Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Ridge Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering experienced two separate changes in condition—lethargy and a significant decrease in activity after a fall—that were not properly reported to the provider by LPNs, despite facility policy requiring such notifications. The provider was not made aware of the resident's lethargy or the unusual inactivity following the fall, and the facility's change of condition policy was not followed.
The facility did not maintain sufficient nursing staff on weekends, as shown by PBJ data for a recent quarter. The Administrator confirmed that restrictions on using agency staff and on licensed staff working as Nursing Assistants contributed to the low staffing levels.
The facility did not submit accurate staffing data to CMS and failed to provide required RN and licensed nursing coverage on several days, as well as having excessively low weekend staffing. These deficiencies were attributed to incorrect coding and staffing restrictions imposed by the previous owner.
The facility did not promptly report incidents of suspected abuse, neglect, and injuries of unknown origin to the State Agency as required. In separate events, a resident was found with an unexplained eye injury, two residents were involved in a physical altercation, and four residents did not receive timely incontinent care. In each case, staff failed to notify the State Agency within the mandated timeframe, despite facility policy requiring immediate reporting.
A resident with severe cognitive impairment and incontinence did not receive timely incontinent care, and no RN assessment was performed after the delay was identified. An APRN evaluated the resident's skin nearly two days later but failed to document the visit until 17 days afterward, contrary to facility policy requiring timely documentation.
A resident with severe cognitive and visual impairments was not provided with recreational activities aligned with their documented interests, such as music, pet therapy, and fresh air, despite these being identified as important. The care plan lacked a recreational activities component, and staff interactions were limited to brief check-ins and television watching, with no individualized engagement or reassessment of preferences.
Residents repeatedly reported receiving cold food, including coffee, soup, and dinner, over several months. Observations showed that meals were often covered with plastic lids containing holes and that there were not enough insulated lids or hot plates to keep food at the required temperature. A test tray confirmed that some food items were served below the facility's policy standard of 140°F, and the Food Service Director acknowledged the deficiency.
The facility did not consistently offer snacks to residents after dinner and before bed, relying instead on residents to request them or be on a specific list. A resident with significant care needs reported not always being offered snacks, and staff interviews revealed inconsistent practices and lack of clarity regarding snack distribution, contrary to facility policy.
Multiple residents experienced physical altercations and neglect when staff failed to prevent resident-to-resident aggression and did not provide timely incontinent care. Despite care plans outlining supervision and regular checks, residents with cognitive and physical impairments were left without necessary care for extended periods, and staff did not seek help when unable to provide required assistance.
The facility did not ensure timely RN assessments following incidents involving injuries, resident altercations, and missed care. In several cases, residents with significant medical needs experienced injuries or prolonged periods without care, and although LPNs performed some assessments and notifications, required RN evaluations and documentation were not completed as per facility policy.
A resident with hemiplegia and multiple care needs was found with unexplained discoloration to the left eye. Although an LPN assessed the injury and notified the responsible party and APRN, the facility did not follow its policy to obtain statements from all staff and the resident to determine the cause of the injury. Interviews confirmed that the required investigation was not completed.
A resident with chronic illnesses, severe cognitive impairment, and significant vision loss was admitted with documented interests in music, outdoor activities, and pet interaction. Despite these preferences being identified in assessments, the care plan only addressed visual impairment and did not include interventions for the resident's activity needs. The resident was found unaware of available activities, lacked access to preferred music, and was not taken outside, with no care plan initiated to address these deficiencies.
Several residents were found with air mattresses set incorrectly for their weight, despite physician orders and manufacturer instructions, and staff were unable to adjust or verify the settings. In one case, a resident with a pressure ulcer was on an improperly set mattress, while another resident at risk for skin breakdown had a mattress set to a firm setting not suitable for their weight. Additionally, a resident with a non-pressure skin condition did not receive timely wound care or monitoring upon readmission, and another resident with malnutrition was on a mattress set for a much higher weight than their own, with staff failing to check or document the correct settings.
