Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Hebrew Center For Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, PTSD, depression, and impaired mobility returned to the facility with wandering and agitation, then had an unwitnessed fall followed by worsening confusion, restlessness, and combativeness. Staff did not notify the on-call provider when the behaviors escalated overnight, and after an APRN determined the resident needed urgent ED evaluation for psychiatric and medical assessment, transfer was delayed for several hours.
A resident with dementia-related behaviors, PTSD, depression, weakness, and an unsteady gait was transferred to the ED for increased confusion and behavioral changes. Although the resident’s bed was still available, the facility refused readmission and issued a discharge notice citing behavioral concerns and alleged danger to self or others, but the record lacked documentation supporting that conclusion. Staff and the APRN reported the resident was confused but redirectable, calm, and not violent or dangerous, and no alternative accommodations were explored before the refusal.
A resident with dementia, CHF, AFib, HTN, and a DVT missed ordered doses of apixaban, clopidogrel, and hydralazine when an LPN documented the meds were unavailable during the med pass. The LPN did not check Pyxis emergency stock or notify the supervisor or provider, and the MAR recorded the doses as Other/See Nurse Notes despite the meds being stocked in Pyxis.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with MS, bipolar disorder, borderline personality disorder, generalized anxiety, and antisocial behavior was care-planned and documented on the resident care card as requiring two-person assistance for all ADLs, including bathing, bed mobility, toileting, personal hygiene, dressing, and transfers, with two staff present during extensive care due to psychosocial and behavioral issues. Despite this, multiple NAs on different shifts reported routinely providing incontinence care, personal hygiene, and repositioning alone, and one NA acknowledged knowing the two-person requirement but choosing to perform early-morning incontinence care independently without consistently checking the care card. The resident later reported that this NA was rough and rushed during turning and incontinence care, and nursing leadership confirmed that, according to the care plan and facility policies, two staff should have been present for ADL care but were not.
A resident with dementia, depression, and HTN had conflicting advance directive documentation: one consent form showed CPR and all life-saving measures, while later physician orders and care plan entries listed DNR/DNI, no tube feeding, and RN pronouncement of death. The record did not contain signed consent showing the resident or HCP approved the change, and the HCP said they agreed verbally but did not sign any authorization. Facility policy required written HCP consent for DNR with two witnesses.
Two residents in a facility experienced mistreatment by a nursing assistant, leading to substantiated allegations of abuse. One resident, with depression and anxiety, was allegedly hit in the eye with a towel and had a railing slammed on their hand. Another resident, with anxiety and depression, faced intimidation and was denied a requested large cup of coffee. The facility's investigation confirmed the abuse, resulting in the termination and suspension of the NA involved.
A resident with Alzheimer's was punched by another resident with bipolar disorder and dementia in the hallway. The aggressor became agitated when the victim walked in front of them and expressed intent to hit before doing so. Staff were unable to redirect the aggressor, leading to the incident.
A resident with dementia and osteoporosis was verbally abused by a nurse aide, but the incident was not reported immediately as required by the facility's policy. An OT overheard the abuse but delayed reporting it to the DON for thirteen days, contrary to the immediate reporting policy.
Delayed provider notification and transfer after fall with escalating behaviors
Penalty
Summary
The facility failed to notify the on-call provider when a resident’s behaviors and altered mental status escalated after an unwitnessed fall, and then failed to immediately transfer the resident after an APRN determined the resident required urgent psychiatric and medical evaluation in the Emergency Department. The resident had diagnoses including dementia with behavioral disturbances, PTSD, depression, muscle weakness, and unsteadiness on feet, and was readmitted to the facility in a different room after a prior hospital transfer. On readmission, the resident was documented as alert to person and place only, with cognitive and hearing impairments, an unsteady gait, impaired thought processes, and a history of wandering and refusing care and treatments. After returning to the facility, the resident was noted to be wandering, going through a roommate’s belongings, confused, agitated, and placed on 15-minute checks with fall mats and a request for psychiatric APRN evaluation. The resident received trazodone for insomnia. During the overnight shift, the resident had an unwitnessed fall and was found sitting on the floor mat next to the bed. The record documented no injuries and that the on-call APRN was notified about the fall, but the record did not identify that the resident’s increasing confusion, restlessness, or combativeness after the fall were reported to the provider during the night. By morning, staff documented the resident as confused, restless, combative, and difficult to redirect. An APRN evaluated the resident and identified acute behavioral changes, continued confusion, and the need for urgent psychiatric and medical evaluation, directing transfer to the ED. Emergency services were not contacted until more than three hours later. Interviews confirmed staff observed escalating behaviors after the fall, that the on-call provider should have been notified overnight, and that the resident should have been transferred immediately after the APRN assessment. The facility policy required provider notification for significant changes in physical, mental, or psychosocial status and documentation of the assessment and notification.
