Deficiencies (last 5 years)
Deficiencies (over 5 years)
31.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
461% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
82% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure in timely notification of a resident's absence following a leave of absence, missed medication administration, inadequate discharge planning, and failure to obtain hospital discharge summaries.
Complaint Details
The complaint investigation focused on Resident #1 regarding failure to notify the physician and administration when the resident did not return timely from a leave of absence, missed medication administration, inadequate discharge planning after a 30-day notice, and failure to obtain hospital discharge summaries after readmission. The nursing home disputed the citations.
Findings
The facility failed to notify the physician, administration, and responsible parties timely when a resident did not return as scheduled from a leave of absence and missed evening medications. The facility also failed to provide adequate discharge planning and orientation for a resident with a 30-day discharge notice. Additionally, the facility did not obtain hospital discharge summaries timely after a resident's readmission. Multiple conflicting Leave of Absence policies were found, causing confusion in staff actions.
Deficiencies (3)
F 0580: The facility failed to notify the resident's physician, administration, and responsible party timely when the resident did not return as scheduled from a leave of absence and missed evening medications.
F 0627: The facility failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer or discharge after a 30-day discharge notice was given.
F 0684: The facility failed to obtain a hospital discharge summary timely after a resident's readmission and failed to ensure staff acted timely when a resident did not return as expected from a leave of absence.
Report Facts
Missed medications: 4
Leave of Absence delay: 9.83
BIMS score: 11
Discharge notice period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor | Failed to obtain hospital discharge summary after resident readmission and did not notify appropriate parties when resident did not return from leave of absence. |
| LPN #1 | Licensed Practical Nurse | Failed to contact resident's physician or APRN to notify missed medication administration. |
| Director of Nursing Services | DNS | Not notified timely about resident's late return from leave of absence and lack of notification to police and physician. |
| Physician #1 | Medical Director | Expected timely notification of missed medications and resident's failure to return from leave of absence. |
| Social Worker | Responsible for discharge planning and communication with resident and other facilities; failed to complete adequate discharge planning. | |
| Administrator | Unaware of 30-day discharge notice and resident transfer plans. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely notify the physician and responsible parties when a resident did not return from a leave of absence as scheduled, missed medications, failure to obtain hospital discharge summaries timely, and inadequate discharge planning for a resident.
Complaint Details
The complaint investigation focused on Resident #1's failure to return timely from a leave of absence, missed medications, lack of timely notification to the physician and administration, failure to obtain hospital discharge summaries, and inadequate discharge planning. The nursing home disputed the citations.
Findings
The facility failed to notify the physician, administration, and responsible parties timely when Resident #1 did not return from a leave of absence as scheduled, missed evening medications, and returned late without proper notification. The facility also failed to obtain hospital discharge summaries timely after readmission and did not provide adequate discharge planning and preparation for Resident #1's transfer. Multiple conflicting Leave of Absence policies were found, causing confusion about proper procedures.
Deficiencies (5)
Failure to notify the resident's physician, administration, and responsible party timely when Resident #1 did not return from a leave of absence as scheduled.
Failure to notify the provider that Resident #1 missed scheduled evening medications.
Failure to provide and document sufficient preparation and orientation to Resident #1 to ensure a safe and orderly transfer or discharge after a 30-day discharge notice.
Failure to obtain hospital discharge summary timely after Resident #1's readmission.
Failure to ensure staff were provided with a current facility policy directing steps to follow when a resident did not return timely from a leave of absence; multiple conflicting policies existed.
Report Facts
Missed medications: 4
Late return time: 590
Hospital readmission date: Sep 1, 2025
Leave of Absence expected return time: 1800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor | Supervisor when Resident #1 was readmitted from hospital without discharge summary; failed to obtain discharge paperwork. |
| RN #2 | Nursing Supervisor | Supervisor on 9/1/2025 shift aware Resident #1 returned without discharge summary; stated responsibility of 3 PM to 11 PM shift to follow up. |
| LPN #1 | Licensed Practical Nurse | Failed to notify Resident #1's physician or APRN about missed medications on 9/8/2025. |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding notification failures and policy issues related to Resident #1's leave of absence and late return. |
| Physician #1 | Medical Director | Expected timely notification of missed medications and leave of absence issues; unaware of multiple conflicting LOA policies. |
| Social Worker | Responsible for discharge planning and issuing 30-day discharge notice for Resident #1; had not completed adequate discharge planning. | |
| Administrator | Facility Administrator | New to facility; unaware of 30-day discharge notice and transfer plans for Resident #1. |
Inspection Report
Renewal
Census: 123
Capacity: 150
Deficiencies: 0
Date: Sep 14, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection and included review of complaint investigations #CT42529 and #121090.
Complaint Details
Complaint investigations #CT42529 and #121090 were reviewed during the inspection. No substantiation status is provided.
Findings
The report indicates that this was a licensing renewal inspection with complaint investigations reviewed. No violations or citations were explicitly noted on the provided page.
Report Facts
Licensed Bed Capacity: 150
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Kraus | Administrator | Personnel contacted during inspection |
Inspection Report
Routine
Deficiencies: 22
Date: Aug 29, 2025
Visit Reason
Routine state inspection survey of New Haven Center for Nursing & Rehabilitation LLC to assess compliance with healthcare facility regulations including resident care, safety, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including resident rights, nutrition and meal service, care planning, medication administration, infection control, staff training, and safety supervision. Specific issues included failure to provide timely meals, failure to ensure residents received ordered double portions, inadequate response to resident council concerns, mismanagement of resident funds, failure to notify family of pressure ulcers, incomplete care plans, unsafe smoking practices, medication errors, inadequate infection prevention program, and failure to provide proper supervision during meals for residents with aspiration precautions.
Deficiencies (22)
F 0550: The facility failed to provide Resident #63 a timely breakfast tray, resulting in the resident rummaging through leftover trays and receiving an incomplete meal.
F 0561: Resident #130 did not receive double portions as ordered and requested, and dietary staff misrepresented portion sizes, causing ongoing nutritional risk.
F 0565: The facility failed to consistently respond and follow up on Resident Council food-related concerns, and the Food Service Director often missed meetings.
F 0568: Resident #45 did not receive quarterly financial statements timely, and discrepancies in personal fund withdrawals were not properly addressed.
F 0580: Resident #76 developed a new stage 3 pressure ulcer, but the resident's representative was not notified timely, and RN assessments were delayed.
F 0602: Resident #45 alleged misappropriation of funds related to unauthorized withdrawals; facility investigation was incomplete and failed to interview implicated staff.
F 0609: The facility failed to timely report an allegation of staff verbal abuse toward Resident #59 to the state agency.
F 0610: The facility failed to remove an employee and initiate a timely investigation following an allegation of verbal abuse to Resident #59.
F 0656: Resident #4's care plan was not updated to include a new diagnosis of dementia, and Resident #17's care plan lacked tracheostomy care interventions.
F 0657: The facility failed to update care plans for residents with unsafe smoking behaviors and failed to revise Resident #128's care plan to include an air mattress.
F 0658: Resident #14's medications were crushed despite orders indicating extended release and enteric coated formulations, constituting medication errors.
F 0677: Resident #41 was not provided necessary nail care and grooming assistance, resulting in long, soiled fingernails and soiled bedding.
F 0684: The facility failed to provide adequate supervision and appropriate diet consistency for Resident #14, resulting in Immediate Jeopardy which was removed after corrective actions.
F 0686: Resident #76's new pressure ulcer was not assessed timely by an RN, treatment was delayed, and weekly skin checks were inconsistently completed.
