Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At West Hartford during CMS and state inspections, most recent first.
Discontinued Schedule II through V controlled substances were stored in a locked file cabinet inside the DON office, but the cabinet was not permanently affixed and the office door was used as the second lock. During observation, the DON office was open and unattended, allowing access from the adjacent hallway. Fourteen discontinued controlled substance prescriptions in bubble packs and bottles were found in the cabinet, including hydromorphone, oxycodone, Lyrica, tramadol, alprazolam, lorazepam, pregabalin, morphine sulfate, and hydromorphone oral solution.
Failure to Reassess and Treat Severe Pain: A resident with cancer, chronic pain, and osteoarthritis continued to report severe pain after receiving ordered analgesics, but nursing documentation did not show timely reassessment, additional intervention, or provider notification. The record showed one episode where pain remained 7/10 after Nucynta was given, and another where pain was rated 10/10 and morphine was administered, but the ordered PRN Nucynta was not documented and no further assessment was recorded.
A resident with chronic pain and severe cognitive impairment did not receive an ordered Schedule II pain medication when the supply ran out and the order was later placed on hold because of an insurance preauthorization issue that the facility was unaware of. In addition, two residents had hydromorphone administrations recorded on the controlled substance log but not on the MAR by LPNs, and expired hydromorphone packs and records were still found in the locked med cart after the orders had ended.
A resident with severe cognitive impairment and chronic pain had orders for Nucynta ER 200 mg q12h and Nucynta 100 mg IR PRN. Staff documented giving two 100 mg IR tablets in place of the ordered ER dose without an order authorizing ongoing substitution, and the MAR and controlled substance record did not match for one documented dose. The DON stated the two formulations were different medications and should not have been used interchangeably.
Failure to Maintain Resident Dignity During Care: Two residents with significant care needs and behavioral concerns were involved in incidents during incontinent care in which staff responded disrespectfully or continued care while the residents were yelling that they were being hurt. One aide told a resident, "I don't like you either," and another resident alleged rough handling during turning and repositioning with a draw sheet, with staff later acknowledging the resident repeatedly screamed during care and that an argument occurred in the room with an RN supervisor and police present.
A resident with intact cognition and functional assistance needs was found keeping topical meds at the bedside and self-applying them without a documented assessment for safe self-administration. The resident reported bringing Jublia and Ammonium Lactate from home and using them independently, while the RN supervisor, APRN, and DNS were initially unaware of the bedside meds and the Efinaconazole use. The record lacked documentation for the Efinaconazole, and staff later noted the medication had not been addressed in the clinical record before a subsequent order allowed self-administration.
Failure to Honor a Resident's Meal Choice: A resident with ESRD, DM, and severe protein-calorie malnutrition was on a renal diet and repeatedly requested a chef salad for dinner, but the request was not consistently provided. The resident reported calling the kitchen multiple times, being told different reasons the salad could not be made or delivered, and feeling discouraged from making requests. Record review and staff interviews showed the resident’s food preferences were not consistently documented or followed, and the dietitian, DNS, and FSD were not consistently aware of the ongoing requests.
A resident with impaired cognition developed speech changes and right-sided weakness, but the change was not immediately escalated to the MD/APRN; the resident was later transferred for stroke eval and found to have an acute pontine infarct. In a separate event, an LPN found a resident with new oozing head/face lesions, applied dressings, but did not assess, document, or notify the RN supervisor, APRN/MD, or resident representative; the record also lacked wound documentation and an order.
Missing Pre-Employment Background Checks for Staff: The facility failed to ensure criminal background checks were completed before an LPN and a NA began working and caring for residents. One employee file had no documentation of a background check, and another employee's eligibility determination background check was completed after hire and orientation. HR stated background checks were supposed to be completed before employment, but could not produce documentation or explain the delay.
PASARR screening not reviewed or updated after new depression diagnosis. A resident was admitted with anxiety, depression, PTSD, and antidepressant orders, but the PASARR Level 1 on file showed no MH diagnosis or meds. The SW stated she did not review the PASARR on admission, did not have it printed in the chart, and did not notify the state authority after the APRN added major depressive disorder.
A resident with severe cognitive impairment and a history of skin lesions had 2 dressed, oozing areas on the scalp/face, but the record lacked wound documentation, assessment, and a provider order. An LPN applied gauze and tape without notifying the RN supervisor or APRN, and the care plan was not revised to include the resident’s recurrent skin lesions or open areas.
Failure to Assist a Dependent Resident Out of Bed: A resident with weakness, anxiety, and depression, who was dependent for transfers and bed mobility, reported not getting out of bed all day despite asking staff on multiple shifts to help. The resident said staff did not always get him/her up on weekends, while an LPN said the request was communicated to the NA. One NA said the resident did not get up because he/she did not ask, but the RN supervisor and DNS stated dependent residents should be offered assistance out of bed even if they do not ask.
Failure to Complete RN Assessments and Ordered Skin Monitoring: A resident with severe cognitive impairment and fragile skin had new oozing lesions on the scalp and face, but the record lacked an RN wound assessment, provider notification, documentation, and weekly body audits ordered by the MD. Another resident with cognitive impairment and multiple cancers developed acute confusion, speech changes, right-sided weakness, and facial droop before hospital transfer for stroke evaluation, but the record did not show a documented RN neuro assessment when the change in condition was identified.
