New Haven Center for Nursing & Rehabilitation LLC

Inspectors wroteBased on clinical record reviews, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were admitted for short term rehabilitation, the facility failed to implement and document an ongoing discharge plan for a resident to ensure a safe and effective transition back into the community.

Inspectors wroteBased on review of clinical records, interviews, and review of facility documents and policies for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff notified the physician/medical director and facility administration timely when a resident failed to return to the facility as scheduled following a leave of absence, and for one of three residents reviewed for accidents, the facility failed to notify the provider that the resident's evening medications were missed.

Inspectors wroteBased on review of clinical records, interviews, and review of facility documents and policies for one (1) of three (3) residents (Resident #1) reviewed for discharge, the facility failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer or discharge from the facility after a thirty-day discharge notice was given.

Inspectors wroteBased on review of clinical records, interviews, and review of facility documents and policies for one of three residents (Resident #1) reviewed for accidents, the facility failed obtain a hospital discharge summary timely after a resident's readmission, and for one sampled resident (Resident #1) reviewed for leave of absence, the facility failed to ensure staff acted timely when a resident did not return as expected from a Leave of Absence, and failed to ensure staff were provided with a current facility policy that directed steps to follow when a resident did not return timely from a leave of absence.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #14) reviewed for nutrition and who required aspiration precautions and supervision with meals, the facility failed to provide a chopped diet as ordered by the physician, failed to provide supervision with eating on 3 days (3 breakfast meals) of the survey, and failed to ensure required safe swallowing strategies were implemented to prevent the resident from choking. These failures resulted in Immediate Jeopardy.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure consistent response and follow-up to Resident Council concerns according to facility policy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Resident 12, 14, 23, 28, 51, 105, 137) the facility failed to provide adequate supervision to prevent accidents and failed to ensure the resident environment remained as free of accident hazards as is possible. For 2 of 7 residents (Resident #12 and 14) reviewed for nutrition and who required aspiration precautions, the facility failed to ensure adequate supervision during meals. For 2 of 12 residents (Resident #23 and 28), reviewed for accidents, the facility failed to ensure adequate supervision and follow smoking policies for residents with smoking violations. [...]

Inspectors wroteBased on review of facility documentation, policy, and interviews for 5 of 5 nurse aides (NA #1, NA #6, NA #16, NA #17, and NA #18), the facility failed to ensure performance evaluations were completed, at least every 12 months.

Inspectors wroteBased on observation, review of facility policy, and interviews, the facility failed to ensure food items were labeled and dated in the kitchen and nourishment rooms and failed to ensure the walk-in freezer was defrosted.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that monitoring and tracking related to a GI outbreak was documented, failed to ensure ongoing infection surveillance tracking, and for 1 of 5 residents (Resident #86) reviewed for infection control, the facility failed to administer medications according to infection control standards and facility policy, and for 1 of 2 residents (Resident #90) reviewed for indwelling catheter, the facility failed to ensure the outlet valve of a supra pubic catheter collection bag was stored in a sanitary manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure ongoing review of antibiotic stewardship including tracking and monitoring of use for residents who required antibiotic treatment for infection.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #15, 18, 22, and 38) reviewed for covid vaccinations, the facility failed to offer and/or provide education on covid vaccinations.

Inspectors wroteBased on observation, review of facility policy, and interviews for 1 of 5 residents (Resident #63) reviewed for dining, the facility failed to provide the resident a breakfast tray in a timely manner, resulting in the resident trying to obtain items from other resident's leftover trays.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #130) reviewed for nutrition, the facility failed to ensure the resident received double portions per his/her request to receive double portions and per the physician order.

