The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MASONICARE HEALTH CENTER HOSPITAL 22 MASONIC AVE WALLINGFORD, CT 06492 Feb. 27, 2018
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
The Condition of Participation for Physical Environment has not been meet. Based on observations and hospital documentation review, the Hospital failed to ensure that the physical environment of the psychiatric unit was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others resulting in a finding of Immediate Jeopardy.

Please see A701
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations and hospital documentation review, the Hospital failed to ensure that the physical environment of the psychiatric unit was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others resulting in a finding of Immediate Jeopardy.


a. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathroom doors, corridor doors, smoke detectors, wall clocks, and patient call bell cords in patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 provided a ligature point that could enable a resident with suicidal tendencies to inflict harm upon themselves.
b. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have over bed lighting grids that can be easily removed, providing residents with a sharp tool that could enable a resident with to inflict harm upon themselves or others.
c. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have window shades installed that can be easily removed, providing residents with a sharp tool that could enable a resident with to inflict harm upon themselves or others.
d. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathrooms within patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have a recessed ceiling light fixture that lacks a device or process to prohibit patients from removing the light bulb and/or gaining access to an energized electrical outlet.
e. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathroom door hardware and corridor door hardware within patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 lack tamper resistant fasteners as required in an in-patient psychiatric program setting.

Interview with the Director of Support Services on 2/26/18 at 10:05 AM and again on 2/27/18 at approximately 12:30 PM identified that environmental rounds were conducted on 9/11/17 and as a result, all new patient beds were purchased and the call bell cords on the beds were zip-tied. The door hinges were not identified as a hazard.

As a result of the above findings, the Hospital instituted an immediate action plan that included removal of all bed cords, removal of all clocks and screws, and covering all smoke detectors. In addition, all patient's were reassessed for suicidality and self-harm. No patients were identified as suicidal or having self-harm tendencies. Nursing staff instituted every 15 minute environmental rounds which will continue until all identified hazards have been mitigated.
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Participation for Patient Rights has not been met. Based on observations and hospital documentation review, the Hospital failed provide a safe environment on the psychiatric unit when it was identified that the unit was not designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others resulting in a finding of Immediate Jeopardy.

Please see A144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations and hospital documentation review, the Hospital failed provide a safe environment on the psychiatric unit when it was identified that the unit was not designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others resulting in a finding of Immediate Jeopardy.


a. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathroom doors, corridor doors, smoke detectors, wall clocks, and patient call bell cords in patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 provided a ligature point that could enable a resident with suicidal tendencies to inflict harm upon themselves.
b. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have over bed lighting grids that can be easily removed, providing residents with a sharp tool that could enable a resident with to inflict harm upon themselves or others.
c. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have window shades installed that can be easily removed, providing residents with a sharp tool that could enable a resident with to inflict harm upon themselves or others.
d. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathrooms within patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 have a recessed ceiling light fixture that lacks a device or process to prohibit patients from removing the light bulb and/or gaining access to an energized electrical outlet.
e. During tour of the geriatric medical psychiatric program on 02/26/18 at approximately 10:00 AM the surveyor, accompanied by the Director of Support Services, observed that the bathroom door hardware and corridor door hardware within patient rooms 424, 425, 422, 423, 421, 420, 419, 417, 416, 418, 415, 413, 410, 408, 411, 407, 406, and 404 lack tamper resistant fasteners as required in an in-patient psychiatric program setting.

Interview with the Director of Support Services on 2/26/18 at 10:05 AM and again on 2/27/18 at approximately 12:30 PM identified that environmental rounds were conducted on 9/11/17 and as a result, all new patient beds were purchased and the call bell cords on the beds were zip-tied. The door hinges were not identified as a hazard.

As a result of the above findings, the Hospital instituted an immediate action plan that included removal of all bed cords, removal of all clocks and screws, and covering all smoke detectors. In addition, all patient's were reassessed for suicidality and self-harm. No patients were identified as suicidal or having self-harm tendencies. Nursing staff instituted every 15 minute environmental rounds which will continue until all identified hazards have been mitigated.