F 0689: The facility failed to provide adequate supervision during meals for residents with aspiration precautions, failed to enforce smoking policies, and failed to conduct risk assessments for independent leave of absence residents.
F 0730: Annual performance evaluations for nurse aides were not completed for 2024 or 2025 for multiple staff.
F 0759: Medication error rate was 12% due to crushing of extended release and enteric coated medications for Resident #14.
F 0802: Dietary aides lacked knowledge of meal ticket reading and food labeling; unlabeled and expired food items were found in refrigerators and freezer with inadequate cleaning.
F 0880: The facility failed to maintain infection prevention and control program documentation, including outbreak tracking and infection surveillance.
F 0881: The facility failed to ensure ongoing antibiotic stewardship including tracking and monitoring of antibiotic use.
F 0882: The facility did not have a designated qualified infection preventionist from August 2024 through February 2025.
F 0883: The facility failed to offer and/or provide education and documentation for COVID-19 vaccinations for sampled residents.
Report Facts
Medication observations: 25
Medication errors: 3
Medication error rate: 12
Residents involved in GI outbreak: 10
Weight loss percentage: 10
Weight loss percentage: 15
Weight loss percentage: 10.53
Number of unlabeled food items discarded: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Crushed extended release and enteric coated medications for Resident #14 |
| RN #1 | Infection Preventionist | Lacked infection surveillance and antibiotic stewardship tracking |
| Dietary Director (Interim) | Dietary Director | Acknowledged unlabeled food items and lack of dietary staff training |
| Administrator | Facility Administrator | Directed dietary staff to serve Resident #59 requested food regardless of allergies |
| RN #3 | Nursing Supervisor | Uncertain about tracheostomy care for Resident #17 |
| RN #5 | RN Supervisor | Failed to assess new pressure ulcer on Resident #76 timely |
| LPN #7 | Licensed Practical Nurse | Failed to notify RN supervisor of new pressure ulcer on Resident #76 |
| NA #1 | Nurse Aide | Failed to supervise Resident #14 during meals and did not read meal tickets |
| NA #14 | Nurse Aide | Unaware of aspiration precautions for Resident #14 |
| RN #4 | MDS Coordinator | Did not ensure care plans were updated for new diagnoses or interventions |
| RN #1 | Wound Nurse/Infection Preventionist | Newly assigned, lacked training and support |
| LPN #14 | Licensed Practical Nurse | Attempted to administer medication dropped on floor to Resident #86 |
| Dietary Aide #5 | Dietary Aide | Unable to explain food labeling and storage |
| Dietary Aide #4 | Dietary Aide | Unable to explain food labeling and storage |
Inspection Report
Deficiencies: 22
Date: Aug 29, 2025
Visit Reason
The inspection was conducted as a comprehensive regulatory survey of New Haven Center for Nursing & Rehabilitation LLC to assess compliance with federal nursing home regulations.
Findings
The survey identified multiple deficiencies across various areas including resident rights, nutrition and food service, medication administration, infection control, care planning, staff performance evaluations, and safety. Several residents experienced issues such as delayed or incorrect meal delivery, failure to provide double portions as ordered, misappropriation of resident funds, failure to notify representatives of new wounds, inadequate supervision during meals, medication errors, and lapses in infection prevention and control.
Deficiencies (22)
Failure to provide timely and correct meals, including delayed breakfast tray delivery and incorrect meal portions.
Failure to ensure resident received double portions per physician order and resident request.
Failure to ensure consistent response and follow-up to Resident Council concerns regarding food quality and staff phone use.
Failure to provide quarterly financial statements to resident responsible for personal funds.
Failure to notify resident representative timely of new pressure ulcer and failure to perform timely RN assessment and treatment.
Failure to protect resident from misappropriation of funds; unauthorized withdrawals and lack of receipts.
Failure to timely report staff-to-resident verbal abuse allegation to state agency.
Failure to remove employee and initiate investigation following reported verbal abuse allegation.
Failure to develop and implement comprehensive care plans for new dementia diagnosis and for tracheostomy care.
Failure to review and revise care plans addressing unsafe smoking behaviors and contraband, and failure to educate residents on smoking safety.
Failure to ensure resident unable to carry out ADLs independently received necessary grooming services.
Failure to administer medications according to professional standards; crushing enteric coated and extended release medications.
Failure to provide sufficient dietary staff competencies and training on meal ticket reading and diet consistencies.
Failure to ensure menus meet nutritional needs, are prepared in advance, followed, updated, reviewed by dietician, and meet resident needs.
Failure to provide chopped diet and supervision for resident with aspiration precautions resulting in Immediate Jeopardy.
Failure to ensure food is served according to resident allergies, intolerances, and preferences.
Failure to procure food from approved sources and to properly label, date, and store food items including defrosting freezer.
Failure to provide and implement an infection prevention and control program including outbreak documentation and surveillance.
Failure to monitor antibiotic use and implement antibiotic stewardship program.
Failure to designate a qualified infection preventionist for approximately 7 months.
Failure to develop and implement policies and procedures for flu and pneumococcal vaccinations including documentation and tracking.
Failure to educate residents and staff on COVID-19 vaccination, offer vaccine to eligible residents and staff, and properly document vaccination status.
Report Facts
Medication observations: 25
Medication errors: 3
Medication error rate: 12
Residents involved in GI outbreak: 10
Weight loss percentage: 10
Weight loss percentage: 15
Weight loss percentage: 10.53
Weight loss percentage: 5.7
Weight loss percentage: 5
Weight loss percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Crushed extended release and enteric coated medications for Resident #14 |
| RN #1 | Infection Preventionist | Infection prevention and control program, antibiotic stewardship |
| Administrator | Directed dietary staff to serve Resident #59 requested food regardless of allergies | |
| Dietary Director (Interim) | Dietary Director | Oversaw dietary operations, acknowledged meal ticket and food mismatches |
| RN #3 | Nursing Supervisor | Uncertain about tracheostomy care for Resident #17 |
| RN #4 | MDS Coordinator | Responsible for care plan updates, admitted lack of clarity on responsibilities |
| RN #5 | Charge Nurse | Failed to assess new pressure ulcer on Resident #76 timely |
| LPN #7 | Licensed Practical Nurse | Identified new pressure ulcer on Resident #76 but failed to notify RN |
| Dietitian #2 | Dietitian | Monitored Resident #130 nutrition and double portions |
| Dietitian #1 | Dietitian | Monitored Resident #130 nutrition and double portions |
| LPN #14 | Licensed Practical Nurse | Attempted to administer medications dropped on floor to Resident #86 |
| NA #1 | Nurse Aide | Delivered incorrect meal to Resident #130 |
| NA #3 | Nurse Aide | Observed Resident #63 rummaging through breakfast trays |
| NA #4 | Nurse Aide | Delivered delayed breakfast tray to Resident #63 |
| NA #5 | Nurse Aide | Notified nurse about Resident #41's long nails |
| NA #6 | Nurse Aide | Observed Resident #105 knocking on smoking area door |
| NA #19 | Nurse Aide | Involved in pizza orders and cash handling for Resident #45 |
| Recreation Director | Assisted residents with ordering food and involved in Resident #45 fund issues | |
| Administrator | Aware of Resident Council concerns and smoking violations | |
| Dietitian #3 | Dietitian | Monitored Resident #4 nutrition and weight |
| APRN #1 | Advanced Practice Registered Nurse | Provided medical orders and oversight for Resident #14 and others |
| SLP #1 | Speech Language Pathologist | Provided swallowing evaluations and recommendations for Resident #14 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 2, 2024
Visit Reason
The inspection was conducted to investigate allegations of verbal abuse by a staff member towards a resident and to review an elopement incident involving a resident who exited the facility unassisted and was found walking outside in unsafe conditions.
