Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 New Haven Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident admitted for short‑term rehab with unstable housing and diagnoses including bacteremia, intraspinal abscess, and anxiety disorder had an established goal of discharge back to the community, with the care plan directing social services and the IDT to coordinate community resources and needed services. Although clinical notes later showed the resident had completed IV antibiotics, was stable, and was being prepared for discharge home, the social service documentation from admission through the anticipated discharge date did not show evidence of ongoing discharge planning, IDT collaboration, referrals or resources for post‑discharge needs, or the resident’s participation in the discharge planning process. The social worker stated that discharge planning discussions occurred, that the resident was encouraged to contact family and friends, and was given 211 as a resource, but these actions were not documented, and the resident reported feeling there was no ongoing assistance with securing housing or discussion of aftercare, contrary to facility policy requiring ongoing, documented discharge planning for short‑stay residents.
Surveyors found that the facility failed to ensure proper functioning of call light indicators above resident room doors. During observation, two residents activated their call bells and the visual indicators outside their rooms did not illuminate, even though the audible signal and visual light at the nurses’ station did work. One resident reported that the call bell often did not work properly despite a recent attempt to fix it. An LPN confirmed that the over-door lights did not illuminate when tested, and the DON stated the expectation that these lights should come on with call bell activation. The Administrator reported that environmental rounds and call bell testing were done but could not specify frequency, and no documentation of such rounds or related maintenance requests was available, despite a written policy requiring both a room light and nurses’ station signal when a call bell is activated.
Failure to document ongoing discharge planning for a resident with unstable housing and anxiety. A resident admitted for short-term rehab after treatment for bacteremia and an intraspinal abscess was expected to return to the community, and the care plan called for SW involvement, community resources, and interdisciplinary discharge coordination. However, the record lacked documentation of ongoing SW work, interdisciplinary collaboration, referrals, discharge readiness, and the resident’s participation, even though staff said housing resources and 211 were discussed and the resident reported no ongoing help with housing or aftercare.
A resident with multiple medical conditions failed to return from a leave of absence as scheduled, and staff did not notify the physician, DON, or administration according to facility policy. Additionally, the provider was not informed when the resident missed several scheduled evening medications due to the absence. The LPN only notified the charge nurse, and the physician confirmed he expected prompt notification of both the resident's absence and missed medications.
A resident with moderate cognitive impairment and multiple medical conditions was issued a 30-day discharge notice for non-compliance with the smoking policy, but the facility failed to provide or document adequate discharge planning, orientation, or communication. Staff interviews revealed a lack of coordination, unresolved insurance issues, and no clear plan for a safe and orderly transfer, leaving the resident uninformed about their discharge status.
A resident with multiple medical conditions was readmitted from the hospital without a discharge summary, and staff did not obtain or review the required documentation as per facility policy. Additionally, when the same resident did not return from an LOA as expected, staff failed to act promptly or follow consistent procedures due to conflicting LOA policies, resulting in delayed notifications and unclear staff actions.
Resident Council concerns were not consistently documented or followed up on per facility policy. Residents repeatedly raised issues about aides using personal phones, poor food quality, unmet food requests, and incorrect meal tickets, but several meetings had no documented facility response. The FSD did not attend multiple council meetings where food concerns were discussed, and interviews showed administration was aware that follow-up was inconsistent and that interdisciplinary responses were not reliably completed.
The facility failed to provide adequate supervision for residents with aspiration precautions and smoking restrictions. Two residents with dysphasia were observed eating without the required meal assistance or supervision, including one who was given an inappropriate breakfast consistency and another who was left eating in bed without staff present. Two other residents with impaired cognition and smoking violations were observed smoking unsupervised in unauthorized areas with cigarettes in their possession, and one resident’s independent LOA was approved without a documented risk assessment despite repeated unsafe behaviors and accidents. The report also noted unsecured oxygen storage and hazards in the smoking area.
A resident with intact cognition and a care plan for nutritional risk was not given a breakfast tray in a timely manner and was observed rummaging through a food truck with dirty breakfast trays to find milk and sugar. An NA redirected the resident and called the kitchen, and another NA later delivered the tray, stating the kitchen had forgotten it. The resident reported waiting for breakfast, getting coffee independently, and being frustrated that the tray was incomplete and had no meal ticket.
Failure to Provide Ordered Double Portions: A resident with DM and breast cancer was ordered a regular diet with double portions and repeatedly reported being hungry after meals. Meal trays over several days showed regular portions instead of the larger amounts listed on meal tickets, and staff gave inconsistent accounts about whether the resident was supposed to receive double portions. Dietitians said the resident had been requesting increased portions for over a year, while the interim DON and dietary staff relied on meal tickets that did not reflect the order.
Failure to provide quarterly resident financial statements. A resident with intact cognition and diagnoses including MDD, malnutrition, and chronic pain reported that the facility managed personal funds but no written financial statement had been received during the year. The BOM said the resident was due a quarterly statement but had no documentation it was delivered, and a system change delayed the next quarter’s statements; the Administrator stated residents should receive quarterly statements and that first quarter statements should have gone out by the end of April.
A resident with impaired cognition, incontinence, diabetes, and high skin-breakdown risk developed a new coccyx/sacral wound that progressed to a stage 3 pressure ulcer. Nursing notes documented the reddened area, then an open area with pain, followed by RN assessment, APRN notification, and wound treatment orders. Interviews and record review showed the resident’s representative was not notified when the wound was first identified and was only updated later, despite policy requiring timely notification of changes in condition.
Resident funds were withdrawn without clear authorization. A cognitively intact resident with MDD, paranoid personality disorder, and chronic pain reported not receiving a written financial statement and later identified three account withdrawals that he/she did not recall approving. Staff described helping with pizza and bake sale purchases, but the resident said cash was given directly for pizza and that baked goods were believed to be covered by the facility or by the rec director personally, while the BOM could not recall direct authorization and the admin noted communication about the charges was unclear.