Missed Weekly Skin Audits and Incomplete RN Assessment for New Coccyx Wound: A resident at risk for skin breakdown had ordered weekly skin audits tied to shower care, but the record did not show the audits were completed on two expected weeks and did not document refusals, education, or reapproach. The resident also developed a new coccyx wound that was noted by nursing staff and later identified as a stage 2 pressure ulcer, but the RN assessment was incomplete because wound measurements were not documented after the resident refused some assessments and wound care.
Failure to Track 24-Hour Fluid Intake for Residents on Dialysis Restrictions: Two residents with ESRD on dialysis had ordered fluid restrictions, but staff did not consistently total intake across shifts or verify 24-hour compliance. Documentation was split between nurse and NA records, staff were unsure who was responsible for calculating totals, and one resident exceeded the ordered limit on multiple days while the other had a supplement served without a clear daily total being monitored.
A resident with Parkinson’s disease, prior DVT, and ongoing tooth pain needed extraction of a failed root canal tooth, but the procedure was delayed because Eliquis was not held. Dental consults showed the tooth required removal, yet the APRN did not document an order to pause the anticoagulant and the extraction was missed more than once. Staff interviews showed unclear follow-up responsibility for dental consults and no tracking system for consult recommendations needing APRN action.
A resident with a stage 3 pressure injury and incontinence was on EBP, but an NA provided oral care and handled soiled linens without gown use despite posted EBP signage and a PPE cart outside the room. Two med carts were also found with loose tablets, unpackaged meds, powder, broken plastic, and other debris inside drawers and behind the drawers, and nursing staff reported there was no set cleaning schedule and some had not been educated on cart cleaning.
A resident with multiple chronic conditions and a stage III pressure ulcer did not consistently receive weekly skin evaluations as required by facility policy. Documentation showed missed assessments over several weeks, with no evidence of resident refusal, and the DON confirmed that these checks should have been completed and recorded.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Multiple resident rooms and common areas experienced excessively high temperatures due to a non-functioning air conditioning system, with some rooms reaching up to 89 degrees Fahrenheit and lacking portable AC units. Residents reported discomfort, and staff interviews revealed poor communication and delayed awareness of the system failure. The facility did not report the loss of air conditioning to the state agency as required, and facility policy for maintaining a comfortable environment was not followed.
A resident with chronic kidney disease had physician orders for daily weights and provider notification for significant weight changes. Weights were not consistently obtained or documented, and a substantial weight gain was not reported to the provider as required. Staff interviews confirmed the lapses in following orders and documentation.
A resident with insulin-dependent diabetes did not have their blood glucose checked before a meal as ordered, due to an LPN being restricted from providing care and failing to seek assistance from another available nurse. This resulted in a two-hour delay in blood sugar monitoring, despite the facility's policy and physician orders requiring timely checks.
Discontinued controlled substances were not secured in a permanently affixed, separately locked compartment
Penalty
Summary
The facility failed to ensure discontinued Schedule II through V controlled substances brought into the facility from an outside pharmacy were stored in a permanently affixed, separately locked compartment. The Director of Nursing Services stated that discontinued controlled substances were kept in a locked file cabinet inside the DNS office until destruction, and identified the office door as the second lock for the cabinet. However, during observation, the DNS office door was wide open with no staff present, and the hallway leading to the administrative offices remained accessible while the office was vacant. The Regional Clinical Director stated the file cabinet could not be moved easily, that a single lock secured the drawer containing the discontinued controlled substances, and that the DNS office door was locked; however, the cabinet was not permanently affixed to the wall and the door from the DNS office to the administrative offices was open. Fourteen discontinued controlled substance prescriptions were found stored in the cabinet in bubble packs or bottles, including hydromorphone, oxycodone, Lyrica, tramadol, alprazolam, lorazepam, pregabalin, morphine sulfate, and hydromorphone oral solution. Each medication had a reconciliation form attached, and the counts matched the remaining quantities in the packages and bottles.
Failure to Reassess and Treat Severe Pain
Penalty
Summary
The facility failed to ensure ongoing assessment, additional pain interventions, and provider notification when a resident with malignant neoplasm of the anus, chronic pain syndrome, and unspecified osteoarthritis continued to report severe pain after receiving prescribed pain medication. The resident was severely cognitively impaired and dependent for toileting, lower body dressing, and transfers. On one occasion, the resident reported pain rated 7/10 and was given 100 mg of Nucynta; a nurse note documented the medication was ineffective about 1 hour and 20 minutes later, with pain still rated 7/10, but no further assessment or intervention was documented. The resident then again reported pain rated 7/10 later that evening and was given another dose of Nucynta. The record also showed that after the resident was placed on hospice, a physician ordered Morphine Sulfate Concentrate Solution 20 mg/mL, 0.25 mL sublingually every 2 hours for dyspnea, with instructions to obtain a new order for an increased dose if no relief occurred, and also ordered 100 mg of Nucynta every 4 hours as needed for severe pain. On another occasion, the resident reported pain rated 10/10 at two separate times and received morphine, but the MAR did not show administration of the ordered PRN Nucynta for the severe pain. Nursing documentation did not show that the pain remained unchanged or that further assessment or interventions were performed. Interviews with the APRN and nursing staff indicated that pain above the resident’s baseline should have prompted reassessment, PRN medication use when indicated, and provider or supervisor notification if pain remained elevated.
