Inspection Reports for
Civita Care Center at Danbury

The complaint investigation involved incidents where Resident #79 and Resident #91 engaged in a physical altercation, and Resident #1 exhibited suicidal ideation and aggressive behavior towards Resident #87, including throwing a remote control causing a bruise. The facility was unable to substantiate abuse by Resident #1 but acknowledged the incidents and initiated corrective actions.

The facility failed to ensure residents were free from verbal and physical abuse by other residents, including incidents of physical altercations and aggressive behaviors. The facility initiated plans of correction including separation of residents, increased monitoring, staff education, and behavioral interventions.

The complaint investigation involved substantiated incidents of resident-to-resident abuse, including verbal threats and physical altercations. Resident #91 was placed on 1:1 monitoring and transferred to the emergency department after an altercation with Resident #79. Resident #1 was transferred twice to the emergency department for suicidal ideation and was involved in an incident where he/she threw a remote control at Resident #87, causing injury. The facility was unable to substantiate intentional abuse by Resident #1 but acknowledged the incidents and initiated corrective actions.

The facility failed to ensure residents were free from verbal and physical abuse by other residents, with documented incidents involving Residents #79, #91, #1, and #87. The facility initiated plans of correction including separation of residents, increased monitoring, behavioral interventions, and staff education limited to a short timeframe.

The facility was found deficient in multiple areas including failure to complete self-administration assessments and obtain physician orders, failure to honor resident code status wishes, inadequate notification of skin issues, failure to prevent resident-to-resident abuse, failure to provide bed hold policy notices, incomplete PASARR coordination, incomplete care planning for combative residents, failure to follow medication monitoring orders, failure to obtain oxygen orders post hospitalization, inadequate supervision and safety in smoking areas, inconsistent monitoring of fluid restrictions, incomplete annual employee evaluations, pharmaceutical service deficiencies including unresolved medication discrepancies and unlabeled medications, failure to complete controlled drug audits, failure to document weekly pressure ulcer assessments, failure to implement enhanced barrier precautions for a resident with an indwelling device, and failure to timely offer pneumococcal vaccines.

The facility had multiple deficiencies including failure to complete self-administration assessments, honor resident code status wishes, notify physicians and representatives of skin issues, prevent resident-to-resident abuse, provide bed hold policy notices, incorporate PASARR recommendations, revise care plans for combative residents, follow medication orders and monitoring, ensure safe smoking practices, monitor fluid restrictions for dialysis patients, complete annual employee evaluations, maintain pharmaceutical controls, document pressure ulcer assessments, implement infection control precautions, and timely offer pneumococcal vaccines.

The complaint investigation was substantiated. Resident #1 fell during a transfer when staff did not use the required mechanical lift and was not assessed by an RN prior to being moved. The resident sustained serious fractures and required hospitalization and surgery.

The facility failed to ensure that Resident #1 was assessed by an RN prior to transfer after a fall, and staff did not follow the resident's plan of care requiring mechanical lift assistance. Resident #1 sustained serious injuries including fractures due to improper transfer and lack of supervision.

The complaint investigation was triggered by a fall incident on 1/22/2025 involving Resident #1, who was non-ambulatory and required mechanical lift assistance. Staff failed to follow the care plan, resulting in the resident falling and sustaining fractures. The investigation confirmed that no RN assessment was done prior to transferring the resident after the fall.

The facility failed to ensure that Resident #1 was assessed by a registered nurse prior to transfer after a fall, and staff did not follow the resident's care plan requiring mechanical lift assistance. Resident #1 sustained fractures and was transferred to the hospital. Interviews and documentation confirmed staff negligence in following transfer protocols.

The complaint investigation involved an alleged resident-to-resident abuse incident on 11/16/2024 where Resident #5 was seen holding a curtain around Resident #4's neck and physically pushing Resident #4. The investigation was unsubstantiated due to lack of evidence on how the curtain was wrapped. Resident #5 was placed on 1:1 monitoring and transported to the hospital. The facility expressed concerns about Resident #5's re-admission due to safety risks.

The facility failed to ensure Resident #5 was free from abuse after Resident #5 was observed holding a curtain around Resident #4's neck, squeezing Resident #4's arm, and pushing Resident #4 with a walker. The investigation was unsubstantiated due to lack of evidence on how the curtain became wrapped around Resident #4. Additionally, the facility failed to maintain complete and accurate medical records for Resident #3 regarding Foley catheter urine output documentation.

The complaint investigation involved an alleged resident-to-resident abuse incident on 11/16/2024 where Resident #5 was seen holding a curtain around Resident #4's neck and physically pushing Resident #4. The investigation was unsubstantiated due to lack of evidence on how the curtain was wrapped. Resident #5 was placed on 1:1 monitoring and transported to the hospital. The facility expressed safety concerns about Resident #5's re-admission.

