Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
81% occupied
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 9
Date: Aug 29, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility environment at West Hartford Health & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe and homelike environment, inadequate discharge planning and notification, incomplete and outdated care plans, delayed treatment orders, improper IV flush administration, incomplete respiratory care orders, unsanitary ice machines, lack of hospice care planning, and failure to maintain water management flushing documentation.
Deficiencies (9)
Failed to ensure a safe, clean, comfortable, and homelike environment; chipped and worn bedside tray tables and peeling wallpaper not reported or repaired.
Failed to ensure transfer/discharge met resident's needs and preferences; resident discharged AMA without proper notification or physician involvement.
Failed to update care plan to accurately reflect pressure ulcer status and resident preferences.
Failed to provide appropriate treatment and care according to orders and resident preferences; delayed treatment orders for post-fall injury.
Failed to ensure proper administration of IV flushes according to policy and orders; flushed heparin before saline.
Failed to ensure respiratory equipment settings were obtained and reflected in physician orders.
Failed to maintain ice machines in a sanitary manner; buildup of black substance inside machines.
Failed to ensure receipt of renewal orders and initiate end-of-life care plan for hospice resident.
Failed to maintain records of monthly water flushes according to water management plan.
Report Facts
Residents reviewed for environmental concerns: 4
Residents reviewed for discharge: 1
Residents reviewed for pressure ulcer: 3
Residents reviewed for accidents/fall: 2
Residents reviewed for antibiotic therapy: 1
Residents reviewed for respiratory care: 1
Ice machines observed: 3
Days delay in treatment orders: 6
Days delay in hospice care plan initiation: 137
Days delay in hospice certification renewal: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in environmental concerns finding regarding bedside tray table |
| NA #8 | Certified Nurse Aide | Named in environmental concerns finding regarding bedside tray table |
| Infection Preventionist | Conducts environmental rounds; unaware of bedside tray table condition | |
| Administrator | Interviewed regarding environmental concerns and discharge AMA | |
| Person #1 | Responsible party involved in Resident #146 LOA and discharge AMA | |
| Social Worker #1 | Interviewed regarding discharge AMA and hospice care plan | |
| Social Worker #2 | Interviewed regarding discharge AMA | |
| APRN #1 | Advanced Practice Registered Nurse | Involved in wound care and post-fall assessment |
| RN #2 | Registered Nurse | Spoke to Resident #146 with slurred speech |
| LPN #5 | Licensed Practical Nurse | Involved in Resident #146 LOA and Resident #9 IV flush administration |
| RN #1 | Infection Preventionist/Wound Nurse | Responsible for updating care plans and wound care |
| PT #2 | Physical Therapist | Interviewed regarding fall of Resident #126 |
| OT #1 | Occupational Therapist Assistant | Witnessed fall of Resident #126 |
| ADNS | Assistant Director of Nursing | Interviewed regarding post-fall documentation and hospice certification |
| DNS | Director of Nursing | Interviewed regarding post-fall documentation and IV flush policy |
| Physical Plant Director | Interviewed regarding ice machine cleaning and water flushing | |
| Regional Director of Environmental Services | Interviewed regarding ice machine cleaning | |
| Special Projects Supervisor | Covered for Physical Plant Director during leave; interviewed about water flushing | |
| Financial Director | Business Office Manager | Interviewed regarding hospice certification paperwork |
Inspection Report
Renewal
Census: 130
Capacity: 160
Deficiencies: 0
Date: Aug 29, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations #1200044, CT#2584350, and CT#2595375.
Complaint Details
Complaint investigations #1200044, CT#2584350, and CT#2595375 were reviewed during the inspection. No substantiation status is provided.
Findings
The report indicates that the inspection was a renewal licensing inspection with complaint investigations reviewed. No explicit findings or violations are detailed in the provided page.