Improper refusal to readmit resident after ED transfer
Penalty
Summary
The facility failed to permit a resident to return after a hospital ED visit, even though the resident’s bed had not yet been filled and there was no documentation that readmission would endanger the health or safety of the resident or others. The resident had been admitted with diagnoses including dementia with behavioral disturbances, PTSD, depression, muscle weakness, and unsteadiness on feet. The clinical record showed the resident was alert to person and place only, had cognitive and hearing impairments, and had an unsteady gait related to a right toe amputation. After readmission, nursing documentation described the resident as confused, restless, wandering to the roommate’s side of the room, and going through belongings, but staff redirected the resident to the nurse’s station and gave PRN trazodone, which was documented as effective. Later documentation and staff interviews identified the resident as confused but redirectable, with behaviors consistent with dementia, and staff stated the resident did not wander into other residents’ rooms or display violent or dangerous behaviors. The APRN stated she was unaware of any dangerous behaviors or incidents and had not documented any assessment indicating the resident posed a danger to others. When the resident was transferred to the ED for increased confusion and behavioral changes, emergency services documented the resident as alert but confused at baseline, calm, cooperative, and voicing no complaints. The facility then notified the responsible party that it would not readmit the resident due to behavioral concerns and issued a discharge notice stating the resident’s health or safety, or that of others, would be endangered by readmission. However, the record did not contain documentation supporting that conclusion, and interviews with the DON, Admissions Director, and multiple nursing staff confirmed there was no documentation of violence, dangerous wandering, or other safety risk, and no alternative accommodations were explored before the refusal to readmit.
Missed Ordered Medications and Failure to Notify Provider
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and failed to notify the provider of missed doses for one resident with dementia with behavioral disturbances, hypertension, congestive heart failure, longstanding persistent atrial fibrillation, and a left upper extremity DVT. The resident’s care plan identified altered cardiac status, a DVT to the left upper arm, and risk for adverse effects related to anticoagulation therapy, with interventions to administer medications as ordered. Physician orders included apixaban 5 mg twice daily for DVT prophylaxis, clopidogrel bisulfate 75 mg daily for blood clot prevention, and hydralazine 50 mg every eight hours for hypertension. Medication administration notes documented that clopidogrel, apixaban, and hydralazine were not given because the medications were not available during the morning medication pass, and the MAR showed those doses were scheduled but recorded as Other/See Nurse Notes. The LPN stated the medications had not arrived from the pharmacy, did not check the Pyxis for emergency supply, and did not notify the nursing supervisor or provider of the missed doses. The APRN stated licensed nurses are required to administer medications per order, check emergency stock when medications are unavailable, and notify the provider when a dose is missed. The DON stated the medications were stocked in the Pyxis and should have been removed and administered per order, and that staff are required to notify the nursing supervisor and provider when medications are unavailable or doses are missed.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Implement Two-Person ADL Care Plan for High-Needs Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan that required two-person staff assistance for all activities of daily living (ADLs) and care for a resident with multiple sclerosis, bipolar disorder, borderline personality disorder, generalized anxiety, and antisocial behavior problems. The resident’s quarterly MDS showed intact cognition, total dependence on staff for toileting hygiene, and substantial/maximal assistance needs for personal hygiene and bathing. The resident’s care plan and resident care card both specified that two staff were required for bathing, bed mobility, toileting, personal hygiene, dressing, transferring, and that two staff should be present for extensive assistance with care due to psychosocial and behavioral issues, including accusatory statements toward staff. Facility policies required that ADL assistance be provided per the person-centered evaluation and care plan and that comprehensive care plans be implemented by qualified staff and monitored by clinical department heads. Despite these directives, multiple NAs reported providing care alone. On the night in question, the bladder elimination flowsheet documented that at approximately 5:30 AM the resident was incontinent and care was provided by a single NA, who later confirmed she performed turning, incontinence care, and brief changing by herself, despite knowing the resident was care-planned for two-person assistance. She stated she sometimes did not check the resident care cards and believed one person could perform the care. Other NAs on different shifts also reported independently providing incontinence care, personal hygiene, and repositioning, and one NA stated she had never seen two staff provide ADL care for this resident. The resident later alleged that the night-shift NA was rough and rushed during incontinence care and turning, and interviews with nursing leadership confirmed that, per the care plan, two staff should have been present for ADLs and that this did not occur.
