Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Majestic Care Of New Haven during CMS and state inspections, most recent first.
A resident with dementia and a history of physical and verbal aggression took adhesive wipe packets from the nurse station and refused to return them despite calm redirection and an offer of a snack from an LPN. An RN observing the interaction approached from behind and sprayed wound cleanser toward the resident’s face without speaking, causing the resident to drop the packets, startle, and wipe his face and eye. A housekeeper witnessed the RN’s actions, and both the LPN and the housekeeper did not immediately report the incident, initially not recognizing it as abuse. The event was later reported to leadership and confirmed on video, and clinical notes documented that the resident had no recollection of the incident and no acute medical concerns.
Dining staff did not consistently follow meal tickets, resulting in several residents not receiving menu items such as broccoli salad and garlic bread, with no substitutions provided. Grievances and interviews confirmed that staff failed to reference meal tickets as required by facility policy.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
A multiple dose liquid medication bottle was found on a medication cart without an open date, despite being marked 'NOT OPEN' and having been used, with a punctured seal and residue present. The medication had been discontinued and was not on the active MAR. An LPN was observed handling the bottle, and the DON confirmed there was no current improvement plan for medication storage, despite a history of similar citations and ongoing audits reported in QAPI meetings.
A resident with a history of heart disease and other conditions was transferred to the ER for chest pain, but the facility did not notify the resident's emergency contact. Documentation did not show that the resident declined such notification, and the care plan indicated family involvement. Staff interviews provided conflicting explanations, and facility policy on notification was not followed.
A resident was subjected to inappropriate verbal comments by the Rehabilitation Director during a discussion about room conditions, including a reference to prison and a remark about being 'outnumbered' in the presence of staff and the resident, all of whom were black except the RD. The resident, who was cognitively intact, became visibly upset by the comments, which were corroborated by other staff present. The facility's policy on verbal abuse was not followed in this incident.
A resident with chronic pain conditions received oxycodone-acetaminophen for pain levels below the physician-ordered threshold, and there was no documentation that nonpharmacological pain interventions were provided as outlined in the care plan. The DON confirmed the medication was administered outside of the prescribed parameters without justification.
A resident with end stage renal disease requiring dialysis did not consistently have pre-dialysis vital signs and communication forms completed by facility staff before appointments. The dialysis center RN reported that the communication sheets were often blank and no separate facility assessment was provided, despite facility policy requiring this documentation. The DON could not verify that the necessary paperwork was sent with the resident.
A bottle of Guaifenesin liquid was found in a medication cart with 'NOT OPEN' written on the label, but the inner seal was punctured and some medication had been used. The bottle lacked an open date, and a resident did not have an active order for this medication. The DON confirmed the absence of a current order, and facility policies did not clearly address required labeling practices.
A facility failed to properly label and store medications on a medication cart, affecting three residents with respiratory conditions. Observations revealed inhalers without open or expiration dates, contrary to facility policy. The DON confirmed the inhalers should have been removed, highlighting a lapse in adherence to medication administration protocols.
A facility failed to properly assess and care plan for a resident with recurrent head lice. Despite a history of lice after leave of absences, the resident's care plan did not address the condition, and there were no documented protocols or assessments during isolation. Treatment was ordered, but no additional orders or staff education on lice protocols were documented. The facility's policies on lice and isolation precautions were not followed, contributing to the deficiency.
A facility failed to ensure residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. A resident with dementia and depression was administered Haloperidol without documented behaviors or follow-up, while another resident with COPD and depression was prescribed Xanax without clear indication or behavior monitoring. The facility did not adhere to its policies requiring behavior monitoring and non-pharmacological interventions before psychotropic medication use.
