Seven nursing assistants and licensed nurses at Ludlowe Center for Health & Rehabilitation told federal inspectors they knew the resident always grabbed siderails during routine care. Several staff members had developed their own workarounds, placing pillows between the resident and the rails to prevent injury.
The resident's hand became trapped in the lower opening of the siderail, sustaining a fracture with discoloration that aligned with the rail's position. The facility's own investigation summary confirmed the fracture occurred when the resident "placed his/her hand in the lower open portion of the siderail."
Nursing assistant statements painted a clear picture of known risks. NA #10 wrote that during Hoyer lift transfers, "Resident #3 always swings his/her arms and grabs" and described using a pillow to position the resident's arms. The resident "also grabs at the pillow," the assistant noted.
NA #11 told inspectors the resident "always grabs the side rails" and said she routinely "places a pillow between Resident #3 and the siderails to prevent Resident #3 from grabbing hold of the siderails" before providing care.
NA #3 used identical protective measures, placing "a pillow between Resident #3 and the siderails to prevent Resident #3 from getting injured."
Licensed practical nurse statements confirmed the pattern. LPN #8 documented the resident's "grabbing behaviors" in a written statement. LPN #7 told inspectors she "was aware Resident #3 had a history of being resistive to care and grabbing the siderails."
Registered nurse #3 said the resident "at times was resistant to care and would grab the siderails on the bed."
Despite universal staff awareness, facility records contained no care plan directing interventions to prevent siderail injuries. The Assistant Director of Nurses acknowledged the resident "had a history of extending his/her right arm into the lower opening of the side rails" but could not explain why no protective interventions appeared in the care plan.
The ADON said existing interventions directed staff to "redirect or deescalate if the resident was agitated" but was "unable to explain why there was no intervention to prevent contact with (grabbing) or prevent injury from the siderail use."
Director of Nurses interviews revealed management knew the risks before the September fracture. The DNS admitted she "was aware Resident #3 had grabbing behaviors prior to the fracture" but "was unable to explain why interventions were not included in the plan of care to direct staff to prevent Resident #3 from hitting his/her hand/arm on the side rails."
The DNS acknowledged basic safety measures should have been implemented. She told inspectors "Resident #3's siderails should have been padded or removed before 9/23/2025 to prevent an injury, and the care plan should have included interventions to protect Resident #1 from grabbing the side rails."
She could not explain why these protections were never put in place.
After the fracture, the facility discontinued siderails and placed a perimeter mattress with raised edges on the bed. The changes came too late for the resident, whose injury could have been prevented with padding or rail removal.
The facility's own policy required the interdisciplinary team to "observe the resident and obtain additional input from staff to identify high risk factors requiring intervention for potential improvement or prevention." Staff had provided abundant input about grabbing behaviors, but the team failed to act.
NA #9's written statement captured the scope of the resident's behaviors: "grabbing on to clothing, grabbing on to staff, and when turned on his/her side, grabbing the siderails."
Multiple staff members had independently developed protective strategies, demonstrating both awareness of the danger and practical solutions. Their individual actions highlighted the absence of systematic facility response.
The resident's fracture represented a predictable outcome of known risks left unaddressed. Federal inspectors found the facility failed to ensure services met professional standards of quality, citing minimal harm with potential for actual harm.
Ludlowe Center is disputing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ludlowe Center For Health & Rehabilitation from 2025-10-06 including all violations, facility responses, and corrective action plans.
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