Medication availability, documentation, and controlled substance inventory failures
Penalty
Summary
The facility failed to ensure one resident’s Schedule II pain medication was available for administration in accordance with the physician order. Resident #1, who had diagnoses including malignant neoplasm of the anus, chronic pain syndrome, and unspecified osteoarthritis, was severely cognitively impaired and dependent for several activities of daily living. The resident had an order for Nucynta ER 200 mg every 12 hours for severe pain, and a nurse note documented the resident was readmitted after a hospital evaluation for multiple right-sided rib fractures, with chronic pain syndrome and osteoarthritis noted as stable and continuation of the medication directed. Resident #1’s Controlled Substance Disposition Record showed the last administered dose of Nucynta ER occurred on one date, while the MAR showed the order was placed on hold seven days after the medication supply had already been depleted. The pharmacist stated the pharmacy received an order for the medication, but it was cancelled because of an insurance preauthorization issue and was not reordered. The facility administrator, DNS, and regional clinical director stated the facility was unaware the prescription was on hold and identified that the resident should not have been without the ordered medication without staff intervening. The facility also failed to document administration of controlled substances and failed to remove expired controlled substances from the medication cart. For Resident #2, hydromorphone doses were recorded on the Controlled Substance Disposition Record, but multiple administrations were not documented on the MAR by two LPNs. For Resident #3, hydromorphone doses were also recorded on the Controlled Substance Disposition Record, but several administrations were not documented on the MAR. In addition, observations showed the controlled substance records and hydromorphone pill packs for Residents #2 and #3 remained in the locked medication cart after the orders had expired, despite the DNS stating controlled substances were to be brought to the DNS immediately after expiration for disposal and reconciliation.
Unapproved substitution and inaccurate controlled substance documentation
Penalty
Summary
The facility failed to ensure the physician’s order for a Schedule II controlled substance was followed for a resident with malignant neoplasm of the anus, chronic pain syndrome, and unspecified osteoarthritis. The resident was severely cognitively impaired and dependent for toileting, lower body dressing, and transfers. The care plan identified the resident as at risk for altered comfort related to anal cancer, osteoarthritis, and multiple right rib fractures, with interventions to medicate as ordered for pain and monitor for effectiveness and side effects. For the resident’s pain management, orders were in place for Nucynta ER 200 mg every 12 hours and Nucynta 100 mg immediate release every 2 hours as needed, not to exceed 6 tablets per day. The Controlled Substance Disposition Record showed that when the 200 mg Nucynta ER was last administered, staff documented administration of two 100 mg Nucynta tablets at the same dates and times as the MAR entries for the 200 mg ER dose, but the record did not identify a physician order authorizing substitution of the immediate release formulation for the extended release medication. APRN #1 stated a one-time order had been given after the nurse dispensed the medication, but it did not authorize continued substitution and the two formulations were different medications. In addition, the MAR documented a 200 mg dose on 5/26/25 at 9:00 PM that was not documented on the Controlled Substance Disposition Record; the DON stated the missing entry indicated the MAR was incorrect. The facility policy required medications to be administered in accordance with the physician order, including time parameters.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to ensure residents were treated in a respectful and dignified manner. Resident #41 was admitted with diagnoses including morbid obesity and anxiety disorder, was moderately cognitively impaired, and required assistance with bed mobility and transfers. The care plan identified the resident as highly demanding with potential verbally abusive behaviors and directed staff to assist at bed level due to behaviors and to anticipate needs and analyze triggers. During incontinent care, Resident #41 reported that NA #7 was rough and told the aide not to be rough. In response, NA #7 stated, "I don't like you either," which was overheard by an LPN. The resident representative, physician, law enforcement, and social services were notified, and the DNS later stated she would expect all residents to be treated in a dignified manner. Resident #41 also reported repeated negative interactions with the aide, and NA #7 acknowledged that the resident was accusatory, demanding, and often yelled at staff during care. NA #7 stated the resident repeatedly said he/she did not like her, but those comments were ignored because they were not unusual for the resident. NA #7 further stated she worked alone with the resident even though she was aware the resident required two staff due to accusatory behavior, and she did not report the resident's repeated statements to determine whether an assignment change was needed. Resident #58 was admitted with diagnoses including pain in the right leg, bipolar disorder, irritability, anger, and diabetes. The quarterly MDS identified intact cognition, extensive two-person assistance needs for bed mobility and toilet hygiene, and verbal behavioral symptoms directed toward others. The resident alleged that two nurse aides rough handled him/her during turning and incontinent care with a draw sheet and reported pain in the right lower extremity. Police were called, and the resident stated staff had been rough and caused pain. During the incident, staff continued care while the resident yelled and screamed that they were hurting him/her and being mean. NA #8 and NA #7 both stated the resident repeatedly yelled during care, did not respond when asked if staff should stop, and care continued. NA #8 also stated that after the police arrived, NA #7 argued with Resident #58 in the presence of the RN supervisor and a police officer, and the DNS later stated she was not aware of that argument during her investigation.