West Haven Healthcare

In the surveyor’s words

From the most serious findings on record at West Haven Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF552Mar 16, 2026

  Based on interview and record review the facility failed to obtain written informed consent for two out of two sampled residents (Residents 30 and 3) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 30 and 3 not receiving adequate or sufficient information regarding psychotropic drugs necessary to make an informed health care decision.Findings: a. During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted Resident 30 on 6/19/2025 with diagnoses including major depressive disorder (a feeling of severe sadness or hopelessness) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is… […]

• No harm, potential for more than minimal, patternF558Mar 16, 2026

  Based on observation, interview, and record review the facility failed to ensure the call light (an alerting device to assist a resident when needed) was within reach and appropriate to the patient's physical ability for two of two sampled residents (Residents 25 and 62). These failures had the potential to delay meeting Resident 25 and 62's needs or result in a fall or accident/injury. Findings: a. During a review of Resident 62's admission Record (AR), the AR indicated the facility re-admitted Resident 62 on 2/11/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, abnormal gait and mobility (irregular walk and movement). […]

• No harm, potential for more than minimal, patternF686Mar 16, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services to promote healing for residents with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 65) by failing to:a. Ensure Resident 65's Low Air Loss Mattress (LAL - a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) pressure was set consistent with the resident's weight. b. Ensure to turn and reposition Resident 65 every two hours in accordance with Resident 65's care plan. […]

• No harm, potential for more than minimal, patternF695Mar 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident was administered oxygen therapy (treatment that provides supplemental oxygen) at the rate ordered by the physician and the resident's care plan (CP) for the use of oxygen was revised for one of one sampled resident (Resident 2). This deficient practice placed Resident 2 at risk for respiratory distress (difficulty breathing).Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility 12/5/2025 with diagnoses including respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and muscle… […]

• No harm, potential for more than minimal, patternF812Mar 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage for one of two resident refrigerators.This deficient practice had the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness. Findings: During an observation of the Nursing Station 3's resident refrigerator in the presence of the Assistant Director of Nursing (ADON) on 3/11/2026 at 9:35 AM, the following were observed:1. Resident 50's opened salad dressing bottle with best-used-by date of 11/13/2025 inside the refrigerator.2. Resident 27's bag of lemons did not have a received date.3. There was a puddle of water at the bottom of Resident 27's bag of lemons. […]