Complaint Details
The verbal abuse allegation was substantiated based on consistent statements from the resident and roommate. The nursing assistant involved was terminated. The elopement incident involved a resident with severe cognitive impairment who left the facility unassisted and was found outside after several hours. The facility delayed notifying police and had procedural failures in monitoring and securing the exit door.
Findings
The facility substantiated verbal abuse by a nursing assistant towards a resident, resulting in the termination of the staff member. The facility also failed to prevent a cognitively impaired resident from leaving the building unassisted, resulting in immediate jeopardy to resident health and safety. Delays in locating the resident and notifying police were identified.
Deficiencies (2)
F 0600: The facility failed to protect a resident from verbal abuse by a staff member who called the resident ugly and made inappropriate comments about the resident's significant other. The abuse was substantiated and the staff member was terminated.
F 0689: The facility failed to ensure a resident who required assistance and an assistive device did not exit the facility without staff knowledge, resulting in the resident being found walking outside in the dark nine miles from the facility after sustaining a fall. This failure resulted in immediate jeopardy to resident health or safety.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for elopement: 3
Distance resident walked outside: 9
Time police called after resident noted missing: 54
Time resident walked outside: 4
Time delay for door lock engagement: 90
Time delay from notification to Administrator: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in verbal abuse finding and elopement incident |
| RN #1 | Registered Nurse | Interviewed regarding verbal abuse allegation |
| Administrator | Interviewed regarding abuse and elopement incidents and surveillance review | |
| DNS | Director of Nursing Services | Interviewed regarding elopement incident and resident supervision |
| Receptionist | Interviewed regarding front door monitoring and LOA procedures | |
| Recreation Assistant | Reported resident outside and searched for resident | |
| Recreation Director | Notified and involved in search for missing resident | |
| PO #1 | Police Officer | Responded to missing resident location |
| MD #1 | Medical Director | Interviewed regarding expectations for police notification |
| APRN #1 | Psychiatric APRN | Reported seeing missing resident off duty |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 2, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding verbal abuse of Resident #2 by a staff member and an elopement incident involving Resident #1 who exited the facility without staff knowledge.
Complaint Details
The verbal abuse complaint was substantiated based on consistent statements from Resident #2 and the roommate, leading to termination of NA #1. The elopement incident involved Resident #1 leaving the facility unsupervised, with delayed notification to police and staff, resulting in immediate jeopardy findings.
Findings
The facility was found to have substantiated verbal abuse against Resident #2 by a nursing assistant, resulting in the termination of the staff member. Additionally, the facility failed to prevent Resident #1, who required supervision and assistive devices, from eloping and being found walking nine miles away, resulting in immediate jeopardy to resident health and safety.
Deficiencies (2)
Failure to protect Resident #2 from verbal abuse by a staff member.
Failure to ensure Resident #1 did not exit the facility without staff knowledge, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for elopement: 3
Distance Resident #1 walked: 9
Time police called after missing report: 54
Time Resident #1 last seen before elopement: 15
Time Resident #1 found by police: 19
Time delay to notify Administrator after resident reported outside: 10
Lock engagement delay: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in verbal abuse finding and terminated for verbal abuse. |
| Registered Nurse #1 | RN | Interviewed regarding verbal abuse incident involving Resident #2. |
| Administrator | Interviewed regarding verbal abuse substantiation and elopement incident. | |
| Recreation Assistant | Reported Resident #1 outside and notified Recreation Director. | |
| Recreation Director | Notified Administrator about missing Resident #1 and initiated search. | |
| Receptionist | Responsible for monitoring front door and LOA forms; involved in elopement incident. | |
| Police Officer #1 | Responded to missing Resident #1 and found resident disoriented. | |
| Director of Nursing Services | DNS | Interviewed regarding Resident #1's supervision and elopement incident. |
| APRN #1 | Off duty psychiatric APRN | Reported seeing Resident #1 several towns away during elopement. |
| Medical Director | MD #1 | Interviewed regarding expectations for police notification in missing resident cases. |
Inspection Report
Plan of Correction
Census: 131
Capacity: 150
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a violation letter dated August 27, 2024.
Findings
Violations #1 and #2 were identified as corrected as of October 11, 2024. The administrator was notified via telephone on October 31, 2024, that all violations were corrected.
Report Facts
Licensed Bed Capacity: 150
Census: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonah Kraus | Administrator | Personnel contacted during inspection |
| Reba Stoddard | NC | Report submitted by and FLIS staff signature |
Inspection Report
Census: 132
Capacity: 150
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a previous violation letter dated September 26, 2024.
Findings
Violation #1 was identified as corrected as of October 24, 2024. The Director of Nursing was notified via telephone on October 30, 2024, that all violations were corrected.
Deficiencies (1)
Violation #1 identified in previous inspection
Report Facts
Licensed Bed Capacity: 150
Census: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pedro Roman | Director of Nursing | Named in relation to notification of correction of violations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to respect a resident's request to call 911 for hospital transfer related to a left lower leg blister and possible infection.
Complaint Details
The complaint was substantiated. Resident #3 and family complained about the handling of the 911 call request and the tone used by RN #1. The facility acknowledged the failure to call 911 as requested and recognized policy miscommunication.
Findings
The facility failed to call 911 for Resident #3 despite the resident's request, citing no assessed medical necessity. The resident was later transferred independently via 911 and hospitalized for left lower extremity cellulitis caused by methicillin resistant staphylococci aureus. Facility staff and administration acknowledged policy and communication issues regarding 911 calls.
Deficiencies (1)
F 0550: The facility failed to honor Resident #3's right to a dignified existence and self-determination by not calling 911 as requested for hospital transfer despite the resident's concerns about a left leg blister and possible infection.
Report Facts
Date of survey completion: Sep 12, 2024
Hospitalization dates: 5
Antibiotic course duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed Resident #3 and did not call 911 despite resident request |
| APRN #1 | Advanced Practice Registered Nurse | Evaluated Resident #3 for left leg blister and open wound |
| Administrator | Interviewed regarding facility policy and handling of 911 call request | |
| DON | Director of Nursing | Interviewed regarding facility policy on 911 calls and resident transfers |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint involving Resident #3, who requested a transfer to the hospital via 911 for a left leg blister and possible infection, which the facility initially did not honor as requested by the resident.
Complaint Details
The complaint involved Resident #3's request to be transferred to the hospital due to a blister and suspected infection on the left leg. The resident and family were dissatisfied with the nursing staff's handling of the situation, specifically RN #1's refusal to call 911 on behalf of the resident and requiring the resident to call independently. The complaint was substantiated by the findings.
Findings
The facility failed to respect Resident #3's request to call 911 and transfer to the hospital despite the resident's insistence, resulting in delayed transfer. The resident was later independently transferred via 911 and hospitalized for cellulitis with methicillin resistant staphylococci aureus infection. Facility staff and administration interviews revealed conflicting understanding of policy regarding resident transfer requests.
Deficiencies (1)
Failure to respect the resident's request to call 911 and transfer to the hospital despite the resident's insistence.