A resident was not referred for a Level II PASRR evaluation after being diagnosed with a new psychotic disorder by an APRN. The facility's process relied on psychiatry providers to report new diagnoses to Social Services, but this step was missed because the diagnosis came from a medical provider. No PASRR policy was provided when requested.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a change in condition was reported to the provider on two separate occasions for a resident with severe cognitive impairment, dementia, diabetes, and anxiety disorder. The resident was known to wander and had a care plan in place to monitor for changes in mental status and ensure a safe environment. On one occasion, a nurse documented that the resident was lethargic and had decreased meal consumption, but only the decreased meal intake was reported to the provider. The provider was present in the facility at the time and stated that, had they been informed of the lethargy, they would have evaluated the resident further. On a subsequent occasion, the resident experienced a fall after tripping near the nurse's station. Following the fall, the resident, who was typically very active and ambulatory, remained in bed for the rest of the day, which was unusual for their baseline behavior. Both the day and evening shift LPNs observed this change in activity level but did not notify the provider of the resident's altered condition. The provider later confirmed that remaining in bed was a significant change for this resident and should have been reported. The facility's policy required that any significant change in a resident's physical, mental, or psychosocial status be evaluated, documented, and reported to the provider and the resident's representative. Interviews with staff and review of documentation confirmed that these requirements were not met in both instances, resulting in a failure to follow the facility's change of condition policy.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to provide an adequate number of nursing staff to meet resident needs every day, as required. Payroll Based Journal (PBJ) data for Quarter 2, 2024, revealed excessively low staffing levels on weekends. During an interview, the Administrator confirmed that the previous owner did not permit the use of agency staff or allow licensed staff to work as Nursing Assistants, which contributed to the insufficient staffing. The facility's mandatory PBJ submissions to CMS reflected these staffing shortages, particularly on weekends, during the specified quarter. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Accurately Report and Maintain Required Staffing Levels
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS, as required. Payroll Based Journal (PBJ) submissions for Quarter 1, 2025, showed that the facility had no Registered Nurse (RN) hours and lacked licensed nursing coverage for 24 hours per day on multiple consecutive days. Additionally, the PBJ report for Quarter 2, 2024, indicated excessively low weekend staffing. During an interview, the Administrator stated that these issues were due to incorrect coding by the previous owner and restrictions on using agency staff or allowing licensed staff to work as Nursing Assistants, which contributed to inadequate staffing levels. The facility did not meet the mandatory requirement to electronically submit accurate staffing information based on payroll data.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, and injuries of unknown origin to the State Agency as required by regulation. In one instance, a resident with hemiplegia and multiple comorbidities was found with discoloration around the left eye, which was identified as an injury of unknown origin. Although the injury was assessed by nursing staff and the responsible party and provider were notified, the incident was not reported to the State Agency. Both the LPN and the Nursing Supervisor acknowledged that the injury should have been classified as an injury of unknown origin and reported, but this did not occur. In another case, a resident-to-resident altercation occurred when one resident, with a history of agitation and aggression, punched another resident in the face in the dining room. The incident was witnessed and reported to an LPN, who assessed the involved residents and notified the provider and responsible party. However, the altercation was not reported to the State Agency until over 17 hours after the event, well beyond the required reporting timeframe. The DON stated that the delay was due to not being made aware of the incident until the following day. Additionally, four residents with varying degrees of cognitive impairment and incontinence did not receive timely incontinent care. The incident was identified by an LPN, who found multiple residents in need of care, and it was later determined that care had not been provided for an extended period. Although the supervisor was made aware of the neglect, the State Agency was not notified until nearly two days after the facility became aware of the situation. Facility policy and staff education materials indicated that such allegations should be reported immediately to supervisors and to the State Agency within two hours, but this protocol was not followed in these cases.
