Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Whitney Rehabilitation Care Center during CMS and state inspections, most recent first.
The facility failed to provide palatable and properly prepared food, as reported by several residents. Issues included overcooked and bland food, lack of fresh produce, and improperly served items like melted ice cream and stale buns. The Food Service Director was aware of some issues but did not conduct formal audits, contrary to facility policy.
The facility's Dietary Department had several deficiencies, including undated open food items, unsanitary ice machine conditions, and improper storage of staff beverages. The Dietary Manager and staff failed to adhere to policies regarding food labeling, cleaning schedules, and storage practices.
The facility failed to ensure proper PPE use for residents on Enhanced Barrier Precautions and Transmission Based Precautions. Staff were observed not wearing gowns during high-contact care for residents with infections, despite clear signage and policies. Additionally, required signage for a resident on Covid-19 precautions was missing, and a dusty fan was found blowing on clean laundry.
The facility failed to follow physician orders for several residents, including not adhering to a positioning plan for a resident with dementia, not documenting daily weights for a resident with CHF, and not continuing anticoagulant therapy for a resident with DVT. Additionally, blood glucose monitoring was not performed for a diabetic resident, leading to a hypoglycemic episode.
A resident with osteoarthritis was verbally abused by an LPN during a confrontation over a medication cart. The LPN used profane and derogatory language, which was witnessed by another LPN who intervened. The incident was reported, substantiated, and led to the termination of the LPN's employment.
A facility failed to address a resident's advance directives upon admission. The resident, with moderately impaired cognition and requiring assistance with ADLs, had a living will specifying no life support systems, yet was recorded as a full code. Interviews with the DON and ADON confirmed that advance directives should have been addressed upon admission, but this was not done. The facility's policy required that a resident's choices regarding advance directives be honored and documented.
A resident was left wearing a hospital gown for several days due to delayed laundry return, impacting their dignity and participation in therapy. Despite being cognitively intact and requiring assistance with dressing, the resident's clothing was not returned for five days. The issue was reported to the laundry department, but the Director of Environmental Services was unaware until later, and the facility's policy for reporting missing items was not followed promptly.
The facility failed to notify responsible parties and physicians of significant changes in residents' conditions. A resident with cognitive impairment developed an open wound without notifying the responsible party. Another resident with CHF experienced a significant weight loss without physician notification. Additionally, a resident refused to wear a prescribed lumbar brace, and the physician was not informed. These actions were contrary to the facility's policies.
A resident with severe cognitive impairment and multiple health issues was not provided necessary grooming assistance, resulting in unshaven and disheveled appearance over several days. Staff interviews revealed inconsistencies in following the facility's grooming policy, with no refusals documented despite the resident's unmet grooming needs.
A resident with a Stage 3 pressure ulcer experienced worsening of the condition due to improper air mattress settings in an LTC facility. The resident's air mattress was set for a weight of 150 lbs, despite the resident weighing 104 lbs, causing discomfort and increased pressure on the wound. The facility failed to obtain a physician's order for the air mattress settings and did not implement a turning and positioning schedule, leading to the deterioration of the resident's wound.
A facility failed to implement a physician's order for a resident's ambulation, leading to a deficiency. The resident, with a history of spinal issues, required a two-person assist for ambulation per the physician's order. However, the nurse aide did not ambulate the resident, believing it was the responsibility of physical therapy. The care card indicated a two-person assist was needed but did not specify that ambulation should occur, leading to documentation that ambulation was not applicable.
The facility failed to follow the posted menu and did not notify residents of meal substitutions. A resident was served breaded fish instead of their pre-selected barbecue spare rib sandwich. The Food Service Director conducted audits but found no inconsistencies, and only one in-service was provided to the Dietary Aide. Further observations showed manicotti was replaced with stuffed shells, and sherbet with ice cream, without notifying residents. The Resident Council confirmed meal tickets often did not match selections or served food.
