West Haven Center For Nursing & Rehabilitation

F 0627

information becomes available. The facility will provide and document sufficient preparation and orientation to the resident(s) to ensure safe and orderly transfer or discharge.

Level of Harm - Minimal harm or potential for actual harm 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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Haven Center for Nursing & Rehabilitation

310 Terrace Ave West Haven, CT 06516

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

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for medication administration, the licensed nursing staff failed to ensure the resident consumed oral medications and applied a topical patch prior to exiting the room and

the medications were not left at the bedside. The findings include:Resident #1's diagnoses included pain, type II diabetes mellitus and dysphagia (difficulty swallowing). The quarterly Minimum Data Set assessment dated [DATE REDACTED] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident had no memory recall deficits and was independent with eating. A physician's order dated 10/14/25 directed to administer lidocaine 5 percent (%) adhesive patch topically (to

the surface of the skin) to the lower back daily at 6:00 AM. The Self-Administration of Medication assessment dated [DATE REDACTED] identified it was not appropriate for Resident #1 to self-administer any medications and Resident #1 did not want to self-administer medications. The Resident Care Plan dated 10/15/25 identified that Resident #1 is at risk for pain related to their physical condition. Interventions directed to monitor for pain and administer medications as applicable. Observations and interview with Resident #1 on 11/25/25 at 10:49 AM identified an unopened lidocaine patch labeled 11/25/25 11-7 on Resident #1's over-the-bed table. Resident #1 explained that the 11PM-7AM nurse placed the lidocaine patch and all of his/her oral medications in a cup on the over-the-bed table and the nurse left the room without ensuring that he/she took the medications. Resident #1 identified the 11PM-7AM nurse always leaves the lidocaine patch for him/her to apply. Resident #1 identified he/she takes the oral medications with breakfast and applies the lidocaine patch herself when he/she was ready, and he/she just has not gotten to

it yet. Review of the active physician's orders on 11/25/25 failed to reflect a physician's order directing Resident #1 may self-administer the lidocaine patch or any other medications. Observations on 11/25/25 at 1:16 PM identified the unopened lidocaine patch labeled 11/25/25 11-7 was still present on Resident #1's over-the-bed table. Observations of Resident #1's room and interview with the Regional Nurse, Licensed Practical Nurse (LPN) #2, on 11/25/25 at 1:28 PM identified an unopened packaging of a lidocaine patch labeled 11/17 11-7 present on Resident #1's over-the-bed table. LPN #2 identified Resident #1 was not to self-administer any medications, including the lidocaine patch and should not have been left at the bedside for Resident #1 to apply. LPN #2 explained to Resident #1 that he needed to dispose of the lidocaine patch and when Resident #1 was ready for the patch, Resident #1 could request a new one from the nurse on duty, to which Resident #1 agreed, and the lidocaine patch was removed from the room and disposed of.

Review of the facility schedule identified Licensed Practical Nurse (LPN) #1 was assigned to Resident #1

on the 11PM-7:00 AM shift on 11/17/25 and 11/25/25. Interview with Resident #1 on 11/25/25 at 1:35 PM identified he/she was unsure of what happened to the lidocaine patch that was on his/her over-the-bed table this morning and he/she was about to put the patch on but it was not there. Resident #1 stated he/she had an extra patch in his/her drawer (dated 11/17/25) that he/she did not apply so he/she placed it on the over-the-bed table in preparation of applying the patch. Although attempted, an interview with LPN #1 was not obtained. Review of the Medication Administration and Documentation policy (undated) directed, in part, that all medications must be administered by the same person who prepared the dose for administration and assures that medications are not left unattended and that they're kept secured in a locked area or in visible control at all times.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet