Apple Rehab West Haven
APPLE REHAB WEST HAVEN in WEST HAVEN, CT — inspection on September 17, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Medication Administration policy (undated) directed, in part, that all medications shall be administered safely and accurately in accordance with physician's orders, facility protocols and applicable state and federal regulations.
Document the administration in the MAR immediately after giving the medication.
Monitor residents for therapeutic side effects and potential side effects of medications.
All resident refusals of medication must be documented in the medical record, including the reason for refusal if provided, and the provider must be notified as appropriate. If medication is not available at the time of administration: notify the physician immediately and request guidance or an alternative order, inform he resident or their responsible party, check with the pharmacy to expedite delivery of the medication and document all actions taken in the resident's medical record and notify the supervisor.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Apple Rehab West Haven
308 Savin Avenue West Haven, CT 06516
SUMMARY STATEMENT OF DEFICIENCIES
Review of the clinical record from 5/8/25 through 8/23/25 failed to identify that an endocrinology appointment was ever scheduled or that the resident was seen by endocrinology.
Review of the Medication Administration Records from May 2025 through August 2025 identified that nursing continued to sign off the 5/7/25 order identifying that Resident #1 required an endocrinology appointment daily at 9:00 AM until 8/22/25 (3.5 months later).
Interview with Person #1 (Endocrinology office) on 9/17/25 at 11:18 AM identified that Resident #1 had not been seen in their office from May to August 2025 and reported that no one from the facility had ever called them to set up an appointment.
Interview with Registered Nurse (RN) #5 (3:00 PM to 11:00 PM Nursing Supervisor) on 9/17/25 at 3:13 PM identified that when a resident is admitted to the facility with hospital paperwork stating they require an appointment with an outside provider, she notifies the provider, notates it on the facility's 24-hour report and then enters an order that shows up on the MAR so that the charge nurse is aware that they need to schedule the appointment. RN #5 identified that the charge nurse is responsible for scheduling the appointment within 72-hours and reported that if they don't have time, it's their responsibility to notify the nursing supervisor for assistance.
She identified that the endocrinology appointment should have been scheduled by the facility, and she was unsure why it had not been.
Interview with the Director of Nursing (DON) on 9/17/25 at 2:41 PM identified that the facility doesn't utilize secretaries or unit managers, so the charge nurses and nursing supervisors are responsible for making appointments and setting up transportation for residents who require appointments outside of the facility.
She reported that although she was not the DON at the time of Resident #1's admission and she was unaware that the resident required an endocrinology appointment, nursing staff should have followed the physician's order and ensured that the appointment was scheduled as directed and that coordination of medical care was preserved for the resident.
The DON identified that staff should have scheduled the appointment within 48 to 72 hours, and she was unsure why staff continued signing off the order daily for three (3) months without scheduling the appointment.
Although requested, policies on following physician's orders and scheduling offsite provider appointments were not provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Apple Rehab West Haven
308 Savin Avenue West Haven, CT 06516
SUMMARY STATEMENT OF DEFICIENCIES
Review of the Nursing Documentation policy (undated) directed, in part, that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift. In extenuating circumstances, documentation may be entered at a later time, but it must be clearly indicated as such to maintain transparency and accuracy.
All entries must be factual, complete, and reflect the resident's current condition and care provided.
Document any changes in the resident's condition, new symptoms, or reactions to treatments immediately and include any actions taken (e.g., physician notification) and resident/family communication.
Facility ID: