Ludlowe Center For Health & Rehabilitation

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

summary identified the discoloration noted on the right hand aligns with the siderail. The summary further indicated the fracture was sustained when Resident #3 placed his/her hand in the lower open portion of the siderail. The summary indicated the siderails were discontinued and a perimeter (raised edge) mattress was placed on the bed. Review of facility investigation identified the following staff statements: LPN #8's written statement dated 9/24/2025 identified Resident #3 had grabbing behaviors. NA #10's written statement dated 9/25/2025 identified Resident #3 had sudden movements and grabbing behaviors, and

during Hoyer lift transfers, Resident #3 always swings his/her arms and grabs. Further, NA #10 indicated

she uses a pillow to position Resident #3's arms during Hoyer lift transfers and Resident #3 also grabs at

the pillow. Interview with NA #11 on 10/6/2025 at 9:18 A.M. identified Resident #3 always grabs the side rails. Further, NA #11 stated before she provides care to Resident #3, she places a pillow between Resident #3 and the siderails to prevent Resident #3 from grabbing hold of the siderails. Interview and

review of NA written statement with NA #8 on 10/3/2025 at 9:41 A.M. identified during care Resident #3 grabs the siderails. Interview, record review and written statement review with RN #3 on 10/3/2025 at 10:48 A.M. identified at times Resident #3 was resistant to care and would grab the siderails on the bed. Interview and written statement review with NA #7 on 10/3/2025 at 11:07 A.M. identified Resident #3 always grabbed and attempted to grab the side rails or Hoyer lift during care. Interview, record review and review of written statement with LPN #7 on 10/3/2025 at 11:11 A.M. identified she was aware Resident #3 had a history of being resistive to care and grabbing the siderails. Interview with NA #3 on 10/3/2025 at 11:22 A.M. identified Resident #3 always grabs the side rails during care and before she provides care to Resident #3,

she places a pillow between Resident #3 and the siderails to prevent Resident #3 from getting injured.

Interview and review of written statement with NA #9 on 10/3/2025 at 11:50 A.M. identified Resident #3 had

a history of grabbing on to clothing, grabbing on to staff, and when turned on his/her side, grabbing the siderails. Record review failed to identify a plan of care that directed interventions to prevent an injury from grabbing onto the side rails. Interview, record review and facility documentation review with the Assistant Director of Nurses (ADON) on 10/6/2025 at 9:56 A.M. identified Resident #3 had agitation at times and had

a history of extending his/her right arm into the lower opening of the side rails. Although the ADON stated

the care plan had interventions that directed staff to redirect or deescalate if the resident was agitated, she was unable to explain why there was no intervention to prevent contact with (grabbing) or prevent injury from the siderail use. Interview with the Director of Nurses (DNS) on 10/6/2025 at 11:45 A.M. identified she was aware Resident #3 had grabbing behaviors prior to the fracture. The DNS 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, such as use of a pillow or padding. The DNS stated 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. The DNS was unable to explain why Resident #3's side rails were not padded or removed prior to the fracture identified on 9/23/202 Review of facility Care Plan Baseline/Comprehensive Person Center Care Plan Policy dated 3/2023, directed in part, the interdisciplinary team will observe the resident and obtain additional input from staff to identify high risk factors requiring intervention for potential improvement or prevention and initiate the comprehensive person center care plan to include the problems, goals, and interventions.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ludlowe Center for Health & Rehabilitation

118 Jefferson Street Fairfield, CT 06825

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited LUDLOWE CENTER FOR HEALTH & REHABILITATION in FAIRFIELD, CT for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-10-06.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 2 deficiencies cited during this inspection of LUDLOWE CENTER FOR HEALTH & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-13.