Report Facts
Licensed Bed Capacity: 160
Census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Personnel contacted during inspection |
| Candace Pettigrew | DNS | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Aug 29, 2025
Visit Reason
Unannounced visits were made to West Hartford Health & Rehabilitation Center on August 29, 2025, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
The report includes complaint investigations related to abuse allegations involving Resident #124, which were determined to be unsubstantiated. The facility failed to notify local law enforcement due to the resident's history of accusatory behaviors and multiple phone calls made by the resident to police on their own.
Findings
The report identifies multiple violations of Connecticut State Agencies regulations related to environmental concerns, abuse allegations, discharge procedures, pressure ulcer care, fall investigations, respiratory care, medication storage, dietary services, and infection control. The facility failed to maintain a safe, clean environment, notify law enforcement of abuse allegations, provide proper discharge notices, update care plans, conduct thorough fall investigations, ensure respiratory equipment orders were current, properly manage medication storage, maintain sanitary ice machines, and document monthly water flushes.
Deficiencies (10)
Facility failed to ensure a safe, clean, comfortable, and homelike environment; bedside tray tables had worn and chipped edges, walls and wallpaper were damaged and peeling.
Facility failed to notify local law enforcement following an allegation of abuse.
Facility failed to allow a resident to return after therapeutic leave, failed to involve interdisciplinary team in discharge, and failed to notify appropriate state agency of resident not returning from leave of absence.
Facility failed to provide written notice to resident prior to discharge and failed to inform resident regarding right to appeal.
Facility failed to ensure staff updated care plan to accurately reflect pressure ulcer status and failed to follow pressure ulcer prevention and management policies.
Facility staff failed to complete comprehensive post fall investigation, provide ongoing documentation, and obtain treatment orders for injury.
Facility failed to ensure respiratory equipment settings were obtained and reflected in physician orders.
Facility failed to ensure expired medications were discarded, labeled appropriately, and personal items belonging to staff were not stored in medication rooms.
Facility failed to ensure 2 out of 3 ice machines were maintained in a sanitary manner.
Facility failed to maintain records of monthly water flushes according to water management plan.
Report Facts
Residents reviewed for environmental concerns: 4
Residents reviewed for abuse allegation: 1
Residents reviewed for discharge: 1
Residents reviewed for pressure ulcer care: 1
Residents reviewed for fall investigation: 1
Residents reviewed for antibiotic therapy: 1
Residents reviewed for respiratory care: 1
Medication rooms reviewed: 4
Ice machines observed: 3
Plan of correction completion dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Signed the notice letter at the end of the report |
| Theresa Sanderson | Administrator | Named as facility administrator in the notice letter |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding Resident #4's bedside tray table condition |
| NA #8 | Certified Nurse Aide | Interviewed regarding Resident #4's bedside tray table condition |
| Infection Preventionist | Interviewed regarding environmental rounds and wallpaper condition | |
| Administrator | Interviewed multiple times regarding various findings and plans of correction | |
| RN #1 | Registered Nurse | Interviewed regarding wound care and fall investigation for Resident #126 |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding flushing of central line for Resident #9 |
| Social Worker #1 | Interviewed regarding Resident #146 discharge and leave of absence issues | |
| Social Worker #2 | Interviewed regarding Resident #146 discharge and leave of absence issues | |
| Director of Physical Plant | Interviewed regarding environmental rounds and ice machine maintenance | |
| Financial Director | Business Office Manager | Interviewed regarding hospice certification paperwork |
Inspection Report
Census: 136
Capacity: 160
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The visit was a desk audit conducted on 1/17/24 to review compliance with regulations and verify the implementation of the plan of correction.
Findings
The administrator was notified that the implementation of the plan of correction was approved. As a result of this desk audit, no deficiencies and/or violations were identified.
Report Facts
Licensed Bed/Bassinet Capacity: 160
Census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Admin | Personnel contacted on 1/17/24 at 1:30 pm during the desk audit |
Inspection Report
Deficiencies: 2
Date: Aug 30, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding timely reporting of suspected abuse, neglect, or injury, and to assess appropriate treatment and care for residents, specifically focusing on Resident #80 who sustained an injury of unknown origin and experienced a significant change in condition.