Failure to Timely Document APRN Visit and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure complete and timely documentation in the medical record for a resident with hemiplegia, aphasia, and severe cognitive impairment. The resident required assistance with activities of daily living (ADLs) and was always incontinent. On a specific date, an LPN identified that the resident had not received timely incontinent care, and this was documented in an incident report. Despite the identification of omitted care, no RN assessment was performed from the time the issue was discovered until the end of the shift. Additionally, an APRN evaluated the resident's skin condition nearly two days after the omitted care was identified, but did not document the visit until 17 days later as a late entry. Both the APRN and the Director of Nursing confirmed that the note should have been written at the time of the visit, in accordance with the facility's documentation policy, which requires documentation at the time of service or by the end of the shift. The failure to document the APRN visit in a timely manner resulted in an incomplete and inaccurate medical record for the resident.
Failure to Provide Activities Based on Resident Preferences and Needs
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, diabetes, severe cognitive impairment, and significant visual impairment was not provided with recreational activities that met their documented interests and preferences. The resident's activity assessment indicated interests in music, pets, fresh air, and other activities, but the care plan failed to include a recreational activities component. Observations revealed that the resident was unaware of available activities, had no access to music in their room, and had not participated in pet therapy or been taken outside for fresh air, despite these being identified preferences. The activities calendar showed pet therapy was available, but it was not offered to the resident, and no individualized music therapy was provided. Interviews with the Assistant Director of Recreation and the Recreational Director confirmed that one-on-one activities were limited to brief social interactions and passive television watching, with documentation sometimes occurring without direct engagement. The staff acknowledged that the resident's interests in music, pets, and fresh air had not been addressed, and no reassessment of activity preferences had been conducted since admission. Facility policy required activities to be centered around individual interests and needs, but this was not implemented for the resident in question.
Failure to Maintain Palatable and Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as evidenced by repeated resident complaints and direct observations. Residents consistently reported issues with cold food, including cold coffee, soup, and dinner, during multiple Food Committee and Resident Council meetings over the course of a year. Despite these ongoing concerns, the Food Service Director (FSD) advised residents to request reheating or replacement of cold meals but did not address the underlying issue. Observations revealed that meal plates were covered with plastic lids containing large holes, and hot plates or insulated lids were not used for residents on the first floor due to concerns about burn risks for those with dementia. The FSD could not explain the purpose of the holes in the lids or their impact on food temperature. Additionally, there were not enough insulated lids and hot plates for all residents on the second and third floors, resulting in inconsistent use of proper equipment to maintain food temperature. A test tray conducted on the third floor showed that food temperatures for certain items, such as pork loin and brussel sprouts, were below the facility's policy requirement of maintaining hot foods at 140 degrees Fahrenheit or more. The FSD acknowledged that the measured temperatures were low and attributed this to the lack of sufficient insulated covers and hot plates. Facility documentation confirmed that the policy required hot foods to be maintained at or above 140 degrees Fahrenheit, but this standard was not consistently met, as demonstrated by both resident feedback and direct temperature measurements.
Failure to Consistently Offer Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were consistently offered to residents after dinner and before bed, as required by policy and resident needs. Resident interviews revealed that snacks were not always offered, and some residents had to request snacks rather than being proactively offered them. One resident with cerebral palsy, chronic kidney disease, and bipolar disorder, who required assistance with activities of daily living and set-up for meals, reported not always being offered snacks despite sometimes wanting one. Observations confirmed that while signage indicated snack times and available options, the process for distributing snacks relied on residents requesting them or being on a specific list. Staff interviews further indicated inconsistency and lack of clarity regarding the snack distribution process. Dietary staff delivered snacks based on a list provided by the dietician or nursing, but residents not on the list, including those who were bedbound, needed to ask for snacks. Nurse aides reported varying practices, with some not offering snacks to each room and others unsure of the policy. The administrator confirmed that staff were responsible for offering snacks but also stated that residents needed to request them. The facility's policy required snacks to be offered at bedtime and upon request, but the actual practice did not ensure all residents were proactively offered snacks as required.
