Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 New Haven Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident admitted for short‑term rehab with unstable housing and diagnoses including bacteremia, intraspinal abscess, and anxiety disorder had an established goal of discharge back to the community, with the care plan directing social services and the IDT to coordinate community resources and needed services. Although clinical notes later showed the resident had completed IV antibiotics, was stable, and was being prepared for discharge home, the social service documentation from admission through the anticipated discharge date did not show evidence of ongoing discharge planning, IDT collaboration, referrals or resources for post‑discharge needs, or the resident’s participation in the discharge planning process. The social worker stated that discharge planning discussions occurred, that the resident was encouraged to contact family and friends, and was given 211 as a resource, but these actions were not documented, and the resident reported feeling there was no ongoing assistance with securing housing or discussion of aftercare, contrary to facility policy requiring ongoing, documented discharge planning for short‑stay residents.
Surveyors found that the facility failed to ensure proper functioning of call light indicators above resident room doors. During observation, two residents activated their call bells and the visual indicators outside their rooms did not illuminate, even though the audible signal and visual light at the nurses’ station did work. One resident reported that the call bell often did not work properly despite a recent attempt to fix it. An LPN confirmed that the over-door lights did not illuminate when tested, and the DON stated the expectation that these lights should come on with call bell activation. The Administrator reported that environmental rounds and call bell testing were done but could not specify frequency, and no documentation of such rounds or related maintenance requests was available, despite a written policy requiring both a room light and nurses’ station signal when a call bell is activated.
Failure to document ongoing discharge planning for a resident with unstable housing and anxiety. A resident admitted for short-term rehab after treatment for bacteremia and an intraspinal abscess was expected to return to the community, and the care plan called for SW involvement, community resources, and interdisciplinary discharge coordination. However, the record lacked documentation of ongoing SW work, interdisciplinary collaboration, referrals, discharge readiness, and the resident’s participation, even though staff said housing resources and 211 were discussed and the resident reported no ongoing help with housing or aftercare.
A resident with multiple medical conditions failed to return from a leave of absence as scheduled, and staff did not notify the physician, DON, or administration according to facility policy. Additionally, the provider was not informed when the resident missed several scheduled evening medications due to the absence. The LPN only notified the charge nurse, and the physician confirmed he expected prompt notification of both the resident's absence and missed medications.
A resident with moderate cognitive impairment and multiple medical conditions was issued a 30-day discharge notice for non-compliance with the smoking policy, but the facility failed to provide or document adequate discharge planning, orientation, or communication. Staff interviews revealed a lack of coordination, unresolved insurance issues, and no clear plan for a safe and orderly transfer, leaving the resident uninformed about their discharge status.
A resident with multiple medical conditions was readmitted from the hospital without a discharge summary, and staff did not obtain or review the required documentation as per facility policy. Additionally, when the same resident did not return from an LOA as expected, staff failed to act promptly or follow consistent procedures due to conflicting LOA policies, resulting in delayed notifications and unclear staff actions.
A resident with severe cognitive impairment and multiple medical conditions, who required supervision and an assistive device for ambulation, exited the facility unnoticed due to staff inattention and a delayed door locking mechanism. The resident was not identified as an elopement risk and did not have a Leave of Absence order. Staff delays in recognizing the resident's absence and in notifying police resulted in the resident being found several miles away, disoriented and injured, after an extended period.
A resident with diabetes and depression, who was cognitively intact and required supervision for ADLs, was verbally abused by a staff member who made derogatory remarks about the resident's appearance and personal loss. Another resident witnessed the incident and confirmed the statements. The facility's policy guarantees freedom from abuse, but the staff member's actions violated this right.
A facility failed to include discharge planning in a resident's care plan, despite the resident's desire to return to the community and an application for the Money Follows the Person program being completed. The care plan lacked discharge goals or interventions, and the social worker did not document the resident's discharge status or MFP application progress in the clinical record due to time constraints.
A resident with a history of myocardial infarction and other conditions was given Nitroglycerin, but the administration was not documented in the MAR as required. The RN supervisor noted the administration in a progress note but failed to update the MAR, contrary to the facility's documentation policy.
