Deficiencies (last 4 years)
Deficiencies (over 4 years)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
275% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
93% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted following complaints and reports of resident-to-resident abuse and behavioral incidents involving multiple residents, including verbal and physical altercations.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to protect residents from verbal and physical abuse by another resident, including an incident where Resident #91 pinned Resident #79 against a wall.
Failure to prevent Resident #1 from throwing a remote control at Resident #87, causing a bruise.
Report Facts
Residents involved: 4
Bruise size: 5
Date of survey completion: May 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Observed and intervened during Resident #91 and Resident #79 altercation |
| RN #7 | Nursing Supervisor | Provided information on Resident #1's behavior and hospital transfers |
| LPN #6 | Charge Nurse | Assessed Resident #1 and Resident #87 after incident and notified Nursing Supervisor |
| NA #1 | Nursing Assistant | Witnessed Resident #91 and Resident #79 altercation and intervened |
| Administrator | Facility Administrator | Provided information on investigation and corrective actions |
Inspection Report
Routine
Deficiencies: 17
Date: May 7, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication self-administration, resident rights, pressure ulcer care, abuse prevention, bed hold policies, PASARR compliance, care planning, pharmaceutical services, accident prevention, infection control, and vaccination protocols.
Findings
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.
Deficiencies (17)
Failure to complete self-administration assessment and obtain physician order for resident self-administering medications.
Failure to honor resident code status wishes and obtain signed code status forms.
Failure to notify physician and resident representative of newly identified non-blanchable skin area and failure to document weekly assessments.
Failure to ensure residents were free from verbal and physical abuse by another resident.
Failure to provide written notice of bed hold policy to resident representatives upon hospital transfers.
Failure to incorporate PASARR Level 2 recommendations into resident's assessment and care plan.
Failure to notify state designated authority of new mental health and intellectual disability diagnosis for resident with existing PASARR.
Failure to revise care plan to include interventions and enhanced monitoring for resident with combative behavior.
Failure to follow physician's orders for lab monitoring of valproic acid levels after initiation of Depakote medication.
Failure to obtain physician's orders for oxygen use post hospitalization and failure to transcribe oxygen orders on readmission.
Failure to ensure adequate supervision and safety in resident smoking area, including unsecured smoking materials, missing lighter, and lack of monthly fire extinguisher inspections.
Failure to consistently monitor and document intake and output for resident on fluid restriction.
Failure to complete annual employee performance evaluations for certified nurse aide.
Failure to timely investigate and resolve controlled medication discrepancy, failure to label and date individual use medication, and failure to complete controlled drug change of shift audits.
Failure to document weekly assessments and healing of newly identified non-blanchable sacral area and failure to notify physician and resident representative.
Failure to place resident with indwelling medical device on enhanced barrier precautions.
Failure to timely offer pneumococcal vaccines to eligible residents and failure to document vaccine status.
Report Facts
Controlled substance shift audits missing: 25
Controlled substance shift audits missing: 19
Controlled substance shift audits missing: 21
Controlled substance shift audits missing: 14
Controlled substance shift audits missing: 23
Controlled substance shift audits missing: 26
Controlled substance shift audits missing: 12
Controlled substance shift audits missing: 19
Controlled substance shift audits missing: 19
Controlled substance shift audits missing: 39
Controlled substance shift audits missing: 47
Fluid restriction noncompliance: 26
Fluid restriction noncompliance: 25
Fluid restriction noncompliance: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication discrepancy investigation and oxygen order review |
| LPN #1 | Licensed Practical Nurse, Infection Preventionist | Named in pressure ulcer and vaccination findings |
| LPN #3 | Regional Corporate Licensed Practical Nurse | Named in smoking supervision and intake/output monitoring |
| LPN #5 | Nursing Supervisor | Named in medication discrepancy and oxygen order review |
| LPN #7 | Licensed Practical Nurse | Named in fall incident investigation |
| LPN #8 | Licensed Practical Nurse | Named in medication discrepancy and unlabeled medication observation |
| LPN #9 | Licensed Practical Nurse | Named in resident-to-resident abuse incident |
| APRN #3 | Advanced Practice Registered Nurse | Named in medication monitoring and PASARR findings |
| APRN #5 | Advanced Practice Registered Nurse | Named in oxygen order and medication monitoring |
| MD #1 | Physician | Named in vaccination and oxygen order findings |
| NA #7 | Nurse Aide | Named in smoking supervision and safety |
| NA #4 | Nurse Aide | Named in fall incident |
| NA #5 | Nurse Aide | Named in intake and output documentation |
| NA #6 | Nurse Aide | Named in intake and output documentation |
| NA #9 | Nurse Aide | Named in resident-to-resident abuse incident |
| Administrator | Facility Administrator | Named in multiple findings including abuse, bed hold policy, PASARR, and vaccination |
| DNS | Director of Nursing Services | Named in multiple findings including medication discrepancy, oxygen orders, smoking supervision, pressure ulcer, and infection control |
| Prior DNS | Former Director of Nursing Services | Named in pressure ulcer findings |
Inspection Report
Renewal
Census: 111
Capacity: 120
Deficiencies: 0
Date: 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.