Advance directive consent and DNR documentation were not properly obtained
Penalty
Summary
The facility failed to implement advance directives according to Resident #57’s expressed wishes and failed to obtain proper written consent from the resident’s health care representative for a DNR order. Resident #57 had diagnoses including dementia, depression, and high blood pressure. The clinical record showed a consent form indicating the resident elected CPR and all life-saving measures, while a physician’s order later directed DNR, DNI, no tube feeding, and RN pronouncement of death. The annual MDS identified moderately impaired cognition, and the RCC note documented that advance directives were reviewed and that the resident remained full code, with Social Services noting the health care representative confirmed full-code status. The record later contained conflicting documentation showing the resident’s advance directives as DNR/DNI, no tube feeding, and RN may pronounce death, but review of the clinical record found no signed consent forms or documentation showing that the resident or the health care representative approved the change from full code to DNR/DNI, no tube feeding, and RN pronouncement of death. Person #1 stated they discussed the DNI/DNR status with staff and agreed with the change, but did not sign any consent or forms authorizing it. RN #6 stated verbal consent may be obtained with two witness signatures for CPR or DNR/DNI, but could not explain why the advance directive form lacked the year and had only one witness signature. The facility policy required surrogate decision-making/HCP consent for a DNR order to be in writing and signed in the presence of two witnesses.
Failure to Protect Residents from Abuse and Mistreatment
Penalty
Summary
The facility failed to protect two residents from mistreatment, resulting in substantiated allegations of abuse. One resident, diagnosed with depression and anxiety, alleged that a nursing assistant (NA) hit them in the eye with a towel and slammed a railing on their hand. The resident was alert and oriented, requiring assistance with self-care. The incident was reported, and the facility's investigation confirmed the abuse, leading to the termination of the NA's employment. The resident expressed feeling ignored and frustrated during the incident. Another resident, also diagnosed with anxiety and depression, alleged intimidation and bullying by the same NA. The resident was independent in eating but required assistance with activities of daily living (ADLs) due to functional limitations and chronic pain. The NA failed to provide the resident with a large cup of coffee as requested, citing a lack of resources, which was later contradicted by the Food Services Director. The facility's investigation substantiated the allegation of abuse, and the NA was suspended. The facility's abuse policy emphasizes the right of residents to be free from abuse, including the deprivation of goods or services. The facility's documentation revealed that staff education on abuse and the facility's abuse policy was initiated following the incidents. However, the report focuses on the deficiencies and events leading to the mistreatment of the residents, highlighting the failure to ensure a safe and respectful environment for the residents involved.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
Resident #4 was not protected from physical abuse when they were punched in the back by Resident #5 while walking in the hallway. Resident #4, who has Alzheimer's disease, insomnia, and cognitive communication deficit, was identified as having difficulty making decisions and required minimal assistance with daily activities. Resident #5, diagnosed with bipolar disorder, dementia, and anxiety, also had difficulty making decisions and required supervision for most activities. On the morning of the incident, Resident #5 became agitated when Resident #4 walked in front of them and, despite Resident #4's attempt to move, Resident #5 struck them in the back. The incident was documented in a nurse's progress note and a Facility Reported Incident form, which detailed that Resident #5 expressed intent to hit Resident #4 before doing so. The Director of Nursing confirmed that both residents were unable to recall the incident details. A nurse aide on duty at the time reported that Resident #5 was agitated and not able to be redirected by staff, leading to the physical altercation. The facility's abuse policy states that each resident has the right to be free from abuse, which includes protection from other residents.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with dementia and osteoporosis in a timely manner. The resident was dependent on staff for most activities of daily living and rarely or never made decisions regarding tasks of daily life. On a specific date, an Occupational Therapist (OT) overheard a nurse aide allegedly telling the resident to 'shut up.' However, the OT did not report this incident immediately as required by the facility's abuse policy, which mandates immediate reporting of any observed, reported, or suspected abuse to administrative staff or a nursing supervisor. The incident was only reported to the Director of Nursing (DON) thirteen days later, at which point the facility completed and submitted a reportable event report to the State Agency. The delay in reporting was contrary to the facility's policy, which requires immediate notification of any abuse allegations. The facility's documentation and interviews confirmed the delay in reporting, highlighting a lapse in adherence to the established protocol for handling abuse allegations.
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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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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) |
|---|---|---|---|---|
| West Hartford Health & Rehabilitation Center | 1.2 mi | ★★★★★ | 22 | 0 |
| Saint Mary Home | 1.8 mi | ★★★★★ | 3 | 0 |
| Autumn Lake Healthcare At West Hartford | 2.6 mi | ★★★★★ | 21 | 0 |
| Chelsea Place Care Center Llc | 2.7 mi | ★★★★★ | 8 | 1 |
| Parkville Care Center | 2.9 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.