Failure to Implement and Document Ongoing Discharge Planning for Short‑Stay Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document an ongoing discharge plan for a short‑stay resident to ensure a safe and effective transition back into the community. The resident had diagnoses including bacteremia, intraspinal abscess and granuloma, and anxiety disorder, and was admitted for short‑term rehabilitation after a hospital stay. On admission, the social service note documented that the resident had unstable housing, had been living at a friend’s house prior to hospitalization, and that discharge plans were discussed with the resident stating they would return to the friend’s house if no other housing options were available. The note also indicated a referral would be made to Money Follows the Person for housing supports, and the admission MDS and care plan identified a goal of discharge back into the community with social services and the IDT to coordinate needed equipment, services, and community resources. A Level of Care Screen by Maximus later confirmed that short‑term care was appropriate for a defined period and directed the facility to continue assisting with discharge planning for appropriate community and support services. Psychological services documented that the resident was experiencing anxiety related to potential early discharge and that the plan was to continue addressing discharge‑related anxiety. An APRN progress note indicated the resident had completed IV antibiotics, was clinically stable, and was preparing for discharge home later that week, pending final coordination. A Transition of Care/Discharge Summary identified an anticipated discharge date and a planned discharge location back into the community. Despite these documented goals and clinical readiness for discharge, review of social service notes from admission through the anticipated discharge date did not show evidence that social services had been working with the resident on discharge back into the community. There was no documentation of IDT collaboration, referrals and resources provided for post‑discharge needs, discharge readiness, or the resident’s participation in the discharge planning process, as required by facility policy. The social worker reported that discharge planning discussions occurred and that she met with the resident to discuss anticipated discharge, encouraged the resident to contact family and friends, and provided 211 as a resource, but these actions were not documented in the clinical record. The resident reported being told they were ready for discharge, needing to secure housing, being told to call 211 if housing could not be found, and feeling there was no ongoing assistance from the facility to secure housing or discussion of aftercare. Facility policy required that discharge planning begin at admission, be reviewed weekly for short‑stay residents, and that progress notes include participants, readiness for discharge, services arranged, and teaching provided, which was not reflected in the record for this resident.
Failure to Ensure Proper Functioning of Resident Call Light Indicators
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call systems functioned as intended, specifically that the visual call light indicators above room doors illuminated when call bells were activated. During a tour of the third floor, when Resident #4 activated the call bell, the visual indicator light outside the room above the door did not illuminate, and the resident reported that the call bell often did not work properly and had recently been serviced by staff. Shortly thereafter, when Resident #1’s call bell was activated, the call light indicator outside that room also failed to illuminate. When the charge nurse (LPN #1) tested Resident #4’s call bell, the light above the room door again did not illuminate, although the audible signal and visual light at the nurses’ station did activate. The DON stated that the expectation was for the call light indicator above a room door to illuminate when the call bell was pressed. The Administrator reported that routine environmental rounds and testing of the call bell system were conducted but could not specify how often these occurred, and no documentation of such rounds or call bell testing was provided upon request. Review of the facility maintenance log from December 2025 through February 2026 did not show any repair requests for the call bell issues in the rooms of Residents #1 and #4. The facility’s Call Bell policy dated 1/1/24 directed that staff would be made aware of a call bell activation by both the buzzer at the nurses’ station and the light above the room, and stated that if a call bell was found to be defective, a hand bell would be provided, but there was no documentation in the report that these policy provisions were followed for these residents.
Failure to Document Ongoing Discharge Planning
Penalty
Summary
The facility failed to implement and document an ongoing discharge plan for a resident admitted for short term rehabilitation who had unstable housing and was expected to return to the community. The resident’s diagnoses included bacteremia, intraspinal abscess and granuloma, and anxiety disorder. Admission documentation noted the resident had been living at a friend’s house before hospitalization, that discharge plans were discussed, and that a referral would be made to Money Follows the Person for housing reports and social service support. The admission MDS identified the resident as alert and oriented with no memory recall deficits and established the overall goal of discharge back into the community. The resident’s care plan identified short-term rehabilitation with a goal of safe discharge back into the community and included interventions for social work involvement, community resources, family preparation, interdisciplinary discharge planning, and coordination of equipment and services. The Level of Care Screen later stated that short term care remained appropriate and that the facility should continue assisting with discharge planning for community and support services. A psychological services note documented anxiety related to potential early discharge and interpersonal conflict in the facility, and an APRN note stated the resident had completed IV antibiotics, remained stable, and was preparing for discharge to home pending final coordination. Review of social service notes from admission through the discharge period did not reflect documentation that social service had been working with the resident regarding discharge back into the community. The social worker stated the interdisciplinary team discussed discharge planning and that she met with the resident to discuss the anticipated discharge, housing resources, and use of 211 if housing could not be secured, but the clinical record did not reflect documentation of interdisciplinary collaboration, referrals, resources provided, discharge readiness, or the resident’s participation in discharge planning. The resident stated there was no ongoing assistance from the facility to secure housing upon discharge and no discussion on aftercare. The facility policy required discharge planning to begin at admission, continue throughout the stay, include weekly review for short stay residents, and document participants, readiness for discharge, services arranged, and teaching provided.
