Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Civita Care Center At Danbury during CMS and state inspections, most recent first.
A resident with intact cognition and multiple chronic conditions was allowed to self-administer medications, including an inhaler and oral packets, without a required assessment or physician's order. Medications were kept unsecured at the bedside, and staff confirmed that no formal evaluation or authorization for self-administration had been completed, contrary to facility policy.
The facility did not ensure that two residents' wishes regarding code status were properly documented and honored. One resident was not educated or asked to sign code status forms upon admission, and another resident's DNR preference was not updated in the EMR, leading staff to follow outdated full code instructions. Nursing staff relied on inaccurate records, and the facility did not follow its own policy for documenting and communicating advance directives.
A resident with multiple health conditions developed a new non-blanchable area on the sacrum, but the facility did not notify the physician or resident representative as required. Documentation of follow-up assessments and implementation of planned interventions was also lacking, and the resident was not added to the wound care rounds for further evaluation.
A resident with a history of depression, bipolar disorder, and opioid dependence was admitted and prescribed medication for opioid dependence. The facility failed to incorporate PASARR Level 2 recommendations, including support group participation and mental health counseling, into the resident's care plan. The responsible social worker did not review or act on the PASARR recommendations, resulting in the resident not being offered or referred to appropriate support services.
A resident with a history of stroke and cognitive decline was later diagnosed with a psychotic disorder with delusions and mild intellectual disabilities. Despite these significant changes, the facility did not notify the state designated authority as required, due to a misunderstanding by the social worker responsible for PASARR coordination and poor communication between the psychiatric group and facility staff.
A resident with dementia and a history of traumatic brain injury exhibited ongoing combative and aggressive behaviors towards staff, as documented in psychiatric consults and staff reports. Despite these behaviors, the care plan was not revised to include interventions for aggression, and enhanced monitoring was only implemented after the resident was involved in a physical altercation with another resident. Facility staff interviews revealed gaps in communication and care plan updates, and required policy for care plan revision was not provided.
Two residents did not receive care according to physician orders: one did not have a required valproic acid level obtained after starting Depakote, despite documentation indicating otherwise, and another received oxygen therapy post-hospitalization without a physician's order, even though hospital recommendations called for it. Facility staff and APRNs confirmed these omissions and documentation errors during interviews and record reviews.
A resident was not transferred according to physician orders, resulting in a fall, and two residents in a supervised smoking program were not properly monitored or provided with secure smoking materials. Staff left smoking materials unattended, failed to account for a lighter, and did not redirect a resident to use a metal ash receptacle. The smoking area lacked required fire extinguisher inspections and proper disposal of cigarette butts, and there was no documentation of staff education on smoking safety.
A resident with end stage renal disease on dialysis and a physician-ordered fluid restriction did not have their intake and output consistently monitored or documented by staff. Despite care plans and orders specifying a 1,000 ml daily fluid limit, staff failed to record intake and output on multiple occasions, and the resident did not meet the restriction as required. Key staff and providers were unaware of these lapses, and the dialysis center was not informed of the inconsistent monitoring.
The facility did not resolve a controlled medication discrepancy in a timely manner, failed to ensure individual-use medications were properly labeled and dated, and did not consistently complete required shift-to-shift controlled drug audits. These deficiencies were identified through observations, documentation review, and staff interviews, revealing lapses in medication management and accountability.
A resident with multiple comorbidities and moderate risk for pressure ulcers developed a non-blanchable area of redness on the sacrum, but the facility failed to document weekly assessments, notify the physician or resident representative, or ensure follow-up by the wound care team. Required interventions and evaluations were not consistently implemented or recorded, resulting in incomplete management and documentation of the pressure ulcer.
A resident with a permcath for dialysis was not placed on enhanced barrier precautions (EBP) as required by facility policy. Staff did not use PPE during care, and there was no signage or physician order for EBP, despite the presence of an indwelling medical device. The deficiency was confirmed through record review and staff interviews.
Several residents with complex medical histories were not timely offered or properly documented for pneumococcal vaccination. An LPN responsible for infection prevention missed vaccine offers due to inconsistent practices, such as not re-offering after refusal, not providing education on all vaccine types, and failing to document vaccine status. The facility's policy required assessment and education on admission, but these steps were not consistently followed.
