Cycle 1
Health 2024-11-12 · Fire 2024-11-12
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
West Hartford, CT
Saint Mary Home
3-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2021 Albany Ave, West Hartford, CT
(860) 570-8200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
256
Certified beds
Average residents
194
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,127
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.08
Baseline 15.79% · Performance 18.61% · Measure score 6.08 · Achievement 6.08 · Improvement 0
Healthcare-associated infections
5.96
Baseline 4.50% · Performance 6.05% · Measure score 5.96 · Achievement 5.96 · Improvement 0
Total nurse turnover
9.17
Baseline 24.52% · Performance 26.22% · Measure score 9.17 · Achievement 9.17 · Improvement 0
Adjusted total nurse staffing
2.63
Baseline 4.07 hours · Performance 3.83 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.33% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 304 · Observed rate 12.83% · Lower 95% interval 9.82% |
| Discharge to community | 56.65% |
50.57%
6.1 pts better
|
Better than the National Rate · Eligible stays 302 · Observed rate 50.33% · Lower 95% interval 51.15% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 142 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 47.93% |
53.69%
5.8 pts worse
|
Numerator 58 · Denominator 121 |
| Discharge mobility score | 38.02% |
50.94%
12.9 pts worse
|
Numerator 46 · Denominator 121 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 144 · Adjusted rate 1.43% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 4.49% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 0.3% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 331 |
| Staff flu vaccination coverage | 65.07% |
42%
23.1 pts better
|
Numerator 218 · Denominator 335 |
| Discharge function score | 52.89% |
56.45%
3.6 pts worse
|
Numerator 64 · Denominator 121 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 81 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 21.84% |
25.2%
3.4 pts worse
|
Numerator 19 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.5%
12.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.4%
0.1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.1% · Q3 3.1% · Q4 4.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
17.1%
17.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.4%
2.7 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.2% · Q3 4.1% · Q4 1.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
17.3%
6.3 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.1% · Q3 10.3% · Q4 10.8% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
19.4%
8.1 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.6% · Q3 10.3% · Q4 11.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
18.1%
2.4 pts better
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 15.7% · Q3 17.6% · Q4 19.5% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
18.4%
0.3 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 18.4% · Q3 23.0% · Q4 17.8% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.6% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.5% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
24.8%
0.7 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 24.9% · Q3 26.1% · Q4 25.4% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.4%
1.4 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.1% · Q3 2.2% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
70.5%
28.7 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
11.1%
2 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
69.7%
29.7 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
25.0%
8.5 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 15.2% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-16 · Fire 2022-02-16
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-07-25 · Fire 2019-07-25
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-11-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-12
K902 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-12
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-12-11
E · Potential for more than minimal harm
2022-02-16
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-02-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-02-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-02-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-24
D · Potential for more than minimal harm
2019-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-09-04
D · Potential for more than minimal harm
2019-07-25
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-09-04
D · Potential for more than minimal harm
2019-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-04
D · Potential for more than minimal harm
2019-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-04
D · Potential for more than minimal harm
2019-07-25
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2019-09-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-26
F · Potential for more than minimal harm
2024-11-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-12
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-12
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-09-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-06-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-01-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-15
G · Actual harm
2022-02-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-03-28
E · Potential for more than minimal harm
2022-02-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-03-28
E · Potential for more than minimal harm
2022-02-16
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2022-03-28
E · Potential for more than minimal harm
2022-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-03-28
D · Potential for more than minimal harm
2019-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-08-30
Penalties and ownership
What sits behind the stars
Ownership
Mercy Community Health Inc.
5% Or Greater Direct Ownership Interest · Organization
Bowens, Marcus
Corporate Officer · Individual
Demaida, Rachael
W-2 Managing Employee · Individual
Hamilton-Crawford, Janice
Corporate Director · Individual
Hamilton-Crawford, Janice
Corporate Officer · Individual
Johnson, Patrick
Corporate Director · Individual
Kane, Ann
Corporate Director · Individual
Latovick, Pamela
Corporate Director · Individual
Latovick, Pamela
W-2 Managing Employee · Individual
Mckeon, Patricia
Corporate Director · Individual
Murphy, Peter
Corporate Director · Individual
Raman, Shyamala
Corporate Director · Individual
Singh, Gagandeep
Corporate Director · Individual
Trinity Continuing Care Services
5% Or Greater Indirect Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Walker, Mark
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Chelsea Place Care Center LLC
Hartford, CT
1-star overall rating with 1-star inspections with abuse icon flag with $32,295 in total fines with 21 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
West Hartford Health & Rehabilitation Center
West Hartford, CT
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hebrew Center For Health And Rehabilitation
West Hartford, CT
4-star overall rating with 4-star inspections with $27,927 in total fines with 6 recent health deficiencies
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