Failure to Notify Physician and Administration of Resident's Absence and Missed Medications
Penalty
Summary
The facility failed to ensure timely notification of a physician, medical director, and facility administration when a resident did not return as scheduled from a leave of absence (LOA). The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, was expected to return to the facility by 6:00 PM but did not return until nearly ten hours later. Staff did not notify the Director of Nursing Services (DNS), the administrator, the resident's physician, or local authorities as required by facility policy when the resident was missing. The DNS confirmed she was not informed until the following morning, and the physician stated he would have expected to be notified promptly if a resident did not return from LOA. Additionally, the facility failed to notify the provider when the same resident missed scheduled evening medications, including Furosemide, Gabapentin, Quetiapine, and Eliquis, due to the resident's absence. The LPN on duty did not contact the physician or advanced practice registered nurse (APRN) regarding the missed doses, only informing the charge nurse. The physician confirmed that he expected to be notified within one to two hours of missed medications to make appropriate decisions. Facility policies required staff to notify the provider and supervisory staff in the event of a medication administration error, which was not followed in this instance.
Failure to Prepare and Document Safe Discharge for Resident
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident who was issued a 30-day discharge notice due to non-compliance with the facility's smoking policy. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, and demonstrated moderate cognitive impairment, was identified as needing set-up assistance with personal hygiene and supervision with transfers and ambulation. Despite care plan interventions directing the social worker to utilize community resources, prepare the resident for discharge, and involve the resident in discharge planning, there was no evidence that these steps were taken. The social worker admitted to not having made additional discharge plans or discussed future arrangements with the resident after the initial notice was given. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The DON was unaware of the discharge details and the resident's status was not included in daily meetings or on the facility's tracking board. The administrator was also unaware of the discharge notice and its reason. The MDS coordinator noted unresolved insurance issues and did not follow up further, while the admissions coordinator at the sister facility had not received a referral. Nineteen days after the notice, the social worker still had not arranged for a safe discharge, and the resident reported not receiving any further information about the transfer after the initial notice.
Failure to Obtain Hospital Discharge Summary and Inconsistent Leave of Absence Procedures
Penalty
Summary
The facility failed to obtain a hospital discharge summary in a timely manner after a resident was readmitted following a fall and hospital transfer. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, returned to the facility without any hospital discharge paperwork. Despite facility policy requiring review of discharge paperwork within 24 hours of return, staff did not request or obtain the necessary documentation from the hospital. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the discharge summary was not obtained or reviewed, and there was no documentation explaining why this was not done. Additionally, the facility did not act promptly when the same resident failed to return from a Leave of Absence (LOA) at the expected time. The resident left the facility with a planned return time but did not come back as scheduled. Nursing notes indicated that the resident was still out nearly three hours after the expected return, and further documentation showed the resident was absent for almost ten hours before being returned by a Good Samaritan. Although the DNS stated that staff attempted to contact the resident's responsible party and local hospitals, there was no documentation of these efforts, and required notifications to the DNS, Administrator, local police, and physician were not completed as directed by facility policy. The investigation also revealed confusion and inconsistency regarding the facility's LOA policies. Multiple versions of the LOA policy were in circulation, with conflicting instructions on the steps staff should take when a resident does not return as expected. Staff had electronic access to a more recent policy, but the DNS and Administrator stated that an older policy was the one in use, as confirmed by corporate leadership. This lack of clarity resulted in staff not having clear, unified guidance on how to respond to residents who do not return from LOA in a timely manner.