Multiple residents with cognitive and behavioral issues were involved in incidents of verbal and physical abuse, including one resident grabbing another by the neck and another throwing a remote control that caused injury. Staff intervened during the incidents, but not all staff received education on managing such behaviors, and the facility did not adequately prevent or monitor for resident-to-resident abuse as required by policy.
Two residents with significant medical conditions were transferred to the hospital on multiple occasions, but the required written notice of the bed hold policy was not provided to them or their representatives at the time of transfer. Interviews confirmed that nursing staff were responsible for this task, but the bed hold policy form was not completed or included in the transfer packet as required by facility policy.
The facility did not complete annual performance reviews for a nurse aide, with the last evaluation occurring five years prior, contrary to facility policy requiring yearly assessments for all employees. The lapse was attributed to frequent staff turnover and responsibility for evaluations rested with the DNS and ADNS.
A resident with impaired mobility and high fall risk, who required a Hoyer lift and two-person assistance for transfers, was transferred by a nurse aide without following the care plan. The aide did not review the resident's transfer requirements and attempted to use a standing scale, resulting in the resident falling and sustaining multiple fractures. Facility documentation and staff interviews confirmed that the established transfer protocol was not followed.
A resident with impaired mobility, who required a mechanical lift and two staff for transfers, was improperly transferred by a nursing assistant using a standing scale, resulting in a fall and fractures. After the fall, the resident was moved by staff, including the DON and two nursing assistants, without an RN assessment, contrary to facility policy and care plan directives.
A resident with severe cognitive impairment and behavioral symptoms was found with a privacy curtain loosely wrapped around their neck and upper body, while another resident with a history of disruptive behaviors was observed holding the curtain, squeezing the resident's arm, and pushing them with a walker. Staff responded to the incident after hearing screaming and separated the residents, with no injuries reported. The event was documented as resident-to-resident abuse without injury, and the facility failed to ensure residents were free from abuse.
A resident with paraplegia and an indwelling catheter did not have urine output consistently documented over several days, despite care plans and facility policy requiring accurate intake and output records. Staff interviews revealed confusion over documentation responsibilities, and facility leadership confirmed that output should be recorded each time the catheter is emptied, even if the amount is zero.
The facility failed to ensure licensed staff documented the administration of medications at the time they were given, as required by professional standards. This deficiency was identified through clinical record reviews, facility documentation, and interviews for 20 residents. The DON speculated that an RN may have administered the medications but failed to save her signature in the system, resulting in the absence of documentation.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including hyperkalemia, end stage renal disease requiring dialysis, and chronic obstructive pulmonary disease was admitted to the facility and expressed a desire to self-administer medications. The resident had intact cognition but required maximum assistance with activities of daily living such as toileting, dressing, and personal hygiene. Despite the resident's request and ongoing self-administration of medications, including an inhaler and oral medication packets, the facility did not complete a self-administration assessment or obtain a physician's order as required by facility policy. Observations revealed that the resident kept multiple medications, including an inhaler and Lokelma packets, at the bedside and in an open dresser drawer. The resident reported independently using these medications, obtaining them from nursing staff as needed, and not having a lock box for secure storage. The resident stated that the nurse provided the inhaler for use as needed and that they had been self-administering Lokelma with each meal since admission. Interviews with facility staff, including the DNS, confirmed that no self-administration assessment had been completed for the resident and that the resident was not officially permitted to self-administer medications. Facility policy required a self-administration observation, a physician's order, care plan documentation, and secure storage for any medications kept at the bedside, none of which had been implemented for this resident prior to the survey findings.
Failure to Honor Resident Code Status Preferences
Penalty
Summary
The facility failed to honor residents' wishes regarding code status for two residents reviewed. For one resident with multiple complex diagnoses, including end stage renal disease and mental health conditions, the clinical record and care plan indicated full code status. However, the resident reported that since admission, no staff had discussed or educated them about code status, nor had they been asked to sign any related forms. The Director of Nursing Services (DNS) confirmed that there was no code status designation in the medical record and that the resident had not signed a code status form, despite facility policy requiring this on admission. For another resident with moderately impaired cognition and several chronic conditions, there was conflicting documentation regarding code status. Although the resident had signed a Do Not Resuscitate (DNR) form after discussing it with staff and a physician, the electronic medical record (EMR) and care plan continued to list the resident as full code. Interviews with nursing staff revealed that they would have initiated CPR based on the EMR, which had not been updated to reflect the resident's most recent wishes for DNR status. The DNS acknowledged that the nurse who witnessed the DNR form should have ensured the physician order was updated in the EMR, but this was not done. Facility policy required that residents be provided with information about their right to accept or refuse medical treatment and that advance directives be documented. In both cases, the facility did not ensure that residents' code status preferences were properly documented, communicated, and honored, resulting in a failure to respect their rights regarding medical interventions.