Failure to report alleged verbal abuse: A cognitively intact resident with food allergies and diabetes reported that a staff member threatened him/her after repeated issues with incorrect food items. The resident said the concern was brought to Admin and the Ombudsman, but the allegation was not reported to the state agency within the required timeframe, despite facility policy requiring abuse allegations to be reported within 2 hours.
Failure to Investigate Alleged Verbal Abuse: A cognitively intact resident with food allergies and dietary restrictions reported that a staff member threatened him/her after repeated complaints about receiving incorrect food items. The resident said the concern was reported to the Administrator and Ombudsman, but the Administrator denied or could not recall the allegation, and the facility did not remove the named staff member or initiate an immediate abuse investigation as required by policy.
Incomplete Care Planning for Dementia and Tracheostomy Needs: The facility failed to update a resident’s care plan after a new dementia diagnosis and failed to develop a person-centered tracheostomy care plan for another resident. The first resident had schizoaffective disorder, anxiety, and a recent hospital stay with dementia added to the diagnosis list, but the care plan did not include dementia or related interventions. The second resident had COPD, respiratory failure, and a tracheostomy with orders for site and inner cannula monitoring, yet the care plan lacked measurable objectives, timetables, and trach-specific interventions.
Care plans were not revised for two residents with smoking-related issues and one resident with an air mattress. Two residents with COPD, impaired cognition, and wheelchair use were observed smoking or obtaining cigarettes in unsafe areas such as the street and parking lot, with one also found with a lighter and contraband concerns, yet the records lacked updated smoking assessments and care plan revisions addressing these behaviors. Another resident with stroke-related deficits and high skin-breakdown risk had an air mattress ordered and in use, but the comprehensive care plan was not updated to include it.
Improper Crushing of Enteric Coated and Extended-Release Medications: An LPN crushed all of a resident’s scheduled meds for dysphagia, including enteric coated iron sulfate, delayed-release pantoprazole, and extended-release metoprolol, before giving them with applesauce. The resident spit out small pieces during administration. The DNS and pharmacist confirmed these meds should not be crushed, and the APRN stated staff were expected to know which meds can and cannot be crushed.
Failure to Provide Needed Grooming and Nail Care: A resident with dementia and severely impaired cognition required assistance with personal hygiene, showering, and grooming, including nail care. Staff observed the resident lying in bed with a soiled blanket and long fingernails with black substance under several nails, and interviews showed the assigned NA had not provided care for over a month. A nursing supervisor later confirmed the nails remained long and soiled, while the interim DNS stated NAs were responsible for trimming nails on shower days and as needed.
A facility failed to complete an RN assessment after an allegation that an NA pulled on a resident’s urinary catheter and verbally mistreated the resident. The facility also did not ensure a severely cognitively impaired resident received needed grooming, with long, soiled fingernails observed despite care plan directions for hygiene and nail care. In addition, consult recommendations for food allergies and podiatry were not timely reviewed or implemented, and an ordered air mattress setting was documented as correct even though observations showed it was set far above the physician order.
Failure to timely assess and treat a new coccyx pressure ulcer and complete weekly skin checks. A resident with diabetes, polyneuropathy, impaired cognition, incontinence, and significant weight loss developed a new coccyx skin issue that was first noted by an LPN, but the RN assessment, wound measurements, and treatment orders were delayed. The wound was later documented as a stage 3 PU, and weekly skin checks were missed or inaccurately documented, including entries that failed to reflect the wound or recorded intact skin despite the ulcer.
A resident with severe cognitive impairment and multiple medical conditions, who required supervision and an assistive device for ambulation, exited the facility unnoticed due to staff inattention and a delayed door locking mechanism. The resident was not identified as an elopement risk and did not have a Leave of Absence order. Staff delays in recognizing the resident's absence and in notifying police resulted in the resident being found several miles away, disoriented and injured, after an extended period.
A resident with diabetes and depression, who was cognitively intact and required supervision for ADLs, was verbally abused by a staff member who made derogatory remarks about the resident's appearance and personal loss. Another resident witnessed the incident and confirmed the statements. The facility's policy guarantees freedom from abuse, but the staff member's actions violated this right.
A facility failed to include discharge planning in a resident's care plan, despite the resident's desire to return to the community and an application for the Money Follows the Person program being completed. The care plan lacked discharge goals or interventions, and the social worker did not document the resident's discharge status or MFP application progress in the clinical record due to time constraints.
A resident with a history of myocardial infarction and other conditions was given Nitroglycerin, but the administration was not documented in the MAR as required. The RN supervisor noted the administration in a progress note but failed to update the MAR, contrary to the facility's documentation policy.
Failure to Implement and Document Ongoing Discharge Planning for Short‑Stay Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document an ongoing discharge plan for a short‑stay resident to ensure a safe and effective transition back into the community. The resident had diagnoses including bacteremia, intraspinal abscess and granuloma, and anxiety disorder, and was admitted for short‑term rehabilitation after a hospital stay. On admission, the social service note documented that the resident had unstable housing, had been living at a friend’s house prior to hospitalization, and that discharge plans were discussed with the resident stating they would return to the friend’s house if no other housing options were available. The note also indicated a referral would be made to Money Follows the Person for housing supports, and the admission MDS and care plan identified a goal of discharge back into the community with social services and the IDT to coordinate needed equipment, services, and community resources. A Level of Care Screen by Maximus later confirmed that short‑term care was appropriate for a defined period and directed the facility to continue assisting with discharge planning for appropriate community and support services. Psychological services documented that the resident was experiencing anxiety related to potential early discharge and that the plan was to continue addressing discharge‑related anxiety. An APRN progress note indicated the resident had completed IV antibiotics, was clinically stable, and was preparing for discharge home later that week, pending final coordination. A Transition of Care/Discharge Summary identified an anticipated discharge date and a planned discharge location back into the community. Despite these documented goals and clinical readiness for discharge, review of social service notes from admission through the anticipated discharge date did not show evidence that social services had been working with the resident on discharge back into the community. There was no documentation of IDT collaboration, referrals and resources provided for post‑discharge needs, discharge readiness, or the resident’s participation in the discharge planning process, as required by facility policy. The social worker reported that discharge planning discussions occurred and that she met with the resident to discuss anticipated discharge, encouraged the resident to contact family and friends, and provided 211 as a resource, but these actions were not documented in the clinical record. The resident reported being told they were ready for discharge, needing to secure housing, being told to call 211 if housing could not be found, and feeling there was no ongoing assistance from the facility to secure housing or discussion of aftercare. Facility policy required that discharge planning begin at admission, be reviewed weekly for short‑stay residents, and that progress notes include participants, readiness for discharge, services arranged, and teaching provided, which was not reflected in the record for this resident.
