Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Haven Healthcare during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of records showed incomplete documentation and planning, with missing interventions and unclear goals for the resident's care.
A resident did not receive IV fluids in a safe and appropriate manner when needed, as the facility failed to follow proper protocols for IV fluid administration.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to accepted professional standards, as observed by surveyors during their review of documentation and information handling practices.
During an active Group A Streptococcus (GAS) outbreak, several LVNs, CNAs, and other staff members lacked accurate knowledge about the nature and transmission of GAS, with some believing it was a virus or fungal infection and others unaware of the outbreak status. Despite in-services being conducted, interviews revealed significant gaps in staff competency regarding infection control, contrary to facility policy requiring such competencies.
Surveyors found that the facility did not post required outbreak notifications, failed to ensure staff performed hand hygiene and wore PPE as required, and did not educate or enforce contact precautions for visitors. These lapses were observed among residents with serious medical conditions, and staff acknowledged the importance of these protocols but did not consistently follow them.
The facility failed to maintain a clean and safe environment in two resident shower rooms, exposing residents to potential mold and injury risks due to broken tiles and cracked grout. Housekeeping staff reported the issues to maintenance, but repairs were not documented or completed. The facility's policies emphasize maintaining a safe environment, but communication and documentation failures led to the observed deficiencies.
The facility failed to transmit the MDS assessments for three residents within the required 14-day period, potentially affecting quality monitoring data. The residents had various medical conditions, including cerebral palsy, rheumatoid arthritis, chronic obstructive pulmonary disease, hypertensive heart disease, heart failure, and acute respiratory issues. The MDS Coordinator confirmed the delay in transmission.
A facility failed to monitor a resident's orthostatic hypotension as per physician's orders while administering antipsychotic medications. The resident, with a history of bipolar disorder and epilepsy, was at high risk for falls. Blood pressure readings were not taken 5 to 10 minutes apart as required, potentially leading to hypotension and increased fall risk. This deficiency was acknowledged by an LVN during a review of the resident's records.
The facility failed to store two boxes of dehydrated and seasoned potato (hash browns) in accordance with its P&P. The boxes were observed to be past their used by date, which was confirmed by the DS and DON. The facility's P&P required that food products be used before the specified date to ensure safety and quality.
The facility failed to provide updated arbitration agreements that included the selection of a neutral arbitrator and a convenient venue for two residents with severely impaired cognition. The outdated agreements were signed by the residents' responsible parties without the necessary information, contrary to the facility's policy requiring the use of the latest compliant version.
A resident with Alzheimer's and bipolar disorder was not assisted at eye level during meal times, compromising their dignity. Staff confirmed that feeding should occur at eye level for dignity and safety, but the practice observed did not align with the facility's policy on promoting dignity.
The facility failed to complete Advance Directive Acknowledgment Forms for two residents, leading to a lack of documentation regarding their treatment preferences. One resident, admitted with hypertension and diabetes, and another readmitted with hemiplegia and dementia, both lacked ADA forms in their records. This oversight was confirmed by the Social Service Director and nursing staff, highlighting a failure to adhere to the facility's policy on advance directives.
A resident with epilepsy and diabetes mellitus was at risk of injury due to torn foam pads on bed grab bars, exposing metal parts. The facility's policy to maintain a hazard-free environment was not upheld, as confirmed by an LVN who acknowledged the safety risk. The resident required partial assistance and was on seizure medication.
A facility failed to provide necessary set-up assistance during lunchtime for a resident with severely impaired cognition, leading to the resident's inability to reach and consume her meal. The resident was observed lying in bed with the food tray placed out of reach, contrary to the facility's policy requiring proper positioning and tray setup.
A resident with a gastrostomy tube was not provided with the necessary care as ordered by the physician. The resident was found with a GT site that had no dressing and bloody drainage, contrary to the prescribed daily treatment. Interviews with staff confirmed the importance of daily dressing changes to prevent infection, which was not followed, leading to a deficiency in care.
