Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hamden Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, prior cervical fracture, back pain, and a documented fall risk experienced an unwitnessed fall, after which nursing staff recorded pain, swelling, and subsequent x‑rays showing osteoarthritis, and initiated neuro checks and vital signs monitoring. Facility policy required documentation of neuro signs and resident status every shift for 72 hours post‑fall to assess for latent injuries, but there were no nursing progress notes in the clinical record for two shifts during the post‑fall period, even though separate neuro and shift‑report sheets existed. This resulted in incomplete medical record documentation of the resident’s condition during the required 72‑hour post‑fall monitoring window.
A resident with HF and COPD and severe cognitive impairment had advance directive paperwork showing DNR and DNI wishes from the conservator, but the physician's order initially listed Full Code. The care plan also referenced code status based on the responsible party's wishes. During record review, an RN identified that the paperwork had not been transcribed correctly into the physician's order.
Soiled Privacy Curtain Not Reported for Replacement: A resident’s bedside privacy curtain had a visible soiled area that was observed during one room check and was still present days later when a housekeeper was working in the room. The HSKP supervisor stated soiled curtains are to be removed and replaced when identified, but this resident’s room was not included on the list of curtains needing replacement.
A resident with ESRD, DM2, PVD, CHF, and a sacral pressure ulcer had a care plan and MDS identifying ongoing skin breakdown risk and weekly wound measurement requirements. Although wound treatments were documented, staff repeatedly failed to record weekly wound measurements over many months, even when the resident was absent during wound rounds; the DON and an LPN stated licensed nurses were expected to complete the measurements.
An electric wheelchair was observed parked in a common lounge area and obstructing an emergency exit while also plugged into a wall outlet and recharging during a fire alarm. No staff were seen removing the chair during the alarm, and an LPN said it belonged to a resident and likely had been placed there by the prior shift. The Maintenance Director stated the chair was preventing egress, and the DON said a fire safety policy existed and a separate room was available for charging electric wheelchairs, but there was no policy.
Hand hygiene was not completed between glove removal and re-gloving during a wound dressing change for a resident with dementia and pressure ulcers. An LPN also used an open bottle of normal saline that had been opened 13 days earlier, while staff were unsure of the facility guidance for the product and the IP/wound nurse stated the saline bottles were good for 24 hours and that no staff training had been provided on the new wound care product.
A resident with severe cognitive impairment and a high risk for falls accessed the shower room unsupervised due to a nonfunctional door alarm, which was found to have a dead battery and lacked regular monitoring. The resident was discovered on the floor with a head injury and was transferred to the hospital, with staff interviews confirming the alarm was not sounding and sometimes not reactivated after use.
A resident with significant mobility impairments and a documented fall risk was transported by staff in a wheelchair without the required leg rests attached, contrary to facility policy. During transport, the resident placed a foot on the floor and fell forward out of the wheelchair, sustaining a bleeding scalp wound that required emergency treatment. Staff interviews confirmed the omission of leg rests during the incident.
Missing Post‑Fall Clinical Documentation in Resident Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete clinical documentation for a resident following a fall, as required by facility policy and accepted standards. The resident had diagnoses including Alzheimer’s disease, a cervical vertebrae fracture, and a history of back pain, and was care planned as being at risk for falls due to prior falls, weakness, impaired mobility, and impaired safety awareness. On the day of the fall, nursing notes documented that the resident was found on the floor after an unwitnessed fall, initially denied pain when standing, later complained of back pain, and was treated with Tylenol. Subsequent notes described grimacing from lower right back and hip pain and a swollen left ankle, with an APRN ordering portable x‑rays, which later showed osteoarthritis of the left ankle and lumbosacral spine. A later note that evening documented no signs of discomfort and normal vital signs and neurological checks. The facility’s falls management policy required that, once a resident was identified as stable after an unwitnessed fall in a poor historian, neurological signs and related assessments be documented on a neurological flow sheet for 72 hours, and that documentation be completed for 72 hours to assess for latent injuries. However, there were no nursing progress notes entered for the 11‑7 AM and 7‑3 PM shifts on the day after the fall, during the 72‑hour post‑fall period. Although shift‑to‑shift report sheets and a neurological documentation sheet existed, they were not part of the clinical record, and the missing progress notes for those two shifts meant the resident’s condition and clinical findings were not documented in the medical record as required during that portion of the 72‑hour post‑fall monitoring period.