Failure to Ensure Proper Functioning of Resident Call Light Indicators
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call systems functioned as intended, specifically that the visual call light indicators above room doors illuminated when call bells were activated. During a tour of the third floor, when Resident #4 activated the call bell, the visual indicator light outside the room above the door did not illuminate, and the resident reported that the call bell often did not work properly and had recently been serviced by staff. Shortly thereafter, when Resident #1’s call bell was activated, the call light indicator outside that room also failed to illuminate. When the charge nurse (LPN #1) tested Resident #4’s call bell, the light above the room door again did not illuminate, although the audible signal and visual light at the nurses’ station did activate. The DON stated that the expectation was for the call light indicator above a room door to illuminate when the call bell was pressed. The Administrator reported that routine environmental rounds and testing of the call bell system were conducted but could not specify how often these occurred, and no documentation of such rounds or call bell testing was provided upon request. Review of the facility maintenance log from December 2025 through February 2026 did not show any repair requests for the call bell issues in the rooms of Residents #1 and #4. The facility’s Call Bell policy dated 1/1/24 directed that staff would be made aware of a call bell activation by both the buzzer at the nurses’ station and the light above the room, and stated that if a call bell was found to be defective, a hand bell would be provided, but there was no documentation in the report that these policy provisions were followed for these residents.
Failure to Document Ongoing Discharge Planning
Penalty
Summary
The facility failed to implement and document an ongoing discharge plan for a resident admitted for short term rehabilitation who had unstable housing and was expected to return to the community. The resident’s diagnoses included bacteremia, intraspinal abscess and granuloma, and anxiety disorder. Admission documentation noted the resident had been living at a friend’s house before hospitalization, that discharge plans were discussed, and that a referral would be made to Money Follows the Person for housing reports and social service support. The admission MDS identified the resident as alert and oriented with no memory recall deficits and established the overall goal of discharge back into the community. The resident’s care plan identified short-term rehabilitation with a goal of safe discharge back into the community and included interventions for social work involvement, community resources, family preparation, interdisciplinary discharge planning, and coordination of equipment and services. The Level of Care Screen later stated that short term care remained appropriate and that the facility should continue assisting with discharge planning for community and support services. A psychological services note documented anxiety related to potential early discharge and interpersonal conflict in the facility, and an APRN note stated the resident had completed IV antibiotics, remained stable, and was preparing for discharge to home pending final coordination. Review of social service notes from admission through the discharge period did not reflect documentation that social service had been working with the resident regarding discharge back into the community. The social worker stated the interdisciplinary team discussed discharge planning and that she met with the resident to discuss the anticipated discharge, housing resources, and use of 211 if housing could not be secured, but the clinical record did not reflect documentation of interdisciplinary collaboration, referrals, resources provided, discharge readiness, or the resident’s participation in discharge planning. The resident stated there was no ongoing assistance from the facility to secure housing upon discharge and no discussion on aftercare. The facility policy required discharge planning to begin at admission, continue throughout the stay, include weekly review for short stay residents, and document participants, readiness for discharge, services arranged, and teaching provided.
Failure to Notify Physician and Administration of Resident's Absence and Missed Medications
Penalty
Summary
The facility failed to ensure timely notification of a physician, medical director, and facility administration when a resident did not return as scheduled from a leave of absence (LOA). The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, was expected to return to the facility by 6:00 PM but did not return until nearly ten hours later. Staff did not notify the Director of Nursing Services (DNS), the administrator, the resident's physician, or local authorities as required by facility policy when the resident was missing. The DNS confirmed she was not informed until the following morning, and the physician stated he would have expected to be notified promptly if a resident did not return from LOA. Additionally, the facility failed to notify the provider when the same resident missed scheduled evening medications, including Furosemide, Gabapentin, Quetiapine, and Eliquis, due to the resident's absence. The LPN on duty did not contact the physician or advanced practice registered nurse (APRN) regarding the missed doses, only informing the charge nurse. The physician confirmed that he expected to be notified within one to two hours of missed medications to make appropriate decisions. Facility policies required staff to notify the provider and supervisory staff in the event of a medication administration error, which was not followed in this instance.
Failure to Prepare and Document Safe Discharge for Resident
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident who was issued a 30-day discharge notice due to non-compliance with the facility's smoking policy. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, and demonstrated moderate cognitive impairment, was identified as needing set-up assistance with personal hygiene and supervision with transfers and ambulation. Despite care plan interventions directing the social worker to utilize community resources, prepare the resident for discharge, and involve the resident in discharge planning, there was no evidence that these steps were taken. The social worker admitted to not having made additional discharge plans or discussed future arrangements with the resident after the initial notice was given. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The DON was unaware of the discharge details and the resident's status was not included in daily meetings or on the facility's tracking board. The administrator was also unaware of the discharge notice and its reason. The MDS coordinator noted unresolved insurance issues and did not follow up further, while the admissions coordinator at the sister facility had not received a referral. Nineteen days after the notice, the social worker still had not arranged for a safe discharge, and the resident reported not receiving any further information about the transfer after the initial notice.
