Inspection Reports for
New Haven Center for Nursing & Rehabilitation

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.

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.

Complaint investigations #CT42529 and #121090 were reviewed during the inspection. No substantiation status is provided.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Complaint Investigation #37723 was conducted and no deficiencies or violations were found; staffing met Public Health Code requirements.

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.

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.

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.

Complaint #37137 was substantiated with findings of violations related to resident privacy, staffing shortages, and pest control deficiencies.

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.

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.

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.

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.

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.

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.

Complaint Investigation #33687 was the basis for the visit. No violations were found during the inspection.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

The visit was complaint-related under Complaint Investigation #CT#31685. Violations were substantiated as noted in the attached violation letter dated 3/7/22.

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.

Complaint investigation ACTS Reference Number 31685 was conducted. Deficiencies were cited as a result of this survey.

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.

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.

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.