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to conduct an assessment to determine whether a resident could safely self-administer medications. Resident #55 was admitted with diagnoses including acute kidney failure, cerebral infarction, and allergic contact dermatitis. The admission MDS identified intact cognition, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for bathing, lower body dressing, and putting on/taking off footwear. The care plan identified a self-care performance deficit due to weakness and directed staff to encourage the resident to participate to the fullest extent possible. Review of the hospital discharge summary showed active medications including Efinaconazole 10% solution and Ammonium Lactate 12%. A physician order was present for Ammonium Lactate to be applied over the whole body every evening, but the physician order record for the reviewed period did not identify an order for Efinaconazole. During observation, a box labeled Jublia was found on the resident’s bedside table, along with two bottles of Ammonium Lactate, one on the dresser and one inside a wash basin. The resident stated both medications were brought from home, that the resident had been using Jublia for several years, and that the resident applied both topical medications without staff assistance. The clinical record did not contain documentation related to Efinaconazole, an assessment showing the resident could safely self-administer it, or where it would be stored. Interviews showed staff were aware that residents who self-administer medications were supposed to be assessed and that outside medications were generally not to be kept at the bedside. RN #6 stated residents approved to self-administer would need a physician order and that medications brought from home would be labeled and kept locked in the medication cart, not at the bedside. APRN #1 and the DNS were not aware the resident was self-administering Efinaconazole or that it was at the bedside, and both stated they were not familiar with the medication at the time. RN #6 later completed an assessment and determined the resident could safely self-administer, updated the care plan, and had the resident sign a contraband notification form; a subsequent physician order then directed Efinaconazole to the toes once daily and allowed self-administration. The DNS later stated she had noted Efinaconazole on the discharge summary and reviewed it with APRN #1, but this was not documented in the resident’s clinical record.
Failure to Honor Resident Meal Choices
Penalty
Summary
The facility failed to provide Resident #2 with his/her meal choices. Resident #2 was admitted with diagnoses including end stage renal disease, diabetes, and severe protein-calorie malnutrition. The resident had intact cognition, a poor appetite several days a week, required no assistance with eating, and was on a renal diet with a renal supplement ordered daily. The care plan included offering substitutes as available, and the nutrition documentation noted that food preferences should be honored as appropriate. The record showed that Resident #2 repeatedly requested a chef salad for dinner and also requested bagged lunches on certain days. A diet requisition form documented the chef salad request, and the resident later stated he/she had called the kitchen many times for a chef salad, but sometimes received it and other times did not. The resident reported that kitchen staff sometimes said they had already prepared salads, did not have lettuce, or did not bring the requested item. The resident also stated that nurse aides told him/her they could not call the kitchen on the resident’s behalf, and that the resident felt discouraged from calling because kitchen staff gave attitude or seemed upset. Interviews and record review showed that the resident’s preferences were not consistently captured or acted upon. The dietitian stated she had only spoken with the resident once on admission and was not aware the resident had been requesting to see her. She also stated the resident could have a chef salad daily as long as it did not include tomatoes, but the meal tracker did not identify chef salad as a preference. The food service director stated she had recently started and had not found notes showing the prior food service director met with the resident to discuss likes and dislikes. The district food service manager stated that if a resident requests a chef salad and it is allowed on the diet, the resident should receive it regardless of the time requested, and that nursing staff or the resident could call the kitchen for a meal choice. The DNS stated she was not aware the resident was not receiving the requested chef salad and said the dietary director was responsible for making sure residents were seen and receiving their choices.
Failure to Notify Physician and Representative of Change in Condition and New Skin Issues
Penalty
Summary
The facility failed to ensure the physician was immediately notified when a resident developed a change in condition that included difficulty with speech and right-sided weakness. The resident was admitted with diagnoses including repeated falls and multiple malignant neoplasms, and the annual MDS identified moderately impaired cognition, clear speech, and the ability to express ideas and wants. The care plan directed staff to monitor and report changes in cognitive function, including difficulty expressing self, difficulty understanding others, level of consciousness, or mental status. On 10/19/25, nursing documentation identified the resident as alert and confused with stable vital signs, but also noted right upper and lower extremity weakness. Later that day, staff documented that the resident was restless, had difficulty forming complete sentences, and was able to follow commands. The resident’s representative was updated, and staff continued to monitor the resident throughout the shift. The next day, the resident was found to have increased weakness, inability to communicate, right arm and leg weakness, and a right facial droop, at which time the APRN saw the resident, EMS was called, and the resident was transferred to the ED. The medical APRN documented increased confusion, dysphagia, expressive aphasia, dysarthria, facial drooping, and right-sided weakness, and the hospital discharge summary identified an acute pontine infarct. Interviews with nursing staff and supervisors showed that one nurse observed speech changes and difficulty using the resident’s arm, but the concern was not clearly escalated to the medical provider at that time. The facility’s policy required prompt notification of the attending physician and resident representative for significant changes in condition. The facility also failed to ensure that the physician and resident representative were notified of newly identified skin issues for another resident. That resident had diagnoses including anaplastic astrocytoma, epilepsy, and sick sinus syndrome, and had recently returned from hospitalization after an unwitnessed fall with hip fracture and surgery. The resident had severely impaired cognition, was incontinent, and dependent on staff for transfers, and the care plan identified fragile skin with weekly body audits. During observation, two dressings were noted on the resident’s head, one on the scalp above the forehead and one at the left temple. The clinical record did not contain documentation of wounds on the head or face, an assessment of the wounds, or a physician’s order related to the areas. An LPN stated that the resident had multiple lesions and two oozing areas, and that she applied gauze and tape with date, time, and initials, but did not assess the areas, notify the RN supervisor, APRN, or resident representative, or document the wounds in the record. The APRN stated she was aware of prior skin lesions but had not been notified of any newly opened or oozing areas or that dressings had been applied. The DNS stated that newly identified wounds were expected to be assessed, reported to the RN supervisor and APRN or MD, documented, and communicated to the resident’s representative.