A facility failed to follow its policy on the use of grab bars for a resident with congestive heart failure and muscle weakness. The facility did not attempt alternative interventions, obtain informed consent, or develop a care plan before installing grab bars, placing the resident at risk for entrapment and injury. Observations and interviews confirmed these deficiencies, despite the resident having intact cognition and using grab bars for bed mobility.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on Lexapro, despite recommendations in the monthly Medication Regimen Review. The resident, who had no documented depressive behavior and was assessed as low risk, did not receive a GDR from February 2024 to January 2025. The Director of Nursing acknowledged the oversight due to hospital transfers, contrary to the facility's policy requiring monthly drug regimen reviews and GDR attempts.
A facility failed to follow infection prevention guidelines for an Enhanced Barrier Precaution (EBP) room when a private caregiver assisted with a bed bath for a resident with a stage 3 pressure ulcer without wearing a gown. The Infection Preventionist Nurse confirmed the requirement for gown use during close contact care, as outlined in the facility's policy. This oversight risked spreading infections within the facility.
A resident with COPD and a history of myocardial infarction was found to have a dirty and dusty electric fan in their room, which was not maintained in a sanitary condition. The facility's staff acknowledged that the fan's condition could cause allergies and respiratory illnesses, contrary to the facility's housekeeping policy requiring daily cleaning of equipment.
A resident at high risk for pressure ulcers was found on a low air loss mattress with improper layering, contrary to facility guidelines. The resident had multiple pressure ulcers and was dependent on staff for repositioning. Interviews with staff confirmed that the additional layers could interfere with the mattress's effectiveness, potentially worsening the resident's condition.
The facility failed to follow its policy on controlled medication storage, leading to missing Percocet tablets from the CS II E-kit. Only one nurse checked the E-kit instead of the required two, and discrepancies were not reported to the DON. This increased the risk of drug diversion.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
Failure to Safely Administer IV Fluids
Penalty
Summary
A deficiency was identified regarding the administration of IV fluids to a resident. The facility failed to ensure that IV fluids were provided in a safe and appropriate manner when needed for a resident. This indicates that the necessary protocols or procedures for IV fluid administration were not followed at the time care was required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Staff Lacked Competency in Infection Control During GAS Outbreak
Penalty
Summary
The facility failed to ensure that licensed vocational nurses (LVNs) and certified nurse assistants (CNAs) possessed the necessary competency to understand and manage different infection types, specifically Group A Streptococcus (GAS), during an active outbreak. Multiple staff members, including the Infection Prevention Nurse (IPN), Director of Staffing Development (DSD), LVNs, CNAs, and a Restorative Nurse Assistant, demonstrated a lack of knowledge regarding the nature of GAS, its mode of transmission, and the current outbreak status within the facility. Interviews revealed that some staff believed GAS was a virus or a fungal infection, while others were unaware of the ongoing outbreak or the type of infection GAS represented, despite in-services reportedly being conducted. Record review showed that the facility had an active GAS outbreak, and both the IPN and DSD stated that in-services had been provided to staff. However, staff interviews indicated significant gaps in understanding, with some staff not knowing that GAS is a bacterial infection spread through respiratory droplets or direct contact. The facility's own policy required competency evaluations, including infection control knowledge, but the observed deficiencies in staff awareness and understanding of GAS indicated that these competencies were not effectively ensured or maintained.
Failure to Implement and Enforce Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain standard infection prevention and control practices as outlined in its own policies and procedures. Surveyors observed that the facility did not post the required Group A Strep (GAS) Outbreak Notification Letter at the entrance, nor was the GAS FAQ/fact sheet made visible to all residents, visitors, and staff as recommended by the Public Health Nurse. The Infection Prevention Nurse confirmed that the notification letter was not posted at the entrance and that the FAQ/fact sheet was only available in the staff breakroom, limiting access for residents and visitors. Multiple instances of staff failing to follow proper infection control protocols were documented. One Certified Nurse Assistant (CNA) was observed not wearing a mask properly and not performing hand hygiene before or after assisting a resident in the lobby. Another CNA entered and exited a resident's room, which was under Enhanced Barrier Precautions (EBP), without performing hand hygiene, despite signage indicating this requirement. Additionally, a Licensed Vocational Nurse (LVN) was seen at the nurses' station with a mask pulled down below the nose and mouth, and another CNA entered a resident's room on EBP without donning the required gown, gloves, or properly wearing a mask. The facility also failed to ensure that visitors were educated and compliant with contact precautions. Family members visiting a resident on contact isolation for methicillin-sensitive Staphylococcus aureus (MSSA) were not informed by staff to wear masks, gowns, or gloves, despite signage and policy requirements. Staff interviews confirmed that it was the responsibility of all staff to remind and educate visitors about appropriate precautions, but this was not done. These failures were observed in residents with significant medical conditions, including end stage renal disease, sepsis, chronic kidney disease, and pressure ulcers, all of whom were at increased risk for infection.
