The Haven of Bridgeport

Inspectors wroteBased on interview and record review the facility failed to ensure they had sufficient staff to meet the needs of the residents timely for 4 of 4 (R1, R2, R13, and R14) residents reviewed for staffing in the sample of 14. This has the potential to affect all 67 residents who currently reside at the facility. Findings Include:The facility Resident Matrix dated 1/5/2026 documents 67 residents currently reside at the facility.1. R2's admission Record with a print date of 1/6/26 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis. R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered timely for 4 of 4 (R1, R2, R13, and R14) residents reviewed for call lights in the sample of 14. Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis. R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. This Focus area includes intervention of, .Ensure call light is within reach and answer promptly. Date Initiated: 11/01/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate sized incontinence briefs for 2 of 4 (R2 and R13) residents reviewed for accommodation of needs in the sample of 13. Findings Include: 1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis. R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents skin was free from moisture associated skin damage (MASD) for 2 of 3 (R2 and R3) residents reviewed for skin care in the sample of 14. Findings Include:Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis. R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided using current standards of practice for 2 of 2 residents (R2 and R13) reviewed for incontinence care in the sample of 14. Findings Include:1. R2's admission Record with a print date of 1/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that includes morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis. R2's MDS (Minimum Data Set) dated 10/31/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 is occasionally incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I am occasionally incontinent of bowel and bladder. Date Initiated: 11/01/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of falls during a mechanical lift transfer for 1 of 3 (R6) residents reviewed for falls in the sample of 19. This past non-compliance occurred between 10/1/25 and 10/8/2025. Findings Include:R6's admission Record with a print date of 11/29/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, acquired absence of left leg, hypertension, anemia, history of falls, unsteadiness on feet, abnormal posture. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating a moderate cognitive deficit. This same MDS documents R6 is dependent on staff for transfers. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to answer call lights in a timely manner for 3 of 12 residents (R6, R7, R8) reviewed for call light response times in a sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was properly restrained while being transported in the facility van for 2 (R1 and R4) of 4 residents reviewed for accidents in a sample of 4. This failure resulted in R1 sustaining a laceration to her head requiring 14 staples and 8 sutures, a fracture to the second digit of the right foot, left nasal bone fracture with deviation of the septum, and bruising to the lower abdomen and upper thighs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received timely assistance with toileting and showers for 2 (R1 and R4) of 4 residents reviewed for Activities of Daily Living (ADL's) in the sample of 10. Findings Include: 1. R4's admission Record with a print date of 10/23/24 documents R4 was admitted to the facility on [DATE] with diagnoses that include sepsis, polyosteoarthritis, malignant neoplasm, dysthymic disorder, hypertension, heart disease, atrial fibrillation, syncope and collapse. R4's MDS (Minimum Data Set) dated 10/16/24 documents a BIMS (Brief Interview for Mental Status) score of 13 which indicates R4 is cognitively intact. This same MDS documents R4 requires substantial/maximal assistance with toilet transfer and moving from a sitting to standing position. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly label/cover food items and prevent cross contamination. This failure has the potential to affect all 67 residents residing in the facility. The Findings Include: On 5/28/24 at 10:00 AM, during the initial tour of the kitchen, the following items were found not to be labeled and/or covered in the refrigerators: drink pitchers not labeled, desert bowls that were covered but not labeled, shredded cheese not labeled, and salad not labeled. The cake was found to be uncovered on a tray and not labeled. During the initial kitchen tour, the bulk sugar container had a cup with no handle in the container. Other food debris that was brown in color was seen in a bulk sugar container, and the lid to sugar container was sticky and had dust and food substance stuck to it. [...]

Inspectors wroteBased on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 3 (R40, R15 and R43) of 3 residents reviewed for PASARR's in the sample of 33. Findings Include: 1. R40's admission Record documents an admission date of 11/02/2021 and documents diagnoses including: Bipolar disorder, current episode mixed, unspecified, with diagnosis date of 5/25/22, Major Depressive Disorder, single episode unspecified, with diagnosis date 11/02/2021, and Unspecified Dementia with a diagnosis date of 11/02/2021. R40's current Level 1 PASARR dated 11/03/2021 documents long term care placement was appropriate. 2. R43's admission Record documents an admission date of 02/19/2019 and documents diagnoses including: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure dependent residents received timely assistance for toileting needs for 2 of 2 residents (R48 and R55) reviewed for Activities of Daily Living in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to prevent falls with injuries for 1 of 1 (R169) residents reviewed for falls in a sample of 33. The Findings Include: R169's admission Record documents an admission date of 5/24/24. The admission record also includes the following diagnoses: unsteadiness on feet, abnormalities of gait and mobility, and lack of coordination. R169's admission MDS (Minimum Data Set) dated 5/27/24 documents that R169 has a BIMS (Brief Interview of Mental Status) score of 15, indicating that R169 is cognitively intact. This same MDS documents in Section GG that R169 needs supervision/touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapeutic diets were provided as ordered for 1 of 2 residents (R18) reviewed for therapeutic diets in the sample of 33. The Findings Include: R18's admission Record documents an admission date of 01/30/2024. admission diagnoses listed include: Atrial Fibrillation, Atherosclerotic heart disease if native coronary artery, heart failure, and essential hypertension. R18's Physician's Order Sheet documents a dietary order of NAS (No Added Salt), regular texture, regular consistency dated 1/30/24. On 05/28/2024 at 11:57 A.M. R18 stated that she never receives the diet that is on the card. R18 stated that she always gets other foods not on the card. Tray diet card documents R18's diet as Heart Healthy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer and immediately report a fall for one (R22) of seven residents reviewed for risk of falls in the sample of 34. This failure resulted in R22 falling against the toilet during a one assist transfer and sustaining a rib fracture with resulting pain. This past noncompliance occurred between 6/17/23 and 7/12/23.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly sanitize dishware. This has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to update restraint assessments and consents for one (R35) of one resident reviewed for restraints in the sample of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct textured diet was provided to one (R9) of one resident reviewed for pureed diets in a sample of 34. This past non-compliance occurred on 06/26/23. R9's Diagnoses Sheet documents admission to this facility on 06/05/09 with a primary diagnosis of Alzheimer's dementia with hemiplegia, and an additional diagnosis of dysphagia dated 06/30/23. Her most recent Minimum Data Set (MDS) dated [DATE] indicates she is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 8. She is assessed to require set-up with supervision only for eating. R9's Care Plan dated 02/16/15 and updated most recently includes - (R9) has a swallowing problem r/t (related to) loss of food/liquids from mouth while eating. [...]

Inspectors wroteBased on interview and record review, the facility failed to update and implement the Pneumococcal Immunization policy and failed to provide Pneumococcal Immunization in accordance with CDC (Centers for Disease Control and Prevention) recommendations for 14 of 15 residents (R7, R16, R17, R42, R13, R28, R35, R10, R31, R22, R26, R11, R5, R33) reviewed for Pneumococcal Immunizations in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that there was no cross contamination during medication pass for 2 of 5 residents (R45, R49) reviewed for infection control in the sample of 35. On 8/9/22 at 8:30 AM, V4 (Licensed Practical Nurse) was observed administering medications to R45 and R49 and did not wash her hands or use alcohol gel between each resident. On 8/10/22 at 3:45 PM, V2 (Director of Nursing) stated she will in-service the nurses again on handwashing and infection control. V2 stated V4 has access to hand gel and should have used it between residents. The facility's undated Medications Administration Oral policy documents under Important Points: line #2 Hand washing is to be performed before beginning, and after each resident contact unless antibacterial agent is used.