Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Saint Mary Home during CMS and state inspections, most recent first.
A resident with documented diagnoses including peripheral vascular disease and a signed paper consent form refusing CPR, artificial respiration, and artificial nutrition experienced an unresponsive, pulseless event while on the toilet. The resident’s DNR/DNI status was not entered into the EMR, and when a NA discovered the resident unresponsive, an LPN initiated CPR and called a code, with another LPN later continuing compressions after being told the resident was a full code. CPR continued until EMS reviewed the paper chart, identified the existing DNR/DNI order, and informed staff, at which point CPR was stopped and the resident was pronounced deceased. The DNS acknowledged that the advance directive was not followed because staff did not check the paper chart, and no facility advance directive policy was provided, despite a CPR/AED policy stating CPR should not be started when a valid DNR is in place.
A resident with a history of polio, osteoporosis, and Alzheimer’s dementia, care planned for leg pain and using a customized wheelchair, complained of left foot pain with grimacing during movement. An LPN documented the pain and administered acetaminophen, and the physician assessed the resident, suspected arthritis, and ordered an x‑ray. The x‑ray order was never entered into the EMR and was not carried out. Days later, hospice staff noted severe pain, deformity, and swelling of the left lower extremity during repositioning, leading to a STAT x‑ray that revealed acute displaced distal tibia and fibula fractures. The DNS and physician later acknowledged the original x‑ray order had been missed and that there was no formal physician order policy, with the facility relying on an informal process for entering and finalizing provider orders in the EMR.
A resident with an open LLE wound and wound vac treatment had a malfunctioning vac, and nursing documented that staff were told to use a wet to dry dressing until a replacement arrived. APRN agreed with the protocol, but the chart did not contain a physician order for the wet to dry dressing, and the DON stated the facility relied on nursing guidelines rather than a documented order.
The facility failed to offer and document COVID-19 vaccinations for several residents, despite having a policy in place. Residents with various medical conditions, including Alzheimer's, diabetes, and dementia, were not assessed or offered the vaccine due to unavailability and lack of proper consent procedures. Staff interviews revealed a gap in vaccine administration since early 2023, leading to a deficiency in immunization practices.
The facility did not ensure ongoing review of resident rights, as evidenced by the absence of such reviews in resident council meetings from May to October 2024. Interviews revealed that residents were not routinely informed about their rights, and the facility lacked policies for the resident council. The Therapeutic Recreation Director confirmed that while residents received rights information upon admission, there was no designated time for review during meetings.
The facility failed to properly assess, care plan, and obtain consents for residents placed on the secured dementia unit. Observations revealed that the unit required a key code for access, and staff interviews highlighted a lack of clear guidelines and documentation for placement. Several residents were placed on the unit without proper assessments or documentation, and responsible parties were not always informed of the specific nature of the unit.
The facility failed to maintain sanitary conditions in medication rooms and carts, with expired medications found and missing temperature logs. Staff interviews revealed unclear responsibilities for cleaning and monitoring, leading to inconsistencies in execution. Facility policies for cleaning and storage were not followed, contributing to the observed deficiencies.
The facility failed to administer the pneumococcal vaccine to two residents who had consented to receive it. One resident, with severely impaired cognition, and another who was cognitively intact, both had consented to the vaccine, but there was no documentation of administration. Interviews revealed that charge nurses and supervisors were responsible for the vaccination process, but the Infection Preventionist nurse was not informed of the oversight. The facility's policy required assessment and administration of the vaccine upon admission, which was not followed.
A facility failed to update a care plan for a resident with dementia and a history of falls, who was admitted to a secured unit due to wandering behavior. The care plan did not address the resident's wandering or elopement risk, despite the resident's admission to the secured unit and documented wandering behaviors. Facility policies required such behaviors to be reflected in the care plan, but this was not done.
A resident with dementia and visual impairment did not receive proper nail care, resulting in a brown/black substance under their nails. Despite the resident's resistance to care, the facility's policy required individualized ADL care, which was not documented or provided. Staff interviews confirmed the resident's resistance and the need for nail cleaning, but documentation was lacking.