Failure to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment in two resident shower rooms, which had the potential to expose residents to mold and injury from broken tile and cracked grout. During observations, a black substance was found on grout lines, and there were cracked, missing, and unsealed grout lines, as well as cracked, broken, and missing tiles. Housekeeping staff acknowledged the unclean condition of the showers and stated that they report repair needs to the Maintenance Department, although the exact date of reporting was not remembered. Housekeeping Staff 1 indicated that there is a maintenance logbook at Nursing Station 1 for reporting repair needs, and she verbally informs the Maintenance Department about issues. However, the Maintenance Supervisor stated that the necessary repairs were not reported to the Maintenance Department. The Maintenance Supervisor also confirmed that the condition of the shower rooms was dirty and posed a health risk to residents. A review of the Maintenance Department's QAPI Report and logbooks showed no entries for repair requests for the shower rooms in question. The facility's policies and procedures emphasize maintaining a safe, clean, and comfortable environment for residents, with specific guidelines for bathroom fixtures and surfaces, painting, and general housekeeping duties. Despite these policies, the facility did not document or address the repair needs in the shower rooms, leading to the observed deficiencies. The lack of communication and documentation between housekeeping and maintenance staff contributed to the failure to address the issues in a timely manner.
Delayed MDS Transmission for Three Residents
Penalty
Summary
The facility failed to complete and transmit the quarterly Minimum Data Set (MDS) assessments in a timely manner for three residents, as required by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual. Specifically, the MDS assessments for Residents 13, 44, and 50 were not transmitted within the mandated 14 days after their respective assessment dates. This delay in transmission had the potential to affect the facility's quality monitoring data. Resident 13 was admitted with cerebral palsy and rheumatoid arthritis, and their MDS indicated intact cognition but dependency on staff for certain activities. Resident 44, readmitted with chronic obstructive pulmonary disease and hypertensive heart disease, was severely cognitively impaired and required assistance with daily activities. Resident 50, admitted with heart failure and acute respiratory issues, was also severely cognitively impaired and needed substantial assistance. The Minimum Data Set Coordinator acknowledged the delay, stating that the assessments were completed but not transmitted to CMS on time.
Failure to Monitor Orthostatic Hypotension in Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order for the administration of antipsychotic medications, specifically Chlorpromazine and Risperidone. The physician's order required monitoring for orthostatic hypotension with two blood pressure readings taken 5 to 10 minutes apart, and observation for adverse side effects. However, the facility did not adhere to these orders, as blood pressure readings were only taken once at 9 a.m. and 5 p.m., without the required second reading in a sitting position. The resident involved, who was admitted with diagnoses including bipolar disorder, epilepsy, muscle weakness, and gait abnormalities, was identified as having intact cognition for daily decision-making. The resident required varying levels of assistance with daily activities and was assessed as high risk for falls due to a history of falls, secondary diagnoses, and mental status. Despite these risks, the facility's failure to follow the physician's orders for monitoring blood pressure could have led to a decrease in blood pressure, causing dizziness and fainting, which could result in falls and injuries. The facility's policy and procedure documents, including the Medication Administration-General Guidelines and the Fall Management Program, emphasize the importance of administering medications as prescribed and preventing falls through meaningful assessments and interventions. However, the facility did not comply with these guidelines, as evidenced by the lack of adherence to the physician's orders for monitoring orthostatic hypotension. This oversight was acknowledged by a Licensed Vocational Nurse during an interview, who confirmed that the required blood pressure readings were not conducted as per the physician's order.