A resident with renal disease, diabetes, and depression did not receive quarterly statements for their Resident Trust Account over the past year. The Business Office Manager, new to her role, was unaware of her responsibility to send these statements, believing Corporate handled it. Upon inquiry, she learned she was responsible, leading to the deficiency.
A resident with no fluid restriction repeatedly requested a water pitcher overnight, but the facility failed to resolve this grievance over several months. Despite acknowledging the issue and planning to order more pitchers, the facility did not ensure availability from 11:00 PM to 7:00 AM, contrary to its grievance policy.
A facility failed to accurately code the MDS for a resident requiring a PASRR Level II assessment. The resident, diagnosed with schizophrenia, depressive episodes, and dementia, was not identified as having a serious mental illness in the MDS, despite a PASRR Level II assessment indicating such. The error was discovered during a review with a social worker, who noted the resident was not listed for Level II coding, and the facility lacked a PASRR policy.
The facility failed to ensure consistent documentation of ADL care for a resident with a history of fractures and osteoarthritis, with a low completion rate of POC documentation. Additionally, the facility did not document meal consumption for another resident with impaired cognition and a femur fracture. Interviews revealed a lack of monitoring and awareness among staff, and the facility lacked specific documentation policies.
A resident with Alzheimer's disease wandered off the property and was found three miles away. The facility failed to investigate the incident promptly or report it to the state agency. Staff interviews revealed a lack of awareness and communication, and the resident knew the code to the elevator, allowing access to the main entrance. The facility's policy for immediate notification and investigation was not followed.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Interviews with residents revealed dissatisfaction with the taste and quality of the food, noting that cold food was not served cold and there was a lack of fresh fruits and vegetables. A taste tray evaluation found that the broccoli stems and manicotti were overcooked, mushy, and bland. The Food Service Director acknowledged the overcooking of broccoli and admitted to not conducting audits on food quality, although he performed undocumented demonstrations with cooks. During a Resident Council meeting, multiple residents reported issues such as uncooked rice, inedible fish, stale burger buns, melted ice cream, and wilted salads. The facility's policy stated that food should be prepared to conserve nutritive value and enhance flavor and appearance, which was not adhered to in these instances.
Dietary Department Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in the Dietary Department, as evidenced by several deficiencies observed during a tour. Open food items in the walk-in freezer and refrigerator were not dated, with some items like chicken patties showing signs of freezer burn. The ice machine and its scoop were found in unsanitary conditions, with the scoop stored in a visibly soiled holder and the machine's vents covered in dust. Additionally, the dish room had dirty ceiling vents, and an uncovered garbage can was found on the clean side of the dish area. Staff practices also contributed to the deficiencies. The Dietary Manager acknowledged that whoever opened food items was responsible for labeling them with an open date, but this was not consistently done. The ice machine had not been cleaned for the current month, and the Dietary Manager indicated that maintenance was responsible for cleaning the vents, but it was their responsibility to notify maintenance when cleaning was needed. Furthermore, staff beverages were improperly stored in the kitchen refrigerator, which was against facility policy, and the Dietary Aide could not justify this action.
