Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 West Haven Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
Improper Discharge During Pending Appeal: A resident with depression, pain, HTN, and DM2 was discharged before the 30-day notice period ended and before the appeal hearing occurred. The facility arranged an RCH placement, but when the resident could not afford it, the resident was sent to a hotel instead. The hearing later found the discharge improper while the appeal was pending, and the Administrator stated she believed the resident could leave voluntarily after accepting the RCH placement.
An LPN failed to ensure a resident with pain, DM2, and dysphagia actually consumed oral meds and received a prescribed lidocaine patch before leaving the room. The resident reported the meds were left in a cup on the over-bed table and the patch was left for self-application, even though the resident was not approved to self-administer meds; unopened patches were later found on the table, and facility policy required meds to be administered by the same person who prepared them and not left unattended.
The DNS served as the RN Supervisor on multiple shifts following RN Supervisor call-outs, despite facility policy and census requirements prohibiting this practice. The DNS confirmed covering these shifts to meet resident needs, and the facility had not consistently maintained separate supervisory coverage during these times.
A resident with multiple medical conditions was transferred to the hospital on several occasions without receiving the required written notification of the facility's bed hold policy. Review of records and staff interviews confirmed that the bed hold policy was not provided or documented at the time of transfer, despite facility policy requiring such notification.
The facility did not notify the appropriate authorities when a resident receiving MD or ID services had a significant change in condition, as required.
Two residents did not have comprehensive, person-centered care plans addressing their clinical needs. One resident with a history of pain lacked a care plan with measurable objectives for pain management, despite ongoing complaints and multiple pain medication orders. Another resident with dementia did not have their diagnosis or related interventions reflected in the care plan, even after clinical confirmation. Facility policy required timely and comprehensive care planning, but this was not followed, resulting in deficiencies.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not adequately implemented to stop new ulcers from developing.
A resident did not receive the medically-related social services needed to help achieve the highest possible quality of life, as required by regulations.
A resident with chronic conditions and intact cognition did not receive their documented preference for two hard-boiled eggs daily at breakfast for over three weeks, despite repeated communication of this preference by the resident, dietitian, and staff. The kitchen substituted other foods when eggs were unavailable, and the Food Service Director was unaware of the ongoing issue. The resident's right to have food preferences honored was not met, as confirmed by observation and staff interviews.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
The facility did not ensure that a qualified Infection Preventionist was designated and allocated sufficient time to manage the Infection Prevention and Control Program. The assigned RN was responsible for multiple roles and did not have dedicated time for infection prevention activities, which contributed to lapses in outbreak management, such as failing to identify a resident with influenza symptoms for testing.
Nurse aides did not receive the required 12 hours of annual in-service training, including dementia management education. After the departure of the staff development nurse, the DNS and an RN took over staff education but were unaware of the full training requirements, resulting in incomplete training hours and missing dementia education. Documentation of completed training was also lacking.
Staff did not promptly inform a resident, the resident's doctor, and a family member about events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with cognitive impairment and skin breakdown risk did not receive zinc as part of a prescribed wound care regimen due to a failure to accurately transcribe the physician's order into the electronic health record. The omission was confirmed through record review and staff interviews, revealing that the facility did not follow its policy for prompt and accurate order entry.
Improper Discharge During Pending Appeal
Penalty
Summary
The facility improperly discharged a resident before the required discharge timeline and while the resident’s appeal was still pending. Resident #1 had diagnoses including depression, pain, hypertension, and type II diabetes mellitus, and a quarterly MDS assessment documented a BIMS score of 15 out of 15, indicating no memory recall deficits and independence with eating, personal hygiene, bed mobility, transfers, and ambulation. The facility issued a 30-day involuntary discharge notice stating the resident would be discharged to a hotel due to improved health and nonpayment, and the notice also informed the resident of the right to appeal within 20 days. After the resident requested a hearing, the facility scheduled an administrative hearing, but discharge planning continued before the hearing occurred. Social service documentation showed the Administrator met with the resident to discuss discharge options, the resident expressed that the hotel was not the first choice, and a Residential Care Home (RCH) was identified and accepted. The facility then scheduled discharge to the RCH for 9/25/25, which was one day before the 30-day notice date of 9/26/25 and six days before the hearing date. On the day of discharge, the resident was taken to the RCH, but could not pay the required amount and chose to go to the hotel instead; the resident was then assisted with hotel check-in and belongings were confirmed. The hearing later found the facility improperly discharged the resident while the appeal was pending and before the 30 days had elapsed, and the discharge was ordered rescinded. The record also showed the hearing date was rescheduled, and the resident was later readmitted from the hotel to the facility. During interviews, the resident stated he/she was not given the choice to return to the facility after the failed RCH placement and was told he/she had already been discharged. The Administrator stated she believed the resident could voluntarily leave after agreeing to the RCH placement and acknowledged she was unaware the resident was required to remain in the facility until the hearing date unless specific exceptions applied; she also stated the resident did not meet those exceptions. The facility policy required 30-day notice, documented exceptions, and sufficient preparation and orientation for safe transfer or discharge.