Improper Food Storage of Hash Browns
Penalty
Summary
The facility failed to store food in accordance with its Policy and Procedure (P&P) for two boxes of dehydrated and seasoned potato (hash browns). During an observation and interview with the Dietary Supervisor (DS) in the dry food storage area, it was noted that the boxes had a received date of 11/19/2024 and a used by date of 1/19/2025, indicating they were past the specified use date. The DS confirmed that food products needed to be used before the used by date to ensure safety and quality. The Director of Nursing (DON) also stated that food items should be used within the specified date to prevent food-borne illnesses. A review of the facility's undated P&P titled 'Storage of Food and Supplies' indicated that labels should be visible, and supplies should be rotated to use the oldest items first, with all food products used per the times specified in the Dry Food Storage Guidelines.
Failure to Provide Updated Arbitration Agreements
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included the selection of a neutral arbitrator and a venue convenient to both the facility and the resident or the resident's responsible party. This deficiency was identified for two residents, both of whom had severely impaired cognition and required significant assistance with daily activities. For Resident 15, the arbitration agreement was signed by the responsible party but did not include the necessary information about a neutral arbitrator and a convenient venue. The Admission Coordinator acknowledged that Resident 15 had the old version of the arbitration agreement form and should have been provided with the updated version. Similarly, for Resident 65, the arbitration agreement was also signed by the responsible party without the inclusion of details regarding a neutral arbitrator and a convenient venue. The Admission Coordinator confirmed that Resident 65 had the outdated form and should have received the revised version. The facility's policy and procedure on arbitration agreements, dated February 2024, indicated that the administrator or designee is responsible for ensuring the use of the latest revision of the arbitration agreement that complies with applicable laws. However, this policy was not followed, leading to the deficiency.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 38, during meal assistance. Resident 38, who was admitted with Alzheimer's disease and bipolar disorder, required partial assistance for upper body dressing and transfers. During an observation, a Certified Nursing Assistant (CNA) was seen feeding Resident 38 ice cream while the resident was sitting up in bed, which was positioned at its lowest level due to fall risk. The CNA was bending over to feed the resident, rather than assisting at eye level, which is necessary for maintaining the resident's dignity. Interviews with staff, including a Licensed Vocational Nurse (LVN), confirmed that feeding should be conducted at eye level to respect the resident's dignity and ensure safety, as it allows staff to better observe for potential choking. The facility's policy on Privacy and Dignity emphasizes promoting resident care in a manner that maintains or enhances dignity and respect. However, the observed practice did not align with this policy, leading to a deficiency in maintaining the resident's dignity during meal assistance.
Failure to Complete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for two residents, resulting in the absence of Advance Directive Acknowledgment (ADA) Forms in their medical records. Resident 185, admitted with conditions including hypertension and diabetes, had no ADA form completed upon admission, as confirmed by the Social Service Director (SSD) and a Licensed Vocational Nurse (LVN). This omission meant that staff were unaware of Resident 185's treatment preferences, potentially leading to medical interventions against the resident's wishes during emergencies. Similarly, Resident 19, who was readmitted with diagnoses such as hemiplegia, sepsis, and dementia, also lacked an ADA form in their clinical record. Despite being cognitively intact and capable of making decisions, there was no documentation of Resident 19's treatment preferences. The Registered Nurse (RN) and SSD confirmed the absence of the ADA form, which should have been completed upon admission or readmission to ensure the resident's rights to accept or refuse treatment were respected.
Deficient Bed Safety Precautions for Resident with Seizures
Penalty
Summary
The facility failed to ensure that the bed grab bar foam pads for seizure precautions were in good condition for a resident diagnosed with epilepsy and diabetes mellitus. The resident, who was admitted in 2020, required partial assistance for daily activities and was on medication for seizure control. During an observation, it was noted that the foam pads on the grab bars of the resident's bed were ripped and torn, exposing the metal bars underneath. This condition posed a risk of injury to the resident, especially during seizure episodes. The facility's policy emphasized maintaining an environment free from accident hazards, yet the grab bars' condition contradicted this policy. A Licensed Vocational Nurse confirmed the poor state of the foam pads and acknowledged the safety risk they posed to the resident. The nurse highlighted that the foam pads were intended to prevent injuries during seizures by cushioning the resident from the metal bars. The facility's failure to maintain these safety precautions was a significant oversight in ensuring the resident's safety.