Failure to Obtain Hospital Discharge Summary and Inconsistent Leave of Absence Procedures
Penalty
Summary
The facility failed to obtain a hospital discharge summary in a timely manner after a resident was readmitted following a fall and hospital transfer. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, returned to the facility without any hospital discharge paperwork. Despite facility policy requiring review of discharge paperwork within 24 hours of return, staff did not request or obtain the necessary documentation from the hospital. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the discharge summary was not obtained or reviewed, and there was no documentation explaining why this was not done. Additionally, the facility did not act promptly when the same resident failed to return from a Leave of Absence (LOA) at the expected time. The resident left the facility with a planned return time but did not come back as scheduled. Nursing notes indicated that the resident was still out nearly three hours after the expected return, and further documentation showed the resident was absent for almost ten hours before being returned by a Good Samaritan. Although the DNS stated that staff attempted to contact the resident's responsible party and local hospitals, there was no documentation of these efforts, and required notifications to the DNS, Administrator, local police, and physician were not completed as directed by facility policy. The investigation also revealed confusion and inconsistency regarding the facility's LOA policies. Multiple versions of the LOA policy were in circulation, with conflicting instructions on the steps staff should take when a resident does not return as expected. Staff had electronic access to a more recent policy, but the DNS and Administrator stated that an older policy was the one in use, as confirmed by corporate leadership. This lack of clarity resulted in staff not having clear, unified guidance on how to respond to residents who do not return from LOA in a timely manner.
Resident Council Concerns Not Consistently Addressed
Penalty
Summary
The facility failed to ensure consistent response and follow-up to Resident Council concerns in accordance with its policy. Review of Resident Council minutes from 1/29/25 through 7/30/25 showed repeated resident concerns about nurse aides using personal phones during work hours, food quality problems including cold meals, greasy or undercooked items, meals served with reported allergens, unmet food requests such as butter, fruit, salt, and pepper, and incorrect meal tickets. The review also found no documented facility response to concerns raised during the 2/26/25, 6/25/25, and 7/30/25 meetings, even though similar issues had been reported previously. The Food Service Director did not attend Resident Council meetings on 3/31/25, 5/28/25, 6/25/25, and 7/30/25 when food-related concerns were discussed. Interviews with residents indicated administration did not consistently follow up on Resident Council and food-related concerns, there was no dedicated food committee, and the Food Service Director did not attend the meetings. The Director of Recreation stated she facilitated the meetings and used a Response Form to refer concerns to departments for review at the next meeting, but interdisciplinary follow-up was inconsistent. The Administrator acknowledged awareness that Resident Council concerns were not being responded to consistently and that the Food Service Director was not attending monthly meetings, and stated he expected the Food Service Director to attend monthly to address food concerns.
Failure to Supervise Meals, Smoking, and Leave-of-Absence Activities
Penalty
Summary
The facility failed to provide adequate supervision during meals for residents who required aspiration precautions and feeding assistance. One resident with dementia, stroke-related deficits, dysphasia, and abnormal weight loss had speech therapy recommendations for small bites, controlled sips, upright positioning, close supervision, and total feeding, yet was observed eating independently in the dining room while a nurse aide stood away from the resident and then left the area. The same resident was later observed in bed with hot cereal and a hot beverage within reach and no staff present, despite the physician’s order for aspiration precautions and total assistance with feeding. Facility staff gave conflicting descriptions of the resident’s meal needs, and the nurse aide documentation reflected independent eating even though the resident was supposed to be fed. A second resident with dementia, dysphasia, and anxiety was also not supervised in accordance with aspiration precautions. That resident’s care plan and speech therapy records identified a chopped or mechanically altered diet, aspiration precautions, and assistance with meals, with recommendations for upright posture, alternating solids and liquids, and cueing to slow the rate of intake. The resident was observed eating a breakfast tray that included a whole hard-boiled egg and a bagel cut only in half, with no staff present. On later observations, the resident was again eating in bed without supervision, including eating scrambled eggs with fingers. Staff interviews showed that the nurse aide did not understand the resident’s diet or aspiration precautions, and the resident was not consistently provided the supervision and feeding assistance described in the record. The facility also failed to supervise residents with smoking and leave-of-absence issues and did not keep the environment free of hazards. Two residents with smoking histories and impaired cognition were observed smoking unsupervised in unauthorized areas near the facility, with cigarettes in their possession and no designated smoking signage, fire-safe disposal containers, or fire control materials present. One resident had prior contraband and smoking violations and was found smoking in the parking lot while on independent leave of absence; another was observed smoking near the front entrance after leaving on approved leave. In addition, one resident with traumatic brain injury, neurocognitive disorder, bipolar disorder, falls risk, and a history of unsafe behaviors had an independent leave-of-absence order without a documented risk assessment before approval, and the record described repeated accidents, intoxication, a fall from a motorized wheelchair, a positive substance-use test, and ongoing unsafe smoking behavior in front of the facility. The report also states that an oxygen tank was not stored securely, the designated smoking area contained hazards, and the smoking cart was left unlocked with smoking materials on top and residents present.
