Advanced Center For Nursing & Rehabilitation

F 0580 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1 stated the nurse aides had notified her shortly after the start of the shift that Resident #2 was short of breath and although she directed them to bring two (2) portable tanks into Resident #2's room she did not check on or assess Resident #2. LPN #1 explained that she should have taken Resident #2's vital signs, assessed Resident #2 and then notified the provider and the nursing supervisor but she did not. Interview with the 7AM-3PM nursing supervisor, RN #1, on [DATE REDACTED] at 12:15 PM identified on [DATE REDACTED] she was rounding on Resident #2's unit around 9:20 AM, and LPN #1 had not reported any issues, stating she had asked LPN #1 if she needed anything and LPN #1 reported she did not. RN #1 explained at 10:40 AM she was by the nurse's station with LPN #1 when NA #1 yelled to them Resident #2 could not breathe and needed help. RN #1 identified she ran down to the room, followed by the Nurse Practitioner (NP) and Resident #2 was noted to be sitting in the wheelchair, with the nasal cannula attached to the oxygen concentrator gasping and using accessory muscles to breathe. RN #1 stated prior to 10:40 AM, LPN #1 did not notify her Resident #2 was having shortness of breath, there were issues with Resident #2's concentrator and portable oxygen tanks were being used. RN #1 identified LPN #1 reported to her she did not conduct a respiratory assessment or take vital signs or oxygen saturation levels that shift. RN #1 identified had LPN #1 notified her immediately of Resident#2's change in condition at 7:45 AM, she would have assessed Resident #2, notified the provider and transferred Resident #2 to the Emergency Department, as Resident #2 had a history of respiratory exacerbations. Interview with the Nurse Practitioner, NP, on [DATE REDACTED] at 10:44 AM identified he was not aware Resident #2 had been reporting shortness of breath since around 7:45 AM on [DATE REDACTED], and he should have been notified immediately so Resident #2 could have been transferred to the ED which could have prevented Resident #2's death.

Interview with the Administrator on [DATE REDACTED] at 11:17 AM identified on [DATE REDACTED] she was unaware Resident #2 had a change in condition three (3) hours prior to Resident #2's death. The Administrator explained LPN #1 should have attended to Resident #2 immediately after staff notified her around 7:45 AM Resident #2 could not breathe and then notify the nursing supervisor and provider. Review of the Change of Condition policy dated [DATE REDACTED] directed, in part, that all residents with a potential change of condition will be identified in a timely manner and any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. All staff are responsible to report any concerns about a resident to the charge nurse. The LPN is to collect data and administer provider ordered treatments or medications as indicated. The RN/supervisor is also to be notified accordingly who will then assess and determine if a change of condition has occurred. The RN will make

the APRN or Medical Doctor (MD) aware of a resident's current condition by in-person notification or telephone call using the Situation-Background-Assessment-Recommendation (SBAR) format.

Documentation will be noted in the residents' medical record and on the 24-hour report to ensure shift to shift communication and continuity of care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, review of facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for supplemental oxygen usage, the facility failed to develop a care plan to address Resident #3's need for oxygen use. The findings include:Resident #3's diagnoses included acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. A physician's order dated 9/19/22 directed to administer oxygen via

a nasal cannula or non-rebreather at two (2) to three (3) liters per minute every shift as needed for Shortness of Breath (SOB) to maintain an oxygen saturation level greater than 92 percent. The quarterly Minimum Data Set assessment dated [DATE REDACTED] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #3 was alert and oriented to person, place, and time, was independent with activities of daily living, and utilized oxygen therapy. Observations of Resident #3 on 9/24/25 at 12:49 PM identified an oxygen concentrator to be running and set at three (3) liters via the nasal cannula. Review of the clinical record on 9/25/25 and 9/26/25 failed to identify a Resident Care Plan (RCP) that addressed Resident #3's respiratory diagnoses and oxygen utilization. Upon further review, on 9/29/25, a care plan was developed and interventions implemented. Interview with the Regional Nurse, Licensed Practical Nurse (LPN) #5, on 9/30/25 at 9:25 AM identified a care plan should have been