Inadequate PPE Use and Signage in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was used for residents on Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP). For Resident #32, who had an ileal conduit and was on EBP for Clostridium Difficile (C-Diff) and Methicillin Resistant Staphylococcus (MRSA), a nurse aide was observed emptying the urinary bag wearing gloves but not a gown, despite signage indicating the need for both. The nurse aide admitted to forgetting to don the gown, although she had received education on EBP. Similarly, Resident #36, who had a feeding tube and a history of extended spectrum beta lactamase (ESBL) resistance infection, was on EBP. A nurse aide was seen performing incontinent care wearing gloves but not a gown, despite being aware of the EBP requirements. The aide misunderstood the need for PPE during incontinent care, which was clarified by the Infection Preventionist, who confirmed that PPE should have been worn. For Resident #74, who had an unhealed pressure ulcer and was on EBP for wound care, a registered nurse conducted wound care without wearing a gown, contrary to the facility's policy. Additionally, Resident #76, diagnosed with Covid-19, was on TBP, but the required signage to alert staff and visitors of PPE needs was missing from the resident's door. The Infection Control Nurse was responsible for the signage but denied removing it. Furthermore, a tour of the laundry room revealed a fan with heavy dust accumulation blowing on clean laundry, indicating a lapse in maintenance and cleanliness protocols.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to adhere to physician's orders for Resident #32, who was diagnosed with conditions including macular degeneration, cataracts, cerebral infarction, and dementia. The resident required substantial assistance for daily activities and was supposed to be positioned out of bed according to a 24-hour positioning plan. However, observations revealed that the resident was often left in bed, contrary to the plan. Nursing progress notes lacked documentation on the resident's comfort, positioning, or pain as required by the physician's order. Interviews with staff indicated a misunderstanding or disregard for the positioning plan, with one nurse aide admitting to keeping the resident in bed based on personal preference rather than the resident's needs or orders. For Resident #69, who had diagnoses including chronic systolic congestive heart failure, the facility failed to document daily weights as ordered by the physician. Although the electronic medication administration record indicated that weights were completed, the actual weights were not recorded in the clinical record. Interviews with staff revealed a lack of communication and documentation processes, with nurse aides responsible for weighing residents but not documenting the results. The failure to update care cards and assignment sheets with the daily weight requirement further contributed to the oversight. Resident #153, with a history of deep vein thrombosis, did not receive the prescribed anticoagulant therapy due to an error in medication order transcription. The facility's policy required following the inter-agency patient referral form for medication orders, but the Lovenox order was incorrectly given an end date, leading to a lapse in administration. Interviews with advanced practice registered nurses and licensed practical nurses highlighted a lack of clarity and verification in the medication ordering process. Additionally, Resident #173, who had diabetes, did not receive necessary blood glucose monitoring due to an inadvertent discontinuation of the order. This oversight resulted in missed monitoring instances and a subsequent hypoglycemic episode requiring hospital transfer.
Verbal Abuse Incident Involving Resident and LPN
Penalty
Summary
The facility failed to protect Resident #106 from verbal abuse by a staff member, resulting in a substantiated incident of mistreatment. Resident #106, who was diagnosed with osteoarthritis and was alert, oriented, and self-mobile in a wheelchair, was involved in a verbal altercation with LPN #12. The incident occurred when Resident #106 allegedly moved LPN #12's medication cart, prompting LPN #12 to engage in a verbal exchange with the resident. During this exchange, LPN #12 used profane and derogatory language towards Resident #106, calling the resident an 'idiot' and a derogatory term. LPN #11 witnessed the incident and intervened by stepping between the two parties. The facility's documentation and interviews confirmed that LPN #12 admitted to swearing at Resident #106, and the incident was reported to the RN supervisor. The Director of Nursing Services (DNS) acknowledged that the verbal exchange should not have occurred, and staff are prohibited from swearing at residents regardless of provocation. The facility's Abuse/Retaliation Prohibition Policy defines verbal abuse as the use of disparaging and derogatory language towards residents. The incident was substantiated, and LPN #12's employment was terminated as a result.
Failure to Address Advance Directives Upon Admission
Penalty
Summary
The facility failed to address advance directives timely for a resident upon admission. Resident #375, who was admitted with diagnoses including hypothyroidism and a femur fracture, had moderately impaired cognition and required assistance with activities of daily living (ADLs). The resident's clinical record included a living will that specified the resident did not want life support systems such as artificial respiration, cardiopulmonary resuscitation, and artificial means of providing nutrition and hydration. Despite this, the resident was recorded as a full code. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that advance directives should have been addressed upon admission, but this was not done for Resident #375. The facility's policy on advanced directives, dated March 31, 2023, required that a resident's choices regarding advanced directives be honored and documented in the care plan and face sheet. The DON and ADON were unable to explain why the advance directives were not addressed during the resident's admission.