Medications Left Unattended at Bedside
Penalty
Summary
Licensed nursing staff failed to ensure Resident #1 consumed oral medications and had a lidocaine 5% adhesive patch applied before leaving the room, and the medications were not left at the bedside. Resident #1 had diagnoses including pain, type II diabetes mellitus, and dysphagia, and the quarterly MDS showed a BIMS score of 15/15 and that the resident was independent with eating. A physician’s order directed the lidocaine patch to be applied topically to the lower back daily at 6:00 AM, and the self-administration assessment stated it was not appropriate for Resident #1 to self-administer medications and that the resident did not want to self-administer medications. During observation and interview, an unopened lidocaine patch labeled for the 11PM-7AM shift was found on Resident #1’s over-the-bed table, and Resident #1 stated the nurse placed the patch and oral medications in a cup on the table and left without ensuring the medications were taken. Resident #1 said the patch was usually left for self-application and that the oral medications were taken with breakfast. A later observation found the unopened patch still on the table, and another unopened patch from an earlier date was also found there. The regional nurse stated Resident #1 was not to self-administer any medications, including the lidocaine patch, and that it should not have been left at the bedside. The facility policy stated medications must be administered by the same person who prepared the dose and must not be left unattended.
DNS Served as RN Supervisor During Staffing Shortages
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services (DNS) did not serve as the nursing supervisor, as required when the average daily census exceeds 60 residents. Review of facility documentation showed that on multiple occasions, following RN Supervisor call-outs, the DNS assumed the role of RN Supervisor for various shifts, including night, day, and evening shifts. The DNS confirmed during an interview that she had served as the RN Supervisor on these occasions and could not recall how many additional shifts or hours she had covered in this capacity since becoming the DNS. The DNS stated that she took on these additional supervisory shifts to meet resident needs after staff call-outs. The facility's policy assigns the DNS responsibility for determining staffing numbers and assignments, with the staffing coordinator tasked with maintaining adequate coverage. The report also notes that the facility had recently hired additional supervisors and per diem nurses to improve supervisor coverage, but these actions occurred after the identified incidents.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
A deficiency was identified when the facility failed to provide required written notification of the bed hold policy to a resident and/or their representative at the time of transfer to the hospital. The resident, who had a history of seizure disorder, chronic lower back pain, and dementia, was hospitalized on three separate occasions. Review of the clinical record and facility documentation revealed no evidence that the bed hold policy, specifying the duration and terms, was given to the resident or their representative during any of these hospital transfers. Interviews with facility staff, including the DNS, social worker, and Chief Clinical Officer, confirmed that the process for providing and documenting the bed hold policy was not consistently followed. Staff were either unsure of their responsibilities or acknowledged that the policy was not being provided or documented as required. Facility policies reviewed indicated that notification of the bed hold policy should be given upon admission and in advance of any transfer, but there was no documentation to support that this occurred for the resident's hospitalizations.