Inspectors wroteBased on review of facility documentation, facility policies, and interviews for the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to provide quarterly financial statements to the resident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #76) reviewed for pressure ulcer, the facility failed to ensure the resident representative was notified of a new wound.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and interviews for the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to protect the resident from misappropriate of resident funds.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #59) reviewed for abuse, the facility failed to report an allegation of staff to resident verbal abuse to the state agency per established timeframes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #59) reviewed for abuse, the facility failed to remove an employee and initiate an investigation following a reported allegation of verbal abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #4 and 17) reviewed for dementia and respiratory care, for Resident #4, the facility failed to develop and implement a comprehensive individualized care plan when the resident was newly diagnoses with dementia, and for Resident #17 the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a tracheostomy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview for 2 of 4 residents (Resident #51 and #105) reviewed for smoking, the facility failed to review and revise the care plan to ensure interventions that addressed the residents history of unsupervised smoking, contraband items, and smoking practices while directly adjacent to the facility property while on LOA to maintain the residents safety, and for 1 of 7 residents (Resident #128) reviewed for nutrition, the facility failed to revise the care plan for an air mattress.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #14) reviewed for medication administration, the facility failed to administer medication according to professional standards.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #41) reviewed for activities of daily living, the facility failed to ensure a resident unable to carry out ADLs independently received necessary services to maintain proper grooming.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #5, 41, 59, 60 and 128) the facility failed to ensure care according to professional standards. For 1 of 3 residents (Resident #5) reviewed for abuse, the facility failed to complete an assessment of the resident following an allegation of staff-to-resident physical mistreatment. For 1 of 4 residents (Resident #41) reviewed for activities of daily living (ADL), the facility failed to ensure a resident unable to carry out ADLs independently received necessary services to maintain proper grooming. For 1 of 7 residents (Resident #59) reviewed for food, the facility failed to implement recommendations from an Allergy and Immunology consult for 40 days. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #76) reviewed for pressure ulcers, the facility failed to ensure an RN assessment and treatment (including an air mattress) was implemented when a new skin condition was found, and failed to complete weekly skin checks.

Inspectors wroteBased on observation, review of the clinical record, facility policies, and interviews for 1 of 2 residents (Resident #17) reviewed for respiratory and tracheostomy care, the facility failed to complete tracheostomy care; including care of the inner cannula per facility policy, failed to change the tracheostomy mask and tubing for 7 weeks, failed to assess the resident for his/her ability to care for and suction the tracheostomy independently including obtaining a physician's orders to allow such, and failed to ensure necessary tracheostomy supplies did not run out.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, the facility failed to ensure the medication error rate was less than 5%.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to ensure the dietary staff had appropriate competencies and skills sets to carry out the functions of the kitchen.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 7 residents (Resident #59) reviewed for food, the facility failed to ensure food was served according to resident allergies, intolerances, and preferences.

Inspectors wroteBased on review of facility documentation, facility policy, and interview, the facility failed to designate a qualified infection preventionist from August 2024 through February 2025 (approximately 7 months).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #15) reviewed for influenza and pneumococcal immunizations, the facility failed to offer and/or provide flu or pneumococcal immunizations.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to ensure that a resident who requires assistance and an assistive device with ambulation did not exit the facility without staff knowledge, resulting in the resident being found walking on the side of a roadway in the dark, nine (9) miles from the facility after he/she sustained a fall. These failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for abuse, (Resident #2), the facility failed to ensure that the resident was free from verbal abuse form a staff member. Resident #2 had a diagnosis of type 2 diabetes and a major depressive disorder. A quarterly Minimum Data Set, dated [DATE] identified that the resident had a Brief Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition, was supervision with Acitivities of Daily Living (ADLs), and had no behaviors. A care plan dated [DATE] identified that the resident has a diagnosis of depression with interventions that directed to administer antidepressants as ordered and to monitor the residents mood for changes. [...]

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #3) reviewed for change of condition, the facility failed to respect the resident's request to call 911 to be transferred to the hospital.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #2) who were reviewed for medication administration, the facility failed to ensure a medication was re-ordered and available at the time the medication was due to be administered and the provider was notified when the medication was not available.