Resident's Dignity Compromised Due to Delayed Laundry Return
Penalty
Summary
The facility failed to ensure the timely return of laundry for a resident, resulting in the resident having to wear a hospital gown for several days. The resident, who was cognitively intact and required assistance with dressing, reported not receiving their clothing back from the laundry for five days. This situation was observed during a Resident Council meeting and further confirmed during interviews with the resident and staff. The resident expressed discomfort and dissatisfaction with wearing a hospital gown, which affected their participation in physical therapy sessions. The issue was reported to the laundry department by a nurse aide, but the Director of Environmental Services was not aware of the missing clothing until several days later. The department was experiencing staffing shortages, and the regular employee responsible for handling such issues had left. The facility's policy required staff to report missing items to supervisors, who would then inform the social worker or administration, but this process was not followed in a timely manner. The social worker was only informed of the issue on the same day as the surveyor's observation, despite the nurse aide being aware of the problem earlier.
Failure to Notify Responsible Parties and Physicians of Resident Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident's development of an open area requiring treatment. Resident #36, who had a history of stroke and was severely cognitively impaired, developed a superficial open area on the right great toe. Despite the facility's policy requiring notification of changes in status, there was no documentation that the responsible party was informed of this condition from the time it was identified until it was resolved. The wound nurse indicated that it was the responsibility of the nurse or unit manager to notify the responsible party, but this did not occur. In another instance, the facility did not notify the physician of a significant weight loss in a resident with congestive heart failure. Resident #69, who was moderately cognitively impaired and had chronic heart failure, experienced a weight loss of more than 3 pounds in one day. The facility's policy required notification of such weight changes, but the physician or APRN was not informed. The APRN confirmed that she would have expected to be notified to assess the situation further. Additionally, the facility failed to notify the physician of a resident's refusal to wear a prescribed lumbar brace. Resident #476, who had multiple vertebral compression fractures, was observed multiple times without the brace, which was required when out of bed. Despite the resident's refusal being reported to an LPN, there was no documentation of physician notification until after surveyor inquiry. The facility's policy required physician notification if a refusal was of significant importance, which was not initially followed.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to provide necessary assistance for grooming to Resident #32, who was severely cognitively impaired and required substantial assistance for daily activities. The resident had diagnoses including macular degeneration, cataracts, cerebral infarction, and dementia, and was identified as needing maximal assistance for eating, toileting, and transfers. Despite the care plan indicating the need for assistance with bathing, dressing, personal hygiene, and grooming, observations over three days showed the resident was unshaven and had disheveled hair. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's grooming policy. A nurse aide admitted difficulty using a disposable razor and did not report the issue to a nurse, contrary to the policy. Another aide and an LPN confirmed that residents should be shaved daily or as needed, with refusals reported to a nurse. However, no refusals were documented for Resident #32, indicating a lapse in communication and adherence to the grooming policy, which aims to maintain residents' dignity and ensure socially acceptable grooming.
Improper Air Mattress Setting Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to properly set and monitor an air mattress for a resident, leading to the worsening of a pressure ulcer. The resident, who had diagnoses including type 2 diabetes mellitus, anemia, and hyponatremia, required extensive assistance for transfers, toileting, and bed mobility. The resident's care plan included the use of an air mattress for a Stage 3 pressure ulcer on the left buttock, but it did not specify the correct settings for the mattress. Additionally, there was no documentation of a turning and positioning schedule, and the nurse aide care card lacked directives for turning and positioning. Observations and interviews revealed that the air mattress was set incorrectly at 150 lbs, despite the resident weighing 104 lbs. The resident expressed discomfort and pain due to the mattress feeling too firm, akin to sitting on rocks. The nursing staff, responsible for monitoring and setting the air mattress, failed to adjust it according to the resident's weight. A physician's order for setting and monitoring the air mattress was not in place, which should have been obtained when the air mattress was first initiated. The wound physician noted that the pressure ulcer had worsened, with increased depth, tunneling, and undermining, indicating that the wound had been exposed to more pressure. The physician attributed the worsening condition to the air mattress being set too firm, which increased pressure on the wound. The facility's air mattress policy required observing the mattress each shift to ensure proper functioning and settings, which was not adhered to in this case.