Report Facts
Dates: Mar 13, 2024
Dates: Mar 18, 2024
Duration: 7
Times: 915
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nursing note author who assessed Resident #3 and did not call 911 on behalf of the resident |
| LPN #2 | Licensed Practical Nurse | Noted blister on left leg and notified APRN and responsible party |
| APRN #1 | Advanced Practice Registered Nurse | Evaluated Resident #3's left leg blister and provided wound care instructions |
| Administrator | Facility Administrator | Interviewed regarding facility policy and expectations for 911 calls and resident transfers |
| DON | Director of Nursing | Interviewed regarding facility policy on resident transfer requests and 911 calls |
Inspection Report
Follow-Up
Census: 126
Capacity: 150
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
A desk audit was conducted on 9/5/24 to review the implementation of the Plan of Correction for the Violation letter dated 7/16/24.
Findings
Violations #1 and #2 were identified as corrected as of 8/20/24. The Administrator was notified on 9/5/24 that all violations were corrected.
Report Facts
Licensed Bed Capacity: 150
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonah Kraus | Personnel contacted during the inspection | |
| Reba Stoddard | NC | Desk Audit staff and report submitter |
Inspection Report
Routine
Census: 123
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, medication administration, and staffing levels at the nursing facility.
Findings
The facility failed to ensure a medication was reordered and available at the time it was due, and the provider was not notified when the medication was unavailable. Additionally, the facility did not maintain staffing levels to meet the minimum required 3.0 hours of direct care on specified dates.
Deficiencies (2)
F 0658: The facility failed to ensure a medication was reordered and available at the scheduled time and did not document provider notification when the medication was unavailable.
F 0836: The facility failed to maintain staffing levels to meet the minimum requirements of Connecticut General Statute 19a-563h regarding 3.0 hours of direct care on 8/10/24 and 8/11/24.
Report Facts
Census: 123
Staffing hours required: 266.91
Staffing hours provided: 210
Staffing hours deficit: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Charge Nurse | Interviewed regarding medication reorder responsibilities and provider notification |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication reorder responsibilities and provider notification |
| Director of Nursing | DON | Interviewed regarding medication reorder responsibilities, provider notification, and staffing policies |
| Administrator | Administrator | Interviewed regarding staffing responsibilities and compliance with 3.0 direct care hour requirements |
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with professional standards of quality, medication administration, and staffing requirements at the nursing facility.
Findings
The facility failed to ensure a medication (Trulicity) was reordered and available at the time of administration and failed to document provider notification when the medication was unavailable. Additionally, the facility did not maintain staffing levels to meet the minimum Connecticut General Statute 19a-563h requirement of 3.0 hours of direct care, falling short by 56 hours on two days.
Deficiencies (2)
Failed to ensure medication was reordered and available at the time of administration and failed to notify provider when medication was unavailable.
Failed to maintain staffing levels to meet minimum state requirements of 3.0 hours of direct care, understaffed by 56 hours on 8/10/24 and 8/11/24.
Report Facts
Census: 123
Staffing hours required: 266.91
Staffing hours actual: 210
Staffing hours deficit: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Charge Nurse | Identified responsibility to ensure medications are reordered and provider notification when medication unavailable |
| Licensed Practical Nurse #1 | LPN | Identified responsibility to reorder medications and notify provider if medication unavailable |
| Director of Nursing | DON | Confirmed charge nurse responsibility for medication reorder and provider notification; identified no documentation of notification |
| Administrator | Administrator | Identified responsibility with DON to ensure staffing meets 3.0 hour requirement; acknowledged staffing shortfall on 8/10/24 and 8/11/24 |
Inspection Report
Monitoring
Census: 128
Capacity: 150
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
A desk audit was completed from 7/19/24 through 7/22/24 to review the implementation of the Plan of Correction for the violation letter dated 5/21/24.
Findings
Violations #1-4 were identified as corrected as of 7/15/24. On 7/22/24, the Director of Nursing Services was notified by telephone that all violations were corrected.
Report Facts
Violations corrected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonah Kraus | Administrator | Personnel contacted during inspection |
| Stephanie Schumann | Report submitted by | |
| Maureen Golay-Markure | Supervisor | Survey Team Leader Supervisor |
Inspection Report
Deficiencies: 2
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and medication administration at the nursing home.
Findings
The facility failed to ensure a comprehensive care plan included discharge planning for one resident and failed to maintain complete and accurate medication administration documentation for another resident.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that included discharge planning and measurable timetables for Resident #1.
F 0842: The facility failed to ensure the clinical record was complete and accurate to include medication administration documentation for Resident #2.
Inspection Report
Deficiencies: 2
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning and medication administration standards at New Haven Center for Nursing & Rehabilitation LLC.
Findings
The facility failed to ensure a comprehensive care plan included discharge planning for Resident #1 and failed to maintain complete and accurate medication administration documentation for Resident #2. Both deficiencies were identified as having minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failure to develop and implement a complete care plan that includes discharge planning for Resident #1.
Failure to ensure clinical record was complete and accurate to include medication administration documentation for Resident #2.
Report Facts
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW #2 | Social Worker | Named in relation to failure to document discharge planning and MFP application status for Resident #1 |
| RN #1 | Registered Nurse | Named in relation to failure to document medication administration on MAR for Resident #2 |
| DNS | Director of Nursing Services | Provided interview regarding documentation expectations for both deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at New Haven Center for Nursing & Rehabilitation LLC.
Findings
The facility was found to have multiple deficiencies including failure to timely act on STAT physician orders for a resident with a change in condition, inaccurate transcription of diet orders upon admission for another resident, failure to maintain complete and accessible medical records for a resident, and failure to ensure a working call system was available in a resident's bathroom and bathing area.
Deficiencies (3)
F 0684: The facility failed to act on STAT physician orders timely for a resident with a change in condition and failed to ensure diet orders were transcribed accurately upon admission for another resident.
F 0842: The facility failed to maintain a complete and accurate medical record for a resident, resulting in inability to conduct an investigation.
F 0919: The facility failed to ensure a working call system was available in a resident's bathroom and bathing area, and no alternative device was provided during the malfunction.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Time delay: 7.27
Date of survey: May 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Medical Director | Provided interview regarding STAT order procedures and expectations |
| DNS | Director of Nursing Services | Interviewed regarding STAT order process and inability to provide documentation of timely order completion |
| DON | Director of Nursing | Interviewed regarding diet order transcription error and call bell malfunction |
| Corporate Nurse | Interviewed regarding inability to produce Resident #15's medical record |
Inspection Report
Monitoring
Census: 134
Capacity: 150
Deficiencies: 0
Date: May 15, 2024
Visit Reason
The inspection was conducted as a licensing inspection with strike monitoring for the New Haven Center for Nursing and Rehab.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. A citation was not issued.
Report Facts
Licensed Beds: 150
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonah Kraus | Personnel contacted during the inspection | |
| Marie Pitigo | Personnel contacted during the inspection |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 15, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements and to identify any deficiencies in care, treatment, and facility operations.
Findings
The facility was found deficient in several areas including failure to timely act on STAT physician orders for a resident with a change in condition, inaccurate transcription of diet orders upon admission for another resident, failure to maintain complete and accessible medical records for a resident from prior ownership, and failure to provide a working call system in a resident's bathroom and bathing area.
Deficiencies (4)
Failed to act on physician STAT orders timely for Resident #12 with a change in condition.
Failed to ensure diet orders were transcribed accurately upon admission for Resident #2.
Failed to maintain a complete and accurate medical record for Resident #15, including timely access to the medical record.
Failed to ensure a working call system was available in Resident #4's bathroom and bathing area.