Complaint Details
Complaint investigations referenced by numbers CT43689, CT43497, and CT43399 were reviewed during this inspection.
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.
Report Facts
Licensed Bed Capacity: 120
Census: 111
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding a fall incident involving Resident #1, who sustained injuries during a transfer attempt without proper use of a mechanical lift as required by the care plan.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure an RN assessment was conducted prior to transferring Resident #1 after a fall.
Failure to provide required assistance with resident transfer, resulting in a fall with injuries.
Report Facts
Date of fall incident: Jan 22, 2025
Date of inspection: Feb 21, 2025
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Involved in transferring Resident #1 without mechanical lift, leading to fall |
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #1 after fall and reported incident |
| Director of Nursing Services | DNS | Interviewed regarding failure to ensure RN assessment prior to transfer |
| ADNS | Assistant Director of Nursing Services | Observed Resident #1 after fall and noted injuries |
| MD #1 | Medical Director | Provided expectations for RN assessment after resident falls |
| MD #2 | Orthopedic Surgeon | Provided medical evaluation of Resident #1's fractures after fall |
| NA #2 | Nurse Aide | Assisted in transferring Resident #1 after fall without RN assessment |
| LPN #2 | Regional Nurse | Interviewed regarding lack of RN assessment documentation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 120
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Investigation Survey with ACT Reference Numbers CT #42886, #43112, and #43121.
Findings
Deficiencies and/or violations were cited as a result of this survey.
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
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Dec 4, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to an alleged resident-to-resident abuse incident involving Residents #4 and #5 on 11/16/2024.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to protect residents from abuse including physical and verbal behaviors between residents #4 and #5.
Failed to maintain complete and accurate medical records including documentation of Foley catheter urine output for Resident #3.
Report Facts
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 2
Brief Interview for Mental Status (BIMS) score: 15
Urine output recorded: 500
Days without urine output documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Wrote nurse's note on 11/16/24 identifying the abuse incident |
| NA #3 | Nurse Aide | Observed Resident #5 holding curtain around Resident #4's neck and separated residents |
| NA #4 | Nurse Aide | Witnessed the incident and reported Resident #5's statement 'He/she deserved it' |
| LPN #2 | Licensed Practical Nurse | Notified about the incident and observed Resident #5 holding Resident #4's arm |
| Administrator | Facility Administrator | Conducted investigation and sent letter to hospital regarding Resident #5's re-admission concerns |
| DNS | Director of Nursing Services | Interviewed regarding investigation and inability to substantiate abuse |
| LPN #1 | Licensed Practical Nurse | Interviewed about missing urine output documentation for Resident #3 |
| NA #9 | Nurse Aide | Provided care to Resident #3 and discussed urine output documentation |
| Regional Clinical Nurse | Regional Clinical Nurse | Interviewed about urine output documentation practices |
Inspection Report
Original Licensing
Deficiencies: 28
Date: 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)
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. |
Inspection Report
Census: 28
Deficiencies: 1
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to review the accuracy of clinical records and ensure that licensed staff documented medication administration in accordance with professional standards.
