25, 8/15/25, and 9/1/25.
Fall date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the initial notice letter regarding the investigation. |
| LPN #1 | Interviewed regarding Resident #98's oxygen use and missing clothing complaint. | |
| Assistant Director of Nurses (ADNS) | Interviewed regarding oxygen orders, geri sleeves, and care plan compliance. | |
| Director of Nurses (DNS) | Interviewed regarding discharge documentation, oxygen tubing, pharmacy recommendations, and fall investigation. | |
| NA #7 | Interviewed regarding missing clothing complaint of Resident #44. | |
| Laundry Aide #1 | Interviewed regarding missing clothing complaint of Resident #44. | |
| Recreation #1 | Reported resident-to-resident abuse incident involving Resident #76. | |
| LPN #5 | Completed reportable event form for Resident #12 fall and provided statements regarding supervision. | |
| RN #3 | Regional RN | Interviewed regarding fall investigation and supervision issues. |
| LPN #4 | Interviewed regarding Resident #12's pain and care post-fall. | |
| NA #12 | Interviewed regarding supervision of Resident #12 at time of fall. |
Inspection Report
Census: 136
Capacity: 144
Deficiencies: 1
Mar 18, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior Violation letter dated 1/31/25.
Findings
Violation #1 was identified as corrected as of 2/28/25, and the Director of Nurses was notified of the correction on 3/18/25.
Deficiencies (1)
| Description |
|---|
| Violation #1 identified in prior inspection |
Report Facts
Licensed Bed Capacity: 144
Census: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elena Noonan | Director of Nurses | Contacted personnel related to findings |
| Judy Birtwistle | SNC | Report submitted by and notified Director of Nurses of correction |
Inspection Report
Follow-Up
Census: 135
Capacity: 144
Deficiencies: 5
Dec 24, 2024
Visit Reason
The visit was a follow-up inspection conducted to review the implementation of the Plan of Correction for previously identified violations.
Findings
All violations identified in the prior violation letter dated 10/11/24 were found to be corrected as of 11/13/24. The director of clinical operations was notified in person of the correction status during the visit.
Deficiencies (5)
| Description |
|---|
| Violation #1a |
| Violation #2a |
| Violation #2b |
| Violation #2c |
| Violation #2d |
Report Facts
Licensed Bed Capacity: 144
Census: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Starzman | Director of clinical operations | Notified in person of correction status of violations during the follow-up visit |
Inspection Report
Renewal
Census: 130
Capacity: 144
Deficiencies: 0
Dec 18, 2023
Visit Reason
The inspection was conducted as a licensing renewal inspection and also included review of complaint investigations #33805 and #25594.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, with attached violation letters referenced but not included in this document.
Complaint Details
The inspection included review of complaint investigations #33805 and #25594; no substantiation status is provided in this document.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Personnel contacted during the inspection |
| Dulce Taylor | DNS | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 144
Deficiencies: 1
May 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #CT25641, focusing on violations of Connecticut State regulations identified during the visit.
Findings
The facility was found to have violations of state regulations, specifically failing to implement a comprehensive care plan addressing a resident's behavioral needs, as documented in clinical records and interviews. The report includes a detailed account of a resident's fall and non-compliant behaviors, and the facility's failure to develop appropriate interventions.
Complaint Details
Complaint Investigation #CT25641 was substantiated with violations identified related to care planning and resident safety following a fall incident.
Deficiencies (1)
| Description |
|---|
| Failure to implement a comprehensive plan of care with interventions to address a resident's behavioral needs. |
Report Facts
Licensed Bed Capacity: 144
Census: 139
Dates of onsite inspection: Inspection conducted on 5/6/22 and 5/10/22.