Failure to Protect Resident From Physical Abuse and Delayed Reporting by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff when a nurse sprayed a liquid wound cleanser toward the resident’s face during an interaction over facility supplies. The resident, who had dementia and moderately impaired cognition, used a wheelchair and had a care plan noting episodes of physical and verbal aggression, including hitting, pushing, yelling, antagonizing others, and blocking hallways. Interventions in the care plan directed staff to approach him calmly, explain tasks before initiating them, offer distractions, remove him from situations, and, if he became combative or resistive, to postpone care and re-approach later. On the day of the incident, the resident took two packets of adhesive wipes from the nurse’s station counter and refused to return them when asked by an LPN, who also attempted to trade a snack for the packets. The resident yelled and refused, and an RN observing from behind the nurse’s station then approached and sprayed wound cleanser near the resident’s face without speaking, causing him to drop the packets. A housekeeper in the hallway observed the LPN calmly trying to coax the items from the resident while he yelled, then saw the RN approach from behind and beside the resident and spray something toward his face, after which the resident startled, looked at the nurse, and began wiping his face and rubbing his eye. The RN then looked down the hall, saw the housekeeper watching, and walked away. The LPN and the housekeeper did not immediately report the incident at the time it occurred because they did not initially recognize it as abuse. The incident was later reported to facility leadership, who reviewed video footage confirming the event. Subsequent clinical notes documented that the resident had no recollection of the incident, no acute concerns, no breathing issues, and mentation at baseline, but the deficiency centered on the willful act of spraying wound cleanser toward the resident’s face and the failure of staff who witnessed the event to promptly report it as required by the facility’s abuse policy.
Failure to Follow Resident Meal Tickets and Menu Postings
Penalty
Summary
The facility failed to ensure that dining staff followed resident meal tickets for four residents, resulting in residents not receiving items listed on their menus. During dining observations, two residents were not served broccoli salad as indicated on their meal tickets, and one resident reported not receiving garlic bread, with no substitutions provided. Review of posted menus confirmed that these items were scheduled to be served, and the postings were not updated to reflect any changes or substitutions. Additionally, grievances from two residents documented ongoing issues with meal trays, specifically that dining staff were not referencing meal tickets and were omitting food items. Interviews with facility leadership confirmed that staff are expected to review meal tickets to ensure residents receive appropriate items and avoid serving restricted foods. The facility's policy requires menus to be followed and to accommodate resident preferences, but observations and records indicated this was not consistently practiced.
Failure to Consistently Temperature-Test Pureed Meals
Penalty
Summary
The facility failed to ensure that pureed meals were consistently temperature-tested for four residents who required pureed diets. During an observation, dietary staff was seen checking the temperature of pureed broccoli, which registered at 130°F. A staff member acknowledged that the food was below the required temperature and indicated that she would reheat it. Interviews confirmed that on multiple occasions, food was not at the appropriate temperature before being served. A review of food temperature logs for December revealed that there were numerous days when no temperature records were documented for breakfast, lunch, or dinner pureed meals, despite four residents being on pureed diets during those times. The facility's policy on safe food handling, which aims to reduce the risk of foodborne illness, was not followed as evidenced by the lack of temperature documentation and inconsistent temperature checks for pureed meals.
Recurring Medication Storage Deficiency Due to Inadequate Labeling and Oversight
Penalty
Summary
The facility failed to maintain an effective process to prevent recurring medication storage issues, as evidenced by the observation of a multiple dose liquid medication bottle on a medication cart that was not properly labeled with an open date. The bottle, marked 'NOT OPEN' in black marker, was found to have been opened and used, with a punctured inner seal and visible red liquid residue. Review of the resident's record revealed that the medication had been discontinued and did not have an active order. This incident was cited under F0761 for improper labeling and storage of drugs and biologicals. Additionally, the facility had a history of similar citations for the same deficiency on multiple previous survey dates. During an interview, the DON confirmed that there was no current improvement plan specifically addressing medication storage, although routine audits were being conducted and results reported in QAPI meetings.
