The Reservoir in West Hartford was fined $2,360 after staff failed to give a resident’s spouse proper written notice that the resident was being transferred to another facility. The resident was moved on July 12 and the resident’s spouse opposed the move because it was far from the spouse’s home.

The move came a week after the resident had left the facility despite being identified as an elopement risk and wearing a WanderGuard sensor, the Department of Public Health (DPH) citation said. Police found the resident in a wooded area about 50 feet behind the facility. Staff told the spouse that a state agency requested the transfer.

Officials at the facility did not return a call seeking comment.

Orchard Grove Specialty Care Center in Uncasville was fined $1,945 for two incidents.

A resident identified as a fall risk fell 14 times between Nov. 8, 2016, and April 27, 2017, according to DPH, and suffered a broken rib and other injuries. Interventions were added to the resident’s care plan following each fall, but staff failed to address the resident’s habit of removing alarms and clothing, according to the citation.

Also, a resident with dementia was found twice with empty or partially empty bottles of medication nearby. On March 6, the resident was found with an empty bottle of cough syrup, admitted to drinking half of it and was taken to a local emergency department. On May 9, the resident went to the hospital after a nurse’s aide found an empty bottle of cough syrup and half a bottle of liquid iron supplements in the resident’s nightstand drawer, according to the citation.

In light of the citation, staff identified areas for improvement and strive to provide individualized care to residents, said John Anantharaj, vice president of clinical services at parent company Apple Rehab.

“Orchard Grove continues to work with DPH and regulatory bodies to meet all standards of care,” he said.

Evergreen Health Care Center in Stafford Springs was fined $1,710 after a patient hit a doorframe while riding in a custom wheelchair, breaking a leg on Nov. 16, 2016. The resident was treated at a hospital and modifications were made to the wheelchair to make it safer, according to DPH.

“Evergreen Health Care Center takes very seriously our obligation to provide quality services to our residents,” said administrator Chris McKinney. “As a result of this incident, we have performed an internal review of our processes and will continue to look for ways to improve the care we provide to all our residents.”

Litchfield Woods Health Care Center in Torrington was fined $1,530 after a licensed practical nurse mistakenly administered nine medications to a resident.

On June 5, the resident received medications intended for a roommate, including several cardiac drugs, the citation said. An investigation found the LPN who administered the medications didn’t check the resident’s wrist ID band and the resident was treated at a local emergency department.

Officials did not return a call seeking comment.

Notre Dame Health and Rehabilitation Center in Norwalk was fined $1,530 after a resident with a seizure disorder didn’t receive a prescribed anti-seizure medication for 27 straight days.

The resident was taken to a hospital March 27, after suffering a seizure while being fed by a staff member, DPH said. An investigation found the resident hadn’t received the anti-seizure medication Depakote from March 1 to March 27, despite a physician’s order that it be administered twice daily, according to the citation.

The incident seems to be related to a computer error, according to administrator Dana Paul. The employee involved no longer works at the facility and new protocols were implemented to prevent similar errors from occurring, Paul said.

“It was an isolated situation,” Paul said. “We have rectified the situation. We’re definitely committed to making sure we maintain our high standard within the facility.”

Douglas Manor in Windham was fined $1,530 after a resident suffered several fractures and a 20-centimeter laceration after falling in a bathroom. The resident’s care plan required staff to use a gait belt when assisting with transfers, but two nurse’s aides failed to use the belt on June 4, DPH said. The resident was treated at a local hospital and both aides were suspended.

Officials did not return a call seeking comment.

Cook-Willow Convalescent Home in Plymouth was fined $1,530 after a resident suffered second-degree burns and blisters on several fingers from pureed food.

A nurse’s aide was helping the resident eat dinner on May 21, when the aide turned to get the resident’s coffee and the resident burned several fingers on pureed green beans. The holding temperature of the food was found to be 160 degrees, according to the citation, when protocol dictated hot foods shouldn’t exceed 135 degrees.

Officials did not return a call seeking comment.

Apple Rehab Saybrook in Old Saybrook was fined $720 after a resident was found unresponsive after a meal on April 28. A physician’s order said the resident, who had dementia and dysphagia, must be supervised when eating, but documentation didn’t show staff assisted the resident during breakfast that day, the citation said. The resident was treated at a local emergency department and returned to the facility.