Findings
The facility failed to report Resident #80's injury of unknown origin to the state survey agency and failed to ensure timely assessment and medical evaluation of the resident's head injury while on anticoagulant medication. The injury was noted but not reported due to staff speculation about its cause, and the resident was not assessed promptly by nursing staff, delaying medical evaluation.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or injury to the state survey agency for Resident #80's injury of unknown origin.
Failure to provide appropriate treatment and care by not ensuring timely assessment and medical evaluation of Resident #80's head injury while on anticoagulant medication.
Report Facts
Date of injury report: May 12, 2023
Date of survey completion: Aug 30, 2023
Medication dosage: 2.5
Date of physician progress note: May 15, 2023
Date of nursing progress note: May 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #2 | Advanced Practice Registered Nurse | Notified of injury on 5/12/23, did not assess resident on injury date, stated protocol for blood thinner patients with head injury is ER evaluation |
| RN #2 | Registered Nurse | Reported injury to APRN #2, did not assess resident on injury date because resident was asleep, assessment delayed until 5/15/23 |
| Administrator | Interviewed on 8/30/23, stated injury was not reported to state survey agency because it was not considered suspicious or significant |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to allegations of mistreatment and concerns related to resident care, injury reporting, pressure ulcer prevention, nurse aide performance evaluations, infection control, and dementia training compliance.
Complaint Details
The visit was complaint-related due to allegations of mistreatment of Resident #125 and concerns about injury reporting, medical assessment, pressure ulcer care, nurse aide evaluations, infection control, and dementia training. The facility was investigating the mistreatment allegations. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure dignified treatment of residents, timely reporting of injuries, appropriate medical assessment, consistent pressure ulcer prevention, completion of nurse aide performance evaluations, proper infection control practices, and provision of required dementia training hours for nurse aides.
Deficiencies (7)
Failed to ensure resident was treated and spoken to in a dignified manner, including incidents of mistreatment and verbal abuse.
Failed to timely report suspected abuse, neglect, or injury of unknown origin to the state survey agency.
Failed to provide timely assessment and medical evaluation for a resident with a significant change in condition and head injury while on anticoagulant medication.
Failed to consistently implement measures to prevent development of pressure ulcers, including failure to offload heels as ordered.
Failed to complete annual performance evaluations for nurse aides.
Failed to utilize personal protective equipment (PPE) during indwelling catheter care as required by enhanced barrier precautions.
Failed to ensure nurse aides received the required eight hours of dementia training for the year 2022.
Report Facts
Deficiencies cited: 7
Pressure ulcer size: 3
Deep tissue injury size: 1.1
New stage two pressure ulcer size: 1
Dementia training hours required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #125 | Resident | Named in mistreatment and dignified care deficiency. |
| Resident #80 | Resident | Named in injury reporting and medical assessment deficiencies. |
| Resident #38 | Resident | Named in pressure ulcer prevention deficiency. |
| Resident #53 | Resident | Named in infection control deficiency. |
| Social Worker #1 | Social Worker | Interviewed regarding Resident #125's concerns. |
| Administrator | Facility Administrator | Interviewed regarding investigation and facility policies. |
| APRN #2 | Advanced Practice Registered Nurse | Involved in assessment of Resident #80's injury. |
| RN #2 | Registered Nurse | Involved in assessment and reporting of Resident #80's injury. |
| RN #5 | Registered Nurse / Infection Control Nurse | Provided infection control interview and observations. |
| LPN #3 | Licensed Practical Nurse | Observed not wearing gown during catheter care. |
| RN #1 | Registered Nurse | Observed Resident #38's heel positioning and provided education. |
| APRN #1 | Advanced Practice Registered Nurse / Wound Specialist | Provided wound care notes for Resident #38. |
| DNS | Director of Nursing Services | Interviewed regarding nurse aide performance evaluations and pressure ulcer prevention. |
| RN #4 | Staff Development Nurse | Interviewed regarding dementia training documentation. |
Inspection Report
Renewal
Census: 139
Capacity: 160
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations numbered 34571, 33411, 33129, and 32884.