Report Facts
Time delay: 7.27
Call bell malfunction duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in relation to Resident #12 vomiting episode and failure to act on STAT orders |
| APRN #2 | Advanced Practice Registered Nurse | Ordered STAT tests for Resident #12 |
| RN #1 | Registered Nurse | Interviewed regarding incident with Resident #12 |
| MD #1 | Medical Director | Provided interview about STAT order procedures |
| DNS | Director of Nursing Services | Interviewed about STAT order process and call bell malfunction |
| DON | Director of Nursing | Interviewed about diet order transcription error and call bell malfunction |
| NA #1 | Nursing Assistant | Observed Resident #4 with non-functioning call bell |
| Maintenance Assistant | Interviewed about call bell repair status | |
| Director of Environmental Services | Interviewed about call bell system repair order | |
| Corporate Nurse | Interviewed about inability to produce Resident #15's medical record |
Inspection Report
Follow-Up
Census: 140
Capacity: 150
Deficiencies: 0
Date: May 6, 2024
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction for the violation letter dated 2/21/24.
Findings
State compliance was unable to be completed during the desk audit, as it was awaiting an approved plan of correction. An approved plan of correction was received on 5/6/24 and approved by the supervisor on 5/14/24, indicating compliance with Violation #1 and Violation #2.
Report Facts
Licensed Bed/Bassinet Capacity: 150
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Schumann | NC | Inspector who conducted the desk audit and submitted the report |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 150
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
An unannounced visit was made to the facility on 3/5/24 for the purpose of conducting a complaint investigation.
Complaint Details
Complaint Investigation #37723 was conducted and no deficiencies or violations were found; staffing met Public Health Code requirements.
Findings
Staffing was reviewed from 2/20/24 to 3/12/24 and found to meet the requirements of the Public Health Code. Deficiencies and/or violations were not identified during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Talamini | RN, BSN Nurse Consultant | Named as the Nurse Consultant involved in the complaint investigation visit. |
| Jonah Kraus | Administrator | Personnel contacted during the inspection. |
| Maria Pitogo | DNS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 5, 2024
Visit Reason
The inspection was conducted following complaints regarding privacy violations during personal care and pest control issues involving mice in a resident's room.
Complaint Details
The investigation was triggered by complaints about privacy violations during personal care for Resident #2 and mice infestation in Resident #1's room. The privacy complaint was substantiated with observations and interviews. The pest control complaint was substantiated by maintenance logs and pest control reports showing delayed notification.
Findings
The facility failed to maintain resident privacy during personal care by leaving doors and privacy curtains open, exposing a resident. Additionally, the facility did not promptly inform the pest control company about mouse sightings in a resident's room, delaying treatment.
Deficiencies (2)
F 0550: The facility failed to ensure privacy was maintained during personal care for Resident #2, with the door and privacy curtain left open exposing the resident's lower body and catheter bag. Facility staff acknowledged this was against policy and a violation of resident dignity.
F 0925: The facility failed to ensure the pest control company was informed promptly about mouse sightings in Resident #1's room, resulting in delayed treatment. A hole in the resident's closet was later sealed following inspection.
Report Facts
Dates of mouse sightings: Reported on 10/17/23, 10/19/23, and 12/26/23 in Resident #1's room
Pest control service dates: Services provided on 10/13/23, 11/13/23, 11/27/23, 12/11/23, 12/21/23, 1/5/24, and 1/8/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | 7AM-3PM Nurse Aide | Observed providing personal care with door and curtain open |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policy on privacy and catheter bag coverage |
| Licensed Practical Nurse #1 | 7AM-3PM Charge Nurse | Interviewed about privacy practices and catheter bag covers |
| Assistant Director of Maintenance | Assistant Director of Maintenance | Interviewed about pest control procedures and mouse sighting notifications |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 150
Deficiencies: 3
Date: Feb 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #37137 regarding violations of Connecticut State regulations.
Complaint Details
Complaint #37137 was substantiated with findings of violations related to resident privacy, staffing shortages, and pest control deficiencies.
Findings
The inspection identified violations related to resident privacy during personal care, failure to maintain adequate staffing levels, and inadequate pest control measures. Plans of correction were submitted addressing these issues.
Deficiencies (3)
Failure to ensure privacy was maintained during personal care for Resident #2, including leaving the door and curtain open while providing care.
Failure to maintain staffing levels to meet minimum requirements for direct care hours, resulting in shortages on specified dates.
Failure to ensure the pest control company was informed and documented mouse sightings in Resident #1's room, leading to untreated pest issues.
Report Facts
Licensed Bed Capacity: 150
Census: 131
Staffing Shortage Hours: 40.61
Staffing Shortage Hours: 44.44
Direct Care Hours Requirement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonah Kraus | Administrator | Named as facility administrator and recipient of the notice. |
| Maria Pitogo | DNS | Named as Director of Nursing Services contacted during inspection. |
| Deborah Smith | RN, NC | Signature of FLIS staff who submitted the report. |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding complaint #37137. |
| Nurse Aide #1 | Identified in privacy violation and resident care findings. | |
| Licensed Practical Nurse #1 | Interviewed regarding hygiene care practices. | |
| Director of Nursing | DON | Interviewed regarding facility policy and staffing. |
| Assistant Director of Maintenance | Interviewed regarding pest control and maintenance issues. | |
| Scheduling Coordinator | Interviewed regarding staffing schedules and compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 5, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to maintain resident privacy during personal care and pest control issues involving mice in a resident's room.
Complaint Details
The complaint involved Resident #2's privacy being violated during personal care and Resident #1's room having mice. The privacy complaint was substantiated with observations and interviews. The pest control complaint was substantiated with documentation and interviews showing delayed notification to pest control.
Findings
The facility failed to ensure privacy for Resident #2 during personal care, with the door and privacy curtain left open exposing the resident. Additionally, the facility failed to promptly inform the pest control company about mouse sightings in Resident #1's room, resulting in delayed treatment. The hole in Resident #1's closet was later sealed.
Deficiencies (2)
Failure to maintain resident privacy during personal care with door and privacy curtain left open exposing Resident #2.
Failure to promptly inform pest control company of mouse sightings in Resident #1's room, delaying treatment.
Report Facts
Dates of mouse activity reported: 10/17/23, 10/19/23, 12/26/23
Pest control service dates: 10/13/23, 11/13/23, 11/27/23, 12/11/23, 12/21/23, 1/5/24, 1/8/24
Date hole sealed: 2/5/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Observed providing personal care to Resident #2 with privacy curtain and door open |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policy on resident privacy and catheter bag coverage |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about unacceptable practice of providing hygiene care with privacy curtain open |
| Assistant Director of Maintenance | Assistant Director of Maintenance | Interviewed about pest control procedures and notification delays |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 17, 2024
Visit Reason
The inspection was conducted to investigate complaints related to care plan revisions, medication availability, resident supervision, and pharmaceutical services at New Haven Center for Nursing & Rehabilitation LLC.
Complaint Details
The complaint investigation focused on issues including failure to revise care plans after significant clinical changes, failure to provide prescribed pain medications leading to withdrawal and emergency hospitalization, failure to supervise a resident who left the facility unattended, and failure to maintain adequate pharmaceutical services for controlled substances. The findings substantiated these complaints with minimal harm identified.
Findings
The facility failed to revise a resident's comprehensive care plan after hospitalization for acute opioid withdrawal and suicidal ideation, failed to ensure availability of prescribed pain medications leading to withdrawal symptoms and emergency hospitalization, and failed to prevent a resident from leaving the facility unattended for an extended period. The facility also failed to maintain adequate pharmaceutical services to prevent lapses in controlled medication availability.