in place identifying Resident #3's respiratory diagnoses and oxygen utilization. LPN #5 explained the Interdisciplinary Team was responsible for reviewing and revising care plans and he was unsure why a care plan was not in place. Review of the Comprehensive Care-Planning policy dated 1/30/25 directed, in part, that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, incorporates identified problem areas and risk factors associated with identified problems, reflects treatment goals, timetables and objectives in measurable outcomes, identifies the professional services that are responsible for each element of care and reflects currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The IDT must

review and update the care plan when there's been a significant change in the resident's condition, when

the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly MDS assessment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Practitioner (NP) and Resident #2 was noted to be sitting in the wheelchair, with the nasal cannula attached to the oxygen concentrator gasping and using accessory muscles to breathe. RN #1 stated prior to 10:40 AM, LPN #1 did not notify her Resident #2 was having shortness of breath, there were issues with Resident #2's concentrator and portable oxygen tanks were being used. RN #1 identified LPN #1 reported to her she did not conduct a respiratory assessment or take vital signs or oxygen saturation levels that shift. RN #1 identified had LPN #1 notified her immediately of Resident#2's change in condition at 7:45 AM, she would have assessed Resident #2, notified the provider and transferred Resident #2 to the Emergency Department, as Resident #2 had a history of respiratory exacerbations. Interview with the Administrator on [DATE REDACTED] at 11:17 AM identified LPN #1 should have attended to Resident #2 immediately after staff notified her Resident #2 could not breathe and then notified the nursing supervisor and the provider immediately.

Review of the Change of Condition policy dated [DATE REDACTED] directed, in part, that all residents with a potential change of condition will be identified in a timely manner and any alteration in a resident's baseline indicates

a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. All staff are responsible to report any concerns about a resident to the charge nurse. The LPN is to collect data and administer provider ordered treatments or medications as indicated. The RN/supervisor is also to be notified accordingly who will then assess and determine if a change of condition has occurred. The RN will make the APRN or Medical Doctor (MD) aware of a resident's current condition by in-person notification or telephone call using the Situation-Background-Assessment-Recommendation (SBAR) format. Documentation will be noted in the resident's medical record and on the 24-hour report to ensure shift to shift communication and continuity of care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Documentation will be noted in the resident's medical record and on the 24-hour report to ensure shift to shift communication and continuity of care. Review of the Oxygen Supply Management policy dated [DATE REDACTED] directed, in part, that the facility is to ensure that all residents requiring supplemental oxygen have immediate access to functional equipment and that any change in respiratory status is assessed, documented and reported without delay. If there's a malfunction in oxygen equipment, the resident will be immediately placed on a portable tank, the supervisor and the provider will be notified and the malfunctioning concentrator will be removed from service. Any report of SOB triggers an immediate nursing assessment including vital signs, oxygen saturation and respiratory exam and then results are documented and reported to the provider and supervisor.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observations, clinical record reviews, facility policy and interviews, the facility failed to ensure a medication cart located in the hallway was locked and medication was secured to prevent unauthorized access. The findings include:Observations on the D1 unit on 9/25/25 at 10:17 AM identified a medication cart in the hallway to the left of the nurse's station, pushed up against the left side of the hall, about one-third of the way down. The medication cart was noted to be unlocked with the cart keys located on the top of the cart, as well as an open bottle of docusate sodium (stool softener), a glucometer, a bottle of glucometer test strips, five (5) empty blister packs of medication, six (6) pre-poured cups of water without covers, an orange cover to an insulin syringe and a cell phone. Upon further observations a resident was noted to walk by the cart and the charge nurse, Licensed Practical Nurse (LPN) #2, was noted to emerge from a resident's room, in which the door had been closed at 10:19 AM. Interview and observations of the medication cart with LPN #2 on 9/25/25 at 10:19 AM identified that although she should not have left any of

the above items on the top of the cart with the cart unlocked and unsecured, she needed to attend to a resident quickly and she did not request the assistance of other staff although she was aware that she left

the cart unlocked with the cart keys on top. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, on 9/25/25 at 12:42 PM identified LPN #2 should not have left items on top of the cart, including the cart keys when the cart was unattended and the medication cart should be locked at all times when the nurse steps away from it. Review of the Medication Cart Management policy (undated) directed,