Findings
The report indicates that this was a licensing renewal inspection with referenced complaint investigations. No violations or citations were explicitly noted in this document.
Report Facts
Complaint Investigations Referenced: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Personnel contacted during the inspection. |
| Candace Pelligrini | Nurse | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 160
Deficiencies: 1
Date: Jul 28, 2022
Visit Reason
A Complaint Investigation Survey was conducted at West Hartford Health and Rehabilitation Center on 7/20/22 and 7/28/22 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
Complaint Investigation Survey, ACTS Reference Number CT #32539.
Findings
No deficiencies were cited as a result of this survey, but Violation #1 was cited.
Deficiencies (1)
Violation #1 was cited
Report Facts
Capacity: 160
Census: 134
Inspection Report
Complaint Investigation
Census: 134
Capacity: 160
Deficiencies: 1
Date: Jul 20, 2022
Visit Reason
Unannounced visits were made to West Hartford Health & Rehabilitation Center to conduct a Complaint Investigation Survey to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, based on Complaint Investigation CT# 32539.
Complaint Details
Complaint Investigation CT# 32539 was substantiated with findings including failure to report a fall with injury as a reportable event and inadequate monitoring and documentation related to Resident #3's fall and injury.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified, including a failure to ensure a fall that required hospital transfer was properly managed, resulting in Resident #3 requiring sutures. The facility failed to report the fall as a reportable event to the State Agency and had deficiencies in monitoring and documentation.
Deficiencies (1)
Failure to ensure a fall that required hospital transfer was reported and managed properly, resulting in Resident #3 requiring sutures and not being reported as a reportable event.
Report Facts
Licensed Bed Capacity: 160
Census: 134
Complaint Number: 32539
Compliance Date: Aug 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Named in relation to complaint investigation and findings |
| Bonni Horwitz | DNS | Personnel contacted during inspection |
| Rebecca Harris | RN | FLIS staff who signed inspection report |
| Errolee Miller | RN | FLIS staff who signed inspection report |
| Judith Birtwistle | Supervising Nurse Consultant | Signed the important notice letter regarding the complaint investigation |
Inspection Report
Follow-Up
Census: 121
Capacity: 160
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
A desk audit review was conducted on 7/23/2021 to review the plan of correction for the violation letter dated 6/2/2021.
Findings
The review of information identified that all violations cited in the previous inspection have been corrected.
Report Facts
Licensed Bed: 160
Census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Personnel contacted during the inspection. |
| Maria Taylor | RN, NC | Representative of FLIS who conducted the desk audit review and signed the report. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 2, 2021
Visit Reason
The inspection was conducted as a regulatory annual survey of West Hartford Health & Rehabilitation Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for bowel regimen, incomplete investigation of a resident fall with major injury, failure to perform weekly weights as ordered, medication administration errors with falsified documentation, inadequate infection control practices, and unsanitary conditions in medication storage areas.
Deficiencies (6)
Failure to follow physician's orders related to bowel regimen for Resident #367, resulting in constipation and abdominal pain.
Failure to complete a thorough investigation regarding a resident (Resident #115) who sustained a major fracture after a fall.
Failure to perform weekly weights as ordered for Resident #99, impacting nutrition monitoring.
Medication administration errors for Residents #58 and #94, including late administration and falsified documentation.
Failure to maintain infection control standards for donning and doffing PPE and handling soiled linen.
Medication storage equipment and medication storage rooms were not maintained in sanitary conditions.
Report Facts
Medication error rate: 7.69
Weight difference: 3
Number of shifts without bowel movement: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings for falsifying medication administration times. |
| RN #1 | Registered Nurse | Provided information on bowel protocol and weight documentation responsibilities. |
| LPN #2 | Licensed Practical Nurse | Administered suppository to Resident #367 and provided interview about bowel regimen. |
| NA #2 | Nursing Assistant | Observed breaching infection control practices related to PPE and soiled linen handling. |
| Administrator | Interviewed regarding fall investigation and facility policies. | |
| Dietician | Interviewed regarding weight monitoring and nutrition interventions for Resident #99. | |
| APRN #2 | Advanced Practice Registered Nurse | Interviewed regarding medication administration orders for Resident #94. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 12, 2021
Visit Reason
Unannounced visits were made to West Hartford Health & Rehabilitation Center by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an inspection.
