East Haven Nursing & Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident in 4 of 4 resident units. Specifically, multiple residents reported cockroach and rodent sightings. In addition, the facility's pest control service record documented pest sightings in 4 resident units.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents had the right to send and promptly receive mail. This was evident in 9 (Residents: #12, #13, #17, #80, #103, #105, #112, #151, #154) out of 39 total sampled residents. Specifically, the facility did not have a procedure in place for residents to send and receive mail on Saturday.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that posted menu items were served, that notification was provided when menu items were substituted and that individual food preferences were honored. This was evident in 3 Residents (Resident #96, #129 and #79) of 6 residents observed during dining, out of 35 total sampled residents. Specifically, residents were not served posted menu items, food preferences, or food items that were listed on the meal tray tickets. Additionally, residents were not notified of menu substitutions.

Inspectors wroteBased on record review and interview during the Recertification Survey from 02/18/2025 to 02/25/2025, the facility did not ensure the Binding Arbitration Agreement granted the residents and/or their designated representatives the right to rescind the agreement within 30 calendar days of signing it. This was evident in 3 (Resident #77, #109, #163) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #77, #109, and #163 did not grant the residents and/or their designated representatives 30 calendar days to rescind the agreement.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure the Binding Arbitration Agreement provides for the selection of a neutral arbitrator agreed upon by both parties and the agreement provides for the selection of a venue that is convenient to both parties. This was evident in 3 (Resident #77, #109, #163) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #77, #109, and #163 had no documented evidence the agreement addresses the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that resident or resident representatives receive their personal funds account statements on a quarterly basis. This was evident in 2 (Resident #79 and Resident #37) of 3 residents reviewed for Personal Funds out of 38 total sampled residents.

Inspectors wroteBased on observation, record review, and interview during the Recertification and Complaint (NY00354174) Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure the residents' right to a safe, clean and comfortable environment was maintained. This was evident in 1 (Unit 1) of 4 units. Specifically, room [ROOM NUMBER]P was observed with chipped wall surfaces, partially detached top dresser, stained ceiling, and peeling non-slip tape on the bathtub.

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Complaint (NY00354174) Survey conducted from 02/18/2025 to 02/25/2025, the facility did not provide food and drink that were palatable and at a safe and appetizing temperature. This was evident in 1 (Unit 4) of 1 unit observed during dining. Specifically, food served during lunch had suboptimal temperatures and were not appetizing or palatable.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure food service equipment are properly cleaned and sanitized. This was evident during the Kitchen Task.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that the Infection Preventionist was a member of the facility's Quality Assessment and Assurance committee and reported to the committee on the Infection Prevention and Control Program on a regular basis. Specifically, the Infection Preventionist had not participated in any of the Quality Assurance & Performance Improvement meetings held between 02/20/2024 and 01/28/2025.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaints survey (NY#00311731) from 02/27/2323 through 03/06/2023, the facility did not ensure that (1) residents' Comprehensive Care Plans (CCP) were reviewed and revised after each assessment, and (2) each resident or resident representative was offered the opportunity to participate in the review of their CCP. This was evident for 5 of 8 residents reviewed for Abuse, 1 of 5 residents reviewed for unnecessary Medication, and 1 of 2 resident review for care planning out 41 residents. (Resident #12, #40, # 173, #181, and #390) Specifically: (1) Care plans for Abuse were not revised quarterly and as needed for Residents # 40, and # 173. (2) Care plan for behavior and abuse was not revised to reflect Resident #181 aggressive behavior. [...]

Inspectors wroteBased on observation, record review and staff interview during the recertification survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation, if the allegation involves abuse or results in serious bodily injury, to the state agency. This was evident for 1 (Resident #63) of 2 residents reviewed for accident. Specifically, an incident where Resident #62 was found on the floor, near the exit door, with a hematoma was not reported to New York State Departement of Health (NYS DOH). The finding is: The facility policy on Accident and Incident Reporting, revised 7/13/22 documented: Our facility strives to make the environment as free from accident hazards as possible. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, the facility did not ensure a resident who is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #114) out of 5 residents reviewed for Unnecessary Medications. Specifically, a Comprehensive Care Plans (CCP) related to Dementia was not developed for Resident #114.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification survey from 2/27/23 to 3/6/23, the facility did not ensure that medication error rates were not 5 percent or greater. This was evident for 2 of 26 medication observations conducted during the Medication Administration task. Specifically, medications were not administered as ordered by the physician: 1). Fluoxetine 20 mg 1 capsule was administered to resident #43 instead of 3 capsules (60 mg). and 2). Brimonidine/Alphagan P 0.15 % eye drops were omitted for Resident #87, leading to a medication error rate of 7.69%.

Inspectors wroteBased on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that food was prepared and served in a sanitary manner. Specifically, 1) cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below; and 2) kitchen staff were observed not following proper handwashing guidelines.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan to meet a resident's medical and nursing needs as identified in the comprehensive assessment was developed for each resident. Specifically, (1) a resident with a tracheostomy (trach) did not have a comprehensive care plan (CCP) related to tracheostomy care; (2) a resident's Dialysis CCP had interventions for an av shunt when the resident had a permacath; and (3) a resident's Urinary Incontinence/Indwelling Catheter CCP did not include interventions to address the care needs for a capped Suprapubic catheter and Foley catheter. This was evident for 3 out of 38 sampled residents (Resident #s 82, 434, and 9).

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, proper hand washing technique between glove changes during tracheostomy (trach) care, maintaining a sanitized barrier for supplies during catheter care, and creating a sanitary barrier for a resident's wound during wound care were not observed. This was evident for 3 of 38 sampled residents observed for Infection Control (Resident #82, #9, and #334)

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promotes his or her quality of life. Specifically, a nurse did not knock on the resident's door prior to entering, verbally address the resident, or explain the procedure being done when they provided tracheostomy (trach) care. This was evident for 1 of 1 residents reviewed for Dignity (Resident #82).

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that a resident's personal privacy was respected during care. Specifically, a resident received tracheostomy (trach) care with the door open and within view of visitors, staff, and residents. This was evident for 1 of 1 residents reviewed for Privacy (Resident #82).

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident receiving 1:1 supervision fell in her room, and an investigation was not initiated. This was evident for 1 of 4 residents reviewed for Accidents (Resident #114).

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility did not provide documentation to verify that a newly hired registered nurse observed making breaches in infection control and using improper technique during wound care completed a wound care competency. This was evident for one nurse providing wound care to 1 of 3 residents reviewed for Pressure Ulcer (#334) . The finding is: Resident #334 was admitted with diagnoses which include Parkinson, Bipolar Disorder, and left arm fracture. The 2/8/20 admission Minimum data Set 3.0 (MDS) assessment documented the resident had severely impaired cognition. [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not ensure that narcotics administered to residents were recorded and reconciled on the narcotics record. Specifically, the Licensed Practical Nurse (LPN #1) administered Narcotic medications to Resident # 1(Tramadol), Resident #2 ((Hydrocodone), and Resident #3 (Alprazolam) without an accurate reconciliation on the narcotic record. This was evident for 3 resident narcotic records on 1 of 4 floors reviewed for the Medication Storage task (1st floor).

Inspectors wroteBased on interview and record review conducted during recertification survey, the facility did not ensure medical records that are accurately documented were maintained. This was evident for 1 of 7 residents (#75) reviewed for unnecessary medications and 1 of 3 residents (#334) reviewed for pressure ulcers out of a total sample of 38 residents.