Apple Rehab West Haven
APPLE REHAB WEST HAVEN in WEST HAVEN, CT — inspection on April 28, 2026.
Found 2 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
completed in full, including the final risk determination section was not completed, and was unable to provide a rationale for the incomplete assessments. RN #1 was also unable to explain how the facility monitors compliance with completion or reassessment of elopement risk assessments.
Review of the facility undated Elopement Risk Policy directed in part, all residents are evaluated for risk of elopement on admission and readmission; every resident admitted to the facility will be evaluated for elopement risk. A care plan will be developed and individualized interventions implemented if the resident is identified to be an elopement risk per the Elopement Risk Evaluation. An activated elopement bracelet (wander guard) will be placed on the resident and documented in the medical record if deemed appropriate.
Each shift, placement of the elopement bracelet will be verified and documented in the medical record.
Functioning of the elopement bracelet will be tested on ce a day by utilizing a tester unit and documented in the medical record.
075403 04/28/2026
Apple Rehab West Haven 308 Savin Avenue West Haven, CT 06516
orders, at each required visit.
clinical record review, facility documentation review, and interviews for three of three residents
physician/designee orders were reviewed and renewed at least once every 60 days.
The findings included: Resident #1's diagnoses included dementia, and delusional disorders.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and required assistance with ADLs and ambulated independently.
The Resident Care Plan (RCP) dated 12/18/2025 identified and alteration in ADL function.
Interventions directed to assist as needed.
Record review identified Resident #1 was on a 60-day schedule for review and renew of physician orders.
Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026.
Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #1. Resident #4's diagnoses included severe protein calorie malnutrition, chronic pulmonary disease and history of transient ischemic attack (mini-stroke).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required assistance for ADLs.
The Resident Care Plan (RCP) dated 1/18/2026 identified Resident #4 needed assistance with ADLs.
Interventions directed to assist as indicated and transfer per MD orders.
Record review identified Resident #4 was on a 60-day schedule for review and renew of physician orders.
Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026.
Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #4. Resident #5's diagnoses included dementia.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment and was dependent ADLs.
The Resident Care Plan (RCP) dated 3/6/2026 identified an alteration in ADLs, and interventions directed to assist as needed and transfer per MD orders.
Record review identified Resident #5 was on a 60-day schedule for review and renew of physician orders.
Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026.
Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #5.
Interview and record review with the DNS and Corporate RN #1 on 4/20/2026 at 2:30 PM identified physician orders should be signed at least every 60-days. MD #1 was new to signing electronic orders and had been educated how to sign them, but indicated the orders for Resident #1, #4 and #5 were not signed. Resident #1 and Resident #4's orders were last signed in September 2025.
RN #1 further stated she was unable to identify when Resident #5's orders were last signed (they were not signed during September 2025).
Interview failed to identify why the facility did not identify the orders were not signed timely and failed to identify a facility process to ensure orders were signed timely.
Subsequent to surveyor inquiry, interview and record review with the DNS and RN #1 on 4/21/2026 at 12:32 PM, identified the orders were now signed.
Although requested, the facility did not provide a policy for surveyor review related to physician orders, or electronic signatures.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.