Failure to Prevent Elopement and Delayed Response for Cognitively Impaired Resident
Penalty
Summary
A resident with multiple complex medical conditions, including opiate dependence, acute infective endocarditis, bacteremia, osteomyelitis, neuropathy, and severely impaired cognition, exited the facility without staff knowledge. The resident required supervision and an assistive device for ambulation, had a history of falls, and was receiving IV medications. Despite these needs, the resident was not identified as being at risk for elopement on the admission assessment, and there was no Leave of Absence (LOA) order in place for the resident. On the day of the incident, the resident was last seen stating an intention to retrieve a deck of cards. Surveillance footage later showed the resident exiting the main entrance behind the Administrator, unnoticed by staff at the front desk, including the Receptionist and the Administrator. The front door's locking mechanism had a 90-second delay before re-engaging, which allowed the resident to leave the building. Staff did not immediately realize the resident was missing; it was only after another resident reported seeing the individual outside that the Recreation Assistant began to investigate. There was a delay of up to ten minutes before the Administrator was notified and a code purple (missing resident) was called. The facility's elopement and code purple policies required immediate action and notification of police when a resident could not be located. However, there was a delay of approximately 54 minutes before the police were contacted. The resident was eventually found by police several miles from the facility, disoriented, inadequately dressed for the weather, and with injuries consistent with a fall. The incident was determined to be an Immediate Jeopardy situation due to the facility's failure to prevent the resident from exiting unsupervised and the delayed response in locating and reporting the missing resident.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and major depressive disorder was subjected to verbal abuse by a staff member. The resident, who had intact cognition and required supervision with activities of daily living, reported that a nursing assistant made derogatory remarks, calling the resident ugly and stating that the resident's significant other died to get away from them. This account was corroborated by the resident's roommate, who overheard the same comments. The incident was documented in a reportable event form and confirmed through interviews with both the resident and the roommate. The facility's abuse policy states that residents have the right to be free from abuse. Despite this, the staff member involved denied making the statements, but the consistency of the resident's and roommate's accounts led to the substantiation of the verbal abuse allegation. The failure to protect the resident from verbal abuse constituted a violation of the facility's obligation to ensure residents are free from all forms of abuse.
Failure to Include Discharge Planning in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident, which included discharge planning. The resident, diagnosed with depression, paranoid personality, and atrial fibrillation, was alert and oriented, requiring substantial assistance for ADL care. The Minimum Data Set (MDS) assessment indicated the resident's desire to be asked about returning to the community, yet no referral to a Local Contact Agency was made. The resident's care plan, dated January 8, 2024, did not identify discharge goals or interventions, despite the social worker completing an application for the Money Follows the Person (MFP) program on January 18, 2024, and providing a copy to the resident. Further review revealed that the care plan meeting on March 12, 2024, attended by the social worker and the resident, did not include information about the MFP application or discharge status. The social worker admitted to not documenting the resident's MFP program application or discharge status in the clinical record due to time constraints. The Director of Nursing Services confirmed that the social worker should have documented the progress of the MFP application in the resident's care plan or clinical record, as per the facility's Care Plan Policy, which mandates the inclusion of the resident's discharge preferences and referrals to support such desires.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate regarding medication administration. The resident, who had a history of myocardial infarction, chronic obstructive pulmonary disease, and heart failure, was identified as often non-compliant with medication administration. A physician's order was in place for Nitroglycerin 0.4mg to be administered sublingually as needed. On a specific date, the charge nurse informed the RN supervisor that the resident was given Nitroglycerin, and the APRN was updated with orders to monitor the resident. However, a review of the Medication Administration Record (MAR) for that month did not show documentation of the Nitroglycerin administration on the specified date. During an interview, the RN supervisor acknowledged documenting the administration in a progress note but failed to record it on the MAR. The Director of Nursing Services confirmed that the RN should have documented the medication administration in the MAR, as per the facility's documentation policy, which requires accurate and timely documentation in the resident's medical record.
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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) |
|---|---|---|---|---|
| Mary Wade Home, The Incorporated | 0.7 mi | — | 3 | 0 |
| Apple Rehab Laurel Woods | 1.3 mi | — | 9 | 0 |
| Leeway, Inc | 1.5 mi | — | 10 | 0 |
| Montowese Center For Health & Rehabilitation | 2.8 mi | — | 1 | 0 |
| Advanced Center For Nursing & Rehabilitation | 3.1 mi | — | 16 | 1 |
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