Findings
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.
Deficiencies (1)
Failure to ensure licensed staff documented medication administration at the time medications were given.
Report Facts
Residents reviewed: 20
Census: 28
Scheduled dose times with missed signatures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Charge nurse on 10/28/23 who failed to sign off medication administration |
| Director of Nursing | Director of Nursing | Provided information on facility policy and RN #1's responsibilities |
| Corporate Nurse Consultant | Corporate Nurse Consultant | Provided information on facility policy and identified missed signatures |
Inspection Report
Routine
Deficiencies: 13
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Civita Care Center at Danbury to assess compliance with healthcare facility regulations, including resident care, medication management, safety, and facility conditions.
Findings
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.
Deficiencies (13)
Failed to obtain a physician's order for Do Not Resuscitate (DNR) to ensure resident's wishes were honored.
Failed to ensure timely PASARR screenings and re-screenings for residents with mental disorders or intellectual disabilities.
Failed to develop a comprehensive care plan related to antibiotic therapy and interventions for resident refusals to get out of bed.
Failed to ensure licensed staff followed the five rights of medication administration, leaving medications unattended and unsupervised.
Failed to ensure a registered nurse completed an assessment when a resident requested hospital transfer and failed to administer medication as ordered.
Failed to complete smoking assessments and review of smoking policy documents for a resident who smoked in the facility.
Failed to provide a back brace in a timely manner for a resident with chronic back pain due to insurance and ordering delays.
Failed to ensure proper disposition and documentation of controlled medication and failed to ensure availability of prescribed antidepressant medication.
Failed to respond to pharmacy recommendations for behavioral monitoring of residents on antipsychotic medications and failed to implement orthostatic blood pressure monitoring as recommended.
Failed to remove expired medical supplies from medication storage and maintain cleanliness of medication refrigerator.
Failed to maintain kitchen and dietary equipment in a sanitary manner, including accumulation of dust, grime, and debris on fans, light fixtures, floors, vents, and food storage containers.
Failed to ensure resident received ordered rehabilitation services as scheduled, with multiple missed physical and occupational therapy sessions.
Failed to maintain hallway tiled floor in good repair and housekeeping closet in a clean condition.
Report Facts
Expired supplies: 5
Expired supplies: 21
Expired supplies: 3
Expired supplies: 1
Expired supplies: 1
Expired supplies: 5
Floor tiles damaged: 52
Missed therapy sessions: 4
Missed therapy sessions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in care plan and medication administration findings |
| LPN #1 | Licensed Practical Nurse | Named in pharmacy recommendation and behavior monitoring findings |
| APRN #1 | Advanced Practice Registered Nurse | Named in pharmacy recommendation and behavior monitoring findings |
| RN #1 | Registered Nurse | Named in medication administration and pharmacy recommendation findings |
| DNS | Director of Nursing Services | Named in multiple findings including advance directives, medication administration, and pharmacy recommendations |
| ADNS | Assistant Director of Nursing Services | Named in medication administration and pharmacy recommendation findings |
| PT #1 | Physical Therapist | Named in rehabilitation service findings |
| OT #1 | Occupational Therapist | Named in pain management and rehabilitation findings |
| LPN #12 | Licensed Practical Nurse | Named in medication storage room findings |
| Dietary [NAME] | Dietary Staff | Named in dietary sanitation findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was conducted following a complaint alleging abuse by a nursing assistant (NA) towards Resident #386 during a medical appointment.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to initiate an investigation after an allegation of abuse involving a nursing assistant and Resident #386.
Report Facts
Residents reviewed: 3
Resident involved: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Person #1 | Family member | Reported the abuse allegation regarding the nursing assistant |
| LPN #6 | Licensed Practical Nurse | Reported the complaint to supervisor and social worker |
| DNS | Director of Nursing Services | Received the complaint and believed the NA was spoken to |
| SW #1 | Social Worker | Identified no documentation of complaint and was new at the time |
| Administrator | Facility Administrator | Could not identify if grievance was offered or initiated |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 15, 2023
Visit Reason
The inspection was conducted following allegations of staff to resident sexual abuse and other mistreatment, triggered by complaints and a police investigation.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failed to protect a resident from sexual mistreatment by a staff member resulting in Immediate Jeopardy.