A resident with left-sided hemiplegia and a care plan requiring two-person assistance for bed mobility and ADLs was provided care by only one nurse aide, contrary to documented requirements. During morning care, the resident lost grip on the bedrail and fell from bed, as confirmed by incident reports and staff interviews. The care provided did not follow the established plan of care.
A resident with left-sided hemiplegia and significant weakness, who required two-person assistance for bed mobility and ADLs, was provided care by only one nurse aide. Despite clear documentation and care plans specifying the need for two staff, the aide proceeded alone, leading to the resident rolling out of bed and falling during morning care. Staff interviews and records confirmed the deviation from the care plan, resulting in a deficiency.
A resident with acute gastroenteropathy, diarrhea, and IV antibiotics required staff assistance to use the bathroom due to an IV pump being plugged into the wall. Staff failed to respond promptly to the call bell, leading the resident to use a bedside wash basin for a bowel movement. The incident was later confirmed by staff and acknowledged by the DON as undignified and inconsistent with resident rights.
Failure to Honor Resident DNR/DNI Due to Lack of EMR Documentation and Chart Review
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented advance directive specifying Do Not Resuscitate/Do Not Intubate (DNR/DNI). The resident was admitted with diagnoses including peripheral vascular disease, cellulitis of the left lower limb, and an unspecified open wound of the left lower limb, and could ambulate with assistance using a four-wheel walker. A “Current Consent for Life Sustaining Procedure” form, located in the resident’s paper chart and signed by both the resident and the Medical Director, documented the resident’s refusal of CPR, artificial respiration, and artificial nutrition. However, this DNR/DNI status was not entered into the electronic medical record. When the resident was later found unresponsive and pulseless on the toilet by a nursing assistant, LPN staff responded assuming the resident was a full code. LPN staff initiated CPR and a code blue was called without first checking the resident’s paper chart for advance directives. One LPN began compressions and another LPN took over CPR after being informed the resident was a full code. CPR continued until EMS arrived and reviewed the resident’s medical records, at which point EMS informed staff that a DNR/DNI order existed in the paper chart. CPR was then stopped and the resident was pronounced deceased. The DNS confirmed that the resident’s advance directives were not followed because the LPN did not review the paper chart, and the facility was unable to provide an advance directive policy. The facility’s existing CPR/AED policy stated that CPR should be initiated unless a valid DNR order was in place or other specific conditions existed, but the resident’s valid DNR/DNI order was not identified or honored at the time of the event.
Missed Physician X‑Ray Order Leads to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received necessary care and services when a physician‑ordered x‑ray for left lower extremity pain was not obtained, resulting in an eight‑day delay in diagnosis of acute displaced fractures of the distal tibia and fibula. The resident had a history of childhood polio, osteoporosis, and Alzheimer’s dementia, and was care planned as being at risk for bilateral leg pain with interventions including pain assessments and monitoring for non‑verbal pain indicators. A rehabilitation screening identified decreased motorized wheelchair driving ability and the need for out‑of‑bed positioning in a customized wheelchair. On one evening, an LPN documented that the resident experienced pain and grimacing with movement of the left foot and administered acetaminophen. The attending physician assessed the resident on site that day, suspected arthritis, and ordered an x‑ray of the left lower extremity. Despite this order, the x‑ray was not entered into the medical record and was not obtained until eight days later, when hospice staff, during repositioning of the resident’s left lower extremity, noted severe pain, deformity, and swelling below the knee, prompting a STAT x‑ray order. The x‑ray subsequently revealed acute mildly displaced spiral fractures of the distal tibia and fibula with diffuse osseous demineralization, and the resident was later transferred to the emergency department, where the fractures were confirmed. Interviews with the DNS and the physician revealed that the original x‑ray order from the earlier assessment was missed and never entered into the EMR, and that the facility had no written physician’s orders policy or protocol, relying instead on a practice in which providers placed draft orders in the EMR for nurses to finalize, or nurses entered orders for covering providers unfamiliar with the EMR.