Complaint Details
Complaint #29576 and #29617 were referenced in the report.
Findings
The facility was found noncompliant with several regulations including failure to ensure comprehensive care plans for residents with suicidal intent, failure to review and revise care plans timely after unauthorized leaves, failure to secure medications on medication carts, and failure to ensure clinical records were complete and accurate regarding frequent checks monitoring and psychosocial support documentation.
Deficiencies (4)
Failure to ensure a comprehensive care plan included staff direction regarding every two-hour safety checks for a resident with a history of suicidal intents.
Failure to review and revise the plan of care timely after an unauthorized leave from the facility for a resident.
Failure to ensure medications were secure and not left unattended on a medication cart.
Failure to ensure the clinical record was complete and accurate to include frequent checks monitoring and psychosocial support documentation.
Report Facts
Date of inspection visit: Mar 12, 2021
Plan of correction submission deadline: Apr 8, 2021
Medication pills observed: 3
Observation time: 7
Safety check interval: 15
Audit frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the violation letter and referenced in relation to complaint investigations |
| Theresa Sanderson | Administrator | Named as recipient of the violation letter |
| Licensed Practical Nurse (LPN) #1 | Observed medication cart unattended and interviewed regarding medication security | |
| Director of Nursing (DON) | Interviewed regarding medication security and clinical record documentation |
Inspection Report
Plan of Correction
Census: 133
Capacity: 160
Deficiencies: 4
Date: Sep 2, 2020
Visit Reason
An unannounced visit was made to West Hartford Health & Rehabilitation Center which concluded on September 2, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to COVID-19 infection control and complaint investigation.
Complaint Details
The visit included a complaint investigation identified by complaint number CT27426. The complaint was related to COVID-19 infection control practices and mask use on the dementia unit. The complaint was substantiated as the facility was found noncompliant with mask use and infection control requirements.
Findings
The facility was found noncompliant with regulations regarding the use of face masks on residents in the dementia unit, failure to conduct specific risk assessments for mask use, and inadequate COVID-19 infection control practices including cohorting and PPE use. Several residents were observed without masks and staff reported challenges with mask tolerance among residents with dementia.
Deficiencies (4)
Residents #1, #3, #4, and #7 had problems with noncompliance wearing face masks and removing masks even with encouragement on the dementia unit.
Facility failed to conduct specific risk assessments related to appropriate use of masks for each resident.
Failure to ensure residents with possible exposure to COVID-19 were cohorted according to CDC guidance and infection control standards.
Failure to ensure proper use of PPE and infection control procedures on the COVID-19 positive unit including donning and doffing of PPE.
Report Facts
Licensed beds: 160
Census: 133
Date of onsite inspection: Apr 29, 2020
Date of onsite inspection: Apr 21, 2020
Date of onsite inspection: Mar 14, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Named in relation to the facility administration during inspection and findings. |
| Bonnie Horwitz | Director of Nursing | Named in relation to the facility administration during inspection and findings. |
| Norma Schuberth | Supervising Nurse Consultant | Signed the plan of correction letter dated June 10, 2021. |
| Jacqueline Ruot | Supervising Nurse Consultant | Signed the plan of correction letter dated March 23, 2021. |
| Janet Peynado-Daley | RN, MSN | Report submitted by on April 29, 2020. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 2, 2020
Visit Reason
An unannounced visit was conducted at West Hartford Health & Rehabilitation Center by the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility failed to conduct risk assessments for safe and appropriate use of masks and failed to encourage or reapply the use of facemasks on a dementia unit, resulting in noncompliance with infection control regulations.