in part, that medication carts shall be maintained in a clean, organized, locked and secured manner at all times. Medication carts are considered extensions of the facility's medication storage area and must comply with all security, sanitation and documentation requirements. Carts must remain locked when unattended, even for brief intervals. Keys are to remain in the possession of the assigned nurse. No food, drink, personal items or unrelated supplies may be stored on or in the cart.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of twenty-one (21) randomly selected residents (Residents #5 and #11), the facility failed to ensure blood work was obtained per the physician's order. The findings include:1. Resident #5's diagnoses included pneumonia, acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), Congestive Heart Failure (CHF), anemia (low levels of healthy red blood cells to carry oxygen throughout

the body), generalized edema (severe buildup of fluid in the tissues of several parts of the body) and hypocalcemia (low calcium levels in the blood). A physician's order dated 9/10/25 directed on 9/12/25 to obtain a Basic Metabolic Panel (BMP) and a Complete Blood Count (CBC) with differential. Review of Resident #5's clinical record failed to identify the blood work was obtained or Resident #5 had refused the blood work. A new physician's order dated 9/25/25 directed to obtain a Comprehensive Metabolic Panel (CMP) and a CBC with differential on 9/26/25 and there were no significant abnormalities. 2. Resident #11's diagnoses included alcohol abuse, hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone) and peripheral vascular disease (narrowing of blood vessels due to deposit buildups which reduces blood flow to the limbs). A physician's order dated 8/30/25 directed on 9/3/25 to obtain a BMP and a CBC with differential. Review of Resident #11's clinical record failed to identify the blood work was obtained or that Resident #11 refused the blood work. Interview with the Regional Nurse, Licensed Practical Nurse (LPN) #5, on 9/30/25 at 12:05 PM identified he was unable to locate documentation the blood work was obtained for Residents #5 and #11, explaining the blood work should have been obtained per the physician's order or the provider should have been notified and rescheduled to

a different date with a new physician's order. Interview with the Nurse Practitioner (NP) on 10/2/25 at 11:22 AM identified that he was unaware the bloodwork was not obtained per the physician's orders for both Residents #5 and #11, explaining the physician's orders should have been followed or he should have been notified the bloodwork was not obtained so he could have placed a new order. The NP identified that nursing staff should have documented in the clinical record why the bloodwork was not obtained, provider notification and any follow-up orders. Review of the Laboratory and Blood Work Services policy dated 01/19/18 directed, in part, that the facility is to ensure that laboratory and bloodwork services are provided

in accordance with physician's orders, resident rights, federal regulations and Connecticut Public Health code standards. All bloodwork will be obtained and processed in a manner that ensures resident safety, accuracy, timeliness and professional standards of quality. Results will be returned to the ordering physician and entered into the resident's medical record. Nursing staff must promptly review results, notify the physician of abnormal or critical values and document the notification.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

treatment. LPN #5 indicated residents who utilize oxygen should have had a physician's order directing to change the oxygen tubing weekly. Review of the Oxygen Tubing policy dated 01/19/18 directed, in part, that

the facility will provide and maintain oxygen tubing in a manner consistent with manufacturer guidelines, infection prevention standards and resident care needs. Oxygen tubing will be changed, labeled, stored and disposed of in accordance with regulatory requirements and facility protocols. Standard nasal cannula/tubing will be changed every seven (7) days or sooner if visibly soiled, contaminated, or per manufacturer instructions. Tubing change dates will be documented in the resident's medical record.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Center for Nursing & Rehabilitation

169 Davenport Avenue New Haven, CT 06519

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

identified maintenance checks the filters weekly for debris and housekeeping was responsible for monitoring the oxygen concentrators filters daily when they clean the room and will notify maintenance of

the need to be cleaned. The Director of Environmental Services identified he was unsure why the filter on Resident #7's concentrator was noted with thick dust. Review of the Fire Safety and Prevention policy dated 1/19/18 directed, in part, to ensure that any cleaning, repair or filling of oxygen equipment is performed by qualified, properly trained staff. All personnel must report observations of malfunctioning equipment and supplies and any unusual incidents. Although requested, policies on servicing of and cleaning oxygen concentrators were not provided.

Event ID:

Facility ID:

If continuation sheet