Missing Pre-Employment Background Checks for Staff
Penalty
Summary
The facility failed to ensure criminal background checks were completed before employees began working and caring for residents. Review of LPN #5's employee file showed a hire date of 9/9/22, but the file did not contain documentation that a criminal background check had been completed. During interview and file review, the HR Specialist stated it was human resources' responsibility to ensure background checks were completed prior to employment and said one should have been completed for LPN #5 because she transferred from another location, but the documentation could not be produced. The HR Specialist also stated she was not employed by the facility when the background check would have been obtained and had not conducted an audit to determine compliance since becoming employed. A second employee file review showed NA #11 was hired on 7/24/24 and completed orientation on 7/25/24, but the Department of Public Health eligibility determination background check was not completed until 7/31/24, 7 days after the hire date. The HR Specialist again stated it was human resources' responsibility to ensure criminal background checks were completed prior to employment and was unable to explain why the background check was not completed before NA #11's hire date. The facility's abuse policy stated that potential employees will be screened for a history of abuse, neglect, and misappropriation of resident property, and that background, reference, and credential checks shall be conducted on potential employees and other staff, with documentation maintained to show the screening occurred.
PASARR screening not reviewed or updated after new depression diagnosis
Penalty
Summary
The facility failed to review Resident #2’s PASARR on admission for accuracy and failed to update the state designated authority after the resident received a new diagnosis of major depression. A PASARR Level 1 screening dated 12/23/24 identified no known or suspected mental health diagnosis, no dementia, no mental health behaviors affecting interpersonal interactions, and no current or recent use of antidepressants, mood stabilizers, antipsychotics, or other mental health medications. The screening also stated there was no evidence of a PASARR condition of a serious behavioral mental health condition. The resident’s hospital discharge summary identified anxiety, depression, and post-traumatic stress syndrome, and the resident was admitted to the facility in December 2024 with diagnoses that included anxiety, depression, and post-traumatic stress syndrome. A physician order dated 12/25/24 directed administration of Amitriptyline, Remeron, and Zoloft, all antidepressants. The Social Services assessment identified anxiety and depression and noted the resident was receiving Zoloft and Remeron. The APRN note dated 12/26/24 stated she reviewed the hospital history and physical, discharge summary, and provider notes, and documented that the resident had depression and was to continue Amitriptyline, Remeron, and Zoloft. The diagnosis list dated 12/26/24 added major depressive disorder, single episode, in partial remission. The admission MDS identified intact cognition and that the resident felt down, depressed, or hopeless 12 to 14 days out of 14 days. The care plan identified depression and included antidepressant administration and monitoring for side effects and effectiveness. The Admissions Coordinator stated she was responsible for obtaining and placing the PASARR in the record, and the Director of Social Services stated she was responsible for reviewing the PASARR on admission and updating the state agency when a resident had a new mental health diagnosis. She stated the resident did not have a PASARR printed in the medical record, did not review the screening, and did not realize the admission PASARR did not reflect depression. She also stated she did not update the state designated authority because she was not notified of the new diagnosis of major depression.
Care plan not updated for resident’s skin lesions and open head areas
Penalty
Summary
The facility failed to revise Resident #7’s care plan to reflect identified skin issues. Resident #7 was admitted in December 2024 with diagnoses including anaplastic astrocytoma, epilepsy, and sick sinus syndrome, and later returned to the facility after a hospitalization from [DATE] through 9/19/25 following an unwitnessed fall that resulted in a hip fracture requiring surgery. The 5-day MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, substantial assistance needed for toileting and bathing, and dependence on staff for transfers. The care plan dated 9/24/25 identified potential or actual impairment to skin integrity and fragile skin, with interventions to conduct weekly body audits and identify and document potential causative factors. On 11/17/25, observation found 2 dressings on Resident #7’s head, one on the top of the scalp above the forehead and one at the left temple, each labeled with 11/14/25, 7-3 M. The clinical record did not contain documentation of wounds on the head or face, an assessment of the wounds, or a physician’s order for treatment. The assigned LPN stated she observed multiple lesions and 2 oozing areas on the forehead and scalp, applied gauze and tape to each area, labeled the dressings, but did not assess the areas, notify the RN supervisor, APRN, or resident representative, or document the wounds in the record. The APRN stated she was aware of prior skin lesions on the face that were rough, scaly, and likely actinic keratoses, but was not notified of any newly opened or oozing areas and had not been told the areas required a dressing. The care plan did not include issues or interventions related to skin lesions or recurrent open areas, and the DNS stated she would expect the care plan to be updated to reflect the resident’s history of skin lesions and intermittent open wounds on the head.