Advance directive orders did not match documented resident wishes
Penalty
Summary
The facility failed to ensure the physician's orders accurately reflected Resident #16's documented advance directive wishes. Resident #16 had diagnoses of heart failure and COPD, and the admission MDS indicated severe cognitive impairment. A physician's order dated [DATE] directed Full Code status, while the care plan dated [DATE] stated the advance directive code status was Full Code or DNR based on the responsible party's wishes. Resident #16's Advance Directive Communication Form documented that a conference with the Conservator of Person indicated a wish for no CPR or DNI, and the physician signed the form on [DATE]. A later physician's order dated [DATE] directed DNR. During an interview and record review on [DATE] at 10:29 AM, RN #3 identified that the physician's order for advance directives indicated DNR and that the signed advance directive paperwork also indicated DNR, DNI, but the paperwork had not been transcribed correctly into the physician's order.
Soiled Privacy Curtain Not Reported for Replacement
Penalty
Summary
The facility failed to ensure housekeeping staff reported a soiled privacy curtain for cleaning and replacement for one resident. On 2/05/2026, an observation of Resident #154’s room showed the bedside curtain opened fully between the two beds, with an approximate 2-3 foot long by 1-foot-high soiled area in the middle of the privacy curtain on the resident’s side of the room. On 2/11/2026, Housekeeper #1 was observed working in Resident #154’s room, and the same soiled area on the privacy curtain was still present. After the housekeeper exited the room, an interview was attempted, and the housekeeper indicated the need to contact the housekeeping supervisor. The Housekeeping Supervisor later stated that privacy curtains are to be removed, replaced with a clean curtain, and the soiled curtains sent to be laundered when identified on the daily room cleaning list. The supervisor reviewed a handwritten list provided by Housekeeper #1 two days earlier that included several resident rooms with soiled privacy curtains needing replacement, but Resident #154’s room was not on the list.
Failure to Complete Weekly Wound Measurements
Penalty
Summary
The facility failed to consistently complete weekly pressure wound assessments with measurements for Resident #103, who had ESRD, a sacral pressure ulcer, gastroparesis, nausea with vomiting, metabolic encephalopathy, type 2 diabetes with diabetic neuropathy, PVD, and chronic systolic CHF. The resident’s care plan identified risk for skin breakdown related to inability to respond to pressure-related discomfort, impaired mobility, bowel and bladder incontinence, and the presence of a wound, with interventions including frequent repositioning, assistance every 2 hours, and pressure-relieving devices. A quarterly MDS also identified the resident as having a Stage 3 pressure ulcer and being at risk for further skin breakdown with pressure-relieving devices and nutritional interventions in place. Clinical records showed the resident returned from the hospital with redness on the coccyx, then later returned from hospitalization with an open sacral wound measuring 1.5 cm x 0.5 cm x 0.5 cm. The care plan directed weekly wound measurements to the coccyx and treatment as ordered, and the MDS later identified the resident as severely cognitively impaired, requiring varying levels of assistance with ADLs and receiving specialized treatment, with an unstageable pressure ulcer noted. Although wound treatments were documented frequently, staff failed to document weekly wound measurements for multiple weeks across December 2024 through February 2026. The DNS stated staff were expected to measure wounds weekly and noted the resident was often away for Friday wound rounds, but could not identify why measurements were not completed; an LPN/wound care nurse stated weekly wound measurements were expected during Friday wound rounds and could also be completed by any licensed nurse performing a dressing change.
