West Haven Center for Nursing & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF658Sep 20, 2022

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure licensed staff met professional standards for quality of care, to include directing staff to activate 911 and providing basic life support measures including CPR, in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding includes: Please cross reference F678 Resident #1 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. […]

• Immediate jeopardy, isolatedF678Sep 20, 2022

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to activate emergency services and failed to provide basic life support measures including CPR, until emergency services arrived for an alert resident who was a full code in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding includes: Please cross reference F658 Resident #1 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had indicated an advanced directive choice. […]

• Actual harm, isolatedF695Sep 20, 2022

  Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #2) reviewed for respiratory assessments the facility failed to ensure a resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment and required limited assistance with transfers, dressing, toileting and personal hygiene and was occasionally incontinent of bladder and always continent of bowels. […]

• No harm, potential for more than minimal, widespreadF727Jun 4, 2025

  Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure the DNS did not serve as the nursing supervisor. The findings include:Review of the Daily Staffing Breakdown dated 2/10/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Night Shift RN Supervisor, from 11:00 PM through 7:00 AM.Review of the Daily Staffing Breakdown dated 2/15/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Day Shift RN Supervisor, from 7:00 AM through 3:00 PM.Review of the Daily Staffing Breakdown dated 2/27/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Evening Shift RN Supervisor, from 3:00 PM through 11:00 PM.Interview with the DNS on 6/4/25 at 11:00 AM identified… […]

• No harm, potential for more than minimal, patternF584Nov 6, 2023

  Based on observation, review of facility documentation, review of job descriptions, and interviews for 1 resident (Resident #34) reviewed for wheelchair maintenance, the facility failed to ensure the residents power wheelchair was in good repair and for 4 out of 4 units, the facility failed to ensure the environment was clean, and maintained in good repair. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure. A physician's order dated 5/5/22 directed Occupational Therapy (OT) to evaluate only for power wheelchair mobility and safety. Resident #34 was readmitted to the facility on [DATE]. […]