Officials did not return a call seeking comment.

The Reservoir in West Hartford was fined $3,000 after a resident died and investigators found staff did not administer CPR for the required period of time, according to the state Department of Public Health (DPH).

The resident, who was at the facility for short-term rehabilitation, had difficulty breathing on Feb. 6, 2016. A licensed practical nurse (LPN) began performing CPR compressions but soon after, a registered nurse told the LPN to stop the compressions, according to DPH.

Policy states staff must perform CPR until emergency personnel arrive, according to the DPH citation. When emergency personnel arrived, they administered CPR and took the resident to a hospital but the resident was dead on arrival.

“We have provided additional education to our staff and are in full compliance,” said spokeswoman Jeanne Moore. “The Reservoir is committed to providing quality care to its patients and residents.”

Advanced Center for Nursing and Rehabilitation in New Haven was fined $3,000 after a resident with acute kidney injury and other diagnoses died. The citation said the resident’s blood had a critically high level of sodium.

A physician’s order said the resident was to take in between 2,000 and 2,400 cubic centimeters of fluids daily, according to DPH, but records from Feb. 10 to Feb. 20, 2017, lacked entries for 11 out of 30 shifts.

According to the citation, one nurse noted the resident’s poor fluid intake but did not notify supervisors, and another nurse failed to assess the resident. After developing a fever and becoming lethargic, the resident was taken to a hospital Feb. 20 and died there six days later.

Officials at the facility did not return a call seeking comment.

RegalCare of West Haven was fined $1,930 for three incidents.

A resident had a pressure wound on the lower back on Nov. 10, 2016, according to DPH, but a doctor’s order to treat it was not written until Nov. 14 and documentation indicated the wound wasn’t treated until Nov. 16.

Another resident, who was being administered oxygen, was injured behind the left ear Dec. 1, 2016. According to DPH, staff did not put protective ear guards on the resident’s oxygen tank, as is protocol and they misclassified the injury as an abrasion when it was a pressure wound.

Staff kept incomplete records on another, anorexic resident at risk for dehydration, the citation said. The resident was supposed to consume 1,669 cubic centimeters of fluids daily, but documentation for several days between Dec. 6 and Dec. 11, 2016, was incomplete. According to DPH, the resident had an elevated white blood cell count on Dec. 12 and needed intravenous fluids.

Officials at the facility did not return a call seeking comment.

Salmon Brook Center in Glastonbury was fined $1,740 after a resident broke several ribs in a fall. Two nurses’ aides were moving the resident with a mechanical lift on Jan. 27, 2017, when a sling near the resident’s right leg came undone, according to DPH.

The resident was treated at a hospital for multiple broken ribs and excess fluid around the lungs. The aides were given written warnings.

Officials at the facility did not return a call seeking comment.

The Villa at Stamford was fined $1,630 for two incidents.

On Sept. 21, 2016, a housekeeper saw a nurse’s aide hit, push, pull and yell at a resident with dementia while shaving the resident in bed, according to DPH. The aide denied the allegations and was fired six days later.

On Dec. 2, 2016, a resident suffered lacerations to the side of the head and behind one ear after a nurse’s aide tried to turn the resident over while providing incontinence care. The resident, who had Parkinson’s disease and traumatic brain injury, required two-person assistance, according to DPH, but the nurse’s aide tried to move the resident without help. The resident was treated at a hospital and returned to the facility three days later.

Officials at the facility did not return a call seeking comment.

Bayview Health Care in Waterford was fined $1,630 for two violations.

In early 2016, a quadriplegic resident fell on three separate occasions while being repositioned in bed by nurses’ aides. After the first fall, on Feb. 14, the resident’s care plan was updated to require two-person assistance for repositioning, but the resident fell again on March 15 and March 19 when a lone nurse’s aide tried to move the resident.

Another resident suffered a skin tear on the upper shin while being moved on Nov. 21, 2016. According to DPH, the resident’s care plan was updated to require the use of shin tubes on both legs during all transfers, but the resident suffered a 3-inch calf laceration Feb. 16, 2017, when a nurse’s aide failed to use the shin tubes.