Inspectors wroteBased on review of facility documentation and interviews, the facility failed to maintain staffing levels to meet the minimum requirements of the Connecticut General Statute 19a-563h regarding 3.0 hours of direct care.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for care plans, the facility failed to ensure a comprehensive care plan included discharge planning.

Inspectors wroteBased on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure the clinical record was complete and accurate to include medication administration documentation.

Inspectors wroteBased on clinical record review and interviews for one of three residents (Resident #12) reviewed for a change in condition, the facility failed to act on physician orders timely for a resident with a change in condition, and for one of four residents (Resident #2) reviewed for nutrition, the facility failed to ensure the diet orders were transcribed accurately upon admission.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #15) reviewed for care and services, the facility failed to maintain a complete and accurate record to include timely access to the medical record.

Inspectors wroteBased on clinical record review, facility documentation review, observations, and interviews for one of three residents (Resident #4) reviewed for call bells, the facility failed to ensure the resident was provided with a device timely to allows the resident to call for staff assistance.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required staff assistance with personal hygiene, the facility failed to ensure privacy was maintained during the provision of personal care.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who was reviewed for a complaint of mice in the room, the facility failed to ensure the pest control company was informed when the mice were first noticed in the resident's room.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents, (Resident # 1), who were reviewed for medication administration, the facility failed to ensure provision of routine and emergency-controlled medications for a resident whose pain medication(s) supply was depleted.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident # 1), who were reviewed for care and services, the facility failed to revise the comprehensive care plan for a resident who required hospitalization for acute opiate withdrawal and verbalized suicidal/homicidal ideations.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident # 1), who were reviewed for pain management, the facility failed to ensure the availability of prescribed pain medication.

Inspectors wroteBased on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for Accidents (Resident #4), the facility failed to ensure that a resident did not leave the facility unattended for an extended period of time without staff knowledge.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that the chemical sanitizing solution was maintained at the recommended concentration level, and failed to ensure that wet wiping cloths were stored in an approved sanitizing solution.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to review the Infection Control Policy and Procedure Manual at least annually and failed to conduct and document environmental rounds, and for 2 residents (Resident #95 and 314) the facility failed to store respiratory equipment according to infection control practices.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews the facility failed to have an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #13, 30, 32, 74, 82) reviewed for pneumococcal vaccines, the facility failed to offer/administer the pneumococcal vaccines according to Centers for Disease Control guidelines.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #47 and 57) reviewed for resident to resident abuse, the facility failed to ensure the residents were free from physical abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure a level II PASARR was completed when required.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #42) reviewed for vision, the facility failed develop a comprehensive care plan to address vision loss, and for 1 resident (Resident #45) reviewed for accidents, the facility failed to care plan and monitor inappropriate sexual behaviors.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #42) reviewed for accidents, the facility failed to revise the care plan after multiple falls.

Inspectors wroteBased on review of the clinical record, facility documentation, policy, and interview for 1 of 5 residents (Resident #82) reviewed for unnecessary medications, the facility failed to follow the physician's orders for monthly vital signs.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for respiratory therapy, the facility failed to change respiratory equipment per facility policy.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to complete nurse aide performance evaluations at least once every 12 months.

Inspectors wroteBased on observation, review of facility policy, and interviews for 4 of 6 medication carts, and 1 of 3 narcotic refrigerator freezers, the facility failed to maintain the medication carts and the narcotic refrigerator freezer in a clean and sanitary manner.

Inspectors wroteBased on review of the clinical record, facility documentation and policy for 1 resident (Resident #112) reviewed for hospitalization, the facility failed to notify the resident and/or the resident's representative and failed to notify the Office of the State Long-Term Care Ombudsman when the residents were transferred to the hospital. Further, for 4 other residents (Resident #1, 6, 53, and 63) reviewed as part of the expansion for hospital transfers, the facility failed provide timely notification to the Office of the State Long-Term Care Ombudsman of the hospital transfers.

