West Haven Center for Nursing & Rehabilitation

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for facility discharges, the facility improperly discharged the resident by discharging him/her one (1) day prior to the thirty (30) day date and six (6) days prior to an involuntary discharge appeal's hearing.

Inspectors wroteBased on clinical records, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for medication administration, the licensed nursing staff failed to ensure the resident consumed oral medications and applied a topical patch prior to exiting the room and the medications were not left at the bedside.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to ensure the DNS did not serve as the nursing supervisor.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Residents #43, 47, 61 and 65) the facility failed to notify the physician and/or resident representative when required. For 1 of 2 residents, (Resident #43) reviewed for death, the facility failed to ensure the physician was notified when medications were not administered according to the physician's orders, when blood sugar and blood pressures were not obtained as ordered, and when blood sugars were noted to be outside the parameter. For 1 of 3 residents (Resident #47) reviewed for accidents the facility failed to notify the physician of a fracture after a fall and a lung nodule. For 1 resident (Resident #61) reviewed for pain, the facility failed to notify the physician with the onset of new pain. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #44) reviewed for hospitalization, the facility failed to ensure the resident or resident representative were notified of the bed hold policy at the time the resident was sent to the hospital.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #19) reviewed for PASARR, the facility failed to ensure the state mental health authority was notified when the resident received a new mental health diagnosis.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #19 and 86) reviewed for dementia care and/or pain, for Resident #19, the facility failed to develop and implement a comprehensive person centered care plan for dementia and for 1of 2 residents (Resident #86) the facility failed to ensure a comprehensive care plan was developed for a resident with a history of pain.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #19) reviewed for PASARR and for 1 of 3 residents (Resident #32) reviewed for falls, for Resident #19 the facility failed to have a care plan for the resident who had positive level 2 PASARR and for Resident #32, the facility failed to revise the care plan following a fall with major injury that resulted in hospitalization.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #43, 32, 44, 62 and 65) the facility failed to provide care according to professional standards of practice. For 1 resident (Resident #43) reviewed for death, the facility failed to ensure medications were administered according to the physician's orders, failed to obtain blood sugar and blood pressures as ordered, failed to follow the physician's order to notify the physician with a blood sugar outside the parameter and failed to complete ongoing assessments after the resident experienced a change in condition. For Resident #32 the facility failed to obtain weights according to the physician's order. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #142) reviewed for pressure ulcers, the facility failed to ensure an RN assessment of a pressure ulcer was completed on admission.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #36) reviewed for discharge, the social worker failed to assist the resident when he/she requested to be transferred to another facility.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident 36) reviewed for choices, the facility failed to ensure food choices were honored.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview, the facility failed to ensure that surveillance monitoring for a respiratory outbreak was accurate and thorough, failed to ensure that the laundry area was maintained in a clean and sanitary manner and for 1 resident (Resident #65) the facility failed to ensure that infection control protocols were implemented following the onset of respiratory symptoms during an active outbreak.

Inspectors wroteBased on review of facility documentation, facility policy, and interview, the facility failed to ensure the Infection Preventionist (IP) worked at least part-time at the facility managing the Infection Prevention and Control Program.

Inspectors wroteBased on review of facility documentation, facility policies, and interviews, the facility failed to ensure nurse aides received no less than 12 hours of in-services, annually, including dementia management training.

Inspectors wroteBased on a review of the clinical record, facility documentation, and staff interviews for 1 of 3 residents (Resident #1) reviewed for quality of care, the facility failed to properly transcribe physician wound treatment orders.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure fall risk assessments were conducted in accordance with the standards of practice.

Inspectors wroteBased on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to notify the physician for a resident who exhibited signs and symptoms and complained of pain and was not due for pain medication administration for several hours.

Inspectors wroteBased on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for neglect, (Resident #1), the facility failed to ensure incontinent care was provided to a resident according to the plan of care and facility policy, resulting in a finding of neglect.

Inspectors wroteBased on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to address the resident complaints of pain.

Inspectors wroteBased on observation, review of facility documentation, review of job descriptions, and interviews for 1 resident (Resident #34) reviewed for wheelchair maintenance, the facility failed to ensure the residents power wheelchair was in good repair and for 4 out of 4 units, the facility failed to ensure the environment was clean, and maintained in good repair.

Inspectors wrote6. Resident #60 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, metabolic encephalopathy, and type 2 diabetes mellitus. The care plan dated 7/14/23 identified Resident #60 was at risk for falls. Interventions included to encourage the use of non-skid footwear, perform a fall assessment, remind resident to use call bell to request assistance before getting out of bed, and to toilet at regular intervals. The admission MDS dated [DATE] identified Resident #60 had intact cognition, required a limited one-person physical assistance with bed mobility, walking in the room, walking in the corridor, dressing, and toilet use. The nurse's note dated 9/22/23 at 8:56 PM identified that Resident #60 was sitting on the floor in front of his/her bed, without socks or shoes, and stated he/she was going to the bathroom. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #399) reviewed for pain management, the facility failed to administer the scheduled pain medication for 15 days because it was not available.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure that nurse aide staff completed annual competencies.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interview, the facility failed to have an emergency supply of narcotics available for resident use, and failed to establish a system of records of all controlled drugs to enable an accurate reconciliation, failed to ensure drug records were in order, and that an account of all controlled drugs was maintained and periodically reconciled.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents, (Resident #89) reviewed for unnecessary medications, the facility failed to ensure the resident was free from significant medication errors when staff failed to administer 18 doses of a medication for attention and concentration deficit and 12 doses of a medication for substance abuse with withdrawal.