Failure to Notify Physician and Resident Representative of New Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident representative after a newly identified non-blanchable area of redness was found on a resident's sacrum. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required moderate assistance with activities of daily living. The non-blanchable area was discovered by the prior DNS during an overnight shift while assisting with incontinent care, and interventions such as a specialty mattress, turn schedule, and barrier paste were planned. Despite these interventions, there was no documentation that the physician or resident representative was informed of the new skin issue, as required by facility policy. Additionally, there was no evidence that a physical or occupational therapy evaluation was requested or completed, nor that the specialty mattress was implemented. The clinical record also lacked follow-up assessments or documentation regarding the sacral area after the initial finding, and the resident was not added to the weekly wound round list for further evaluation by the wound physician. Interviews with facility staff confirmed that the appropriate notifications and follow-up assessments did not occur. The APRN and wound nurse were not informed of the new skin issue, and the wound nurse indicated that the resident should have been added to the wound rounds for further assessment. Facility policy required notification of significant changes in a resident's condition to both the physician and resident representative within 24 hours, but this was not documented or carried out in this case.
Failure to Incorporate PASARR Recommendations into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to incorporate the recommendations from a Level 2 Preadmission Screening and Resident Review (PASARR) determination into the assessment and care plan for a resident with a history of depression, anxiety, bipolar disorder, and opioid dependence. The resident was admitted with these diagnoses and was prescribed Buprenorphine-Naloxone for opioid dependence. The PASARR Level 2 outcome specifically recommended that the resident be provided with services and support, including access to a support group for recovery from substance abuse and mental health counseling. Despite these recommendations, the facility did not update the resident's care plan to reflect the need for a support group or mental health counseling. The social worker responsible for PASARR compliance did not review the Level 2 PASARR recommendations and was unaware of the requirement to provide support group services. As a result, the resident was not offered or referred to a support group for recovery from substance abuse, nor was this intervention included in the care plan. Interviews with facility staff confirmed that the social worker did not submit the PASARR within the required timeframe and did not follow up on the recommendations after receiving the Level 2 approval. The facility's policy requires that PASARR recommendations be incorporated into the resident's assessment and care planning, but this was not done in this case, resulting in a failure to coordinate assessments and services as required.
Failure to Notify State Authority of New Psychiatric and Intellectual Disability Diagnoses
Penalty
Summary
The facility failed to notify the state designated authority when a resident received new diagnoses of psychotic disorder with delusions and mild intellectual disabilities. The resident, who was initially admitted with diagnoses including stroke, metabolic encephalopathy, diabetes, and cognitive decline, later received additional psychiatric and intellectual disability diagnoses as documented in various clinical notes and physician orders. Despite these significant changes in the resident's condition, the required notification to the state authority was not made. The social worker responsible for PASARR coordination believed that because the resident already had a Level 2 PASARR, there was no need to update the state authority when new diagnoses were made. However, upon contacting the state designated authority, it was clarified that the resident did not have a Level 2 PASARR and that any new psychiatric diagnosis should have been reported so the state could evaluate the need for specialized services. This misunderstanding led to a failure in updating the PASARR process as required by policy. Throughout the period in question, there was a lack of communication between the psychiatric group and the social worker, which contributed to the oversight. The facility's policy requires the social worker to track, make referrals, care plan, and update PASARR with any changes, but these steps were not followed when the resident's diagnoses changed. Interviews with facility staff confirmed the breakdown in communication and the failure to notify the state authority as required.
Failure to Revise Care Plan for Resident with Escalating Combative Behaviors
Penalty
Summary
The facility failed to ensure that appropriate interventions, including enhanced monitoring, were implemented for a resident with a documented history of combative behavior towards staff. The resident, who had diagnoses of dementia and a history of traumatic brain injury, exhibited ongoing combative and aggressive behaviors as documented in multiple psychiatric consults and staff reports. Despite these documented behaviors, the care plan did not include specific interventions to address the resident's aggression towards staff, and there was no evidence that the care plan was revised in response to the escalating behaviors. The care plan only addressed wandering and intrusiveness, with interventions such as encouraging diversional activities and walking with staff, but did not address the resident's combative actions. The deficiency was further evidenced when the resident became the aggressor in a physical altercation with another resident, resulting in the need for 1:1 enhanced monitoring only after the incident occurred. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's combative behaviors, and there was no policy provided for care plan revisions based on changes in condition. The facility's policy required the interdisciplinary team to document and adjust interventions based on behavioral changes, but this was not followed in the case of this resident.