Failed to provide emotional support to a resident following an allegation of staff to resident physical mistreatment.
Failed to respond appropriately to all alleged violations including failure to report and investigate sexual abuse allegations.
Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failed to develop and implement a complete care plan that meets all the resident's needs, including ensuring two staff present during care for a combative resident.
Failed to provide trauma-informed care by not identifying a resident's history of trauma, triggers, or individualized care related to PTSD.
Failed to ensure nurse aide competencies were completed upon hire and annually to include all necessary skill sets.
Failed to ensure annual abuse training was completed for nurse aides.
Report Facts
Residents affected: 1
Residents affected: 1
Date of incident: Jan 30, 2023
Date of survey completion: Mar 15, 2023
Number of nurse aides reviewed: 5
Number of nurse aides without documented competencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Alleged perpetrator of sexual abuse to Resident #1 |
| NA #2 | Nurse Aide | Failed to report allegation of sexual abuse and failed to protect Resident #1 |
| SW #1 | Social Worker | Failed to provide emotional support to Resident #3 following mistreatment allegation |
| ST #1 | Speech Therapist | Victim of sexual assault by NA #1 and reporter of concerns about Resident #1 |
| OT #1 | Occupational Therapist | Provided representation for ST #1 and reported concerns about NA #1 |
| APRN #1 | Advanced Practice Registered Nurse | Provided medication adjustments for Resident #1 after abuse incident |
| Director of Nursing | Director of Nursing | Interviewed regarding nurse aide competencies and abuse training |
| Corporate Director of Education | Corporate Director of Education | Responsible for nursing education and addressing nurse aide competency issues |
| Psychologist #1 | Psychologist | Provided psychiatric evaluation and diagnosis of PTSD for Resident #1 |
| RN #1 | Registered Nurse | Received report of physical aggression from Resident #3 |
| NA #6 | Nurse Aide | Reported being struck by Resident #3 and lacked annual abuse training in 2022 |
| Administrator | Facility Administrator | Interviewed regarding investigation and response to abuse allegations |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 31, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, abuse prevention, infection control, medication management, and vaccination policies at Civita Care Center at Danbury.
Findings
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.
Deficiencies (10)
Failure to ensure residents could readily access petty cash when needed.
Failure to ensure resident or representative's advance directives were known and followed.
Failure to notify responsible party of development of pressure ulcers.
Failure to timely report suspected abuse and report investigation results to proper authorities.
Failure to thoroughly investigate allegations of verbal abuse and injuries of unknown origin.
Failure to ensure accurate PASARR Level II coding on MDS assessments for residents with serious mental illness or intellectual disability.
Failure to obtain physician's order for oxygen therapy for Resident #18.
Failure to store emergency medications with appropriate expiration dates in emergency medication box.
Failure to annually review and approve Infection Control, IV Therapy, and Nursing Policy and Procedure Manuals by Medical Director, DNS, and Administrator.
Failure to educate and offer pneumococcal vaccines to residents and/or their representatives.
Report Facts
Expired medications: 4
Oxygen flow rate: 2
Date of survey completion: Mar 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | MDS Coordinator | Identified errors in PASARR Level II coding on MDS assessments. |
| DNS | Director of Nursing Services | Interviewed regarding multiple deficiencies including abuse reporting, advance directives, infection control policy review, and vaccination program. |
| LPN #5 | Observed Resident #18 using oxygen without physician order. | |
| RN #4 | Witnessed verbal altercation between residents #9 and #79. | |
| RN #2 | Infection Control Nurse | Observed expired medications in emergency medication box. |
| Administrator | Acknowledged failure to ensure annual policy review and approval. | |
| APRN #1 | Advanced Practice Registered Nurse | Provided clinical information regarding Resident #18 oxygen use. |
Viewing
Loading inspection reports...