Failure to Provide Meal Set-Up Assistance
Penalty
Summary
The facility failed to provide necessary set-up assistance during lunchtime for Resident 15, who was at risk for dehydration, malnutrition, and weight loss. Resident 15, who had severely impaired cognition and required set-up assistance with eating, was observed lying in bed with the food tray placed on an overbed table that was too high and out of reach. Despite the resident's inability to reach the tray or stand up, the food was not set up in front of her, preventing her from eating while the food was warm. Licensed Vocational Nurse 1 confirmed that Resident 15 needed the food tray to be set up in front of her to eat independently. The Director of Nursing also stated that the resident should be positioned upright with the food tray set up and opened in front of her to ensure the food remains warm and palatable. The facility's policy on assisting residents with in-room meals was not followed, as it required the resident to be positioned upright and the tray to be adjusted to a comfortable position and height for easy access.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a gastrostomy tube (GT) as ordered by the physician and indicated in the care plan. Resident 234, who was admitted with diagnoses including dysphagia and gastrostomy, had an order for daily GT site treatment involving cleansing with normal saline, applying calcium alginate, and securing with a split gauze dressing. However, during an observation, the resident was found with a GT site that had no dressing and bloody drainage, indicating that the prescribed care was not being followed. Interviews with the Registered Nurse Supervisor and the Treatment Nurse confirmed that the GT site dressing changes should be done daily and as needed to maintain skin integrity and prevent infection. The Director of Nursing also stated that the GT site should be clean and covered with a dressing as ordered. The facility's policy on feeding tube site care emphasized daily inspection and appropriate dressing application to prevent irritation and infection, which was not adhered to in this case.
Failure to Implement Policy on Grab Bars Use
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of grab bars for Resident 237, who was admitted with diagnoses including congestive heart failure and muscle weakness. The facility did not ensure that appropriate alternative interventions were attempted and found insufficient before installing grab bars. Additionally, there was no documented evidence of informed consent being obtained from Resident 237 or their representative, nor was there an individualized care plan developed to address the specific needs of the resident concerning the use of grab bars. During observations and interviews, it was noted that Resident 237 had intact cognition and was using grab bars for bed mobility without prior attempts of alternative interventions. The facility's Director of Nursing and Minimum Data Set Coordinator confirmed the lack of documentation for alternative interventions, informed consent, and a care plan. The facility's policy required an assessment of alternatives, informed consent, and an updated care plan, none of which were followed, placing Resident 237 at risk for entrapment and injury.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident who had been taking Lexapro, a medication used to treat depression, since February 2024. Despite recommendations for a GDR in the resident's monthly Medication Regimen Review (MRR) dated August 2024, the facility did not attempt a GDR from February 2024 to January 2025. The Director of Nursing (DON) acknowledged that the GDR was overlooked due to hospital transfers and emphasized the importance of completing a GDR to reduce potential side effects of Lexapro. The resident, who was admitted to the facility with diagnoses including major depressive disorder, had no documented depressive behavior from September 2024 to January 2025. The resident was assessed as having a low risk in a psychiatric evaluation and was cognitively intact with the capacity to understand and make decisions. The facility's policy required the attending physician to review the drug regimen monthly and attempt a GDR unless clinically contraindicated, which was not adhered to in this case.
Failure to Follow Enhanced Barrier Precaution Protocol
Penalty
Summary
The facility failed to adhere to infection prevention guidelines for an Enhanced Barrier Precaution (EBP) room, which is an infection control measure requiring the use of gloves and gowns during high-contact patient care. This deficiency was observed when a private caregiver (PC) was inside the room of a resident, identified as Resident 78, assisting with a bed bath without wearing a gown. The resident had been admitted with diagnoses including hypertension and a stage 3 pressure ulcer, which necessitated the EBP to prevent the spread of bacteria. The PC acknowledged not wearing a gown during the bed bath, despite the EBP signage posted at the door and the understanding that the measure was to protect both the resident and caregivers from cross infections. The Infection Preventionist Nurse (IPN) confirmed that Resident 78 was on EBP due to a stage 2 pressure ulcer and that the PC should have worn a gown during close contact care activities, such as bathing. The facility's policy and procedure on Standard and Enhanced Precautions, dated April 2024, indicated that EBP should be used during high-contact resident care activities, including dressing, bathing, and showering. The physician's order summary also confirmed the requirement for EBP due to the resident's pressure ulcer. This oversight in following the infection control protocol had the potential to spread infections from the resident to the PC, staff members, and other residents in the facility.