Failure to Implement Physician's Order for Resident Ambulation
Penalty
Summary
The facility failed to implement a physician's order for ambulation for a resident with a history of wedge compression fracture, osteoarthritis, and thoracolumbar fusion. The resident was cognitively intact and required assistance with activities of daily living due to decreased mobility. The care plan indicated the resident needed a one-person assist for ambulation using a rolling walker, but a physician's order later required a two-person assist. Despite this, the nurse aide responsible for the resident did not ambulate the resident, believing that physical therapy was responsible for this task. The nurse aide followed the Resident Care Card, which indicated a two-person assist was needed for ambulation but did not specify that ambulation should occur. Consequently, the nurse aide documented that ambulation was not applicable, as she believed the responsibility lay with physical therapy. Interviews with the rehabilitation director and therapists revealed that orders for ambulation were not specific in terms of frequency or location, and the facility's practice was for nursing staff to assist with ambulation as needed, without explicit direction in the physician's order.
Failure to Follow Posted Menu and Notify Residents of Meal Substitutions
Penalty
Summary
The facility failed to adhere to the posted menu and did not provide prior notification to residents when meal substitutions were made. During an observation of the lunch meal, a resident who had pre-selected a barbecue spare rib sandwich was instead served breaded fish, despite the barbecue spare rib sandwich being available. This inconsistency was noted despite previous complaints from the Food Committee about meal tickets not matching what was served. The Food Service Director (FSD) had conducted audits in April 2024 but found no inconsistencies, and no further audits were completed after that month. Additionally, the FSD provided only one in-service to the Dietary Aide responsible for checking meal tickets, but could not recall the content of the training. Further observations revealed that manicotti was listed on the menu, but stuffed shells were served instead, and sherbet was substituted with ice cream halfway through service without notifying residents. The FSD attributed these errors to a mistake in removing the wrong item from the freezer and an unexplained shortage of ice cream. During a Resident Council meeting, it was confirmed that meal tickets often did not reflect the residents' selections or the food served. These findings highlight a failure in the facility's dietary services to follow the posted menu and communicate changes to residents, leading to dissatisfaction and confusion among the residents.
Failure to Provide Quarterly Resident Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements for residents with a Resident Trust Account, specifically affecting one resident with intact cognition and diagnoses including renal disease, Diabetes Mellitus, and depression. The resident reported not receiving quarterly banking statements for the past year after a change in bookkeeping staff. The Business Office Manager, who assumed her role in April, was unaware of her responsibility to send these statements, mistakenly believing that Corporate was responsible. Upon inquiry, she discovered that she was indeed responsible for providing the statements, which had not been sent due to this misunderstanding.