Failure to Prevent Resident-to-Resident Altercations and Neglect of Timely Care
Penalty
Summary
The facility failed to prevent resident-to-resident altercations and did not ensure residents were free from neglect, as evidenced by multiple incidents involving several residents. In one instance, a resident with dementia and severe cognitive impairment was punched in the face by another resident with Alzheimer's disease and a history of agitation and aggression. The altercation occurred in the dining room and was witnessed by a visitor. Documentation revealed that the care plan for the aggressive resident included interventions such as keeping the resident near the nursing station and providing one-on-one supervision, but these measures were not effectively implemented at the time of the incident. The event was not documented in a timely manner, and the initial nursing note failed to identify the actual date of the altercation. Another incident involved a resident with Alzheimer's disease and behavioral disturbances who became agitated during morning care and pushed a nurse aide, then pushed another resident, causing that resident to fall. The care plan for the aggressive resident included interventions to approach the resident calmly and anticipate needs, but the resident had recently become more impulsive and difficult to redirect. Staff interviews confirmed that the resident was agitated and that the incident occurred while another resident was walking by. Additionally, the facility failed to provide timely incontinent care to four residents with varying degrees of cognitive impairment and physical dependency. Documentation and staff interviews revealed that these residents went extended periods—ranging from nearly 7 to over 10 hours—without receiving incontinent care, despite care plans directing checks every two hours. The nurse aide responsible for their care did not check on the residents as required and did not notify supervisory staff when assistance was needed. The facility's investigation substantiated that neglect had occurred, as the residents did not receive necessary care to avoid physical harm or distress.
Failure to Complete Timely RN Assessments After Incidents and Care Omissions
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed in a timely manner for multiple residents following incidents involving accidents, resident-to-resident altercations, and potential abuse. In one case, a resident with hemiplegia and other significant medical conditions was found with discoloration around the left eye. Although an LPN assessed the injury and notified the APRN, there was no documentation of an RN assessment or investigation into the cause of the injury, despite facility policy requiring such action for injuries of unknown origin. The Director of Nursing Services (DNS) confirmed that the RN supervisor was responsible for the assessment and documentation, but no explanation was provided for the omission. In another incident, two residents were involved in a physical altercation, with one resident punching another in the face. The event was witnessed and reported to an LPN, who performed an assessment and notified the APRN and responsible party, but did not notify the nursing supervisor. There was no evidence of an RN assessment for either resident following the altercation, contrary to facility policy that requires immediate notification of the nursing supervisor and a thorough assessment after any allegation or observation of abuse. The DNS acknowledged that the nursing supervisor should have been informed and an assessment completed. Additionally, four residents with significant cognitive and physical impairments did not receive timely incontinent care, with gaps ranging from nearly 10 to over 10 hours between care episodes. When this lapse was identified, there was no documentation of RN assessments or skin checks for these residents, despite facility procedures directing a physical assessment in such situations. Late entries by LPNs and an APRN note did not address the period during which care was omitted. The DNS confirmed that RN assessments were not completed as required after the incident was discovered.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete investigation into an injury of unknown origin for a resident with hemiplegia, hypertension, and diabetes. The resident, who was cognitively intact but required extensive assistance for self-care and mobility, was found with discoloration around the left eye. Documentation shows that the LPN was notified of the injury, assessed the resident, and informed the responsible party and APRN, who ordered diagnostic tests and interventions. However, the required investigative process, including obtaining statements from all staff who worked with the resident in the previous 72 hours and from the resident, was not completed as per facility policy. Interviews with the LPN, RN Supervisor, and DNS confirmed that no staff or resident statements were collected to determine the cause of the injury. The RN Supervisor acknowledged not assessing the resident or initiating the investigation, and the DNS confirmed that statements should have been obtained but could not provide a reason for the omission. Facility policy mandates timely investigation and collection of staff statements for injuries of unknown origin, but this protocol was not followed in this case.