Deficiencies (1)
Failure to conduct risk assessments for safe and appropriate use of masks and failure to encourage or reapply facemasks on a dementia unit.
Report Facts
Residents reviewed for infection control: 7
Date of compliance: Sep 24, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the plan of correction letter. |
| Theresa Sanderson | Administrator | Named as facility administrator in the report. |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 1, 2020
Visit Reason
An unannounced visit was made to West Hartford Health & Rehabilitation Center on July 1, 2020, by the Department of Public Health for the purpose of conducting a Covid-19 focused infection control survey.
Findings
The survey identified violations of Connecticut state regulations related to infection control and cohorting of residents exposed to COVID-19. Specific findings included improper cohorting of residents who required transmission-based precautions, residents sharing rooms with others who had recovered from COVID-19, and failure to ensure residents wore facemasks or had privacy curtains closed to provide protective barriers.
Deficiencies (3)
Failure to ensure residents with possible exposure to COVID-19 were cohorted according to CDC guidance and infection control standards.
Residents requiring transmission-based precautions were sharing rooms with residents who had recovered and met criteria for residing on a negative/unexposed unit.
Residents who required transmission-based precautions were not wearing facemasks and privacy curtains between beds were not closed to provide a protective barrier.
Report Facts
Vacant beds: 44
Transmission-based precautions duration: 14
Plan of Correction effective date: Jul 1, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Author of the violation letter. |
| RN #1 | Infection Preventionist | Interviewed regarding COVID-19 cohorting recommendations. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 2, 2020
Visit Reason
An unannounced visit was conducted on June 2, 2020, by the Facility Licensing and Investigations Section of the Connecticut Department of Public Health to perform a COVID-19 focused infection control survey at West Hartford Health & Rehabilitation Center.
Findings
The facility failed to ensure appropriate infection control practices during the COVID-19 pandemic, specifically involving improper doffing of personal protective equipment by a staff member leaving a COVID-19 positive unit, contrary to CDC guidelines and facility policy.
Deficiencies (1)
Failure to ensure appropriate infection control practices were implemented to prevent and control the spread of infection during the COVID-19 pandemic, including improper removal of gloves and isolation gown by a staff member leaving a COVID-19 positive unit.
Report Facts
Date of visit: Jun 2, 2020
Plan of correction submission deadline: Jun 20, 2020
Date effective for plan of correction: Jun 12, 2020
Time of observation: 1055
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Facility administrator addressed in the notice |
| Jacqueline Ruot | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations |
| Director of Nursing | Observed staff member during infection control survey and responsible for plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 2, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure appropriate infection control practices were implemented to prevent and control the spread of infection during the COVID-19 pandemic. Specifically, a nurse aide was observed leaving a COVID-19 positive unit without properly doffing personal protective equipment (PPE) before disinfecting equipment outside the unit.
Deficiencies (1)
Failure to ensure appropriate infection control practices during COVID-19, including improper doffing of PPE by staff leaving a COVID-19 positive unit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding infection control observation and policies. | |
| Nurse Aide #1 | Observed leaving COVID-19 positive unit without proper doffing of PPE. |
Inspection Report
Abbreviated Survey
Census: 110
Capacity: 160
Deficiencies: 0
Date: May 19, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 6, 2020
Visit Reason
A COVID-19 Focused Survey was conducted on May 6, 2020 at West Hartford Health and Rehabilitation to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
Deficiencies were not cited as a result of this survey, indicating compliance with infection prevention and control requirements related to COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 6, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at West Hartford Health and Rehabilitation Center.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2020
Visit Reason
An unannounced visit was conducted to investigate compliance with infection control regulations at West Hartford Health & Rehabilitation Center.
Complaint Details
The investigation was triggered by concerns regarding infection control practices related to COVID-19. The complaint was substantiated by observations and record reviews confirming room sharing of COVID-19 positive and negative residents.
Findings
The facility failed to ensure that a COVID-19 negative resident did not share a room with a COVID-19 positive resident. The Director of Nursing stated that both residents remained in the same room because the facility treated all residents as if they were COVID positive, despite several empty rooms being available.