The investigation found that Resident #5 was observed holding a curtain around Resident #4's neck, squeezing Resident #4's arm, and pushing Resident #4 with a walker. The facility was unable to substantiate the abuse due to lack of evidence on how the curtain became wrapped around Resident #4. The facility requested consultation with the hospital regarding Resident #5's re-admission due to safety concerns. Additionally, a separate deficiency was found related to incomplete documentation of urine output for Resident #3 with a Foley catheter.

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.

The investigation was complaint-related, focusing on missed documentation of medication administration. The complaint was substantiated with findings of multiple missed signatures by the assigned RN during the shift.

The facility failed to ensure licensed staff documented medication administration at the time medications were given for 20 of 28 sampled residents. Multiple instances of missed signatures on medication administration records were identified during the 7:00 AM to 3:00 PM shift on 10/28/23.

The facility failed to ensure licensed staff documented medication administration at the time medications were given, with multiple instances of missed signatures on medication administration records for 20 of 28 sampled residents. The facility policy requires signing off medications at the time of administration, which was not followed by the assigned nurse.

The complaint involved an allegation by Resident #386 and family that a nursing assistant was rude and disrespectful and almost hit the resident with a wheelchair leg during a medical appointment. The complaint was reported to staff but no formal grievance or Accident and Investigation (A&I) was initiated. The complaint was substantiated as the facility failed to follow policy requiring investigation.

The facility failed to initiate an investigation or grievance following the abuse allegation. Documentation and interviews revealed no formal investigation or grievance was filed, contrary to facility policy requiring immediate investigation of abuse allegations.

The facility was found deficient in multiple areas including failure to honor residents' advance directives, incomplete PASARR screenings, inadequate care planning, medication administration errors, failure to conduct RN assessments, improper medication storage and handling, delayed rehabilitation services, and unsanitary conditions in dietary and medication storage areas.

The facility had multiple deficiencies including failure to obtain physician orders for advance directives, incomplete PASARR screenings, lack of comprehensive care plans for antibiotic therapy and refusals of care, failure to follow medication administration protocols, incomplete nursing assessments, missing smoking assessments, delayed provision of pain management devices, improper medication disposition, unavailable medications, failure to respond to pharmacy recommendations, expired supplies in medication storage, unsanitary kitchen conditions, missed rehabilitation sessions, and unsafe and unclean facility areas.

The complaint was substantiated as the facility did not follow policy to investigate the allegation of abuse reported by Resident #386's family member. The grievance log and medical records lacked documentation of any investigation or grievance filed. Interviews confirmed the failure to initiate required procedures.

The facility failed to initiate an investigation after the allegation of abuse. Interviews and record reviews showed no grievance or Accident and Investigation (A&I) was initiated despite policy requiring immediate investigation of abuse allegations.

The complaint investigation was substantiated with findings of Immediate Jeopardy related to staff to resident sexual abuse of Resident #1 by a nurse aide. Additional findings included failure to provide emotional support, failure to investigate allegations properly, failure to implement trauma-informed care, and deficiencies in nurse aide competencies and training.

The facility failed to protect residents from sexual and physical abuse by staff, failed to provide emotional support following abuse allegations, failed to conduct comprehensive investigations, and failed to ensure trauma-informed care and proper nurse aide competencies and training. Immediate Jeopardy was identified related to sexual abuse of Resident #1 by a nurse aide.

The complaint investigation was triggered by an allegation of sexual assault by a nurse aide (NA #1) against Resident #1, which was substantiated and resulted in Immediate Jeopardy. Additional allegations included failure to report and investigate abuse, emotional support failures, and inadequate care planning.

The facility failed to protect residents from sexual abuse by a nurse aide, failed to provide emotional support following abuse allegations, failed to respond appropriately to alleged violations, and failed to ensure trauma-informed care and proper staff competencies. Immediate Jeopardy was identified related to sexual abuse and inadequate investigation and response.

The facility was found deficient in multiple areas including failure to ensure residents' access to petty cash, inaccurate documentation of advance directives, failure to notify responsible parties of pressure ulcers, inadequate reporting and investigation of abuse allegations, inaccurate PASARR Level II coding on MDS assessments, lack of physician orders for oxygen therapy, expired emergency medications, failure to annually review infection control policies, and failure to properly educate and offer pneumococcal vaccines to residents.

The facility was found deficient in multiple areas including resident rights to manage finances, advanced directives, notification of pressure ulcers, abuse reporting and investigation, accurate resident assessments, oxygen therapy orders, medication storage, infection control policy review, and pneumococcal vaccination procedures.