Failure to Develop Comprehensive Activity Care Plan for Resident with Visual and Cognitive Impairments
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan addressing the activity needs and preferences of a resident with chronic kidney disease, diabetes, bilateral cataracts, and hypertension. The resident was admitted with a history of interests such as drawing, fishing, music, and being outdoors, and was identified as having severe cognitive impairment and highly impaired vision. The resident's Minimum Data Set assessment indicated that it was very important for them to listen to preferred music, go outside for fresh air, and be around animals. However, the care plan only addressed impaired visual function and included interventions such as one-on-one staff visits, without addressing the resident's specific activity preferences. During observation and interview, the resident was found lying in bed with the television on, without access to a radio or music player, and was unaware of available recreational activities. The resident reported not being involved in activities or taken outside for fresh air. Review with the Assistant Director of Recreation confirmed that no care plan had been initiated for the resident's activity needs, and there were no interventions in place to provide appropriate activities as identified in the resident's assessment.
Failure to Ensure Proper Air Mattress Settings and Timely Wound Care
Penalty
Summary
The facility failed to ensure that air mattresses were set at the appropriate settings according to physician orders, resident weight, and manufacturer instructions for multiple residents. In one case, a resident with a stage 3 pressure ulcer was observed lying on an air mattress set at a level inconsistent with the resident's weight, as indicated by the attached instruction card. Nursing staff were unable to confirm or adjust the settings appropriately and did not reference the manufacturer's instructions, despite the presence of clear guidance on the mattress and from the vendor. The facility's policy required nurses to set the correct air mattress setting based on the resident's current weight, but this was not followed. Another resident, who was at risk for pressure ulcers and receiving hospice care, was found on an air mattress set to a firm setting, which was not appropriate for the resident's weight. Nursing staff were unable to explain or adjust the settings and did not know the correct correlation between the resident's weight and the mattress setting. The settings card on the pump was left blank, and staff relied on maintenance or the vendor for guidance rather than following facility policy or physician orders. Documentation indicated that staff signed off on checking the settings every shift, but observations showed the settings remained incorrect over several days. Additionally, the facility failed to initiate timely treatments for a resident with a non-pressure skin condition. Upon readmission from the hospital, the resident had wounds that were not measured or described in the nursing assessment, and no treatment or monitoring orders were put in place for several days. The hospital discharge paperwork included wound care instructions, but these were not implemented by the nursing staff. The Director of Nursing confirmed that it was expected for hospital treatment orders to be followed upon readmission, but could not explain why this was not done. Another resident with malnutrition was found on an air mattress set for a much higher weight than their own, despite staff documentation indicating the setting was checked every shift. The resident and a family member reported the mattress felt excessively hard, and staff admitted to not verifying the settings as required.
Failure to Refer for Level II PASRR After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new mental disorder was identified. The resident was admitted with diagnoses of cerebral infarction and Parkinson's disease, and at admission, no mental disorder was present. The initial Level I PASRR screening indicated that a Level II evaluation was not required, but also stated that a new screening must be submitted if new information or changes occurred. Subsequently, an Advanced Practice Registered Nurse (APRN) documented a new diagnosis of psychotic disorder with delusions due to a known physiological condition. Despite this new diagnosis, the facility did not initiate a Level II PASRR evaluation. During interviews, the Director of Social Services confirmed that the process for identifying new mental disorders relied on psychiatry providers reporting new diagnoses to Social Services, who would then notify the appropriate agency for a Level II PASRR. However, in this case, the diagnosis was made by a medical APRN rather than a psychiatry provider, resulting in the process being missed. Additionally, the facility was unable to provide a policy for PASRR when requested.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 360 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ridgefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint John Paul Ii Center | 4.3 mi | ★★★★★ | 9 | 0 |
| Ridge Crest At Meadow Ridge | 4.9 mi | ★★★★★ | 3 | 0 |
| Havencare At Hancock Hall | 4.9 mi | ★★★★★ | 0 | 0 |
| Havencare At Filosa | 5 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Danbury | 5.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Laurel Ridge Center For Health & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.