Inspection Report
Renewal
Census: 111
Capacity: 120
Deficiencies: 0
May 4, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations identified by numbers CT43689, CT43497, and CT43399.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. Certification files were reviewed as part of the process.
Complaint Details
Complaint investigations referenced by numbers CT43689, CT43497, and CT43399 were reviewed during this inspection.
Report Facts
Licensed Bed Capacity: 120
Census: 111
Inspection Report
Complaint Investigation
Census: 100
Capacity: 120
Deficiencies: 0
Feb 19, 2025
Visit Reason
A Complaint Investigation Survey was conducted at Civita Care Center at Danbury on February 19, 20, and 21, 2025, to determine compliance with 42 CFR Part 483 requirements for long term care facilities.
Findings
Deficiencies and/or violations were cited as a result of this survey.
Complaint Details
Complaint Investigation Survey with ACT Reference Numbers CT #42886, #43112, and #43121.
Report Facts
Licensed Bed Capacity: 120
Census: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chioma Thomas | Administrator | Personnel contacted during the inspection. |
| Angela Cohen | Director of Nursing (DNS) | Personnel contacted during the inspection. |
| Farah Passard | Assistant Director of Nursing (ADNS) | Personnel contacted during the inspection. |
Inspection Report
Census: 113
Capacity: 120
Deficiencies: 0
Jan 30, 2025
Visit Reason
The inspection was a Desk Audit conducted on 1/30/25 to review compliance and licensing status of the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this desk audit inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chioma Thomas | Administrator | Personnel contacted during the inspection on 1/30/25 at 11:45 AM |
Inspection Report
Original Licensing
Deficiencies: 28
Sep 27, 2024
Visit Reason
The document is a Change of Ownership Pre-Licensure Consent Order for BH Danbury LLC d/b/a Civita Care Center at Danbury seeking an initial license to operate a Chronic and Convalescent Nursing Home at 107 Osborne Street, Danbury, CT.
Findings
The report outlines extensive requirements and conditions for licensure including the appointment of an Independent Nurse Consultant (INC), Environmental Consulting Firm (ECF), staffing requirements, quality assurance programs, and detailed plans of correction addressing facility compliance with state and federal regulations. Numerous facility deficiencies and corrective actions are detailed in the Plan of Correction, including structural, safety, and operational issues that must be addressed within specified timeframes.
Deficiencies (28)
| Description |
|---|
| Ceiling tiles in kitchens, soiled utility rooms, janitors’ closets, and laundry areas lack required cleanable/washable/non-porous surfaces. |
| Food storage racks in dietary department have non-cleanable surfaces not promoting a clean and sanitary environment. |
| Wallpaper throughout the facility is peeling, marring, and damaged requiring audit and repair or replacement. |
| Sidewalks do not provide a level, safe, or reliable exit discharge and require repair. |
| Improper signage on liquid oxygen storage room, not compliant with NFPA 99. |
| Doors equipped with delayed egress do not have required signage per NFPA 101 Life Safety Code. |
| Hand sanitizers throughout the facility lack proper storage and have caused damage to flooring. |
| Furniture throughout the facility lacks cleanable or sanitary surfaces and requires replacement. |
| Handwashing sinks in medication rooms lack proper 6-inch wrist blades for infection control. |
| Corroded and damaged drainpipes on 3-bay sinks in dietary department require replacement. |
| Malfunctioning grease separator allowing overflow of food-based material. |
| Elevator prone to frequent breakdowns requiring repair or replacement. |
| Two boilers are not operational and require repair or removal. |
| One of two circulator pumps is not operational and requires repair or removal. |
| Damaged gates for dumpster require replacement. |
| Rotted wooden retaining wall at top of parking lot requires replacement. |
| Resident windows throughout the facility lack screens. |
| Folding table in laundry room lacks cleanable/washable/sanitary surface and requires replacement. |
| Shower cores lack cleanable surfaces or have improper grouting requiring repair or replacement. |
| Railings throughout the facility are worn and damaged from hand sanitizer and require repair or replacement. |
| Windows and screens are fogged with broken or missing seals requiring audit and repair. |
| Resident room 312 has more than 20% of walls covered with combustible materials not compliant with NFPA. |
| Ice machines require audit for reliability, cleanliness, and proper operation. |
| Nurses’ station and office chairs require audit for damage and cleanable surfaces. |
| Air conditioning unit is not functioning properly and requires repair or replacement. |
| Exit discharge walkways have unsafe grade changes requiring repair. |
| Sprinkler heads are loaded per NFPA 25 and require inspection and repair. |
| Hemco call bell system lacks parts availability and requires evaluation or replacement. |
Report Facts
Plan of Correction completion timeframe: 12
Signage installation timeframe: 180
Audit completion timeframe: 90
Inspection completion timeframe: 60
Inspection completion timeframe: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eli Schwarcz | Manager, Member of LLC | Member of Licensee who executed the Pre-Licensure Consent Order. |
| Lorraine Cullen | Branch Chief, Healthcare Quality and Safety Branch, Department of Public Health | Department representative executing the Pre-Licensure Consent Order. |
| Jay Pepper | Managing Member | Signed the letter concluding the Plan of Correction document. |
| Robert Boulanger | Certified Fire Inspector 221 | Prepared the Plan of Correction report for fire safety and facility compliance. |
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