Failure to Follow Physician Orders for Lab Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician's orders and ensure appropriate monitoring and documentation for two residents. For one resident with chronic obstructive pulmonary disease, major depressive disorder with psychotic features, and dementia, the facility did not obtain a required valproic acid level after the initiation of Depakote, despite a physician's order and pharmacy recommendation. Documentation in the medical record indicated the lab was completed, but interviews and record review confirmed that no specimen was collected and no lab result was available. The APRN who ordered the lab was unable to locate any evidence of the result and acknowledged uncertainty about why documentation indicated the lab had been reviewed. For another resident with congestive heart failure and dementia, the facility failed to obtain a physician's order for oxygen therapy following a hospitalization for respiratory failure, sepsis, and pneumonia. Although the hospital discharge summary recommended continued oxygen therapy with specific parameters, the admission orders did not include oxygen. Nursing notes showed the resident continued to receive oxygen without a corresponding physician's order, and the APRN later acknowledged the omission was an oversight. Documentation errors also occurred, with a progress note incorrectly stating the resident no longer required oxygen, despite ongoing administration. Facility policies required that all services, including medication administration and lab monitoring, be documented accurately and that orders for treatments such as oxygen specify rate, flow, route, and rationale. The failures in both cases were confirmed through interviews with nursing and APRN staff, review of clinical records, and facility documentation, demonstrating a lack of adherence to physician orders and facility policy regarding medication and treatment management.
Failure to Prevent Accidents and Ensure Safe Smoking Practices
Penalty
Summary
A deficiency occurred when a resident with a history of falls, impaired cognition, and multiple comorbidities was not transferred according to the physician's order, which required the assistance of two staff members and specific footwear. Instead, a nurse aide attempted the transfer alone, resulting in the resident falling in the bathroom. There was no documentation confirming whether a gait belt or the prescribed footwear was used at the time of the fall. The Director of Nursing Services (DNS) confirmed that the nurse aide did not follow the care plan or physician's order, and the Administrator was unaware of the two-person assist requirement at the time of the incident. Another deficiency was identified regarding the supervision and safety of a resident participating in a supervised smoking program. The facility failed to ensure that smoking materials, including lighters, were properly secured and accounted for. During observation, a staff member left a caddy containing cigarettes unattended in an unlocked area, and the lighter was missing and unaccounted for. Additionally, the resident was observed flicking cigarette ash onto a wet cement patio and wood mulch, rather than using the designated metal ash receptacle, without staff intervention or redirection. Further observations revealed that the fire extinguisher in the smoking area had not been inspected or documented for several months, and there was no evidence of monthly checks or related policies available. The smoking area also contained a wooden planter with multiple discarded cigarette butts, indicating improper disposal of smoking materials. The facility lacked documentation of staff education or in-service training on smoking supervision and safety prior to the survey, and the required quarterly smoking assessments for the resident were not found in the clinical record.
Failure to Consistently Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of intake and output for a resident with end stage renal disease who was on a physician-ordered fluid restriction of 1,000 ml per day and received dialysis. The care plan and physician's orders specified the fluid restriction, but staff did not consistently document the resident's intake and output, and the resident did not meet the prescribed fluid restriction on multiple occasions across several months. The intake and output records for March, April, and early May showed repeated failures in both documentation and adherence to the fluid restriction, with staff not recording intake and output as required. Interviews with nurse aides revealed that intake and output were to be documented electronically, but there were lapses in documentation. The regional clinical support LPN and the DNS both acknowledged awareness of non-compliance with the intake and output policy, despite prior education provided to staff. Neither the DNS nor the LPN was aware that the resident was not meeting the fluid restriction as ordered. Additionally, the physician's orders did not initially specify the breakdown of fluid allocation between nursing and dietary services until after surveyor inquiry. Further, the dialysis center RN was not notified by the facility about the inconsistent monitoring of intake and output, and both the attending physician and APRN were unaware that the physician's order for fluid restriction was not being followed. The facility's policy required accurate and timely documentation of fluid intake, but this was not consistently performed, leading to the deficiency in care for the resident requiring specialized dialysis services.
