Ludlowe Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ludlowe Center for Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 5, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for a change in condition, the facility failed to ensure the resident was served food consistency in accordance with physician orders when a resident on a ground dysphagia diet was served a peanut butter sandwich. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included a history of myocardial infarction, pulmonary embolism, end stage renal disease, and diabetes. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person, place time and situation. […]

• Immediate jeopardy, isolatedF806Apr 5, 2022

  Based on clinical record review, facility documentation review, and interviews for one of two residents (Resident #1), reviewed for allergies, the facility failed to ensure the resident was not served food that the resident was identified as allergic to. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included a history of myocardial infarction, pulmonary embolism, end stage renal disease, and diabetes. Review of hospital discharge summary dated 3/17/2022 identified Resident #1 was allergic to peanuts, all nuts and tree nuts. A physician's order dated 3/17/2022 directed that Resident #1 had an allergy to peanuts and tree nuts. […]

• Actual harm, isolatedF689Oct 6, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure a resident with known grabbing behaviors was free from injury related to side rail use. The findings include:Resident #3 had diagnoses that included dementia with behavioral disturbance, anxiety, depression, reduced mobility, and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15) indicative of severely impaired cognition, exhibited physical and verbal behavioral symptoms directed toward others, was dependent on staff for all ADLs, including bed mobility and… […]

• Actual harm, isolatedF689Sep 15, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interview, for the resident (Resident #12) reviewed for accidents, the facility failed to provide adequate supervision for a resident at risk to fall, who was placed in a common area to be closely watched and fell, sustaining an acute fracture at the base of the femoral neck. Additionally, the facility failed to maintain supervision during shift changes, ensure staff assignment/accountability, timely identify and report significant changes in condition, and implement care plan interventions.The findings include:Resident #12's diagnosis included Alzheimer's Disease and dementia. […]

• Actual harm, isolatedF689Oct 2, 2024

  Based on record review and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the environment was free from hazards when the resident hit his/her leg on the side rail during a transfer resulting in a laceration that required 15 sutures. The findings include: Resident #1 had diagnoses that included difficulty in walking, muscle weakness, and unsteadiness on his/her feet. The admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent for transfers. The Resident Care Plan (RCP) dated 7/30/2024 identified Resident #1 had a deficit in self-care and mobility. […]