Deficiencies (4)
F 0657: The facility failed to revise the comprehensive care plan for a resident after hospitalization for acute opioid withdrawal and suicidal/homicidal ideation.
F 0684: The facility failed to ensure availability of prescribed pain medication, resulting in a resident experiencing opioid withdrawal and requiring emergency services.
F 0689: The facility failed to ensure a resident did not leave the facility unattended for an extended period without staff knowledge.
F 0755: The facility failed to provide pharmaceutical services to ensure routine and emergency-controlled medications were available, resulting in medication lapses for a resident.
Report Facts
Missed doses of Morphine: 6
Missed doses of Oxycodone/Acetaminophen: 3
Resident missing duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Responsible for prescribing pain medication and involved in care of Resident #1 during withdrawal and medication refill issues. |
| Director of Nursing | DNS | Interviewed regarding care plan revisions and medication availability issues for Resident #1. |
| Licensed Practical Nurse #3 | LPN and MDS Nurse | Responsible for checking hospital paperwork and care plan revisions; failed to update care plan for Resident #1. |
| Pharmacist #1 | Pharmacist | Interviewed about medication availability and STAT order procedures related to Resident #1. |
| Licensed Practical Nurse #6 | LPN | Reported Resident #4 missing and involved in medication administration and shift report on day of incident. |
| Medical Director #2 | Former Medical Director | Interviewed regarding controlled medication availability and transition of responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to revise a resident's comprehensive care plan after hospitalization for acute opiate withdrawal and suicidal/homicidal ideations, failure to ensure availability of prescribed pain medication, failure to prevent a resident from leaving the facility unattended, and failure to provide pharmaceutical services to meet residents' needs.
Complaint Details
The visit was complaint-related, triggered by concerns about care plan revisions, medication availability, resident safety, and pharmaceutical services. Substantiation status is not explicitly stated.
Findings
The facility failed to revise the care plan for a resident with acute opioid withdrawal and suicidal ideation, failed to ensure timely availability and administration of prescribed pain medications leading to withdrawal symptoms and emergency hospitalization, failed to prevent a resident from leaving the facility unattended for six hours without staff knowledge, and failed to maintain adequate pharmaceutical services including emergency controlled medications.
Deficiencies (4)
Failed to revise the comprehensive care plan for a resident after hospitalization for acute opioid withdrawal and suicidal/homicidal ideations.
Failed to ensure availability and administration of prescribed pain medications, resulting in opioid withdrawal and emergency room visit.
Failed to ensure a resident did not leave the facility unattended for an extended period without staff knowledge.
Failed to provide pharmaceutical services to meet the needs of residents, including lack of emergency controlled medications in the emergency box.
Report Facts
Deficiencies cited: 4
Medication doses missed: 5
Medication doses missed: 3
Resident missing time: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Responsible for prescribing pain medication and involved in care of Resident #1 during withdrawal and medication refill issues. |
| Director of Nursing | DNS | Interviewed regarding care plan revision responsibilities and medication availability issues. |
| Licensed Practical Nurse #3 | LPN and MDS nurse | Responsible for checking hospital paperwork and care plan revisions; failed to update care plan for Resident #1. |
| Pharmacist #1 | Pharmacist | Interviewed about medication orders and emergency box medication availability. |
| Medical Director #2 | Former Medical Director | Interviewed about scheduled medication availability in emergency box and transition of responsibilities. |
| Licensed Practical Nurse #6 | LPN | Provided statement regarding Resident #4's missing incident and medication administration. |
| Nursing Assistant #6 | NA | Assigned to Resident #4 on day of missing incident and provided information about resident's whereabouts. |
| Administrator | Facility Administrator | Interviewed about Resident #4's elopement incident and facility response. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding staff attendance at a Resident Council meeting without invitation, failure to timely report an allegation of neglect, and incomplete clinical documentation following the neglect allegation.
Complaint Details
The investigation was triggered by complaints regarding staff attendance at a Resident Council meeting without invitation and an allegation of neglect involving Resident #1 not being changed overnight. The neglect allegation was substantiated as staff failed to timely report it and failed to notify the State Agency.
Findings
The facility failed to ensure staff did not attend the Resident Council meeting unless invited by residents. The facility also failed to timely report an allegation of neglect to the State Agency and failed to document a skin assessment following the neglect allegation. Interviews and record reviews confirmed these deficiencies.
Deficiencies (3)
F 0565: The facility failed to ensure staff did not attend the Resident Council meeting unless invited by the Council. Staff attended a meeting documented as a Resident Council meeting but was called at staff request.
F 0609: The facility failed to timely report an allegation of neglect and failed to notify the State Agency as required. Staff did not report the allegation properly and the DON did not follow up or notify authorities.
F 0842: The facility failed to ensure clinical documentation was complete and accurate by not documenting a skin assessment after an allegation of neglect. The RN performed an assessment but did not document it.
Report Facts
Number of persons assisting Resident #1: 2
Number of persons assisting Resident #1: 1
Date of Resident Care Plan: Jun 8, 2023
Date of Resident Council meeting: Aug 8, 2023
Date of neglect allegation: Aug 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Notified of neglect allegation, performed skin assessment but failed to document it. |
| DON | Director of Nursing | Interviewed regarding Resident Council meeting and neglect allegation reporting. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 24, 2023
Visit Reason
The inspection was conducted following complaints regarding staff attendance at Resident Council meetings without invitation, failure to timely report an allegation of neglect, and incomplete clinical documentation related to a skin assessment after an allegation of neglect.
Complaint Details
The complaint involved allegations that staff attended a Resident Council meeting without invitation, neglect of Resident #1 who was not changed during the night shift on 8/7/2023, and failure to timely report the neglect allegation to the State Agency. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting a few residents.
Findings
The facility failed to ensure staff did not attend Resident Council meetings unless invited by residents, failed to timely report an allegation of neglect to the State Agency, and failed to document a skin assessment following the neglect allegation. Interviews and record reviews confirmed these deficiencies with minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
Facility failed to ensure staff did not attend the Resident Council meeting unless invited by the Council.
Facility failed to timely report an allegation of neglect and failed to notify the State Agency in a timely manner.
Facility failed to ensure the clinical record was complete and accurate to include documentation of a skin assessment completed following an allegation of neglect.
Report Facts
Residents Affected: 3
Date of Survey Completed: Aug 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Notified of neglect allegation, performed skin assessment but failed to document it. |
| DON | Director of Nursing | Interviewed regarding Resident Council meeting and neglect allegation reporting. |
Inspection Report
Routine
Deficiencies: 16
Date: Apr 3, 2023
Visit Reason
Routine inspection of New Haven Center for Nursing & Rehabilitation LLC to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, failure to provide timely notifications for hospital transfers, late and missing MDS transmissions, incomplete PASARR screenings, inadequate care planning for vision loss and inappropriate sexual behaviors, failure to follow physician orders for vital signs, improper respiratory equipment maintenance, unclean medication carts, improper sanitizing solution use in the kitchen, incomplete staffing data submission, infection control program deficiencies, lack of antibiotic stewardship, and failure to administer pneumococcal vaccines as required.
Deficiencies (16)
F 0600: The facility failed to protect residents from physical abuse by roommates, with incidents involving hitting with objects and verbal altercations resulting in minimal harm.
F 0623: The facility failed to provide timely notification to residents, representatives, and the State Ombudsman of hospital transfers for multiple residents.
F 0625: The facility failed to notify residents or representatives in writing about bed-hold policies during hospital transfers for a resident.
F 0640: The facility failed to transmit residents' admission, quarterly, annual, and discharge MDS assessments timely and completely, with many assessments submitted late or never submitted.