Failure to Ensure Timely Controlled Substance Discrepancy Resolution and Medication Labeling
Penalty
Summary
The facility failed to ensure proper management and accountability of controlled medications, as evidenced by an unresolved discrepancy in the electronic medication cabinet. An alert indicating a discrepancy was present on the medication cabinet for at least four days, and neither agency staff nor regular nursing supervisors had the access or authority to resolve it. The Director of Nursing Services (DNS) was ultimately responsible for investigating and resolving such discrepancies but had not accessed the cabinet or performed any inventory of controlled substances for a period of 20 days. The discrepancy, related to the count of Oxycodone 10 mg, was only resolved after surveyor intervention, revealing a lack of timely oversight and investigation as required by facility policy. Additionally, the facility failed to ensure that medications intended for individual resident use were properly labeled and dated. During an observation of a medication cart, a bottle of saline nasal spray was found without any resident identifying information, and the nurse present could not confirm to whom the medication belonged. The facility's policy required all multi-dose over-the-counter medications to be labeled and dated, but this was not followed, and the medication was subsequently disposed of after the deficiency was identified. The facility also did not consistently complete required controlled drug/change of shift audits. Review of audit forms for multiple medication carts over several months revealed numerous missing shift-to-shift controlled substance counts, with many forms either incomplete or not provided at all. Facility policy mandated that licensed nurses from both outgoing and incoming shifts jointly conduct and document these counts, but this process was not reliably followed, resulting in gaps in documentation and accountability for controlled substances.
Failure to Document and Communicate Pressure Ulcer Assessment and Interventions
Penalty
Summary
A deficiency occurred when the facility failed to document weekly assessments and the healing process of a newly identified non-blanchable area of redness on the sacrum for one resident. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required significant assistance with activities of daily living. A non-blanchable area was discovered during incontinent care, and initial interventions such as a specialty mattress, turn and positioning schedule, and barrier paste were planned. Despite these interventions, the clinical record did not show evidence that a physical or occupational therapy evaluation was requested or completed, nor that a specialty mattress was implemented. There was also no documentation of further assessments of the sacral area after the initial finding, nor any record of physician or resident representative notification regarding the new skin issue. The facility's treatment administration record indicated that weekly skin checks were signed off, but there was no specific observation documentation of the sacral area. Interviews with facility staff confirmed that the wound nurse and the advanced practice registered nurse were not notified of the new skin issue, and the resident was not added to the weekly wound rounds for further evaluation. The facility's policy required assessment and documentation of significant risk factors and physician involvement in identifying and managing pressure ulcers, but these steps were not followed as documented in the clinical record.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
A deficiency was identified when a resident with end-stage renal disease and dependence on renal dialysis, who had a permcath (an indwelling medical device) in place, was not placed on enhanced barrier precautions (EBP) as required by facility policy. The physician's orders directed staff to observe the permcath site every shift and monitor for signs and symptoms of infection, but did not include a directive for the use of EBP. The care plan addressed the risk for complications related to dialysis and included monitoring for bleeding at the port site, but did not mention EBP. The facility's EBP list did not identify the resident as requiring EBP, and there was no signage on the resident's door indicating EBP status. During interviews, staff members, including an LPN and the Infection Preventionist, confirmed that the resident had not been placed on EBP and that personal protective equipment (PPE) was not used during care. The DNS acknowledged that the resident should have been on EBP due to the presence of the permcath and that appropriate orders and signage were missing. Facility policy states that EBP should be used for residents with indwelling medical devices, regardless of MDRO colonization, but this was not implemented for the resident in question.
