Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ludlowe Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe dementia, behavioral disturbances, and daily grabbing behaviors sustained a finger fracture after repeatedly grabbing and becoming trapped in bed side rails. Despite staff awareness of the resident's behaviors and frequent incidents of grabbing the rails, the care plan did not include specific interventions to prevent injury from side rail use, such as padding or removal. The lack of adequate supervision and failure to address known risks led to the resident's injury.
A resident with dementia, severe cognitive impairment, and a history of aggressive grabbing behaviors did not have a care plan that included specific interventions to prevent injury from side rails, despite staff awareness and documentation of these behaviors. The omission led to the resident sustaining a hand fracture after grabbing the side rail, with staff interviews confirming the lack of formalized preventive measures in the care plan.
A resident with dementia was slapped in the face by another resident, also with dementia, in a recreation room. The affected resident had a care plan addressing prior incidents and required monitoring, but the physical abuse occurred without provocation. Facility staff confirmed the event and separated the residents afterward, but the incident reflects a failure to protect the resident from abuse as required by policy.
A resident with multiple chronic conditions experienced a critically low blood pressure that was recorded by a nursing assistant but not communicated to the assigned LPN. As a result, supervisory staff were not notified, and no timely assessment or intervention occurred, contrary to facility policy requiring prompt notification and evaluation of significant changes in condition.
A resident with a femur fracture and UTI did not receive Vancomycin as ordered due to a transcription error. The medication was placed on hold from 3/3 to 3/6, despite orders for daily administration. The error was discovered on 3/7, and the medication was restarted. The facility's policy requires timely administration per physician orders.
A resident with hemiplegia and muscle weakness did not receive timely incontinent care after requesting assistance during the night shift. The nurse aide on duty was the only one assigned to the unit and became occupied with other tasks, forgetting to return to the resident. The resident had to wait approximately 2.5 hours until the next shift for care. The unit was short-staffed, and there was a lack of communication about the need for additional help.
A facility failed to provide adequate staffing, resulting in a resident not receiving timely incontinent care. The resident, who required assistance with toileting, requested care during the night shift but had to wait over two hours due to staffing shortages. The scheduled NA called out, and the facility's attempt to cover the shift was unsuccessful, leaving the remaining NA overwhelmed and unable to meet all residents' needs.
Failure to Prevent Injury from Side Rail Use in Resident with Behavioral Risks
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia with behavioral disturbances, and a history of grabbing behaviors was not adequately protected from injury related to side rail use. The resident was non-ambulatory, dependent on staff for all activities of daily living, and exhibited daily grabbing behaviors, including grabbing side rails during care and transfers. The care plan identified the resident's behavioral risks and directed staff to monitor and intervene before agitation escalated, but did not include specific interventions to prevent injury from side rail use, despite staff being aware of the resident's tendency to grab the rails. Multiple nursing assistants reported that the resident consistently grabbed the side rails during care, sometimes requiring them to place a pillow between the resident and the rails to prevent injury. On one occasion, a nursing assistant observed the resident's hand stuck between the bars of the side rail but did not notify a nurse, as this was a frequent occurrence. The facility's documentation and interviews confirmed that the resident's right hand and fingers were found swollen and bruised, with an x-ray revealing an acute nondisplaced fracture of the fifth finger. The injury was determined to have occurred when the resident's hand became trapped in the lower opening of the side rail, aligning with the observed bruising. Despite the known risk behaviors and repeated incidents of grabbing the side rails, the care plan lacked interventions such as padding or removal of the side rails to prevent injury. Facility leadership, including the Director of Nursing and Assistant Director of Nursing, acknowledged awareness of the resident's behaviors but could not explain why preventive measures were not implemented prior to the injury. The facility's behavior management policy required maintaining a safe environment, but this was not achieved in this case, resulting in the resident sustaining a fracture.
Failure to Implement Comprehensive Care Plan for Resident with Grabbing Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific interventions to address a resident's known grabbing behaviors, particularly in relation to the use of side rails. The resident had a history of dementia with behavioral disturbances, severely impaired cognition, and was dependent on staff for all activities of daily living, including bed mobility and transfers. The care plan identified the resident's potential for aggressive behaviors and included general interventions such as monitoring behaviors and redirecting agitation, but did not include targeted measures to prevent injury from grabbing side rails. Despite multiple staff members documenting and reporting that the resident consistently grabbed side rails and exhibited sudden, resistive movements during care and transfers, the care plan lacked interventions to mitigate the risk of injury from these behaviors. Staff interviews revealed that, in practice, some staff used pillows to position the resident's arms or to prevent grabbing, but these actions were not formalized in the care plan. The facility's documentation and investigation confirmed that the resident's grabbing behaviors were well known prior to the incident. An incident occurred in which the resident sustained a nondisplaced fracture of the right hand, with evidence indicating the injury was caused by the resident placing their hand in the lower opening of the side rail. The facility's summary and staff interviews confirmed that the discoloration and injury aligned with the side rail, and that the side rails were subsequently discontinued and replaced with a perimeter mattress. However, prior to the injury, the care plan did not include interventions such as padding or removing the side rails to prevent injury, despite the resident's established risk and staff awareness of the behaviors.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including dementia, anxiety disorder, and adjustment disorder was involved in an incident where another resident, also diagnosed with dementia, slapped them on the right side of the face in a recreation room. The care plan for the resident who was slapped had previously identified a risk for resident-to-resident incidents and included interventions such as providing emotional support and monitoring for changes in mood or behavior. Despite these interventions, the incident occurred without provocation, as observed and documented by facility staff. Facility documentation and staff interviews confirmed that the two residents were separated following the incident, and there was no indication of prior altercations between them. The resident who was slapped did not sustain an injury and denied pain. The facility's abuse policy states that each resident has the right to be free from abuse, but the incident demonstrates a failure to ensure this protection for the resident involved.