Inspectors wroteBased on observation, review of facility policy, and interviews, the facility failed to maintain sanitizing solution at acceptable parameters (200 ppm or above) and ensure the ice machine was free from dark black spots in the interior.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure review of the antibiotic stewardship program was completed at least annually.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to have a designated Infection Preventionist (IP) with the required specialized training in infection control, after 9/29/23.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews the facility failed to maintain an environment free of pests.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #63) reviewed for participation in care planning, the facility failed to invite the resident and the resident representative to participate in the quarterly care plan meetings.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #63 and 87) reviewed for code status, the facility failed to receive the code status in a timely manner, signed by the resident or resident representative, and failed to have the code status physician's order in place.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #20, 34, 87 and 399) the facility failed to notify the physician and/or the resident representative when indicated. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #17) reviewed for resident-to-resident abuse, the facility failed to protect the resident from physical abuse by Resident #57, who had a history of wandering in the facility.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #17) reviewed for resident-to-resident abuse, the facility failed to ensure a thorough investigation of the incident was completed, documented and available for review.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #8, 59, 70 and 89) the facility failed to develop a comprehensive care plan as follows: [...]

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #2 and 59) reviewed for PASARR and respiratory care, the facility failed to conduct quarterly care plan meetings and for 1 of 5 residents (Resident #35) reviewed for unnecessary medications, the facility failed to ensure the care plan addressed target behaviors for a resident who required psychotropic medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #95) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on the scheduled shower days.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure licensed clinical staff maintained active CPR certifications.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #8) reviewed for communication, the facility failed to develop and provide an ongoing program of activities for the resident who is hearing impaired and for 1 resident (Resident #95) reviewed for recreation, the facility failed to develop and provide an ongoing program of activities including music and television.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #87) reviewed for positioning, the facility failed to provide an appropriate wheelchair on admission which resulted in the resident not being able to get out of bed for 107 days.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #2) reviewed for accidents, the facility failed to ensure a resident's environment was free from an accident hazard.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for the only resident (Resident #59) reviewed for enteral feeding, the facility failed to follow the physician's order related to enteral feedings and free water flushes including documentation of the daily totals of each.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interview for 2 residents, (Resident #34 and 63), reviewed for respiratory care, for Resident #34 the facility failed to ensure a properly fitting CPAP mask was available, which resulted in the resident's inability to wear the CPAP for 4 months and for Resident #63 the facility failed to store a portable oxygen cylinder properly per facility policy.

Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, facility policy, the facility failed to ensure adequate staffing to meet the needs of the resident, including staff to escort the resident to a follow up orthopedic appointment.

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure that the DNS served as the director of nursing on a full-time basis. (According to Appendix PP §483.35(b)(2) the facility must designate a registered nurse to serve as the director of nursing on a full-time basis, and §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents, and Full-time is defined as working 40 or more hours a week).

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to ensure annual evaluations were completed for nurse aide staff.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #20 and 89) reviewed for unnecessary medications, the facility failed to ensure a physician/APRN reviewed and responded to the pharmacy consultant's monthly recommendations.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #20 and 35) reviewed for unnecessary medications, the facility failed to ensure a prn psychotropic medication order was limited to 14 days.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #70) reviewed for behaviors, the facility failed to remove a discontinued controlled medication from the medication cart according to the facility policy, and subsequently, staff borrowed the medication for another resident's use.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #95) reviewed for transmission based precautions, the facility failed to adhere to PPE standards, and failed to ensure the infection control program policies were in place for the facility in accordance with actual facility type, and failed to ensure an annual review was completed of the infection control program policies.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents (Resident #34) reviewed for respiratory care, the facility failed to ensure the clinical record reflected complete and accurate data related to BiPap/CPAP daily usage, and for 1 of 3 residents (Resident #60) reviewed for accidents, the facility failed to maintain a complete medical record that was accurate and readily accessible for a resident sustaining an unwitnessed fall, and for 1 resident (Resident #95) reviewed for choices, the facility failed to ensure the clinical record reflected complete and accurate documentation related to showers, and for 1 resident (Resident #399) reviewed for pain management, the facility documented that pain medication was administered to the resident despite the pain medication not being available for 15 days.

Inspectors wroteBased on observations, staff interviews and review of facility policies for 1 of 2 medication storage rooms, the facility failed to ensure expired medications were discarded, failed to ensure the narcotic/medication and the nourishment freezer was defrosted, and for 1 of 4 medication carts, the facility failed to maintain the medication cart in a clean and sanitary manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #21) reviewed for rough care, the facility failed to immediately notify the DNS of the allegation and failed to ensure timely removal of persons identified as allegedly delivering rough care, pending the investigation.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to provide timely incontinent care to a resident requiring assistance.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and procedures and interviews for one of one sampled resident (Resident #2) reviewed for mood and behavior, the facility failed to ensure Resident #2 was assessed for safety or that a physician's order was in place to address the resident's leave of absence (LOA) privileges and for 1 of 4 residents (Resident #35) reviewed for pain, the facility failed to ensure recommendations for a specialty provider were responded to in a timely manner.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #21) reviewed for pressure ulcers, the facility failed to ensure the nutritional status was re-evaluated following the development of a facility acquired pressure ulcer.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #39) reviewed for nutrition, the facility failed to ensure the Dietician evaluate a significant weight loss in a timely manner.

Inspectors wroteBased on clinical record review, review of facility policy and interviews for 4 of 4 residents (Resident #41, Resident #44, Resident #51, and Resident #66) reviewed for hospitalizations, the facility failed to ensure the Ombudsman was notified when residents were transferred from the facility and discharged to the hospital.