Missing Physician Order for Wound Vac Malfunction Care
Penalty
Summary
The facility failed to ensure Resident #1’s clinical record was complete and accurate by not documenting a physician order for wound care after the resident’s wound vac malfunctioned. Resident #1 had diagnoses including an unspecified wound and local infection of the skin and subcutaneous tissue, and the admission MDS showed a BIMS score of 15, indicating intact cognition. The resident’s care plan identified an open wound/impaired skin integrity to the left lower extremity with treatment to apply a wound vac on Mondays, Wednesdays, and Fridays, and a physician order directed use of a wound vac at low continuous suction of 125 millimeters. A nursing note documented that the wound vac malfunctioned and that the Infectious Disease Nurse and Med Essentials representative were notified. Staff were advised to apply a wet to dry dressing until a new wound vac would be delivered the next morning, and APRN #1 stated he/she was aware of the malfunction and agreed with the wet to dry dressing protocol. However, the record did not contain a physician order dated 8/31/2025 for the wet to dry dressing, and the DON stated the facility did not have a policy or protocol directing staff what to do when a wound vac malfunctioned, although staff were trained to follow the [NAME] Nursing Procedure and Skills Guidelines. The facility’s Physician Services policy required physician, PA, NP, or CNS orders for the resident’s immediate care and needs.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered and assessed for five residents, leading to a deficiency in immunization practices. Resident #83, admitted with pneumonia, multiple rib fractures, and Alzheimer's disease, had severely impaired cognition and was not offered a COVID-19 booster vaccine. Similarly, Resident #97, who was cognitively intact and admitted with type 2 diabetes mellitus, spinal stenosis, and COPD, was not assessed for past COVID-19 immunization or offered the vaccine. Resident #120, with end-stage renal disease, anemia, and dementia, also had severely impaired cognition and was not offered a COVID-19 booster. Resident #160, cognitively intact and admitted with schizoaffective disorder, a femur fracture, and heart failure, was not up to date with COVID-19 vaccinations and was not offered a booster. Lastly, Resident #187, with a dislocated hip prosthesis and dementia, was not assessed for past COVID-19 immunization or offered the vaccine. Interviews with facility staff revealed that the COVID-19 vaccine was not offered due to unavailability, and consents were not part of the admission packet. The facility's policy required offering the vaccine, but it was last administered in January 2023. Staff were aware of the need for consents and vaccine administration but failed to implement these processes effectively, resulting in a lapse in vaccination offerings and documentation.
Failure to Review Resident Rights in Council Meetings
Penalty
Summary
The facility failed to ensure that resident rights were reviewed on an ongoing basis. A review of the resident council's monthly meeting minutes from May 2024 through October 2024 showed that resident rights were not reviewed during these meetings, nor was resident rights information disseminated to the resident council or residents in general. An interview with the resident council confirmed that the facility did not review resident rights during their meetings and did not routinely provide resident rights information. The Therapeutic Recreation Director stated that residents received a Resident's [NAME] of Rights upon admission, but there was no designated time to review these rights during meetings, and the facility lacked policies addressing the resident council. The Administrator indicated that the recreation department was responsible for conducting the resident council meetings and expected the recreation staff to review resident rights with the residents during these meetings.