Deficiencies (1)
Failure to ensure that a COVID-19 negative resident did not share a room with a COVID-19 positive resident.
Report Facts
Plan of correction submission deadline: May 16, 2020
Resident sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and provided contact for questions regarding violations. |
| Theresa Sanderson | Administrator | Named as the facility administrator in relation to the violation and plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2020
Visit Reason
A COVID-19 Focused Survey and complaint investigation was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Complaint Details
The visit was complaint-related and included a substantiated deficiency regarding infection prevention and control related to COVID-19 cohorting and room sharing.
Findings
The facility failed to ensure that a COVID-19 negative resident (Resident #3) did not share a room with a COVID-19 positive resident, despite having several empty rooms available. The facility treated all residents as if COVID positive and did not place isolation signs on doors. Resident #3 required assistance and the privacy curtain between roommates was open during observation.
Deficiencies (1)
Failure to ensure that a COVID-19 negative resident did not share a room with a COVID-19 positive resident.
Report Facts
Date of survey: Apr 29, 2020
Plan of correction completion date: May 22, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding room sharing and infection control practices |
| NA #3 | Nursing Assistant | Interviewed regarding resident care and privacy curtain use |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 29, 2020
Visit Reason
An unannounced visit was made to West Hartford Health & Rehabilitation Center on April 29, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility failed to ensure that a resident who was COVID-19 negative did not share a room with a resident who tested positive for COVID-19. The Director of Nursing indicated that both residents remained in the same room due to mobility limitations and the facility treated all residents as if they were COVID positive without posting signs for droplet and contact precautions.
Deficiencies (1)
Failure to ensure that a COVID-19 negative resident did not share a room with a COVID-19 positive resident.
Report Facts
Date effective: May 22, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter from Facility Licensing and Investigations Section |
| Theresa Sanderson | Administrator | Administrator of West Hartford Health & Rehabilitation Center named in the letter |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2020
Visit Reason
A COVID-19 Focused Survey and complaint investigation was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Complaint Details
The visit was complaint-related and included a COVID-19 focused survey. The complaint involved infection control practices related to COVID-19 cohorting and isolation procedures.
Findings
The facility failed to ensure that a COVID-19 negative resident (Resident #3) did not share a room with a COVID-19 positive resident, despite having several empty rooms available. The facility treated all residents as if COVID positive and did not place isolation signs on doors. Education and corrective actions were planned to address cohorting and response to lab results.
Deficiencies (1)
Failure to ensure a COVID-19 negative resident did not share a room with a COVID-19 positive resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding room sharing of COVID-19 positive and negative residents and infection control practices. | |
| NA #3 | Interviewed regarding care assistance and privacy curtain use for Resident #3. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 21, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found the facility compliant with no deficiencies cited related to infection prevention and control practices for COVID-19.
Inspection Report
Follow-Up
Census: 138
Capacity: 160
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
A desk audit was conducted on 8/14/19 to review the implementation of the plan of correction dated 6/14/19, to ensure implementation and compliance.
Findings
The desk audit found that the facility was implementing the plan of correction related to previous deficiencies. The audit focused on compliance with wound assessment protocols and other corrective measures.
Report Facts
Licensed Bed: 160
Census: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Personnel contacted during inspection |
| Megan Edson-Sawyer | RN, Nurse Consultant | Conducted the desk audit |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 14, 2019
Visit Reason
Unannounced visits were made to West Hartford Health & Rehabilitation Center which concluded on June 14, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation of noncompliance.
Findings
The facility failed to ensure that weekly wound assessments were conducted and/or documented in the clinical record for one resident, resulting in a partial amputation due to wet gangrene. The facility identified the responsible staff and implemented corrective measures including education, audits, and assigning responsibility to the Director of Nursing.
Deficiencies (1)
Failure to ensure weekly wound assessments were conducted and documented for Resident #1, leading to inadequate wound management and partial amputation.