Delayed Breakfast Tray and Improper Access to Dirty Tray Cart
Penalty
Summary
The facility failed to provide Resident #63 a breakfast tray in a timely manner, and the resident was observed trying to obtain items from other residents’ leftover breakfast trays on a food truck. Resident #63 was admitted in July 2025 with diagnoses including anxiety disorder, specified depressive episodes, and orthopedic aftercare. The admission MDS identified intact cognition, independence with eating, and a need for supervision or touch assist with ambulating 50 feet. The care plan identified the resident as at increased risk for alterations in nutritional status and directed staff to encourage oral intake at meals and provide a regular texture diet with thin liquids. On 8/24/25, Resident #63 was observed opening the door to the food truck containing dirty breakfast trays and rummaging through the trays. A nurse aide told the resident not to go through the old trays and redirected the resident back to the room, then closed the truck door. Minutes later, the resident re-entered the food truck, removed a carton of milk and sugar, and stated that the breakfast tray never came and that the resident wanted sugar for coffee. The nurse aide reported calling the kitchen to notify them that the resident had not yet received breakfast. Another nurse aide later delivered the breakfast tray to the resident’s room and stated the kitchen had forgotten to send it. The resident reported being tired of waiting, going to the dining room for coffee, and looking through the dirty cart for milk and sugar; the resident also stated the tray contained one egg instead of two, a bagel with cream cheese, oatmeal, and grape juice, and there was no meal ticket on the tray to confirm the order.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to ensure that a resident received double portions as requested and as ordered by the physician. The resident was admitted with diagnoses including diabetes and malignant neoplasm of the breasts, and a physician order dated 6/20/24 directed a regular diet with double portions. The resident was also documented by the dietitian as requesting increased portions because he/she was still hungry after meals, and the resident agreed to receive an egg salad sandwich at lunch and dinner. Despite this, the resident later reported that meal portions were small, that he/she remained hungry after meals, and that no one offered snacks between meals or at bedtime. Observation and record review showed repeated mismatches between what the meal tickets directed and what the resident actually received. On multiple mornings, the resident received regular portions instead of the ordered double portions, including trays with one hardboiled egg and one bagel instead of two of each, two pancakes and corned beef hash instead of the larger amounts listed, scrambled eggs and one slice of toast instead of double portions, and two slices of French toast and one sausage patty instead of the larger amounts listed on the meal ticket. The resident stated that dietary staff cut items in half and counted them as two portions, and that sandwiches and toast were not being provided in the amounts expected. Interviews showed confusion and inconsistent communication among dietary staff, the dietitians, and administration. The interim Director of Dietary stated the resident was only supposed to receive one egg and one bagel and did not know why the meal ticket showed two. Later, the same director acknowledged the resident had received regular portions and that double portions were not reflected on the meal ticket. Dietitians stated the resident was supposed to have been receiving double portions for over a year and that emails had been sent regarding the order, but the meal tickets were not updated. Staff also reported that the Administrator had verbally told dietary staff to give the resident double portions, while the Director of Dietary stated he had not received changes from the dietitian or nursing staff and relied on the meal tracker showing a regular diet.
Failure to Provide Quarterly Resident Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to the only sampled resident reviewed for personal funds, Resident #45. Resident #45 was admitted in June 2021 with diagnoses including major depressive disorder, moderate protein-calorie malnutrition, and chronic pain, and the annual MDS identified intact cognition. During interview, Resident #45 stated that the facility oversaw his/her personal funds and that no written financial statement had been received in 2025. The Business Office Manager stated that Resident #45 was responsible for self and had most recently received a quarterly statement at the end of March or beginning of April 2025, but she had no documentation to show the statement was provided. She explained that quarterly statements were normally placed in residents’ mailboxes for delivery by recreation staff, and that a recent fund management system change delayed the 4/1/25 through 6/30/25 statements until later on 8/26/25. She also stated residents were verbally notified of the system change and possible delay, but no documentation of that notification was provided. The Administrator stated residents should receive quarterly financial statements and that first quarter statements should have gone out by the end of April.
Failure to Notify Resident Representative of New Pressure Ulcer
Penalty
Summary
The facility failed to ensure the resident representative was notified when Resident #76 developed a new wound. Resident #76 was admitted in July 2023 with diagnoses including polyneuropathy, bipolar disorder, and diabetes, and the annual MDS identified moderately impaired cognition, total incontinence of bowel and bladder, maximum assistance needs for toileting, dressing, personal hygiene, turning, and transfers, and significant recent weight loss. The care plan identified the resident as at risk for skin impairment related to decreased mobility and included weekly skin checks and notification of the physician or APRN of any changes. On 7/27/25, nursing documentation noted a reddened area to the coccyx and that the resident was added to the skin rounding report. On 8/10/25, nursing documentation identified an open area at the top of the coccyx measuring 0.5 cm by 1.0 cm, with the resident reporting pain to the area. Later that day, another nurse documented an open area on the sacrum, measured the wound, applied a dry protective dressing, notified the APRN, and placed the resident on the skin rounding report for the next day. A physician order on 8/11/25 directed wound cleansing and dressing treatment, and subsequent nursing and wound physician notes described the wound as a stage 3 sacral pressure ulcer with drainage and later debridement of slough tissue. Interviews confirmed the resident representative was not notified when the new wound was first identified. RN #1 stated the resident representative should have been updated when the wound was first noted and again when the RN assessment and treatment orders were obtained, but the representative was not notified on 7/27/25, 8/10/25, or 8/13/25. The DNS stated the charge nurse or RN supervisor was responsible for notifying the resident representative when the open area developed and treatment was ordered, and after record review confirmed the representative had not been notified of the new pressure area or treatment until 8/20/25, 11 days after discovery. The facility policy required changes in condition to be reported to providers and families, with repeated attempts documented until successful.