Unsanitary Electric Fan Poses Health Risk to Resident
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident, which had the potential to affect the resident's quality of life and overall health. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD) and a history of myocardial infarction, was found to have a standing white electric fan in their room with dirty and dusty blades. This observation was made during a concurrent observation and interview with the Registered Nurse Supervisor, who acknowledged that the dirt and dust on the fan blades were not good and might cause allergies to the resident. Further interviews with the Maintenance Supervisor and the Director of Nursing confirmed that the dirt and dust on the fan could lead to respiratory illnesses. The facility's policy and procedure on housekeeping indicated that all equipment inside the resident's room should be cleaned and maintained daily to prevent infection. However, the failure to adhere to this policy resulted in the unsanitary condition of the fan, posing a risk to the resident's respiratory health.
Failure to Follow Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) for pressure ulcer prevention and care for a resident who was at high risk for developing pressure ulcers. The resident, who was on a low air loss (LAL) mattress, was observed with multiple layers on the mattress, including a flat sheet, a folded flat sheet, and a disposable chux pad. This setup contradicted the facility's guidelines, which specified that only one flat sheet and a chux pad should be used to maintain the effectiveness of the LAL mattress. Interviews with Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed that the additional layers could interfere with the mattress's function and potentially worsen the resident's condition. The resident had a history of multiple pressure ulcers, including a Stage 3 ulcer and several unstageable ulcers, and was dependent on staff for various activities, including repositioning. The facility's P&P emphasized the importance of identifying residents at risk and implementing measures to prevent pressure ulcer development, such as frequent repositioning and the use of support surfaces. However, the failure to follow these guidelines and the improper use of the LAL mattress compromised the resident's care and increased the risk of further skin breakdown.
Failure to Follow Controlled Medication Storage Procedures
Penalty
Summary
The facility failed to follow its policy and procedures on controlled medication storage in one of the medication storage rooms. Specifically, two licensed nurses were not present when checking the Controlled Substance II Emergency Kit (CS II E-kit), leading to the discovery that five tablets of 10 mg Percocet and two tablets of 5 mg Percocet were missing. The incident was reported by LVN 5, who noticed that the plastic covering of the CS II E-kit was carefully ripped and the red tags were cut and placed back to make it appear intact. This discrepancy was not reported immediately to the Director of Nursing (DON) as required by the facility's policy and procedures (P&P). Additionally, the Cart 1 Controlled Drug Reconciliation (CDR) form was not filled out correctly, indicating a failure to properly document and monitor the controlled medications, which could lead to drug diversion. The facility's P&P mandates that two licensed nurses conduct a physical inventory of all controlled medications at each shift change and document it on the controlled medication accountability record. However, interviews with various licensed nurses revealed that it was common practice for only one nurse to check the CS II E-kit, contrary to the facility's P&P. This practice increased the risk of discrepancies and potential drug diversion, as evidenced by the missing Percocet tablets. The facility's Pharmacy Consultant emphasized the importance of monitoring controlled substances like Percocet due to their high potential for misuse and severe consequences such as overdose or death. The DON confirmed that the staff did not follow the P&P, and the failure to properly document and monitor the controlled medications posed a significant risk for errors and drug diversion.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,467 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Covina Medical Center D/p Snf | 0.2 mi | — | 15 | 0 |
| West Covina Healthcare Center | 0.6 mi | — | 16 | 0 |
| Clara Baldwin Stocker Home For Women | 0.6 mi | — | 24 | 0 |
| Victoria Care Center | 0.8 mi | — | 13 | 0 |
| Garden View Post Acute Rehabilitation | 1.1 mi | — | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for West Haven Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.