Deficiency in Secured Unit Placement and Documentation
Penalty
Summary
The facility failed to adequately assess, care plan, and obtain consents for residents placed on the secured dementia unit, leading to deficiencies in resident care. Observations during the survey period revealed that the secured unit had entrance doors that required a key code for access, and staff were responsible for inputting the code for visitors. The facility assessment indicated that residents with dementia and wandering behaviors would be considered for placement on the secured unit, but it lacked specific criteria or functions for such placement. Interviews with facility staff, including the Administrator, Social Worker, Director of Nursing Services (DNS), and Medical Director, highlighted a lack of clear guidelines and documentation for placing residents on the secured unit. The Administrator and DNS acknowledged that there was no policy for the dementia unit, and placement decisions were made by an interdisciplinary team without consistent documentation or reassessment. The Medical Director noted that while there was a process for placement, it lacked formal guidelines, and provider notes varied among different providers. The report detailed the cases of six residents who were placed on the secured unit without proper assessments or documentation. For instance, one resident with severe dementia and no history of wandering was placed on the unit without a care plan indicating the need for such placement. Another resident was moved to the secured unit without the responsible party being informed of the specific nature of the unit. These cases illustrate the facility's failure to ensure that the secured unit was the least restrictive setting for residents and to obtain necessary consents from families or conservators.
Medication Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that medication rooms and carts were maintained in a sanitary condition and that medications were stored appropriately. Observations revealed expired medications in the overstock cabinets and medication carts, with some medications being several months past their expiration dates. Additionally, the medication storage rooms had refrigerators and freezers with heavy frost accumulation and soiled interiors, and temperature logs were missing for numerous dates. Interviews with nursing staff indicated a lack of clarity regarding responsibilities for cleaning and restocking medication storage areas. Staff members were unsure of who was responsible for monitoring refrigerator temperatures and cleaning out expired medications. The night shift was identified as responsible for these tasks, but there was inconsistency in their execution. The Infection Preventionist and Director of Housekeeping acknowledged the need for defrosting freezers and cleaning soiled refrigerators and medication carts. The facility's policies for cleaning refrigerators and storing medications were not adhered to, as evidenced by the presence of expired medications and unclean storage areas. The policy required regular cleaning by housekeeping and daily temperature checks by the night shift, but these were not consistently performed. The lack of communication between nursing staff and housekeeping further contributed to the deficiencies observed in the medication storage areas.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents, despite having obtained consent for the vaccination. Resident #83, who was admitted with diagnoses including pneumonia, multiple rib fractures, and Alzheimer's disease, had severely impaired cognition. The resident had given consent for the pneumococcal vaccine on June 26, 2024, but the clinical records did not show that the vaccine was administered or that the resident had changed their decision. Similarly, Resident #160, who was cognitively intact and admitted with schizoaffective disorder, a fracture of the right femur, and heart failure, also consented to the vaccine on the same date. However, there was no documentation in the clinical records indicating that the vaccine was administered or that the resident had changed their decision. Interviews with the Infection Preventionist nurse and the Nursing Supervisor/Unit Manager revealed that the charge nurses and supervisors were responsible for obtaining consent, securing a physician's order, ordering the vaccine, administering it, and documenting it in the resident's immunization records. The Infection Preventionist nurse was not informed that the vaccine was not administered, and the charge nurse or supervisor did not notify her of any issues. The facility's policy required that all new residents be assessed for pneumococcal vaccine status upon admission and that the vaccine be administered per physician's order. However, the process was not followed, leading to the deficiency.
Failure to Update Care Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident with a history of dementia and falls, who was admitted to the secured unit due to wandering behavior. Despite the resident's admission to the secured unit and the presence of wandering and exit-seeking behaviors, the care plan did not address these issues. The care plan only included interventions related to the resident's cognitive deficits and activities of daily living (ADL) assistance, without mentioning the resident's wandering or elopement risk. The facility's documentation and interviews revealed that the resident had been moved to the secured unit after wandering off the current unit, yet the care plan was not updated to reflect this change or the associated risks. The facility's policies required that behaviors such as wandering or elopement be reflected in the care plan, but this was not done. Additionally, the facility did not utilize wander guards, which were mentioned in their wandering/elopement policy, further indicating a lack of comprehensive planning for the resident's safety.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident diagnosed with dementia, disorientation, and difficulty swallowing. The resident was identified as severely cognitively impaired, moderately visually impaired, and required moderate assistance for personal hygiene. Observations over several days revealed a brown or black substance under the resident's fingernails on both hands, with some nails having jagged edges. Despite the resident's resistance to care, the facility's policy required individualized ADL care, which was not documented or provided in this case. Interviews with staff indicated that the resident often resisted care, and if the resident refused, care, including nail care, was not provided. The nursing assistant acknowledged the need for nail cleaning, and the unit manager confirmed that assistance would be provided if needed. However, the facility failed to document the resident's ADL care needs as required by their policy, and the NA ADL flow sheets for the last two months were not provided upon request.