Failure to Notify Emergency Contact of Resident Transfer
Penalty
Summary
The facility failed to notify the emergency contact of a resident who was transferred to the emergency room for chest pain that was not relieved by Nitroglycerin and at the resident's request. Record review showed no documentation that the resident's emergency contact, his brother, was notified of the transfer. There was also no documentation indicating that the resident did not want his emergency contact notified. The resident's care plan indicated family involvement in the last 14 days and did not specify any wishes to exclude the brother from notification in emergencies. Interviews with facility staff revealed conflicting information. The DON stated that the resident did not wish for his brother to be notified and that this was reflected in the care plan, but review of the care plan did not support this claim. The Regional Nurse Consultant indicated that the brother was not notified because the resident was his own responsible party. Facility policy allows for disclosure of information to individuals involved in the resident's care or for notification purposes, but there was no evidence that this policy was followed in this instance.
Verbal Abuse Involving Inappropriate and Racially Charged Comments by Staff
Penalty
Summary
A deficiency occurred when a resident was subjected to inappropriate and potentially racially charged verbal comments by the Rehabilitation Director (RD) in the presence of other staff members. The incident took place during a discussion about the condition of the resident's room, specifically the walls being only half painted. The RD responded to the resident's complaint by making a comment referencing prison, which the resident found offensive, especially as he stated he had never been to prison and that prison was no place for an educated black man. The RD then remarked that she was 'outnumbered' and left the room, a statement interpreted by those present as referring to the racial makeup of the group. The resident was visibly upset during subsequent interviews, raising his voice and appearing emotional when recounting the incident. Multiple staff members, including an LPN and a QMA who were present, corroborated the resident's account of the RD's comments. The facility's investigation included statements from those involved, confirming the sequence of events and the nature of the remarks made. The resident was found to be cognitively intact, with a BIMS score of 15, and was able to clearly articulate his experience. The facility's policy defines verbal abuse as the use of disparaging or derogatory language toward residents, which was not adhered to in this instance.
Failure to Follow Pain Management Orders and Document Nonpharmacological Interventions
Penalty
Summary
A resident with multiple pain-related diagnoses, including arthritis, lupus, and sciatica, had physician orders for oxycodone-acetaminophen to be administered every 8 hours as needed for severe pain greater than 7 on the pain scale. However, the medication was administered on several occasions when the resident reported pain levels below the threshold specified in the order, with documented pain scores of 4 and 6. There was no documented justification for administering the medication outside the prescribed parameters. Additionally, the resident's care plan included interventions for nonpharmacological pain management, such as position changes, relaxation, a quiet environment, back rubs, and diversional activities. Despite this, there was no documentation in the progress notes that these nonpharmacological interventions were provided on the dates when the medication was administered for pain levels below 7. The DON confirmed that the medication should not have been given for pain less than 7 and could not provide a reason for the deviation from the physician's order.
Failure to Ensure Proper Dialysis Communication and Collaboration
Penalty
Summary
The facility failed to ensure proper collaboration with an off-site dialysis center for a resident diagnosed with end stage renal disease and dependent on renal dialysis. Review of the resident's dialysis communication records revealed that the pre-dialysis section, which should include vital signs, was incomplete or missing on multiple dates. The resident reported that the facility did not always complete the required communication form that he took to dialysis appointments, which contained his medications and the dialysis communication sheet. Interviews with facility staff and the dialysis center RN confirmed that the facility often sent the dialysis communication sheet blank and did not provide a separate facility assessment with the resident. The DON stated that the facility conducted its own assessments and sent them in a packet with the resident, but could not provide evidence that these assessments were actually sent, as no folder was maintained and the information was not tracked. The facility's policy required continued assessment and appropriate paperwork to be sent with the resident to the off-site dialysis center, which was not consistently followed.
