New Haven Center for Nursing & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at New Haven Center for Nursing & Rehabilitation LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF658Aug 3, 2022

  Based on review of the clinical record, facility documentation, facility policy and interviews for 21 residents who reside on the Birch & Cedar unit (Resident #1 - 21) the facility failed to administer medications as prescribed, failed to notify the DNS and physician when medications were not administered, failed to complete assessments of the residents' condition after medications were omitted, failed to monitor residents who had significant medication omissions and failed to accurately document the medication omissions. Further, the facility failed to ensure licensed staff followed professional standards of practice including report to the oncoming and off going shifts, narcotic count and ensuring the security of the narcotic keys. […]

• Immediate jeopardy, patternF725Aug 3, 2022

  Based on review of the clinical record, facility documentation, facility policy and interviews, the facility failed to ensure sufficient staff (licensed nurses) on 7/2/22 during the 3:00 PM to 11:00 PM shift to provide care and services and to respond to each residents' needs on the 1st floor Birch & Cedar unit (21 residents). Further, when 1 licensed nurse was a no call, no show, the current licensed nurse who had worked on the unit for the 7:00 AM to 3:00 PM shift left without an oncoming nurse to take the unit. […]

• Immediate jeopardy, isolatedF803Aug 29, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #14) reviewed for nutrition and who required aspiration precautions and supervision with meals, the facility failed to provide a chopped diet as ordered by the physician, failed to provide supervision with eating on 3 days (3 breakfast meals) of the survey, and failed to ensure required safe swallowing strategies were implemented to prevent the resident from choking. These failures resulted in Immediate Jeopardy. The findings include: Resident #14 was admitted to the facility in May 2021 with diagnoses that included dementia, dysphasia, and anxiety. […]

• Immediate jeopardy, isolatedF689Dec 2, 2024

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to ensure that a resident who requires assistance and an assistive device with ambulation did not exit the facility without staff knowledge, resulting in the resident being found walking on the side of a roadway in the dark, nine (9) miles from the facility after he/she sustained a fall. These failures resulted in a finding of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF684Apr 27, 2022

  Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #7 and 8) reviewed for diabetic management, for Resident #7 the facility failed to have [MEDICATION(S)] (a medication to treat severely low blood sugar), readily available and to administer the [MEDICATION(S)] to Resident #7 to reverse a critically low blood sugar. Additionally, the licensed staff failed to follow standards of practice to treat the resident's [CONDITION(S)] and instead applied ice on the resident body which resulted in the resident becoming hypothermic with a body temperature of 90.9 F (normal body temperature ranges from 97.5°F to 98.9°F). […]