Inspection Reports for
Ludlowe Center for Health and Rehabilitation

The complaint investigation focused on Resident #3 who had dementia with behavioral disturbances and known grabbing behaviors. The resident sustained a fracture to the right hand caused by grabbing and hitting the side rails. Multiple staff interviews confirmed the resident's grabbing behaviors and the lack of adequate preventive interventions in the care plan. The side rails were removed only after the injury was identified.

The facility failed to develop and implement a comprehensive care plan with interventions to prevent injury from grabbing behaviors, resulting in a resident sustaining a nondisplaced fracture of the proximal phalanx of the right hand due to contact with the side rails. The side rails were not padded or removed prior to the injury, and staff interventions to prevent injury were inadequate.

The complaint investigation was substantiated based on evidence that Resident #64 assaulted Resident #76 by slapping him/her in the face. Both residents have dementia. No injury was observed and the facility separated the residents following the incident.

The facility failed to ensure Resident #76 was free from abuse after Resident #64 slapped Resident #76 in the face. Both residents have dementia, no injury was noted, and the facility took steps to separate the residents and monitor their behavior.

The facility was found deficient in multiple areas including failure to ensure proper self-administration evaluation for oxygen therapy, failure to address resident grievances regarding missing belongings, incomplete discharge documentation, incomplete care plans for indwelling catheters and skin protection, failure to follow care plan interventions for resident transfers and skin care, inadequate supervision leading to a resident fall with fracture, failure to maintain dated oxygen tubing and obtain physician orders timely, and delayed response to pharmacy recommendations.

This investigation was complaint-driven, involving complaints #2611071, #120675, and #120671. The report details substantiated violations related to resident care and facility compliance.

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.

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.

The complaint investigation found that the nursing assistant did not notify the nurse of Resident #1's low blood pressure reading of 76/33 on 1/1/2025 at 9:46 AM. The charge nurse and supervisor were not informed, and no assessment or notification to the APRN was completed, violating facility policy.

The facility failed to ensure that the nursing assistant notified the nurse timely of Resident #1's low blood pressure reading of 76/33 on 1/1/2025. Interviews with nursing staff confirmed the lack of notification and assessment, despite facility policy requiring notification and evaluation of changes in condition.

The facility failed to ensure a physician order was transcribed accurately, resulting in Resident #3 not receiving Vancomycin as ordered on multiple days. The error was due to an incorrect start date entered by nursing staff, leading to missed doses without adverse effects.

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.

The complaint investigation focused on accident hazards and side rail use. It was substantiated that a resident sustained a laceration from hitting a bed side rail during transfer. The facility also failed to properly assess and document side rail use for multiple residents.

The facility failed to ensure a safe environment free from hazards, resulting in a resident sustaining a 12-centimeter laceration requiring sutures after hitting a bed side rail during transfer. Additionally, the facility failed to assess, obtain consent, and secure physician orders for side rail use for multiple residents, with 59 residents lacking side rail orders and six lacking assessments, despite side rails being used on all beds for mobility.

The complaint investigation substantiated that Resident #2 did not receive incontinent care timely after requesting it during the 11:00 PM to 7:00 AM shift on 5/13/24. Staffing shortages on the Passport unit were also confirmed as a contributing factor.

The facility failed to provide timely incontinent care to Resident #2 after a request during the 11:00 PM to 7:00 AM shift on 5/13/24, resulting in a delay of two to two and a half hours. Additionally, the facility was found to be short staffed on the Passport unit during that shift, contributing to the failure to meet resident care needs.

The complaint involved an allegation of sexual abuse where Resident #45 was kissed by Resident #96. The allegation was substantiated based on witness statements, resident care plans, and interviews. Resident #96 had a history of hypersexuality and dementia. The facility lacked clear policies or procedures for monitoring residents in shared community areas at the time of the incident.

The facility failed to ensure Resident #45 was free from sexual abuse. The investigation found that Resident #96 kissed Resident #45 in a shared lounge area. Staff monitoring and policies regarding supervision in the community area were inadequate. The facility had care plans and policies addressing abuse prevention, but monitoring lapses occurred.

The complaint involved an allegation of sexual abuse where Resident #45 was kissed by Resident #96 without consent. Investigations included interviews with nursing assistants, nurses, social workers, and review of clinical records and facility policies. The facility failed to ensure adequate monitoring and protection of residents in shared community areas.

The facility failed to ensure a resident was free from sexual abuse, failed to incorporate PASSR Level 2 recommendations into care plans, failed to update levels of care with new diagnoses, failed to perform weekly weights for a newly admitted resident, and failed to discard unadministered and expired medications properly. Deficiencies were noted in monitoring residents in shared community areas and in documentation and policy adherence.

The facility failed to ensure a complete and accurate clinical record documenting written notice and reasons for multiple room changes for Resident #1. Interviews confirmed that although room changes were discussed, documentation was lacking and a policy for room changes was not provided.

Complaint Investigation #CT25641 was substantiated with violations identified related to care planning and resident safety following a fall incident.

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 investigation #31981 was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Deficiencies were identified and substantiated.

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.

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.

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 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.

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.

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 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.

The facility failed to ensure the emergency medication box was fully stocked according to the formulary and lacked a current policy for maintaining it. Additionally, medication administration errors were observed, including crushing medications that should not be crushed and incorrect dosages, resulting in a 15% medication error rate.

Complaint investigation #26653 was substantiated with violations identified related to dental care consent and documentation for Resident #1.

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 #26653 triggered the visit. The letter references the complaint number and investigation related to alleged violations.

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 #24969 triggered the investigation and licensure inspection.

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 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.

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.