F 0644: The facility failed to ensure a required Level II PASARR screening was completed for a resident with schizoaffective disorder.
F 0656: The facility failed to develop comprehensive care plans addressing vision loss and failed to care plan and monitor inappropriate sexual behaviors for residents.
F 0657: The facility failed to revise a resident's care plan after multiple falls and failed to address blindness in the care plan.
F 0684: The facility failed to follow physician orders for monthly vital signs for a resident on multiple occasions.
F 0695: The facility failed to change respiratory equipment weekly as ordered and had unauthorized humidifier use for a resident on oxygen therapy.
F 0730: The facility failed to complete annual nurse aide performance evaluations in 2022.
F 0761: The facility failed to maintain medication carts and narcotic refrigerator freezer in a clean and sanitary manner, with loose pills, stains, and ice buildup observed.
F 0812: The facility failed to maintain chemical sanitizing solution at recommended concentration and failed to store wet wiping cloths in approved sanitizing solution in the kitchen.
F 0851: The facility failed to submit complete and accurate Payroll Based Journal staffing data for Quarter 1, 2022 by the required deadline.
F 0880: The facility failed to review the Infection Control Policy annually, failed to conduct and document monthly environmental rounds, and failed to store respiratory equipment according to infection control practices.
F 0881: The facility failed to implement an antibiotic stewardship program including protocols, monitoring, education, and feedback to prescribers.
F 0883: The facility failed to offer or administer pneumococcal vaccines to multiple residents despite having consent forms on file.
Report Facts
MDS transmission delays: 13
Falls: 8
Sanitizing solution concentration: 400
Missing RN hours: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Infection Preventionist | Responsible for infection control program and antibiotic stewardship; noted deficiencies in program implementation |
| DNS | Director of Nursing Services | Interviewed regarding multiple deficiencies including MDS transmission, care planning, infection control, and vaccine administration |
| LPN #1 | Interviewed regarding medication cart cleanliness | |
| LPN #2 | Interviewed regarding medication cart cleanliness and narcotic refrigerator | |
| LPN #3 | Interviewed regarding medication cart cleanliness | |
| LPN #4 | Interviewed regarding medication cart cleanliness | |
| LPN #5 | Interviewed regarding respiratory equipment maintenance | |
| LPN #6 | Interviewed regarding respiratory equipment and BiPAP mask storage | |
| Administrator | Interviewed regarding medication cart cleanliness and infection control responsibilities | |
| Dietary Manager | Interviewed regarding kitchen sanitizing solution and practices | |
| Dietary Aide #1 | Interviewed regarding kitchen sanitizing buckets | |
| RN #2 | Involved in resident abuse incident investigation | |
| SW #2 | Social Worker | Interviewed regarding resident sexual behavior incident |
Inspection Report
Routine
Deficiencies: 15
Date: Apr 3, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident abuse prevention, notification procedures, care planning, medication management, infection control, and vaccination protocols.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, failure to provide timely notifications for hospital transfers, late and missing MDS transmissions, incomplete PASARR screenings, inadequate care planning for vision loss and inappropriate sexual behaviors, failure to follow physician orders for vital signs, improper respiratory equipment maintenance, unclean medication carts, inadequate infection control program implementation, incomplete antibiotic stewardship, and failure to administer pneumococcal vaccines according to CDC guidelines.
Deficiencies (15)
Failure to protect residents from physical abuse by roommates.
Failure to provide timely notification to residents, representatives, and ombudsman for hospital transfers.
Failure to provide bed-hold notice for hospital transfers.
Failure to timely transmit MDS assessments to the State.
Failure to complete required Level II PASARR screening for a resident with schizoaffective disorder.
Failure to develop comprehensive care plans addressing vision loss and inappropriate sexual behaviors.
Failure to revise care plan after multiple falls and to reflect blindness diagnosis.
Failure to follow physician orders for monthly vital signs monitoring.
Failure to change respiratory equipment weekly as ordered and improper use of humidified air without order.
Failure to complete annual nurse aide performance evaluations.
Medication carts and narcotic refrigerator freezer were not maintained in a clean and sanitary manner.
Failure to submit complete and accurate Payroll Based Journal staffing data.
Failure to review Infection Control Policy annually, conduct/document environmental rounds monthly, and improper storage of respiratory equipment.
Failure to implement an effective antibiotic stewardship program including monitoring and education.
Failure to offer/administer pneumococcal vaccines according to CDC guidelines despite documented consents.
Report Facts
Deficiencies cited: 17
MDS transmission delays: 90
MDS transmission delays: 105
Falls: 8
Oxygen tubing change frequency: 7
Sanitizing solution concentration: 400
PBJ reporting deadline: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Infection Preventionist | Responsible for infection control program and antibiotic stewardship; noted deficiencies in policy review, education, and monitoring |
| DNS | Director of Nursing Services | Interviewed regarding multiple deficiencies including MDS transmission, care planning, infection control, and vaccination |
| LPN #3 | Witnessed resident abuse incident and reported | |
| SW #2 | Social Worker | Interviewed regarding resident sexual behavior incident and delayed notification |
| Dietary Manager | Interviewed regarding kitchen sanitizing solution and practices | |
| Administrator | Interviewed regarding facility responsibilities and awareness of deficiencies |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 150
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #33687.
Complaint Details
Complaint Investigation #33687 was the basis for the visit. No violations were found during the inspection.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 150
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Bashkin | Personnel contacted during inspection | |
| Donna Campbell | DNS | Personnel contacted during inspection |
| Errolee Bryan Miller | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 150
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation identified by Complaint Investigation #CT#31685, to assess violations of Connecticut State regulations at the New Haven Center for Nursing & Rehab.
Complaint Details
The visit was complaint-related under Complaint Investigation #CT#31685. Violations were substantiated as noted in the attached violation letter dated 3/7/22.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. Specifically, a violation related to incomplete, inaccurate, and unprofessional clinical record documentation for one of two residents reviewed was found.
Deficiencies (1)
Failure to maintain the clinical record in a complete, accurate and professional manner for Resident #1, including incomplete documentation of activities of daily living by nursing staff.
Report Facts
Licensed Bed Capacity: 150
Census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Donato | Vice President of Clinical Services | Personnel contacted during the inspection. |
| Terri D. McNeil | RNC | FLIS staff who submitted the report. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice letter regarding the plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 17, 2022
Visit Reason
A complaint investigation (ACTS Reference Number 31685) was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
Complaint investigation ACTS Reference Number 31685 was conducted. Deficiencies were cited as a result of this survey.
Findings
The facility failed to maintain the clinical record for one resident in a complete, accurate, and professional manner, specifically lacking timely and appropriate documentation of activities of daily living by nursing aide staff.
Deficiencies (1)
Failure to maintain clinical records in a complete, accurate, and professional manner for Resident #1, including missing documentation of nursing aide care during multiple shifts.
Report Facts
Dates of missing documentation: 3
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Acting Director of Nurses | Interviewed regarding documentation expectations for nursing aide staff. | |
| RN supervisor/designee | Responsible for auditing completion of ADL documentation per shift. | |
| DNS | Responsible for monitoring compliance with the plan of correction. |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
This document is a Pre-Licensure Consent Order for New Haven Center for Nursing & Rehabilitation LLC seeking an initial license to operate a Chronic and Convalescent Nursing Home in Connecticut.