Failure to Notify Authorities of Significant Change for MD/ID Residents
Penalty
Summary
The facility failed to notify the appropriate authorities when residents receiving services for mental disorders (MD) or intellectual disabilities (ID) experienced a significant change in condition. This deficiency was identified based on the observation that required notifications were not made as mandated when such changes occurred for these residents.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant clinical needs. For one resident with a history of pain, the care plan did not include measurable objectives or goals for pain management, despite multiple physician orders for pain medications and documented complaints of inadequate pain control. The resident reported that pain was not being well managed, leading to an unsanctioned visit to urgent care for further evaluation and recommendations. Facility documentation and staff interviews confirmed that the omission of a pain management care plan was an oversight, and the care plan was not updated in a timely manner to reflect the resident's needs. For another resident with a diagnosis of dementia, the care plan failed to reflect the new diagnosis and did not include interventions to address dementia-related needs. The resident had a history of stroke, fibromyalgia, and chronic pain, and was receiving multiple medications, including antipsychotics and antidepressants. Despite a neurological consult and psychiatric note confirming the diagnosis of dementia with hallucinations and paranoia, the care plan was not updated to include dementia care or related interventions. Staff interviews revealed that the responsibility for updating care plans was not consistently followed, and the care plan did not reflect changes in the resident's condition. Facility policies required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for all residents, including those with pain and dementia. The care planning process was to include ongoing assessments and timely updates to reflect changes in residents' diagnoses and needs. However, the facility did not ensure that care plans were updated or comprehensive for the residents reviewed, resulting in deficiencies in meeting their physical, psychosocial, and functional needs.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to meet their individual needs.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preferences, specifically the daily provision of two hard-boiled eggs for breakfast. The resident, who had chronic pain, thoracic intervertebral disc degeneration, and COPD, was cognitively intact and independent with eating. The care plan and meal tickets consistently reflected the resident's preference for hard-boiled eggs, and the dietitian had communicated these preferences to the dietary and kitchen staff. Despite this, the resident did not receive hard-boiled eggs for over three weeks, and this was confirmed by both the resident and staff interviews, as well as direct observation. Staff interviews revealed that the kitchen substituted other foods when hard-boiled eggs were unavailable, and the Food Service Director was unaware of the ongoing lack of eggs and the resident's unmet preference. The resident had repeatedly voiced complaints to staff and the administrator, but the issue persisted, with the administrator referencing the cost of eggs rather than addressing the resident's needs. Facility documentation and interviews confirmed that the resident's right to have individual food preferences honored was not met, as required by facility policy and resident rights.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Designate and Allocate Time for Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated to manage the Infection Prevention and Control Program at least part-time, as required. Review of facility documentation and interviews revealed that the assigned RN, who was responsible for the infection control program, was also performing multiple other roles, including wound care, staff development, and RN supervision during the day shift. The RN and the Director of Nursing Services (DNS) both confirmed that there was no specific or quantifiable amount of time set aside for infection prevention duties, and they worked on the program only when time allowed. Punch records and staffing assignments showed that the RN was scheduled as the RN supervisor for the majority of the month, with no additional hours dedicated to infection prevention activities outside of this role. During an influenza outbreak, the facility's surveillance tracking log did not identify a resident with symptoms consistent with influenza as requiring testing, indicating a lapse in outbreak management. The facility's job description for the Infection Control Coordinator specified that the primary responsibility was to direct the infection control program, but the actual practice did not align with this requirement. The facility assessment also indicated that there should be one designated Infection Preventionist, but the evidence showed that this role was not being fulfilled as intended.
Failure to Provide Required Annual In-Service and Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the federally required minimum of 12 hours of in-service training annually, including specific training in dementia management. Review of facility documentation for the 2024-2025 period showed a lack of records confirming that nurse aides completed the required hours of in-service education, and there was no evidence that dementia management training was provided. Interviews with the Director of Nursing Services (DNS) and the Staff Development Nurse (RN) revealed that after the previous Staff Development Nurse left in August 2024, the position remained vacant for several months, and the responsibility for staff education was assumed by the DNS and RN. They acknowledged that they were unaware of the 12-hour annual in-service requirement and estimated that nurse aides had only completed approximately 8 hours of training in 2024. Additionally, dementia education was not provided in 2024 or up to the date of the survey in 2025. Facility policies require that all nurse aides receive regular, structured, and documented in-service education relevant to their roles, including dementia care and abuse prevention, but the facility did not maintain adequate documentation of completed training or competencies. The DNS and RN confirmed that while some mandatory annual education topics were covered, documentation was inconsistent, and dementia-specific training was overlooked. The lack of a dedicated staff development nurse and insufficient record-keeping contributed to the failure to meet regulatory requirements for nurse aide training and education.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, are not provided in the report.
Failure to Accurately Transcribe and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to properly transcribe and implement a physician's wound treatment order for a resident with multiple diagnoses, including Parkinson's disease, mild cognitive impairment, and a history of skin impairment. The resident's care plan identified a risk for skin breakdown and included interventions to prevent pressure ulcers. On review, the wound care progress note recommended applying zinc to the peri-wound area of the right heel, along with collagen, Hydrofera Blue, and a dry protective dressing. However, the physician's order entered into the electronic health record omitted the zinc application, and treatment records did not show that zinc was applied as recommended. Interviews with the wound physician confirmed that zinc was intended to be part of the wound care regimen, and facility leadership acknowledged that the physician's order should have matched the treatment recommendation. The facility's policy required prompt and accurate entry of orders into the electronic health record, but this was not followed, resulting in the omission of zinc from the resident's wound care treatment.
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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 West Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orange Health Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Apple Rehab West Haven | 1.8 mi | ★★★★★ | 37 | 1 |
| Advanced Center For Nursing & Rehabilitation | 2 mi | ★★★★★ | 20 | 1 |
| Grimes Center | 2.4 mi | ★★★★★ | 13 | 0 |
| Autumn Lake Healthcare At The Willows | 4.1 mi | ★★★★★ | 7 | 0 |
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