Failure to Assist Dependent Resident Out of Bed
Penalty
Summary
The facility failed to assist Resident #20 out of bed upon request. Resident #20 was admitted in April 2025 with diagnoses including weakness, anxiety, and depression. The quarterly MDS identified intact cognition, no behavioral symptoms, and dependence for chair/bed-to-chair transfers, lying to sitting, and sitting to standing. The care plan identified the resident as at risk for skin breakdown related to decreased mobility, incontinence, and need for assistance with bed mobility, with interventions for staff assistance with bed mobility, turning, and repositioning, and also identified fall risk related to the need for assistance with ADLs/transfers and medication use, with interventions including encouraging use of the call bell when assistance was needed. Resident #20 stated that the day before the survey, he/she did not get out of bed all day despite asking nurse aides and nurses on both day and evening shifts to be helped out of bed or to sit at the edge of the bed. The resident said he/she likes to get out of bed daily for a few hours around lunchtime and usually eats in the dining room during the week, but on weekends staff did not always get him/her up. On observation the resident was in bed, and later stated he/she had asked the nurse aide earlier in the day to get out of bed and hoped to do so before the aide left. An LPN stated the resident usually requests to get up for lunch and that she had communicated the request to the nurse aide the day before. One nurse aide stated the resident did not get out of bed because the resident did not ask, while the RN supervisor and DNS stated that dependent residents should be offered to get out of bed and that staff should offer even if the resident does not ask.
Failure to Complete RN Assessments and Ordered Skin Monitoring
Penalty
Summary
The facility failed to ensure an RN assessment was completed after newly identified skin issues were observed on a resident’s face and scalp, and failed to ensure weekly body audits were completed as ordered. The resident had diagnoses including anaplastic astrocytoma, epilepsy, and sick sinus syndrome, and had recently returned to the facility after hospitalization for an unwitnessed fall with a hip fracture requiring surgery. A physician’s order directed weekly skin evaluations, and the care plan identified fragile skin with interventions to conduct weekly body audits and document potential causative factors. However, the record did not show body audits were completed in October or November. On observation, two dressings were present on the resident’s head, one on the top of the scalp above the forehead and one at the left temple, each labeled with a date, time, and initials. The clinical record did not contain documentation of wounds on the head or face, wound assessments, or a physician’s order for those areas. An LPN stated she saw multiple lesions and two oozing areas, applied gauze and tape, labeled the dressings, but did not assess the areas, notify the RN supervisor or APRN, or document the wounds in the record. The APRN stated she was aware of prior facial skin lesions but had not been notified of any newly opened or oozing areas and had not been told the areas required a dressing. The facility also failed to ensure a comprehensive RN assessment was completed and documented when another resident had a change in condition. That resident had diagnoses including repeated falls and multiple malignant neoplasms, and the care plan directed staff to monitor and report changes in cognitive function and mental status. Nursing notes documented confusion, right-sided upper and lower extremity weakness, difficulty forming complete sentences, restlessness, inability to lift the right arm or leg, and a right facial droop before transfer to the hospital for stroke evaluation. The record did not show a documented RN neurological assessment at the time the change was identified, and staff interviews reflected uncertainty about whether an RN assessment or APRN notification had been completed.
Missed Weekly Skin Audits and Incomplete RN Assessment for New Coccyx Wound
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for one resident with venous insufficiency, transient ischemic attack, major depressive disorder, moderately impaired cognition, bladder incontinence, and risk for pressure ulcers/injuries. The care plan identified the resident as at risk for skin breakdown due to limited mobility and incontinence, with weekly skin assessments by a licensed nurse and daily observation of skin condition. A physician order directed weekly skin audits with shower on Friday day shift, but the record review found no weekly skin evaluations completed on 8/1/25 or 8/8/25. Nursing notes did not document that the resident refused those weekly skin evaluations, and the DNS stated she would have expected to see documentation of refusals, education, and reapproach if the resident declined care. The record also showed a new open area to the coccyx identified on 7/31/25, with an RN assessment noting the area and notifying the APRN, who ordered cleansing and calcium alginate treatment. On 8/1/25, the resident refused assessment and wound care to the new open area, and on 8/8/25 the resident again refused to be seen by the wound doctor and wound RN for a new wound consultation. A later change-in-condition note and wound specialist follow-up documented a new stage 2 pressure ulcer to the coccyx, with the resident having refused care until that visit. The DNS stated the wound nurse saw the coccyx wound on 8/8/25 and called it a stage 2 but did not document measurements, and she expected a complete RN assessment with wound measurements after refusals were documented.