Compliance by date: Plan of correction compliance date set for 7/20/22.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dulce Taylor | DNS | Personnel contacted during the inspection. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice letter related to the plan of correction. |
| Terri D. McNeil | RNC | FLIS staff who signed the licensing inspection report and submitted the report. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 144
Deficiencies: 2
Mar 30, 2022
Visit Reason
A complaint investigation was conducted on 3/30/2022 by a representative of the Facility Licensing and Investigations Section to identify deficiencies or violations at Ludlow Center for Health & Rehabilitation.
Findings
Violations of the General Statutes of Connecticut and regulations were identified during the inspection, including failures related to diet order compliance and allergy management for Resident #1, resulting in findings of Immediate Jeopardy. A plan of correction was submitted to address these issues.
Complaint Details
Complaint investigation #31981 was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Deficiencies were identified and substantiated.
Severity Breakdown
Immediate Jeopardy: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident #1 was served food consistency in accordance with physician orders when a peanut butter sandwich was served on a ground dysphagia diet, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Facility failed to ensure Resident #1 was not served food to which they were allergic, resulting in Immediate Jeopardy. | Immediate Jeopardy |
Report Facts
Licensed Bed Capacity: 144
Census: 137
Compliance Date: Apr 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Rosato | RN NC | Representative of FLIS who conducted the complaint investigation and signed the report |
| Patricia Page | Administrator | Named in plan of correction and correspondence |
| Dulce Taylor | DNS | Named in inspection report as personnel contacted |
| RN #1 | Nurse involved in the incident of serving peanut butter sandwich to Resident #1 | |
| LPN #1 | Charge nurse involved in the incident and subsequent interviews | |
| Maureen Golas Markure | MSN, RN, SNC Supervising Nurse Consultant | Signed the notice letter regarding the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 12, 2021
Visit Reason
An unannounced visit was conducted on November 12, 2021, by the Facility Licensing and Investigations Section of the Connecticut Department of Public Health to investigate a complaint regarding the facility's failure to honor resident choices.
Findings
The facility failed to provide a recliner chair to Resident #1 as requested by the resident and family, despite physician orders and multiple documented requests. Documentation and communication failures were noted regarding the recliner chair request.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's unmet request for a recliner chair. The complaint was substantiated by findings that the facility did not provide the chair and failed to document or communicate the request properly.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Resident #1's choice for a recliner chair was honored according to resident preference and physician's order. |
Report Facts
Dates referenced: 6
Compliance deadline: Dec 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Author of the notice letter regarding the investigation and plan of correction. |
| Patricia Page | Administrator | Facility administrator addressed in the notice and signer of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 144
Deficiencies: 1
Nov 12, 2021
Visit Reason
A complaint investigation (ACTS Reference Number CT31128) was conducted at Ludlowe Center for Health & Rehabilitation on 11/12/21 by the Department of Public Health to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility failed to ensure that Resident #1's choice was honored by not providing a recliner chair as requested by the resident, family, and physician's order. Documentation and communication failures were identified regarding the recliner chair request.
Complaint Details
Complaint investigation ACTS Reference Number CT31128 was conducted to determine compliance with long term care facility regulations. The complaint involved failure to honor resident choice regarding provision of a recliner chair for Resident #1. The complaint was substantiated as deficiencies were identified.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident choice was honored by not providing a recliner chair for Resident #1 as requested and ordered by physician. | SS=D |
Report Facts
Capacity: 144
Census: 133
Completion date for plan of correction: Dec 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed and stated he was not informed of recliner chair request for Resident #1 | |
| DNS | Director of Nursing Services | Interviewed and stated she was not aware of recliner chair request for Resident #1 and identified documentation failures |
Inspection Report
Renewal
Census: 130
Capacity: 144
Deficiencies: 0
Aug 18, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the Ludlowe Center for Health & Rehab.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. A narrative report and attached violation letter provide additional details.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Personnel contacted during the inspection. |
| Dulce Taylor | DNS | Personnel contacted during the inspection. |
Inspection Report
Re-Inspection
Deficiencies: 2
Aug 18, 2021
Visit Reason
Unannounced visits were made to Ludlowe Center For Health & Rehabilitation, LLC which concluded on August 18, 2021, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a re-certification survey.