Report Facts
Date of wound tracking note: Nov 14, 2018
Number of occasions wound was assessed: 7
Date of hospital summary: Mar 1, 2019
Date of APRN progress note: Mar 2, 2019
Date of interview with Infection Control Nurse #2: Jun 13, 2019
Date of interview with Administrator: Jun 14, 2019
Plan of correction submission deadline: Jul 8, 2019
Corrective measure effective date: Jul 26, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant from Facility Licensing and Investigations Section |
Inspection Report
Follow-Up
Census: 134
Capacity: 160
Deficiencies: 1
Date: Mar 14, 2019
Visit Reason
The visit was a desk audit and onsite inspection to review the institution's plan of correction for a violation letter dated 3/27/19 and to verify correction of previous violations.
Findings
Based on observations and interview with the Director of Nurses, all violations 1a, 2a, 3a & b, 4a & b, 5a, 6a, and 7a were corrected. The desk audit was conducted on 5/23/19 with narrative report attached.
Deficiencies (1)
Violations 1a, 2a, 3a & b, 4a & b, 5a, 6a, and 7a were corrected
Report Facts
Licensed Bed: 160
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Millicent Reynolds | RN | Inspector who conducted the inspection and authored the report |
| Bonnie Horwitz | DNS | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 21, 2018
Visit Reason
An unannounced visit was made to West Hartford Health & Rehabilitation Center on December 21, 2018 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility failed to ensure a policy was in place to direct staff on procedures to follow once Cardio-Pulmonary Resuscitation (CPR) is required. Resident #1 had a choking episode requiring CPR and transfer to hospital. The Director of Nurses confirmed no CPR policy was in place, though the facility follows American Heart Association guidelines and requires CPR certification for licensed staff.
Deficiencies (1)
Facility failed to ensure a policy was in place to direct staff members on procedures to be followed once Cardio-Pulmonary Resuscitation (CPR) is required.
Report Facts
Date of resident data: Aug 28, 2018
Date of nurse note: Nov 4, 2018
Date of interview: Dec 21, 2018
Date of correction: Feb 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Caron | Supervising Nurse Consultant | Signed letter directing response to deficiencies |
| Theresa Sanderson | Administrator | Facility administrator addressed in the letter |
| Director of Nurses | Interviewed on 12/21/18 regarding CPR policy absence |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 150
Deficiencies: 1
Date: Dec 2, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to complaint investigation #CT 24472 and violations of Connecticut General Statutes and regulations were identified.
Complaint Details
Complaint investigation #CT 24472 was substantiated with violations identified and a violation letter dated 2019-01-09.
Findings
The facility was found to have deficiencies including failure to have a policy in place for CPR and medical emergencies, requiring all licensed staff to have CPR certification. A plan of correction was developed and education provided to nursing staff.
Deficiencies (1)
Facility failed to ensure a policy was in place to direct staff on procedures for Cardio-Pulmonary Resuscitation (CPR).
Report Facts
Licensed Bed Capacity: 150
Census: 139
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Horwitz | Director of Nursing | Named in relation to the CPR policy deficiency and interview during complaint investigation. |
Inspection Report
Renewal
Census: 132
Capacity: 160
Deficiencies: 1
Date: Jan 12, 2017
Visit Reason
The inspection was conducted as a renewal licensure inspection combined with complaint investigations #20065, #20221, and #19506, and a certification survey.
Complaint Details
The inspection included complaint investigations #20065, #20221, and #19506. Specific substantiation status is not stated.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. The facility failed to ensure complete and accurate medical records for a resident involved in a fall incident, among other deficiencies.
Deficiencies (1)
Failure to ensure that the medical record was complete and accurate for Resident #131 who had a fall incident.
Report Facts
Licensed Bed Capacity: 160
Census: 132
Inspection Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Sanderson | Administrator | Named in relation to the plan of correction and inspection process. |
| Helen Sullivan | ONS | Personnel contacted during inspection. |
| Cher Michaud | Supervising Nurse Consultant | Signed the letter detailing violations and inspection findings. |
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