Failure to Properly Label and Store Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that only current medications with appropriate labeling were present in medication carts, as observed during a review of one out of three carts. A bottle of Guaifenesin liquid labeled for a specific resident was found with the words 'NOT OPEN' written on it, but the inner seal was punctured and some medication had been used, indicating it had been opened. There was no open date on the bottle, and the resident did not have an active order for this medication at the time of the review. The Director of Nursing confirmed that the resident should have had an order but did not currently have one. The facility's medication storage policy did not specify labeling practices, while the labeling policy required multidose vials to be labeled with the date opened or accessed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts reviewed. During an observation, it was found that an inhaler for a resident with chronic obstructive pulmonary disease had no open date labeled, and another resident's inhaler had an open date but no expiration date. Additionally, a third resident's inhaler had neither an open date nor an expiration date. These labeling deficiencies were identified during a review of the medication cart in the 200 Hall, and the Qualified Medical Assistant indicated that staff usually checked the cart to ensure proper labeling and discarded any medications that were not labeled or expired. The Director of Nursing confirmed that the inhalers should have been removed from the cart. The residents involved had various respiratory conditions, including chronic obstructive pulmonary disease and asthma, and had specific physician orders for their inhalers. The facility's policy on medication administration required the disposal of medications that were not securely closed, outdated, contaminated, or deteriorated, and emphasized the timely removal of such medications from stock. However, the facility did not adhere to this policy, resulting in the observed deficiencies.
Failure to Assess and Care Plan for Resident with Head Lice
Penalty
Summary
The facility failed to ensure proper assessment and care planning for a resident with a known contagious condition, specifically head lice. Resident E, who had a history of recurrent head lice after returning from leave of absences, was not adequately assessed or care planned for this condition. The Director of Nursing indicated that Resident E was to be checked for lice upon return to the facility, and treatment orders were to be obtained and communicated to staff. However, Resident E's care plan did not address lice infestation, and there were no documented protocols or assessments conducted during her isolation period. Resident E's medical record indicated she had been seen by a nurse practitioner for head lice, and treatment was ordered. Despite this, there were no additional treatment orders or documentation of staff education on lice protocols. Progress notes revealed that Resident E had been isolated in her room for approximately four weeks due to lice, but there was no formal documentation of when the isolation began or ended. Additionally, there was no evidence that other residents sharing her bathroom were checked for lice. The facility's policies on head lice and isolation precautions were not followed, as there was no documentation of assessments, treatment regimens, or decontamination procedures. The Director of Nursing was unable to find any orders for isolation or documentation of staff education on lice protocols. This lack of adherence to policies and procedures contributed to the deficiency in providing appropriate treatment and care for Resident E.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. Resident D, who had diagnoses including dementia, chronic pain, generalized anxiety disorder, sleep disorder, and major depressive disorder, was hospitalized for a change in condition. Upon her return to the facility, she was administered Haloperidol Lactate for anxiety/agitation without documentation of behaviors requiring its use, notification to the provider, or follow-up documentation after administration. The care plans for Resident D included non-pharmacological interventions, but there was no evidence that these were implemented prior to the administration of the psychotropic medication. Resident J, diagnosed with chronic obstructive pulmonary disease and major depressive disorder, was also given psychotropic medication without proper documentation of behaviors or non-pharmacological interventions. Despite having no documented symptoms of anxiety, Resident J was prescribed Xanax, an anti-anxiety medication, without a clear indication for its use. The facility's records did not include a care plan or behavior monitoring for the use of Xanax, nor did they document potential adverse effects due to its use alongside other sedating medications. The facility's policies on Mood and Behavior Management and Psychotropic Management require that residents receiving psychotropic medications have a supporting diagnosis, appropriate indication for use, and a behavior monitoring program in place. However, these requirements were not met for Residents D and J, as there was a lack of documentation and implementation of non-pharmacological interventions and behavior monitoring. This deficiency was identified during a survey, which included interviews and record reviews, revealing the facility's failure to adhere to its own policies and regulatory requirements.
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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) |
|---|---|---|---|---|
| Golden Years Homestead | 3 mi | ★★★★★ | 7 | 0 |
| Chateau Rehabilitation And Healthcare Center | 3.2 mi | ★★★★★ | 20 | 0 |
| Waters Of Fort Wayne Skilled Nursing Facility, The | 3.3 mi | ★★★★★ | 5 | 0 |
| Heritage Park | 4.4 mi | ★★★★★ | 7 | 0 |
| Celebrate Senior Living Of Fort Wayne | 4.4 mi | ★★★★★ | 12 | 0 |
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