Findings
The facility was found to have violations related to pharmaceutical services and nursing staff medication administration errors, including out-of-stock emergency medications and a medication error rate exceeding 5%. The facility lacked current policies for maintaining emergency medication stock and had errors in medication preparation and administration.
Deficiencies (2)
| Description |
|---|
| Failed to ensure emergency medications were available in the emergency medication box; several medications were out of stock or unavailable. |
| Failed to ensure medication error rate was less than 5%; observed medication errors including crushing medications that should not be crushed and improper administration techniques. |
Report Facts
Medication error rate: 15
Compliance deadline: Sep 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Named as contact for questions regarding violations and instructions |
| Patricia Page | Administrator | Named as recipient of the inspection report and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 18, 2021
Visit Reason
A Recertification survey was conducted on 8/11/21, 8/12/21, 8/16/21, 8/17/21 and 8/18/21 at Ludlowe Center for Health and Rehabilitation to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to pharmacy services including failure to maintain emergency medication box stock, and medication administration errors resulting in a medication error rate exceeding 5%. The facility provided a plan of correction including re-education of staff and audits to ensure compliance.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure emergency medications were available as noted on the formulary; four medications were out of stock in the emergency medication box. | SS=D |
| Facility failed to ensure medication error rate was less than 5%; observed medication administration errors including crushing medications that should not be crushed and incorrect dosage given. | SS=D |
Report Facts
Date of survey completion: Aug 18, 2021
Medication error rate: 15
Number of missing medications in emergency box: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed crushing medications that should not be crushed and medication administration errors |
| RN #2 | Acting RN Supervisor | Interviewed regarding emergency medication box stock and formulary |
| DNS | Director of Nursing Services | Interviewed regarding emergency medication box stocking issues and plan for monitoring |
Inspection Report
Abbreviated Survey
Census: 80
Capacity: 144
Deficiencies: 0
Apr 26, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey.
Inspection Report
Complaint Investigation
Census: 143
Capacity: 144
Deficiencies: 1
Jan 9, 2020
Visit Reason
An unannounced visit was made on January 9, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint investigation.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, specifically related to dental care consent and documentation for Resident #1. The facility did not provide a policy regarding dental services and failed to ensure the resident was seen by a dentist as required.
Complaint Details
Complaint investigation #26653 was substantiated with violations identified related to dental care consent and documentation for Resident #1.
Deficiencies (1)
| Description |
|---|
| Failure to provide a policy regarding dental services and failure to ensure Resident #1 was seen by a dentist as required. |
Report Facts
Licensed Bed Capacity: 144
Census: 143
Plan of Correction Compliance Date: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Named in relation to the complaint investigation and plan of correction. |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice of violation and complaint investigation documents. |
| Laura Trombley Norton | Nurse Consultant | Conducted the desk audit review on March 12, 2020. |
| Stacy Taylor-Smith | Director of Nursing | Mentioned in interview regarding dental care findings. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 9, 2020
Visit Reason
An unannounced visit was made to Ludlowe Center for Health & Rehabilitation on January 9, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility was found to be noncompliant with regulations regarding dental care for a sampled resident, specifically failing to ensure routine dental care was provided after consent was obtained. The facility did not have a policy regarding dental services and failed to document that the resident was seen by a dentist despite consent being signed.
Complaint Details
Complaint #26653 triggered the visit. The letter references the complaint number and investigation related to alleged violations.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that routine dental care was provided to the resident after consent to treat was obtained, including lack of documentation that the resident was seen by the dentist and absence of a facility policy regarding dental services. |
Report Facts
Complaint number: 26653
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the letter and is the contact for questions regarding the violations and instructions |
| Patricia Page | Administrator | Named as recipient of the letter and signed the plan of correction response |
Inspection Report
Plan of Correction
Deficiencies: 4
Apr 18, 2019
Visit Reason
Unannounced visits were made to Ludlowe Center For Health & Rehabilitation, LLC concluding on April 18, 2019, for the purpose of conducting an investigation and a licensure inspection by the Facility Licensing and Investigations Section of the Department of Public Health.