Electric Wheelchair Blocked Emergency Exit During Fire Alarm
Penalty
Summary
The facility failed to ensure an electric wheelchair was not obstructing an emergency exit and failed to ensure staff used the appropriate location for charging the wheelchair battery per facility practice. During a fire alarm on 2/05/2026 at 10:35 AM, observation identified an electric wheelchair parked in the open lounge area at the end of the resident unit hall next to a coffee table, where it was obstructing the facility emergency exit. The wheelchair was also plugged into a wall outlet in the common lounge area and was recharging. No staff were observed attempting to remove the chair during the fire alarm. An LPN stated the chair belonged to a resident on the unit and must have been placed there by the prior shift. The Maintenance Director later stated the wheelchair was not allowing egress and indicated the chair would be moved immediately. The DON stated a fire safety policy regarding exit doors existed and that a separate room was available for charging electric wheelchairs, but there was no policy.
Hand Hygiene and Saline Use During Wound Care
Penalty
Summary
The facility failed to ensure staff completed hand hygiene between doffing and donning gloves during a dressing change for a resident with dementia, pressure ulcers, decreased mobility, and a history of pressure ulcers. During observation of the dressing change to the resident’s right outer foot, an LPN removed the soiled dressing, removed gloves, and put on a clean pair of gloves without performing hand hygiene before reaching for a 4x4 dressing. The surveyor intervened and reminded the LPN that hand hygiene was needed after removing gloves. The facility also failed to ensure staff used a cleansing solution that had not expired for the dressing change. The LPN used a small bottle of normal saline that had a handwritten opening date showing it had been opened 13 days earlier, while the bottle also had a manufacturer expiration date stamped on the cap. The LPN stated the bottle would be good to use until the manufacturer expiration date and was not sure whether the facility had a policy for how long an open bottle of normal saline could be used. The Infection Preventionist/wound nurse stated the saline bottles were good for 24 hours and was unaware of any staff training related to the transition to the new saline product. The DON later indicated the bottle used during the observation was discarded and that no training had been provided regarding the new wound care product.
Failure to Maintain Functional Shower Room Door Alarm Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the shower room door alarm was functioning, which was intended to prevent unsupervised access and potential falls for residents at risk. The incident involved a resident with severe cognitive impairment, a history of falls, and multiple medical conditions including dementia, diabetes, and hypertension. The resident was assessed as high risk for falls and required assistance with transfers and ambulation, as documented in the care plan and physician's orders. On the day of the incident, the resident was found lying on the floor in the shower room with a head laceration and was subsequently transferred to the hospital, where further injuries were identified. Multiple staff interviews confirmed that the shower room door alarm was not sounding at the time the resident was found. It was revealed that the alarm required manual activation by entering a code after use, and staff sometimes forgot to reactivate it. Additionally, the alarm was found to be nonfunctional due to a dead battery, and there was no documentation to show that the alarm was regularly monitored or maintained. The facility was unable to provide a policy regarding the shower room door alarm when requested. The lack of a functioning alarm and absence of maintenance documentation directly contributed to the resident's unsupervised access to the shower room and subsequent fall with injury.
Failure to Use Wheelchair Leg Rests During Resident Transport Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular accident, unspecified dementia, right-sided hemiplegia, and muscle weakness, who was non-ambulatory and required a wheelchair for mobility, was transported within the facility without the leg rests attached to the wheelchair. The resident's care plan identified them as a fall risk and required the use of leg rests during wheelchair transport, as specified by facility policy. Despite these directives, staff failed to attach the leg rests while assisting the resident during a recreation program. As a result, the resident placed their foot on the floor while being pushed in the wheelchair, causing them to fall forward out of the chair. The fall resulted in an open, actively bleeding scalp wound, requiring transfer to the emergency department for treatment. Interviews with staff confirmed that the leg rests were not in place at the time of the incident, and facility policy mandates their use during transport.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hamden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arden Care Center | 1.1 mi | ★★★★★ | 28 | 0 |
| Whitney Rehabilitation Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Whitney Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Montowese Center For Health & Rehabilitation | 4.3 mi | ★★★★★ | 1 | 0 |
| Leeway, Inc | 4.7 mi | ★★★★★ | 10 | 0 |
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