Findings
The order outlines detailed requirements and conditions for licensure including contracting with an Independent Nurse Consultant (INC), appointing an Infection Preventionist, maintaining staffing ratios, conducting rounds, establishing quality assurance programs, developing water management and emergency preparedness plans, and contracting with an Environmental Consulting Firm (ECF) for life safety compliance. It also sets forth reporting, monitoring, and compliance obligations to ensure patient safety and regulatory adherence.
Report Facts
INC consulting hours: 32
INC contract duration: 6
Fine amount: 1000
Nurse aide staffing ratio 1st shift: 10
Nurse aide staffing ratio 2nd shift: 12
Nurse aide staffing ratio 3rd shift: 20
Licensed nurse staffing ratio all shifts: 30
Medical Director medical record audits: 5
ECF initial onsite review timeframe: 30
ECF report development timeframe: 30
ECF re-evaluation frequency: 3
Physical plant inspection completion deadline: 2023
Vendor payment timeframe: 90
Documentation retention period for rounds: 5
Documentation retention period for quality assurance meetings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Menajem Salamon | Member | Member of New Haven Center for Nursing & Rehabilitation LLC, signatory of the Pre-Licensure Consent Order |
| Donna Ortelle | Section Chief, Healthcare Quality and Safety Branch | Department of Public Health official signing the Pre-Licensure Consent Order |
Inspection Report
Routine
Deficiencies: 14
Date: Jun 15, 2021
Visit Reason
Routine inspection of New Haven Center for Nursing & Rehabilitation LLC to assess compliance with healthcare regulations, including resident rights, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding treatment and leave of absence, inadequate advance directive communication, unsafe equipment maintenance, failure to protect residents from abuse, incomplete staff training, medication and assessment inaccuracies, improper medication and supply storage, and lapses in infection control practices.
Deficiencies (14)
F 0561: The facility failed to honor resident self-determination and choice, including administering COVID-19 vaccine without proper consent and restricting resident leave during a COVID-19 outbreak.
F 0578: The facility failed to provide information about advance directives in a manner easily understood by a Spanish-speaking resident and did not obtain signed advance directive consent.
F 0584: The facility failed to ensure preventative maintenance of shower chairs and hot water supply, resulting in unsafe shower chairs and intermittent lack of hot water.
F 0600: The facility failed to protect residents from abuse by other residents and staff, including inadequate interventions for aggressive residents and failure to prevent staff-resident altercations.
F 0607: The facility failed to provide abuse and neglect training upon hire to a nurse aide who was involved in a resident altercation and was terminated for gross misconduct.
F 0623: The facility failed to timely notify the ombudsman of resident hospital transfers as required by policy.
F 0641: The facility failed to accurately code Minimum Data Set (MDS) assessments for pressure ulcers, medications, PASRR status, and insulin administration.
F 0645: The facility failed to complete a required PASRR for a resident with serious mental illness due to workload constraints.
F 0684: The facility failed to conduct quarterly smoking assessments and failed to monitor orthostatic blood pressures as ordered for a resident on antipsychotic medication.
F 0726: The facility failed to ensure nursing staff received competency training in tracheostomy care, enteral feeding, and intravenous therapy.
F 0761: The facility failed to ensure safe and secure storage of intravenous medications and supplies, and medications were stored in an unlocked clean utility room accessible to residents.
F 0812: The facility failed to label food items brought in by family members with resident name and date as required by policy.
F 0814: The facility failed to properly store waste in a covered compactor, which was broken and uncovered, posing a sanitation risk.
F 0880: The facility failed to follow infection control practices including hand hygiene during insulin administration, medication preparation, and tracheostomy care, and failed to maintain consistent monthly environmental rounds.
Report Facts
Residents admitted during outbreak: 5
COVID-19 cases: 16
Nurses trained in tracheostomy care: 10
Nurse aides trained in intravenous therapy: 17
Months without environmental rounds: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nurse Aide | Named in abuse and neglect finding, terminated for gross misconduct |
| RN #6 | Nursing Supervisor | Interviewed regarding abuse incident involving Resident #332 and NA #4 |
| RN #1 | MDS Coordinator | Identified coding errors in MDS assessments |
| LPN #5 | Licensed Practical Nurse | Failed to monitor orthostatic blood pressures as ordered |
| RN #2 | Registered Nurse | Failed to perform hand hygiene during tracheostomy care |
| RN #3 | Staff Development Nurse | Responsible for competency training, unaware of resident with enteral feeding tube |
| LPN #7 | Licensed Practical Nurse | Failed to perform hand hygiene between medication preparations |
Inspection Report
Routine
Deficiencies: 15
Date: Jun 15, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, infection control, medication administration, safety, abuse prevention, and other aspects of care in a nursing facility.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding treatment refusal and leave of absence during COVID-19 outbreak, inadequate consent processes for COVID-19 vaccination, failure to provide advance directive information in a resident's primary language, unsafe equipment maintenance, failure to protect residents from abuse, inadequate staff training on abuse policies, failure to notify ombudsman of resident hospitalizations, inaccurate MDS assessments, incomplete PASRR screenings, failure to conduct quarterly smoking assessments, failure to monitor orthostatic blood pressures as ordered, inadequate staff competencies in specialized care, unsecured medication storage, improper food labeling, uncovered waste compactor, and lapses in infection control practices including hand hygiene and environmental rounds.
Deficiencies (15)
Failure to honor resident's right to refuse COVID-19 vaccination and leave of absence during outbreak.
Failure to provide advance directive information in a manner understandable to resident's primary language.
Failure to ensure preventative maintenance on shower chairs and hot water supply.
Failure to protect residents from abuse by other residents and staff.
Failure to provide abuse/neglect training upon hire to nurse aide.
Failure to notify ombudsman of resident hospital transfers.
Failure to accurately code MDS assessments for medications, pressure ulcers, and PASRR.
Failure to complete PASRR when required.
Failure to conduct quarterly smoking assessment.
Failure to monitor orthostatic blood pressures as ordered for resident on antipsychotic medication.
Failure to ensure nursing staff received competency training in tracheostomy care, enteral feeding, and IV therapy.
Failure to ensure safe and secure storage of intravenous medications and equipment; unsecured medications in unlocked rooms.
Failure to label food items brought in by family members stored in nourishment refrigerators.
Failure to properly cover and secure waste in municipal solid waste compactor.
Failure to follow infection control practices including hand hygiene during medication administration and tracheostomy care; failure to maintain monthly environmental rounds.
Report Facts
Residents admitted during outbreak: 5
COVID-19 cases: 16
Nurses trained in tracheostomy care: 10
Nurse aides trained in IV therapy: 17
Months without environmental rounds: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nurse Aide | Named in abuse incident and termination for gross misconduct; lacked abuse training upon hire |
| RN #6 | Nursing Supervisor | Interviewed regarding abuse incident involving Resident #332 and NA #4 |
| RN #1 | MDS Coordinator | Identified inaccuracies in MDS assessments and responsibility for quarterly smoking assessments |
| LPN #5 | Licensed Practical Nurse | Failed to monitor orthostatic blood pressures as ordered for Resident #36 |
| RN #2 | Registered Nurse | Failed to perform hand hygiene during tracheostomy care for Resident #232 |
| RN #3 | Staff Development Nurse | Responsible for competency training; unaware of resident with enteral feeding tube |
| LPN #7 | Licensed Practical Nurse | Failed to perform hand hygiene between medication administration tasks |
| Administrator | Interviewed regarding medication storage and abuse training records | |
| Director of Maintenance | Interviewed regarding compactor and maintenance issues | |
| Director of Dietary | Interviewed regarding waste compactor use | |
| Regional Director of Dietary | Interviewed regarding waste compactor use |
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