Findings
The report identified multiple violations of Connecticut General Statutes and Regulations related to advanced directives, fall prevention, unnecessary medication monitoring, and food service safety. The facility was required to submit a plan of correction addressing these deficiencies.
Complaint Details
Complaint #24969 triggered the investigation and licensure inspection.
Deficiencies (4)
| Description |
|---|
| Failure to ensure advanced directives information was reviewed with the resident's representative within 48 hours. |
| Failure to provide an environment free from accident hazards and/or provide necessary assistive devices to prevent accidents. |
| Failure to monitor for specific targeted behaviors related to antipsychotic medication use. |
| Failure to distribute and serve food in accordance with professional standards for food service safety. |
Report Facts
Complaint number: 24969
Dates referenced: Multiple dates between 2019-01-02 and 2019-04-18 referenced in findings
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Named as recipient of the notice and author of the plan of correction letter |
| Connie Greene | Supervising Nurse Consultant | Signed the initial notice letter |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 144
Deficiencies: 13
Apr 15, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints and to review the plan of correction submitted for prior violations.
Findings
Violations of Connecticut State Statutes and regulations were identified related to resident care, medication management, fall prevention, food service safety, and documentation. The facility was found to be in substantial compliance during follow-up visits after submission of plans of correction.
Complaint Details
Complaint investigations were conducted for complaints #24969, #23158, #23221, #24848, and #24631. Violations were substantiated and plans of correction were reviewed and found to be implemented with substantial compliance achieved.
Deficiencies (13)
| Description |
|---|
| Failure to ensure advanced directives information was reviewed with resident's representative within 48 hours. |
| Failure to provide an environment free from accident hazards and provide necessary assistive devices to prevent accidents. |
| Failure to monitor specific targeted behaviors related to antipsychotic medication use. |
| Failure to distribute and serve food in accordance with professional standards for food service safety. |
| Failure to notify APRN in a timely manner when a change in condition was identified and failure to notify family member with medication changes or need for medical procedure. |
| Failure to ensure a comprehensive care plan for residents with indwelling catheters and those at risk for falls. |
| Failure to ensure behavior monitoring was completed in accordance with facility policy for residents receiving psychotropic medication. |
| Failure to ensure discharge referral was sent timely to home health agency and all medical needs were reflected on discharge paperwork. |
| Failure to ensure liquid pain medication was not diluted, altering strength and dosage administered. |
| Failure to ensure accurate medication counts and controlled substance accountability. |
| Failure to ensure wound care and skin tear treatments were properly documented and followed. |
| Failure to ensure proper notification and documentation related to Foley catheter care and insertion. |
| Failure to ensure proper documentation of meal intake and coordination of hospice services. |
Report Facts
Licensed Bed Capacity: 144
Census: 140
Inspection Dates: Array
Plan of Correction Submission Deadline: May 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Administrator | Named in relation to plan of correction and facility compliance. |
| Deborah Cavalier | Director of Nursing Services (DNS) | Named in relation to findings and interviews. |
| Connie Greene | Supervising Nurse Consultant | Named in relation to complaint investigation and correspondence. |
| Denise Oley | Nurse Consultant | Named in relation to report submission and plan of correction review. |
| Aneta Predka | Registered Nurse | Named in relation to report submission and inspection findings. |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 174
Deficiencies: 0
Mar 12, 2018
Visit Reason
The inspection visit was conducted as a licensing inspection including a renewal and to investigate complaint number 22911.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation number 22911 was conducted and found no violations.
Report Facts
Licensed Bed Capacity: 174
Census: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Page | Personnel contacted during inspection | |
| Deborah Cavalier | Personnel contacted during inspection |
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