Failure to Provide Two-Person Assist as Directed in Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and left-sided hemiplegia, who required extensive two-person physical assistance for bed mobility and activities of daily living (ADLs), was provided care by only one nurse aide. The resident's care plan, physical therapy evaluation, and nurse aide care card all specified the need for two-person assistance at all times due to the resident's inability to use the left side and significant weakness. Despite these documented requirements, a float nurse aide provided care alone during morning care, resulting in the resident rolling out of bed and falling to the floor while attempting to hold onto the bedrail. The incident report and staff interviews confirmed that the nurse aide was aware of the two-person assist requirement but proceeded alone because the other aide was occupied. The resident was unable to maintain grip on the bedrail due to left-sided weakness and subsequently slipped to the floor. Documentation and interviews with nursing staff and administration further verified that the care provided was not in accordance with the established plan of care, as the resident's need for total assistance was not met at the time of the incident.
Failure to Provide Required Two-Person Assistance Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and left-sided hemiplegia, who required extensive two-person physical assistance for bed mobility and activities of daily living (ADLs), was provided care by only one nurse aide. The resident's care plan, physical therapy evaluation, and nurse aide care card all specified the need for two-person assistance at all times due to the resident's inability to use the left side and significant weakness. Despite these documented requirements, a float nurse aide provided care alone during morning care, resulting in the resident rolling out of bed and falling to the floor while attempting to hold onto the bedrail. The resident was unable to maintain grip due to weakness and fell, though no injuries were reported. Interviews and documentation confirmed that the nurse aide was aware of the two-person assist requirement but proceeded alone because the other aide was occupied. The incident report, staff statements, and clinical notes all indicated that the resident's care was not provided in accordance with the established plan, directly leading to the fall. The deficiency was further substantiated by staff interviews acknowledging the deviation from the care plan and the resident's specific needs for assistance.
Failure to Respond Timely to Call Bell Results in Loss of Dignity for Resident with Diarrhea
Penalty
Summary
A resident with diagnoses including acute gastroenteropathy, diarrhea, Methicillin susceptible staph infection, unsteadiness, weakness, and depression required staff assistance to unplug an IV pump before toileting. The resident's care plan identified a self-care deficit, risk for falls, ongoing IV antibiotics, contact precautions for diarrhea and Norovirus, and risk for skin breakdown. The resident was noted to be frequently incontinent of stool and required moderate assistance with ambulation and supervision for transfers. On the date in question, the resident experienced an episode of diarrhea and activated the call bell for assistance, as the IV was plugged into the wall and prevented independent access to the bathroom. Facility staff did not respond to the call bell in a timely manner, resulting in the resident using a bedside wash basin to relieve a bowel movement. Interviews confirmed that the resident was upset about the lack of response and that staff later found the soiled wash basin on top of the garbage can. The Director of Nursing acknowledged that if staff had responded promptly, the resident would have likely used the bathroom, and that the incident was not dignified. Facility policy states residents have the right to dignity and privacy in care, which was not maintained in this instance.
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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) |
|---|---|---|---|---|
| Chelsea Place Care Center Llc | 1.6 mi | ★★★★★ | 8 | 1 |
| West Hartford Health & Rehabilitation Center | 1.6 mi | ★★★★★ | 22 | 0 |
| Hebrew Center For Health And Rehabilitation | 1.8 mi | ★★★★★ | 33 | 0 |
| Parkville Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Bloomfield Center For Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 2 | 0 |
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