Failure to Timely Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure timely offering and documentation of pneumococcal vaccines for four out of eight residents reviewed. For several residents with significant medical histories, including dementia, diabetes, stroke, and chronic respiratory conditions, the clinical records and preventative health documentation did not reflect up-to-date pneumococcal vaccine status or evidence that the vaccine was offered as required. In some cases, the vaccine was not offered at all, while in others, only one type of pneumococcal vaccine was offered without education or re-offering of other recommended vaccines. Documentation of vaccine status and education was also missing from the residents' records. Interviews with the infection preventionist LPN revealed inconsistent practices, such as missing vaccine offers due to form discrepancies, not re-offering vaccines after initial refusal, and not considering eligibility based on comorbidities. The facility's policy required assessment and offering of pneumococcal vaccines upon admission or readmission, with proper education and documentation, but these steps were not consistently followed. The medical director confirmed that the residents in question were eligible for vaccination according to CDC guidelines.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Staff Education
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive and behavioral disturbances. In one case, a resident with dementia and behavioral symptoms verbally threatened another resident, who responded by physically grabbing the first resident around the neck and pinning them against the wall. Staff intervened to separate the residents, and no injuries were reported. Prior to this incident, there was no documented history of aggression between these residents, but the facility's response to the altercation was limited in scope, as not all staff received education on managing such behaviors. In another incident, a resident with a history of borderline personality disorder and depression, after returning from a hospital evaluation for suicidal ideation, threw a remote control at their roommate, resulting in a bruise to the roommate's face. The roommate reported ongoing verbal abuse and agitation from the resident prior to the physical altercation. Staff and another resident witnessed the event, and the injured resident was assessed and requested a room change. The resident who threw the remote had previously exhibited emotional distress and was evaluated by hospital staff before returning to the facility. The facility's policies define abuse as the willful infliction of injury or intimidation, including resident-to-resident altercations, and require ongoing assessment and care planning to prevent such incidents. However, the events described indicate that the facility did not adequately identify, monitor, or intervene to prevent resident-to-resident abuse, nor did it ensure that all staff were educated on recognizing and managing behaviors that could lead to conflict or harm.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to the resident or their representative at the time of hospital transfers for two residents. One resident with diagnoses including congestive heart failure and dementia was transferred to the hospital on two separate occasions and returned each time, but there was no documentation that the required bed hold policy notice was given during either transfer. Similarly, another resident with hypoxia and Alzheimer's disease was also transferred to the hospital twice and returned, with no evidence that the bed hold policy notice was provided at or after the time of transfer. Interviews with the Administrator and a nursing supervisor confirmed that it was the nursing staff's responsibility to ensure the bed hold policy was provided to the resident or their representative at the time of transfer. The nursing supervisor acknowledged that the bed hold policy form was not completed for one of the residents due to oversight, and that the policy was not included in the transfer packet. The facility's own policy requires that written information about bed hold rights, payment policies, and transfer details be given to the resident and representative prior to transfer, but this was not followed in these cases.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete annual employee performance reviews for at least one certified nurse aide, as required by facility policy. Review of one nurse aide's personnel file showed that her last performance review was conducted five years prior, despite her continued employment. The facility's policy mandates that all employees, regardless of employment status, receive annual evaluations based on their hire date or a facility-defined cycle. During an interview, the Administrator stated that the responsibility for ensuring completion of these evaluations rested with the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS), and attributed the lapse to frequent staff turnover.
Failure to Follow Transfer Protocol Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow the established plan of care for a resident with reduced mobility, depression, and anxiety, who was non-ambulatory and required the assistance of two staff members and a Hoyer lift for all transfers. The resident's care plan, ADL records, and physician orders all specified the need for a Hoyer lift and two-person assistance due to high fall risk and impaired physical mobility. Despite these documented requirements, a nurse aide attempted to transfer the resident to a standing scale without reviewing the care plan or confirming the transfer method with the supervising nurse. During the transfer, the nurse aide assumed the resident could stand and transfer independently because the resident had previously moved from bed to wheelchair without assistance. The aide wheeled the resident into the shower room, positioned the wheelchair in front of the standing scale, and assisted the resident to stand and step onto the scale. As the resident attempted to move further onto the scale, their legs buckled, resulting in a fall that caused significant injuries, including fractures to the left tibia, left fibula, and right femur. Facility documentation and interviews confirmed that the nurse aide did not follow the resident's plan of care, which required the use of a Hoyer lift and two staff for transfers. The Director of Nursing Services and the nurse aide both acknowledged that the proper protocol was not followed, and the incident occurred as a result of this failure. The facility's falls protocol policy also directed staff to implement interventions based on assessments to prevent falls, which was not adhered to in this case.