Inspectors wroteBased on review of the clinical record, facility documentation and policy for 1 resident (Resident #112) reviewed for hospitalization, the facility failed to provide a bed-hold notice when the resident was transferred to the hospital. 1. Resident #112 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. A nurses note dated 12/28/22 identified Resident #112 was transferred to the hospital for a psychiatric evaluation. A nurses note dated 12/31/22 identified Resident #112 was readmitted to the facility. A nurses note dated 1/2/23 identified Resident #112 was transferred to the hospital for a psychiatric evaluation. Review of the clinical record failed to reflect the facility had provided the resident and/or the resident representative a notice of the bed hold policy when the resident was transferred to the hospital on [DATE] and 1/2/23. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 13 of 13 residents (Residents #3, 5, 10, 21, 47, 75, 81, 83, 95, 97, 103, 105, and 106), reviewed for resident assessments, the facility failed to transmit the residents' admission, quarterly, annual, and discharged MDS assessments in a timely manner in accordance with regulatory requirements.

Inspectors wroteBased on review of facility documentation, and interviews, the facility failed to provide complete and accurate direct care staffing information for the Payroll Based Journal (PBJ) staffing data report by the reporting period due date.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure nursing received education, training and competencies related to respiratory and enteral feeding care and IV therapy.

Inspectors wrote2. Resident #85 was admitted to the facility with diagnoses that included dementia. The quarterly MDS dated [DATE] identified Resident #85 had severely impaired cognition. Review of the admission record identified Person #4 was Resident #85's Power of Attorney (POA) for care. Review of the immunization consent tracking record dated 12/20/20 identified consent to administer the COVID-19 vaccination to Resident #85 was not obtained, and the residents POA could not be reached. Nurse's note dated 12/22/20 identified Resident #85 was provided education and signed a consent to receive the COVID-19 vaccine. A nurse's note dated 12/29/20 identified Resident #85 refused the COVID-19 vaccination and the nursing supervisor was aware. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #117) reviewed for advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an advanced directive.

Inspectors wroteBased on observation, review of facility policy, and interviews the facility failed to ensure preventative maintenance was conducted on facility equipment used in the shower room.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 4 of 6 residents (Resident #73, 26, 432 and 332) reviewed for resident to resident altercations and allegations of mistreatment, the facility failed to protect Resident #73, 26 and 432 from Resident #95's abuse, and failed to ensure Resident #332 was free from staff abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #332) reviewed for abuse, the facility failed to provide training, upon hire, to a nurse aide on the abuse/neglect policy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #11) reviewed for hospitalization, the facility failed to notify the ombudsman of when the resident was transferred to the hospital multiple times.

Inspectors wroteBased on review of the clinical record, facility documentation and interviews for 1 of 5 residents (Resident #50) reviewed for PASRR, the facility failed to complete a PASRR when required.

Inspectors wroteBased on review of the clinical record, facility policy and staff interviews for 1 of 16 residents (Resident #7) reviewed for smoking, the facility failed to conduct a quarterly smoking assessment, and for 1 of 3 sampled residents (Resident #36) reviewed for unnecessary medications, the facility failed to consistently monitor orthostatic blood pressures for a resident who was prescribed an antipsychotic medication.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure safe and secure storage of intravenous (IV) medications and equipment. Additionally, the failed to ensure drugs and biologicals were secured in a locked environment and only authorized personnel were permitted access.

Inspectors wroteBased on observation, review of facility documentation and interview, the facility failed ensure food items were stored in accordance with facility policy.

Inspectors wroteBased on observation, review of facility documentation, facility policy and interviews, the facility failed to properly store waste in a covered compactor.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #29, 89 and 232) reviewed for infection control, the facility failed to follow infection control practices according to professional standards. Additionally, the facility failed to consistently maintain monthly environmental rounds.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 6 residents (Resident #8, 10, 12, 44, 95 and 123) reviewed for MDS assessments, the facility failed to accurately code the MDS for medications and Pre-admission Screening and Resident Review (PASRR).