On March 15, Leeway Inc. of New Haven was fined $3,000 in connection with a resident who was hospitalized on Feb. 23 with low levels of phosphate and potassium after a medication error. The resident was not given seven doses of potassium chloride despite a doctor’s order, the state Department of Health citation said. A registered nurse said later that she was tired and missed the order, the citation said.

There was a second medication error once the resident returned to the home, and the same nurse missed the doctor’s order for three doses of an anti-depression drug, the DPH citation said. The nurse could not explain why the error happened.

Administrator Heather Aaron said additional auditing of medications is now taking place.

“There was not a pattern here of medical errors,’’ she said. “This was an individual circumstance that we self-reported to the state.”

On May 4, Salmon Brook Center in Glastonbury, which is owned by Genesis Health Care, was fined $1,840 in connection with a resident who fell out of a wheelchair on Dec. 1 and broke a hip after a nurse’s aide left the person at a nurse’s station. Another nurse’s aide did not recall being asked to watch the resident and had gone to assist another resident when the first one fell, the citation said.

The director of nursing said the staff should have been supervising the resident at all times, the citation said.

The home was also cited in connection with a resident with dementia who was able to leave the home on July 4. A video showed a dietary aide had let the resident through a door into a service hallway, where the resident was left alone and got out to a parking lot, the citation said. The home then re-trained the staff on not allowing residents to go into a service hallway unless accompanied by a staff member.

Another Genesis home, The Willows in Woodbridge, was fined $1,635 on April 28 in connection with a resident who fell from a wheelchair on July 14, 2015 and sustained a broken leg.

A nurse’s aide reported turning away from the resident when the resident stood up and fell, the citation said.

In two April 22 citations, The Reservoir in West Hartford, another Genesis home, was fined a total of $1,275 in connection with incidents in May 2015 and September 2015.

The home was fined $735 in connection with a resident who became agitated and refused to go to an emergency room on May 9, 2015. The resident then called 911 and claimed to be in danger, the citation said. The police arrived and sent the resident an emergency room to be evaluated.

DPH found that an advanced practice registered nurse or doctor should have been informed when the resident initially refused to go to the emergency room.

The Reservoir was fined $540 in connection with a newly admitted resident who missed 22 doses of an anti-coagulant medication in September 2015 after a registered nurse supervisor neglected to confirm the medication order, the citation said.

In response to the incident, the staff developed a new protocol verifying medication orders for new admissions, the citation said.

Jeanne Moore, a Genesis spokeswoman, released the following statement in response to the citations: “When a Genesis center receives a deficiency and fine, the center works closely with the state survey agency to quickly regain compliance. The center also provides additional staff education and training when appropriate. Genesis HealthCare centers are committed to providing quality care to its patients and residents.”

On Feb. 5, two fines totaling $2,740 were imposed on the Golden Hill Health Care Center in Milford in connection with an incident July 31 in which a resident broke a leg.

The resident was diagnosed with a broken leg and bruises on Aug. 1, DPH records show. The state found that the home had failed to notify a physician for eight hours after the staff noticed the resident moaning and crying.

The home was also cited in connection with the same incident when DPH found that a nurse’s note failed to document that the resident was assessed after showing signs of pain. Records also showed that the resident was not sent to a hospital emergency room until more than 10 hours after he or she had signs of unrelieved pain, DPH concluded.

Two nurse’s aides were disciplined in connection with the incident, including one aide who made a false statement about the way he or she transferred and showered the resident, records show.

Ben Atkins, chairman of Traditions Senior Management of Clearwater, Florida, said his firm began managing Golden Hill in January for the non-profit Eagle Lake Foundation, which is taking over the home. He pointed out that the citations refer to deficiencies that happened at Golden Hill before his company was involved.

“We’ve very serious about the care we provide,’’ he said.

On Feb. 26, Regency Heights of Stamford was fined $1,370 for several incidents, including one in which a nurse’s aide punched a resident, DPH records show.

On April 16, the resident struck the aide first, and the aide punched the person in the arm, records show. The resident was not injured. A doctor and local police were called and the aide was removed from the unit. A witness said the aide could have just walked away. The aide reported that the resident had “done this to me before and I deserve respect,” DPH’s citation states.

The home was also cited in connection with a May 12 incident in which a resident suffered a broken toe when a shower door inadvertently closed on the resident’s foot, DPH records show. The home found a nurse’s aide should have gotten help in holding the door open, and the aide was given a written warning and re-training, record show.