Failure to Ensure RN Assessment Prior to Transfer After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, depression, and anxiety, who was care planned and ordered to require a mechanical lift with two staff for all transfers, experienced a fall with injury during an attempted transfer. The resident was non-ambulatory and required maximal assistance with activities of daily living, as documented in the care plan, physician's orders, and care card. Despite these directives, a nursing assistant attempted to obtain the resident's weight using a standing scale, resulting in the resident's legs buckling and a subsequent fall that led to a left ankle and right femur fracture. Following the fall, multiple staff, including the DON, ADON, and two nursing assistants, were present in the shower room where the incident occurred. The DON and ADON did not conduct or ensure an RN assessment was performed prior to the resident being moved from the scale to the wheelchair. Instead, the nursing assistants, with the DON present, lifted the resident back into the wheelchair without an assessment, despite facility policy and staff expectations that a resident should not be moved after a fall until an RN assessment is completed. Interviews with staff and review of facility documentation confirmed that no RN assessment was conducted prior to transferring the resident after the fall. The facility's fall protocol requires a nurse to assess, document, and report on the resident's condition following a fall, including vital signs, musculoskeletal function, and pain assessment. The failure to follow these protocols and the resident's care plan led to the deficiency identified in the report.
Failure to Protect Resident from Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and behavioral symptoms was involved in an incident with another resident who had moderately impaired cognition and a history of disruptive behaviors. The incident involved one resident being found with a privacy curtain loosely wrapped around their neck, upper back, chest, and shoulders, while the other resident was observed holding the curtain and squeezing the resident's arm, as well as using a walker to push into the resident. Staff responded to screaming and yelling from the room, immediately separated the residents, and found no injuries. Multiple staff interviews confirmed that the curtain was wrapped around the resident's neck and that the resident was being physically restrained and pushed by the other resident. The resident who was the subject of the incident was unable to explain how the curtain became wrapped around their neck, and staff noted that this resident lacked the dexterity to do so themselves. The other resident made a statement indicating intent, saying the other "deserved it." Despite the lack of direct witnesses to the start of the incident, facility documentation and staff interviews consistently described the physical altercation and the presence of the curtain around the resident's neck. The facility's investigation was unable to substantiate how the curtain was placed, but the event was documented as resident-to-resident abuse without injury. The facility's policy requires protection from all forms of abuse, but the incident demonstrated a failure to ensure that residents were free from abuse.
Failure to Accurately Document Foley Catheter Output
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with paraplegia and an indwelling catheter, as required by professional standards and facility policy. The resident's care plan included interventions to monitor intake and output, and the facility's urinary catheter care policy directed staff to maintain an accurate record of daily output. However, clinical record review revealed that no urine output was documented for the resident over a four-day period, and on a subsequent day, output was only partially recorded. Additionally, there was no documentation of urine output on the day the resident was sent out for further evaluation due to an abdominal mass and lack of urine output. Interviews with nursing staff and nursing assistants indicated confusion and lack of clarity regarding responsibility for documenting urine output. One LPN stated she did not record the output because she believed it was the nursing assistant's responsibility, while the nursing assistant could not recall if she had documented or reported the output. Facility leadership confirmed that output should be documented in the computer system whenever a foley catheter is emptied, even if the amount is zero, but could not explain the gaps in documentation. These failures resulted in incomplete and inaccurate medical records for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure licensed staff documented the administration of medications at the time they were given, as required by professional standards. This deficiency was identified through clinical record reviews, facility documentation, and interviews for 20 of 28 sampled residents. Specifically, on the 2 [NAME] Unit, multiple instances of missed signatures were noted for scheduled medication doses during the 7:00 AM to 3:00 PM shift. The Corporate Nurse Consultant and the Director of Nursing (DON) confirmed that the facility policy mandates signing off on medications immediately after administration, which was not adhered to by RN #1 on the specified date. The DON speculated that RN #1 may have administered the medications but failed to save her signature in the system, resulting in the absence of documentation. Despite attempts, an interview with RN #1 could not be obtained. The facility policy, last revised in April 2019, clearly directs that the individual administering the medication must initial the resident's medication administration record (MAR) after giving each medication and before administering the next ones. This policy was not followed, leading to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 338 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Glen Hill | 0.8 mi | ★★★★★ | 0 | 0 |
| Saint John Paul Ii Center | 1.4 mi | ★★★★★ | 9 | 0 |
| Havencare At Hancock Hall | 1.6 mi | ★★★★★ | 0 | 0 |
| Havencare At Filosa | 1.7 mi | ★★★★★ | 1 | 0 |
| Bethel Health Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.