Resident funds were withdrawn without clear authorization
Penalty
Summary
The facility failed to protect Resident #45 from the wrongful use of the resident’s money. Resident #45 was admitted with diagnoses including major depressive disorder, paranoid personality disorder, and chronic pain. The quarterly and annual MDS assessments identified the resident as cognitively intact, with no acute change in mental status, no hallucinations or delusions, and no physical, verbal, or wandering behaviors at the time of review. Resident #45 stated that the facility oversaw personal funds and that he/she had not received a written financial statement in 2025. When the resident later reviewed the quarterly statement with Social Services, three withdrawals were identified that the resident did not recall authorizing: two withdrawals of $20 and one withdrawal of $10. The resident reported that the last withdrawal he/she had personally made was in December 2024 or January 2025 and said the discrepancies had been brought to the Business Office Manager’s attention. The Business Office Manager stated that residents could request withdrawals from their personal accounts and that she could not recall Resident #45 coming directly to her for the withdrawals. The Recreation Director stated that she sometimes assisted residents with ordering food and that she had obtained money from the Business Office Manager for a pizza order, but she could not recall who signed for the withdrawal. Facility documents showed a $10 withdrawal for a bake sale and two $20 withdrawals for pizza. Resident #45 stated that he/she believed the baked goods were covered by the facility or by the Recreation Director’s personal money and denied authorizing the withdrawals. The resident further stated that when pizza was ordered, he/she gave cash directly to NA #19 and was not told that money would be taken from the facility account. The Administrator later stated that the Recreation Director had not clearly communicated that the pizza and bake sale items were not provided by the facility and that money would be withdrawn from the resident’s account.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the state agency within the required timeframe. Resident #59, who was admitted in 12/2023 with diagnoses including allergies, unspecified asthma, and diabetes mellitus, was documented as cognitively intact, independently mobile with a wheelchair, and independent with eating. The care plan identified food-related needs, including accommodating food preferences and avoiding pork, dairy, eggs, tomatoes, and breaded foods due to allergies and lactose intolerance. Resident #59 stated that [NAME] #2 threatened him/her by saying, "I am going to get you," after repeated problems with receiving incorrect food items had been reported to Administration. The resident reported that the concern had been brought to the Administrator and Ombudsman without follow-up. During interviews, the Administrator initially denied that the resident reported the threat and later stated he could not recall the report, while also acknowledging that any allegation of mistreatment or abuse should be reported immediately to the state agency. The facility policy defined verbal abuse as oral, written, or gestured language used as a threat to harm and required all allegations of abuse to be reported to the Department of Public Health within two hours of the allegation.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to remove an employee and initiate an investigation after Resident #59 reported an allegation of verbal abuse. Resident #59 was admitted in 12/2023 with diagnoses including allergies, unspecified asthma, and diabetes mellitus. The quarterly MDS identified the resident as cognitively intact, independent with eating, and independently mobile with a wheelchair. The care plan dated 3/10/25 identified the resident had the potential for alteration in nutrition and required accommodations for food preferences and allergies, including avoidance of pork, dairy, eggs, tomatoes, and breaded foods. Resident #59 reported that [NAME] #2 threatened him/her by saying, “I am going to get you,” after the resident repeatedly raised concerns about receiving incorrect food items. The resident stated the concern was reported to the Administrator and Ombudsman without follow-up. During interviews, the Administrator denied that Resident #59 reported a threat and later stated he could not recall the resident reporting that [NAME] #2 had threatened him/her. The facility policy for Resident Abuse stated that all residents are to be free from abuse, including verbal threats, and that any allegation of abuse requires an immediate investigation with any staff member named in the allegation removed pending completion of the investigation.
Incomplete Care Planning for Dementia and Tracheostomy Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive individualized care plan for a resident newly diagnosed with dementia after a hospital stay. The resident had a history of schizoaffective disorder and anxiety, was readmitted after hospitalization for urinary tract infection and behavioral disturbances, and the hospital discharge summary identified dementia along with agitation, schizoaffective disorder, and anxiety. The diagnosis of dementia was added to the EMR after return to the facility, and the APRN documented that the resident had recently been hospitalized for behavioral disturbances and agitation, with medications adjusted by psychiatry and supportive care continued. Review of the care plan showed that it did not reflect dementia or interventions related to dementia. The quarterly MDS identified moderately impaired cognition, and the resident had an active diagnosis of dementia, but the care plan dated after readmission did not include that diagnosis. During interviews, the DNS stated that nursing and the interdisciplinary team were responsible for updating care plans, but she did not know exactly who was responsible when a resident received a new diagnosis of dementia. The MDS coordinator stated she did not know who was responsible to ensure care plans were updated and accurate after readmission, and she could not identify when a baseline or comprehensive care plan should be completed on readmission. The facility also failed to develop a comprehensive person-centered care plan for a resident with a tracheostomy. The resident had diagnoses including acute and chronic respiratory failure with hypercapnia, malignant neoplasm of the supraglottic and anterior surface of the epiglottis, and COPD. The quarterly MDS identified the resident had intact cognition and was receiving oxygen therapy, suctioning, and tracheostomy care, but the care plan did not identify interventions, measurable objectives, or timetables for the tracheostomy. Nursing documentation showed orders to monitor the tracheostomy site and inner cannula every shift, while the nursing supervisor stated she was unsure whether the tracheostomy had an inner cannula or what daily care was required. The interim DNS stated that the resident returned from the hospital with a cuffed Shiley 6.0 tracheostomy and that a comprehensive tracheostomy care plan had not been developed.