Failure to Provide Overnight Water Pitchers
Penalty
Summary
The facility failed to resolve a grievance regarding a resident's request for a water pitcher to be available overnight. The resident, who was cognitively intact and independent with eating and oral hygiene, expressed concerns during multiple Resident Council meetings about the unavailability of water pitchers from 11:00 PM to 7:00 AM. Despite the facility's documentation of plans to order more water pitchers and address the issue, the resident's request was not fulfilled over several months. The facility's grievance policy requires prompt resolution of complaints, but this was not achieved in this case. The resident's medical history included anemia, cervical disc disorder, and peripheral vascular disease, and there was no fluid restriction in place. The facility's failure to provide a water pitcher overnight persisted despite repeated mentions in Resident Council meetings and the facility's acknowledgment of the issue. The Assistant Director of Nursing Services confirmed that while water was offered in cups at night, the facility had not yet implemented a system to ensure water pitchers were available overnight, as initially promised.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for a resident who required a Preadmission Screening and Resident Review (PASRR) Level II assessment. The resident, who had diagnoses including schizophrenia, depressive episodes, and dementia, was identified as severely cognitively impaired and required extensive assistance with daily activities. Despite the PASRR Level I assessment indicating the need for a Level II assessment due to schizophrenia, the MDS did not reflect the resident's status as having a serious mental illness as determined by the state Level II PASRR process. The deficiency was identified during an interview and clinical record review with a social worker, who acknowledged that the PASRR documentation in the clinical record included a Level II assessment completed in 2015. However, the resident was not listed for Level II coding, leading to an incorrect MDS assessment. The facility did not provide a policy for PASRR when requested, indicating a lack of procedural guidance in ensuring accurate assessments for residents with serious mental illnesses.
Inadequate Documentation of ADL Care and Meal Consumption
Penalty
Summary
The facility failed to ensure consistent documentation by the Nurse Aide (NA) related to the provision of Activity of Daily Living (ADL) care for Resident #61, who had diagnoses including a wedge compression fracture, osteoarthritis, and a history of breast cancer. The resident was cognitively intact and required assistance with ADLs. However, the Point Of Care (POC) documentation from 6/20/24 to 8/29/24 showed a low completion rate of 29.4% for documenting bed mobility, transfers, toileting, and personal hygiene. Interviews revealed that charge nurses and unit managers were not adequately monitoring the POC documentation, and the Licensed Practical Nurse (LPN) was unaware of the requirement to check NA documentation. The facility lacked a policy for NA documentation, ADL documentation, and POC documentation. Additionally, the facility failed to ensure a complete and accurate medical record for Resident #375, who was admitted with diagnoses including hypothyroidism and a femur fracture. The resident had moderately impaired cognition and required assistance with ADLs. The facility did not document the meals consumed by the resident on 2/22 and 2/23/2024 for breakfast and lunch. The Director of Nursing Services (DNS) acknowledged the failure to document meal consumption and could not explain why it was not done. The facility's undated Documentation Policy indicated that NAs are responsible for completing the residents' flow sheet.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an incident where a resident with Alzheimer's disease and adjustment disorder wandered off the property unattended. Despite being identified as a low risk for wandering, the resident left the facility and was found three miles away by a family member. The facility did not initiate a Facility Reported Incident form or an investigation until nearly three months after the incident occurred. Staff interviews revealed that the resident had been able to exit the facility without staff awareness, and there was no immediate notification to the state agency as required by policy. On the day of the incident, the resident expressed a desire to go home and refused to wear a wander guard. One-to-one supervision was initiated, and the resident was added to the wanderer/elopement list. However, the clinical record lacked documentation of an immediate investigation or reporting to the state agency. Interviews with staff, including the Nursing Supervisor, LPN, and Receptionist, indicated a lack of awareness and communication regarding the resident's elopement. The Director of Nursing (DON) was not fully informed about the resident's whereabouts and the extent of the elopement until much later. The facility's exit doors required a code to open, but the resident knew the code to the elevator, which allowed access to the first floor and main entrance. The Maintenance Assistant and Administrator confirmed that the code had not been changed for an extended period, and there was no schedule for changing it. The facility's Elopement Assessment policy required immediate notification and investigation, which was not followed in this case, leading to a significant delay in addressing the incident and reporting it to the appropriate authorities.
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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) |
|---|---|---|---|---|
| Hamden Rehabilitation & Healthcare Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Arden Care Center | 2 mi | ★★★★★ | 28 | 0 |
| Whitney Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Montowese Center For Health & Rehabilitation | 3.9 mi | ★★★★★ | 1 | 0 |
| Skyview Rehab And Nursing | 4.7 mi | ★★★★★ | 22 | 0 |
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