Failure to Notify Nurse of Significant Change in Resident Condition
Penalty
Summary
A deficiency occurred when staff failed to ensure timely notification of a significant change in condition for a resident with chronic kidney disease, heart failure, and dementia. The resident's care plan included monitoring vital signs due to fluid deficit and increased caloric demand. On the morning in question, a nursing assistant recorded a critically low blood pressure of 76/33 but did not notify the assigned LPN. The LPN, who was unaware of the low reading, stated she only checked vital signs in the EMR if required for medication administration, which was not the case for this resident. As a result, no evaluation or further assessment was completed at that time. Interviews with supervisory staff, including the RN supervisor, APRN, and DON, confirmed that they were not informed of the resident's low blood pressure and that facility policy required notification and assessment in such cases. The facility's practice was for nursing assistants to document or verbally report vital signs to the nurse, who was then responsible for reviewing and acting on them. The failure to communicate the significant change in the resident's condition led to a lack of timely assessment and intervention, as required by facility policy.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure a physician order for Vancomycin was transcribed accurately, resulting in a medication administration error for a resident with a non-displaced right femur fracture and urinary tract infection. The resident was supposed to receive Vancomycin every 24 hours as per the physician's order dated 3/3/2023, but the medication was inadvertently placed on hold from 3/3/2023 to 3/6/2023. The error was identified on 3/7/2023, and the medication was restarted. The resident's care plan and physician orders clearly indicated the need for daily administration of the antibiotic, but the transcription error led to missed doses. The incident was documented in a facility incident report, which noted that the unit manager discovered the error on 3/7/2023. Interviews with staff revealed that RN #2 had entered the start date for the medication incorrectly, leading to the hold. Despite attempts, an interview with the former Director of Nursing Services was not obtained. The facility's Medication Pass Policy emphasizes the importance of administering medications safely and timely per physician orders, which was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to a resident who was cognitively intact but dependent on assistance for toileting and personal hygiene. The resident, who had diagnoses of hemiplegia and muscle weakness, was occasionally incontinent of bladder and required assistance with toileting. On the night in question, the resident requested incontinent care from a nurse aide between 4:30 AM and 5:00 AM, but the aide did not return to provide the care due to being occupied with other duties and being the only aide on the unit. As a result, the resident did not receive the requested care until the next shift, approximately 2.5 hours later. Interviews with staff revealed that the unit was short-staffed, with only one nurse aide assigned during the shift, and there was a lack of communication regarding the need for additional assistance. The nurse aide who was supposed to assist did not come to the unit, and the LPN on duty was unaware of the staffing issue. The facility's practice was to attend to residents' needs promptly, but this was not adhered to in this instance, leading to the deficiency.
Inadequate Staffing Leads to Delayed Incontinent Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, specifically for incontinent care. Resident #2, who was cognitively intact but dependent on assistance for toileting, was occasionally incontinent of bladder. On the night in question, the resident requested incontinent care between 4:30 AM and 5:00 AM, but the nursing assistant (NA#1) was unable to provide care immediately due to being the only NA on the unit and needing to respond to other call lights. As a result, Resident #2 did not receive the requested care until two to two and a half hours later when the first shift nurse's aide arrived. The staffing issue arose because NA#2, who was scheduled to work, called out, and the facility attempted to cover the shift by splitting NA#3's hours between two units. However, NA#3 was not informed of this change and only worked on the third floor, leaving NA#1 without the necessary assistance. The charge nurse (LPN #1) was unaware of the staffing shortage and did not assist NA#1. The facility's usual staffing pattern for the shift was two NAs and one licensed nurse, but this was not maintained, leading to the deficiency in care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mozaic Senior Life | 1 mi | — | 31 | 0 |
| Cambridge Health And Rehabilitation Center | 2 mi | — | 2 | 0 |
| Springs At 3030 Park, The | 2.2 mi | — | 3 | 0 |
| Civita Care Northbridge | 2.6 mi | — | 5 | 0 |
| Maefair Center For Health & Rehabilitation | 2.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.