Regency Heights was also cited in connection with an incident Oct. 20 when a resident fell out of a lift sling and hit his or her head while being moved from a bed to a wheelchair, records show. The resident was hospitalized for three days for a hematoma.

The state found that the aide had failed to check the straps on the lift before moving the resident out of bed, records show. Two aides were provided with additional training because of the incident, records show.

On Jan. 5, 2014, a Regency Heights resident was observed with a large bruise on the face. It was determined that the resident had been moving him or herself in a wheelchair and was not wearing non-skid socks when he or she should have been, records show. A nurse’s aide reported that he or she did not know the resident required non-skid socks, records show.

A DPH found that the resident had fallen four times in 2014 – on July 14, Aug. 10, Sept. 21 and Dec. 21 – and that the home did not revise its care plan after the August and December falls.

Regency Heights was also cited in connection with an incident on Dec. 14, 2014, in which a resident broke a bone in the hand, records show. DPH found that two aides had transferred the resident out of bed using a lift without the consent of a licensed staff member, records show.

The home was also cited in connection with a resident with diabetes who was hospitalized after not being given three doses of a required drug, DPH found. The hospital reported the incident to the state because a doctor felt it would not be safe to return the resident to Regency Heights, DPH records show. Three nurses reported that they could not find the drug, did not call a doctor and did not notify a supervisor, DPH found. One nurse was fired and two were given written warnings, DPH records show.

Administrator Grace Flight said the home is in full compliance with state regulations and “everything has been corrected that was cited.’’

On Jan. 22, Montowese Health and Rehabilitation Center was fined $1,230 in connection with a July 1 incident in which one resident was hospitalized after taking another resident’s medication, DPH records show.

A registered nurse reported going into a room with medication for both residents when he or she heard one of the residents cry out from the bathroom and appeared to be about to fall, records show. The nurse put both residents’ medicine on a table in front of one resident’s bed while helping the other. The nurse found that the resident in bed had taken some of the other resident’s drugs by mistake, records show.

DPH found that the nurse violated the home’s policy, which states that medications should never be left unattended.

“The facility is now back in substantial compliance with federal and state standards of medication practice protocol,’’ Genine Tannoia, director of nursing services at Montowese, said.

On Feb. 5, Masonicare Health Center of Wallingford was fined $1,160 in connection with a resident who fell on April 24 and broke an arm when an aide was transferring the resident from the bed to a wheelchair, records show. The aide admitted that before moving the resident, she had not checked the care plan, which required that two aides move the person using a lift, records show.

Masonicare spokeswoman Margaret Steeves said an investigation was conducted, which led to the firing of the employee involved in the incident.

On Feb. 6, The Reservoir of West Hartford was fined $1,020 in connection with a resident who was given a medication used to treat heart failure for three days in May even though a doctor had ordered it discontinued, DPH records show. The resident was treated at a hospital for toxicity involving the drug Digoxin, records show.

In response to the incident, the licensed nurses were retrained and audits were conducted of all residents on Digoxin, records show. The Reservoir’s administrator declined to comment.

On Feb. 23, Crossings East Health and Rehabilitation Center of New London was fined $1,020 in connection with a resident who developed a pressure sore on Jan. 3 of this year. DPH found that the resident’s care plan lacked documentation that the home had consistently monitored the resident’s skin.

Stacey Brady, a spokeswoman for Crossings East, said the home quickly submitted a correction plan to DPH after the incident and is waiting for word that the plan has been accepted.

“We are committed to providing our patients with the utmost of care,’’ she said.

On Feb. 17, Talmadge Park Health Care of East Haven was fined $420 in connection with a resident who began choking on a piece of sandwich Dec. 11. The resident, who has depression and bipolar disorder, said he or she had tried to choke as a way to commit suicide, records show.

A physician reported that he or she was not informed that it was a suicide attempt until the next day, records show. The resident was hospitalized that day, records show.

Talmadge Park Administrator Ted Vinci said the home’s staff quickly performed the Heimlich maneuver and prevented the resident from choking. He conceded there was unclear communication when the incident was reported to a physician.

“This was an isolated issue and although no disciplinary action was warranted, we have provided additional training for the staff regarding improved communication to physicians,’’ he said.