Failure to Track 24-Hour Fluid Intake for Residents on Dialysis Restrictions
Penalty
Summary
The facility failed to monitor and total fluid intake for residents on dialysis-related fluid restrictions, including two residents reviewed for specialty medical procedures. Resident #2 was admitted with end stage renal disease and congestive heart failure, had intact cognition, was on dialysis, and had a therapeutic diet. The care plan and physician orders directed an 1800 ml per day fluid restriction, with a later order dividing the amount between nursing and dietary. During observation, a renal supplement container with 237 ml of supplement was present at the resident’s bedside, and the resident stated that nurses gave the supplement each day from the original carton and that he/she knew about the fluid restriction. Staff interviews showed there was no clear system for calculating or tracking the resident’s 24-hour fluid total. An LPN stated that nurses documented intake on the TAR each shift and nurse aides documented meal and snack intake in their system, but she did not look daily to see whether the resident remained within the 24-hour restriction and did not know who was responsible for adding up totals across shifts. An RN supervisor stated that the facility did not currently have a resident on fluid restriction that she was aware of, was unsure who was responsible for the 24-hour calculations, and had not looked up any resident’s 24-hour totals in at least a month. The DNS stated there was no one responsible to add the 24-hour total for residents on fluid restrictions related to dialysis and that there was not a system in place. Resident #21 was admitted with end stage renal disease and dependence on renal dialysis. A physician order directed a 1000 ml per day fluid restriction with amounts divided between dietary and nursing across shifts. The quarterly MDS identified intact cognition, hemodialysis, and a therapeutic diet, and the care plan directed encouragement of the fluid restriction. Review of the Kardex Fluid Intake flowsheets and MAR Diet Fluid Restriction flowsheets for 14 days showed the documentation was independent of one another and total fluid intake was not calculated; the resident exceeded the 1000 ml restriction on 10 of those days. Interviews with the resident and multiple staff showed inconsistent awareness of the restriction, uncertainty about where fluid documentation was recorded, and no clear process for tallying daily or 24-hour totals. The DNS stated that the nurse aides documented fluid intake in the Kardex and nurses documented intake in the MAR, but there was no mechanism in place to gather daily totals.
Dental Extraction Delayed When Eliquis Was Not Held
Penalty
Summary
The facility failed to provide dental services for a resident who needed extraction of tooth #21 and was receiving Eliquis, a blood thinner. The resident had a history of Parkinson’s disease and prior thrombosis of the left femoral vein, and the record showed ongoing dental problems including a tooth infection, pain, and a failed root canal. Dental documentation identified that tooth #21 required extraction, and the resident’s care plan noted risk for oral health problems related to broken or missing teeth and anticoagulant therapy. A dental consultation identified that the extraction was planned, but the procedure did not occur on the scheduled date because the resident was receiving Eliquis and it had not been held. The extraction was rescheduled, but on the later date it again did not occur because the Eliquis was still not placed on hold and the resident was unavailable. Review of the medical and nursing progress notes for the period surrounding the scheduled procedures did not identify an APRN review of the dental consultations or a physician order to pause Eliquis for the extraction. Interviews and record review showed that dental appointment information and consultation summaries were sent electronically to the DNS, Unit Manager, and Medical Records staff, but the Unit Manager responsible for follow-up had recently changed. The current Unit Manager stated she was not aware of the resident’s dental appointment details and had no system to track consult findings needing APRN follow-up. The APRN stated she routinely reviewed dental recommendations and would have written an order to hold Eliquis if she had reviewed the consultation, but she could not recall doing so for the missed extraction.
EBP Not Followed and Medication Carts Found Dirty
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions (EBP) for a resident with a stage 3 pressure injury and significant care needs. The resident was admitted with diagnoses including right-sided hemiplegia, stage 3 pressure ulcer of the back, and weakness. The resident’s record showed moderately impaired cognition, bowel incontinence, frequent bladder incontinence, and dependence on staff for toileting, bathing, and dressing. A physician’s order directed EBP because of the wound, and the care plan identified a stage 3 pressure injury to the sacrum. During observation, a PPE cart and EBP signage were posted outside the resident’s room, identifying that staff and providers must wear gloves and a gown for high-contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. A nursing assistant was observed providing oral care while wearing only clear gloves and no gown, then handling soiled linens from the resident’s bed while still wearing only gloves. The nursing assistant used her abdomen to push the soiled linen while holding the bag, and later stated she had not realized the resident was on EBP, had not noticed the PPE cart before entering, and was unsure when PPE was required. Facility staff confirmed the nursing assistant had completed prior EBP in-service training and that additional education would be provided. The facility also failed to keep medication carts clean and sanitary. On one medication cart, loose capsules and tablets were found in a drawer, along with scattered debris and a large amount of powder, crushed unpackaged tablets, opened blister packets, paper, and plastic pieces behind the drawers at the bottom of the cart. On another cart, loose tablets were found in a drawer, including tablets inside a cardboard box with pen needles, and additional debris behind the drawers including broken plastic pieces, unpackaged tablets, a blank wristband, unopened ampules, and a white substance along the interior back and sides of the cart. Licensed nurses stated there was no set schedule for cleaning the carts, one nurse had never looked behind the drawers or at the bottom of the cart, and another nurse had not been educated on cleaning the medication carts.