Care plans not revised for unsafe smoking and air mattress use
Penalty
Summary
The facility failed to review and revise the care plans for two residents with smoking-related concerns and one resident with an air mattress. For Resident #51, the record identified chronic obstructive pulmonary disease, alcohol dependence, nicotine dependence, severely impaired cognition, and use of a manual wheelchair. A physician’s order allowed smoking with supervision, and the care plan identified the resident as a smoker with interventions to follow the facility smoking policy. However, after the resident returned from hospitalization following a fall from the wheelchair while on leave of absence, the record did not contain smoking assessments after readmission or for 2025, and the care plan was not revised to address smoking in unsafe areas adjacent to the facility while on leave of absence. Resident #51 was observed in a wheelchair on the street in front of the facility, self-propelling and then lighting and smoking a cigarette. The resident stated he/she went out to the street daily to smoke and kept cigarettes and a lighter on his/her person. The Administrator stated that residents signed themselves out multiple times a day to smoke in the street or at the park across the street, that residents were not searched or asked about lighters, and that education about the street being unsafe was verbal. The clinical record did not identify a care plan related to smoking in unsafe areas adjacent to the facility while on leave of absence. For Resident #105, the record identified chronic obstructive pulmonary disease, opioid dependence, peripheral vascular disease, severely impaired cognition, and use of a manual wheelchair. A quarterly smoking assessment stated the resident did not have a history of unsafe smoking habits and could safely smoke on an independent leave of absence, and the care plan identified the resident as a smoker with interventions to follow the smoking policy and education on contraband and other policies. However, the record did not identify a physician’s order for supervised smoking, smoking assessments related to unsafe smoking in undesignated areas, or revisions addressing smoking in the parking lot or street, contraband concerns, noninvasive searches after leave of absence, or the resident’s stated wish to no longer go on leave of absence. Resident #105 was observed obtaining cigarettes from the smoking cart, later observed in the street directly in front of the facility, and later observed actively smoking in the parking lot near the entrance bridge. A reportable event form documented that the resident had a lighter and that the lighter had either been given to the resident in the parking lot or hidden in underwear, and that the resident agreed to noninvasive room and body searches and would no longer be given cigarettes when leaving the facility. The clinical record did not contain documentation of the smoking safety concerns, the room search, or education related to smoking and contraband. For Resident #128, the record identified stroke with right-sided involvement, dysphasia, aphasia, severe cognitive impairment, high risk for skin breakdown, and a pressure-reducing device for the bed. A physician’s order directed the air mattress to be set at 150 lbs. and checked every shift, but the comprehensive care plan was not updated to include the air mattress that had been applied in March 2025.
Improper Crushing of Enteric Coated and Extended-Release Medications
Penalty
Summary
The nursing facility failed to administer medications according to professional standards for one resident who had dysphasia, acid reflux, atrial fibrillation, hypertension, and severely impaired cognition. The resident’s care plan directed staff to administer medications as ordered by the physician, and the physician’s order included iron sulfate enteric coated, pantoprazole delayed release, metoprolol 24-hour extended release, Seroquel, Senna-s, Nesina, Tylenol, trazodone, and Eliquis. During medication observation, an LPN prepared all 9 medications together, placed them in a pouch, crushed all of them with a pill crusher, and mixed the crushed medications with applesauce before administering them to the resident. During administration, the resident picked small pieces of medication out of the mouth and placed them on the bed sheet, and continued to spit out small pieces while the LPN gave the remaining spoonfuls. The LPN then left the room and moved on to the next resident. The LPN stated she always crushes this resident’s medications because of dysphasia and said she had been instructed during orientation to crush all medications for any resident with dysphasia. Later, the LPN acknowledged she knew medications that are enteric coated, extended release, or delayed release should not be crushed, but believed it was acceptable in this situation until informed by the DNS. The DNS stated nurses should know when medications can and cannot be crushed and confirmed that crushing iron sulfate enteric coated, pantoprazole delayed release, and metoprolol extended release would be a medication error. The pharmacist also stated that enteric coated, delayed release, and extended release medications should not be crushed, and specifically identified the resident’s iron sulfate, pantoprazole, and metoprolol as medications that should not have been crushed. The APRN stated nurses were expected to follow physician orders and know which medications can be crushed, and indicated she was not notified of the error until the following day.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living independently received necessary grooming services to maintain proper hygiene. Resident #41, who was admitted with diagnoses including dementia, osteoarthritis, rash, and seborrheic dermatitis, had severely impaired cognition and required partial/moderate assistance with personal hygiene. The care plan identified the resident needed assistance with showering and grooming, including shaving and nail care, but did not identify a history of refusing care. Observation showed the resident lying in bed with a blanket partially soiled in a black substance, and the resident's fingernails were long with a thick black substance under multiple fingernails. Staff interviews indicated the assigned nurse aide had not provided care for the resident in over a month and would notify the nurse about the need for nail trimming. A nursing supervisor later observed the fingernails remained long and soiled, and the resident agreed to allow cleaning. The interim DNS stated nurse aides were responsible for trimming nails on shower days and as needed, and that they should report any refusal or issues to the charge nurse.
Failure to Assess After Alleged Abuse, Provide Grooming, and Implement Consult and Equipment Orders
Penalty
Summary
The facility failed to complete an RN assessment after an allegation that a nurse aide pulled on a resident’s urinary catheter twice and told the resident to shut up while providing care. The resident was severely cognitively impaired, dependent for bed mobility and toileting, and had an indwelling urinary catheter. Another resident reported witnessing the incident during the overnight shift and said the allegation was reported to the Administrator the next morning. The reportable event was initiated and the employee was removed from the schedule, but the clinical record and reportable event documentation did not identify a documented RN assessment of the resident’s condition after the allegation. The facility also failed to ensure a resident received necessary grooming care. A resident with severely impaired cognition and a care plan calling for assistance with showering and grooming, including shaving and nail care, was observed lying in bed with a blanket partially soiled in a black substance. The resident’s fingernails were long, and thick black substance was visible under multiple fingernails. Staff interviews identified that nurse aides were responsible for grooming and hygiene, including nail care, and that nail care should be completed on shower days and as needed, but the resident’s nails remained untrimmed and soiled during observations. The facility further failed to implement consult recommendations for other residents. One resident with food allergies and suspected allergic reactions was evaluated by Allergy and Immunology, which recommended strict avoidance of all eggs and milk products, but the consult was not received and reviewed by facility staff for 40 days after the consult. Another resident with diabetes, PAD, and foot/nail issues had a podiatry consult recommending regular debridement/trimming, moisturizing lotion, and antifungal treatment, but the record did not show those recommendations were reviewed and implemented. In addition, a resident with stroke-related impairments and high pressure injury risk had an air mattress ordered to be set at 150 lbs and checked every shift, yet observations showed the mattress running at 350 lbs while staff documentation continued to sign off that it was set per order.
Failure to timely assess and treat a new coccyx pressure ulcer and complete weekly skin checks
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident #76, who was admitted with diagnoses including polyneuropathy, bipolar disorder, and diabetes. The resident’s care plan identified risk for skin impairment related to decreased mobility and included weekly skin checks and notification of the physician for any changes. The annual MDS documented moderately impaired cognition, total dependence for several ADLs, incontinence of bowel and bladder, and significant recent weight loss. On 7/27/25, an LPN documented a reddened area on the coccyx and notified the RN supervisor, but the note did not include a description of the area, including size or whether it was blanchable. On 8/10/25, another LPN documented a 0.5 cm by 1.0 cm open area at the top of the coccyx with pain, and later that day an RN measured the area, applied a dry protective dressing, notified the APRN, and placed the resident in the skin rounding book. A physician order was then written on 8/11/25 for wound cleansing and dressings. The wound was later documented by the wound nurse and wound physician as a stage 3 pressure ulcer, with measurements and drainage noted, and the wound physician later documented debridement and that the resident was still awaiting a low air loss mattress. The record also showed that weekly skin assessments ordered for Saturdays were not consistently completed. Assessments were missing on 7/26, 8/2, and 8/16/25, and one weekly skin assessment failed to reflect the coccyx redness while another documented intact skin despite the stage 3 pressure ulcer noted in nursing documentation. Interviews with the RN, DNS, and RN supervisor indicated that when a new wound is identified, an RN is expected to assess and document the wound, notify the APRN or physician, and obtain treatment orders the same day, but this did not occur when the coccyx redness was first identified.
Failure to Prevent Elopement and Delayed Response for Cognitively Impaired Resident
Penalty
Summary
A resident with multiple complex medical conditions, including opiate dependence, acute infective endocarditis, bacteremia, osteomyelitis, neuropathy, and severely impaired cognition, exited the facility without staff knowledge. The resident required supervision and an assistive device for ambulation, had a history of falls, and was receiving IV medications. Despite these needs, the resident was not identified as being at risk for elopement on the admission assessment, and there was no Leave of Absence (LOA) order in place for the resident. On the day of the incident, the resident was last seen stating an intention to retrieve a deck of cards. Surveillance footage later showed the resident exiting the main entrance behind the Administrator, unnoticed by staff at the front desk, including the Receptionist and the Administrator. The front door's locking mechanism had a 90-second delay before re-engaging, which allowed the resident to leave the building. Staff did not immediately realize the resident was missing; it was only after another resident reported seeing the individual outside that the Recreation Assistant began to investigate. There was a delay of up to ten minutes before the Administrator was notified and a code purple (missing resident) was called. The facility's elopement and code purple policies required immediate action and notification of police when a resident could not be located. However, there was a delay of approximately 54 minutes before the police were contacted. The resident was eventually found by police several miles from the facility, disoriented, inadequately dressed for the weather, and with injuries consistent with a fall. The incident was determined to be an Immediate Jeopardy situation due to the facility's failure to prevent the resident from exiting unsupervised and the delayed response in locating and reporting the missing resident.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and major depressive disorder was subjected to verbal abuse by a staff member. The resident, who had intact cognition and required supervision with activities of daily living, reported that a nursing assistant made derogatory remarks, calling the resident ugly and stating that the resident's significant other died to get away from them. This account was corroborated by the resident's roommate, who overheard the same comments. The incident was documented in a reportable event form and confirmed through interviews with both the resident and the roommate. The facility's abuse policy states that residents have the right to be free from abuse. Despite this, the staff member involved denied making the statements, but the consistency of the resident's and roommate's accounts led to the substantiation of the verbal abuse allegation. The failure to protect the resident from verbal abuse constituted a violation of the facility's obligation to ensure residents are free from all forms of abuse.
Failure to Include Discharge Planning in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident, which included discharge planning. The resident, diagnosed with depression, paranoid personality, and atrial fibrillation, was alert and oriented, requiring substantial assistance for ADL care. The Minimum Data Set (MDS) assessment indicated the resident's desire to be asked about returning to the community, yet no referral to a Local Contact Agency was made. The resident's care plan, dated January 8, 2024, did not identify discharge goals or interventions, despite the social worker completing an application for the Money Follows the Person (MFP) program on January 18, 2024, and providing a copy to the resident. Further review revealed that the care plan meeting on March 12, 2024, attended by the social worker and the resident, did not include information about the MFP application or discharge status. The social worker admitted to not documenting the resident's MFP program application or discharge status in the clinical record due to time constraints. The Director of Nursing Services confirmed that the social worker should have documented the progress of the MFP application in the resident's care plan or clinical record, as per the facility's Care Plan Policy, which mandates the inclusion of the resident's discharge preferences and referrals to support such desires.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate regarding medication administration. The resident, who had a history of myocardial infarction, chronic obstructive pulmonary disease, and heart failure, was identified as often non-compliant with medication administration. A physician's order was in place for Nitroglycerin 0.4mg to be administered sublingually as needed. On a specific date, the charge nurse informed the RN supervisor that the resident was given Nitroglycerin, and the APRN was updated with orders to monitor the resident. However, a review of the Medication Administration Record (MAR) for that month did not show documentation of the Nitroglycerin administration on the specified date. During an interview, the RN supervisor acknowledged documenting the administration in a progress note but failed to record it on the MAR. The Director of Nursing Services confirmed that the RN should have documented the medication administration in the MAR, as per the facility's documentation policy, which requires accurate and timely documentation in the resident's medical record.
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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 New Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Wade Home, The Incorporated | 0.7 mi | ★★★★★ | 4 | 0 |
| Apple Rehab Laurel Woods | 1.3 mi | ★★★★★ | 11 | 0 |
| Leeway, Inc | 1.5 mi | ★★★★★ | 10 | 0 |
| Montowese Center For Health & Rehabilitation | 2.8 mi | ★★★★★ | 1 | 0 |
| Advanced Center For Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 20 | 1 |
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