Failure to Perform and Document Weekly Skin Evaluations
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including anemia, diabetes mellitus, chronic kidney disease, and congestive heart failure, did not receive weekly skin evaluations as required by facility policy. The resident was assessed as having moderately impaired cognition, was always incontinent of bowel and bladder, and was at risk for skin integrity issues, with an actual stage III pressure ulcer present. The care plan specified weekly body audits, but clinical documentation showed that skin evaluations were inconsistently performed, with several weeks and an entire month lacking any documented assessments. There was no evidence in the nursing notes that the resident refused these evaluations during the period in question. The Director of Nursing confirmed that weekly skin checks should have been completed and documented in the electronic medical record, and that refusals should be recorded and communicated to the provider. However, the facility was unable to provide documentation for multiple missed weeks, and the undated facility policy required both daily skin checks by Certified Nursing Assistants and routine checks by licensed nursing personnel. The failure to perform and document weekly skin evaluations as per policy led to the identified deficiency.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices, which showed that staffing levels and licensed nurse coverage were insufficient to meet regulatory requirements.
Failure to Maintain Comfortable Temperatures Due to Air Conditioning System Breakdown
Penalty
Summary
The facility failed to provide residents with a comfortable environment, as evidenced by excessively high temperatures in multiple resident rooms and common areas. Observations on the day of survey revealed room temperatures ranging from 80.2 to 89 degrees Fahrenheit, with several rooms lacking functioning air conditioning units. Residents reported discomfort due to the heat, with one resident stating their room was too warm and another noting that the therapy/rehab room reached 90 degrees Fahrenheit. The facility's air conditioning system was not operational due to leaks in the cooling system lines, and repairs were delayed pending the arrival of necessary supplies. At the time of the survey, only a limited number of portable air conditioning units were available and functioning, despite the facility having a larger number of resident rooms. Interviews with facility staff revealed lapses in communication and awareness regarding the air conditioning system failure. The Director of Maintenance was aware of the issue and had obtained a repair proposal, but the Administrator was not informed of the system's malfunction until the day before the survey and was unaware of the impending heat wave. The Administrator also did not report the loss of air conditioning to the state agency, as required, and was unable to explain the facility's cooling system or identify when she was first notified of the problem. Facility policy required prompt reporting and maintenance of environmental systems to ensure resident comfort, which was not followed in this instance.
Failure to Obtain Daily Weights and Notify Provider of Significant Weight Gain
Penalty
Summary
A deficiency was identified involving a resident with chronic kidney disease who had physician orders for daily weights and provider notification if weight increased by more than two pounds in one day or five pounds in three days. The resident's care plan also included monitoring for weight variations and notifying the provider of significant changes. During a review of January records, it was found that weights were only recorded on seven days, with nine documented refusals by the resident and fifteen days with no weight recorded or refusal documented. Staff interviews confirmed that daily weights were not consistently obtained as ordered, and there was no clear explanation for the missing documentation or lack of follow-up on days when weights were not recorded. Additionally, a significant weight gain of ten pounds over three days was documented, but there was no evidence that the physician or advanced practice registered nurse (APRN) was notified as required by the physician's order. Interviews with the dietician, LPN, DNS, and administrator confirmed that the notification did not occur and that the facility could not provide a policy regarding the process. The failure to obtain daily weights and notify the provider of significant weight changes constituted a failure to provide care and treatment according to physician orders and the resident's care plan.
Failure to Obtain Timely Blood Glucose Monitoring Due to Staff Assignment and Communication Issues
Penalty
Summary
A deficiency occurred when staff failed to obtain a blood glucose measurement prior to a meal for a resident with insulin-dependent diabetes mellitus, as required by physician orders. The resident's care plan specified the need for blood glucose monitoring before meals and at bedtime. On the day of the incident, the assigned LPN was not permitted to provide care to the resident due to a prior family request, and upon realizing this, the LPN notified the supervisor. However, when it was time to check the resident's blood sugar before lunch, the LPN attempted to contact the day supervisor, who was unavailable due to attending to another resident's urgent need. The LPN did not seek assistance from another nurse on the unit and waited for the supervisor, resulting in a two-hour delay in obtaining the blood glucose reading. The resident's blood glucose was eventually checked by the supervisor, with a result of 243, and the family and APRN were notified. Documentation and interviews confirmed that the LPN was aware of the restriction on providing care to the resident and that there was another nurse available on the unit who was not asked to assist. The facility's policy required blood glucose monitoring as per physician orders, but the lack of timely staff coverage and communication led to the delay in treatment for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Hartford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amberwoods Of Farmington | 1.6 mi | ★★★★★ | 10 | 0 |
| Autumn Lake Healthcare At New Britain | 2 mi | ★★★★★ | 0 | 0 |
| West Hartford Health & Rehabilitation Center | 2.5 mi | ★★★★★ | 22 | 0 |
| Hebrew Center For Health And Rehabilitation | 2.6 mi | ★★★★★ | 33 | 0 |
| Parkville Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.