Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Newington during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and a history of aggressive behavior was removed from their room for an extended cleaning and placed in a common area without an individualized supervision plan. During this time, NAs were distributing lunch trays and an LPN was performing blood glucose checks, leaving the resident inadequately monitored. The resident entered another resident’s room, struck that resident, and was then pushed, resulting in a fall and facial injuries, including a laceration and a maxillary sinus fracture. A prior incident had occurred months earlier in which the same aggressive resident stepped out of their doorway on a secured memory care unit and punched another cognitively impaired, wandering resident in the face, causing facial swelling. These events occurred despite care plans and facility policies identifying the need for monitoring, redirection, and protection from abuse.
A resident with dementia, schizoaffective disorder, and adjustment disorder, identified as severely cognitively impaired and living on a secured memory care unit due to behavioral issues, struck another resident, causing facial swelling. After this incident, the resident was moved from a secured to a non-secured unit and continued on 1:1 monitoring, but the existing RCP—developed when the resident was on the secured unit and addressing psychotropic use, refusal of care, paranoia/delusions, hitting, and need for redirection—was not revised to reflect the room change. The DON confirmed the move and lack of RCP updates, and a SW stated the IDT normally meets to adjust the plan of care around room changes, which did not occur, contrary to the facility’s comprehensive care planning policy requiring measurable, data-driven care plans.
A resident with dementia, schizoaffective disorder, severe cognitive impairment, and a history of aggressive and resident-to-resident altercations was involved in an unwitnessed physical altercation with another resident, resulting in a fall, facial laceration, and a closed fracture. The resident was sent to the hospital for evaluation and then readmitted, but the hospital discharge paperwork did not include the expected psychiatric evaluation or harm clearance. The admitting RN did not obtain psychiatric clearance or a no-harm letter at the time of readmission, and the resident was not evaluated by a psychiatric provider until nearly eight hours later. Facility leadership acknowledged that the readmitting RN was responsible for identifying missing documentation and that there was no specific policy for psychiatric evaluations or 1:1 assignments following physical altercations.
Staff failed to safely open double doors to a secured unit, resulting in a cognitively impaired, ambulatory resident with dementia and osteoarthritis being struck by the door and falling. The resident, who frequently paced near walls and was care planned as a fall risk, was standing near the corner by the unit entrance when a CNA opened the door from the hallway side without adequately ensuring the area was clear, despite the presence of glass windows in the doors. The door hit the resident, causing a fall, nosebleed, and subsequent diagnosis of a closed nasal bone fracture after hospital evaluation.
A resident with multiple complex conditions, including contractures and a history of wrist surgeries, had documented orthopedic evaluation and wrist procedures, as well as a grievance alleging lack of PT. Facility records noted the resident’s return from wrist surgery and referenced specialized therapy needs and difficulty arranging outside therapy, and stated the resident was not appropriate for therapy pending splint removal. However, the clinical record lacked therapy notes related to the wrist surgery, documentation of the orthopedic procedure, and outside consult records for an extended period, and the facility could not produce any therapy documentation for that time frame, contrary to its own charting policy and expectations stated by the APRN and DON.
A resident with severe cognitive impairment and a history of wandering exited a secured memory care unit and the facility unsupervised during a period of high visitor traffic. Staff did not maintain required supervision at exit doors, allowing the resident to leave unnoticed and be found by police offsite.
A resident with dementia and Parkinson's disease experienced a fall, but staff did not complete the required Morse Fall Scale assessment afterward as mandated by facility policy. The next fall risk assessment was not conducted until several months later, despite the expectation that such assessments occur after each fall.
A resident who was dependent on staff for personal hygiene and had cognitive impairment was found with dirty linen and a soiled incontinent brief left on furniture surfaces in their room. The assigned nurse aide stated the items were left due to an unavailable soiled linen cart, and acknowledged they should have been bagged and removed. An LPN confirmed that proper infection control procedures were not followed, and the facility could not provide a relevant policy when asked.
Unsafe and Unclean Resident Areas: Survey observations found urine odor, sticky floors, rust-colored stains, peeling wallpaper, standing dirty water in a hallway fountain, and black substance with exposed insulation and wiring in multiple resident rooms and hallways. An LPN said the fountain had not worked since prior to COVID and was not cleaned regularly, while an RN said the sticky floor issue had been addressed with housekeeping. A resident lounge was also observed to be hot and humid because the AC was not working, and a resident reported the room had been unusable for more than two months.
Secured Unit Placement Lacked Required Documentation The facility failed to document the basis for placing four residents on a secured unit, including why the setting was the least restrictive, physician involvement, and consent from the resident or responsible party. Records and interviews showed mixed resident conditions: some had intact cognition and no wandering, while others had dementia or behavioral diagnoses, yet the charts still did not show individualized placement rationale. Residents and family members reported that the secured-unit placement had not been discussed, and some residents described other residents entering rooms, taking items, and causing disruption.
Late Quarterly MDS Assessments: Quarterly MDS assessments were not completed within the required 14-day ARD window for 6 sampled residents. An LPN MDS coordinator said she handled the MDS sections, while an RN regional MDS coordinator was responsible for signing and submitting them. She stated the assessments were delayed after the full-time RN MDS coordinator left and only limited remote help was available, and she said the RN regional MDS coordinator knew she was behind.
Infection Control Program Documentation and Water Management Failures: The facility failed to document monthly environmental rounds and monthly infection surveillance reports and trend analyses, and it did not maintain required flushing documentation for its water management plan. The Infection Preventionist RN and DNS could not locate missing environmental round and surveillance records, and staff could not explain why required flushing of identified low-use water locations was not documented as scheduled. The facility also could not provide the contracted water management binder referenced in the current plan.
Missing Antibiotic Surveillance Tracking and Quarterly Review Documentation: The facility failed to maintain antibiotic stewardship surveillance records showing antibiotic use and outcomes were collected, documented, and analyzed. The IP and DON could only locate limited monthly tracking reports and could not provide evidence that quarterly antibiotic usage reviews were presented at quarterly medical staff meetings, despite the facility policy requiring monthly surveillance data to be used for infection control trending and stewardship review.
A resident who was cognitively intact but dependent for most ADLs was observed with a cup of meds left at the bedside while the nurse left the room, and the resident self-administered the meds without nurse observation. In a separate event, an LPN documented alprazolam ER as given to a resident even though the med had not yet been delivered, was not in the emergency supply, and no record showed the facility had that medication available at the time.
Skin checks, wound follow-up, and mattress settings were not carried out as ordered. One resident had an open buttock area noted without timely weekly skin checks or a provider order documented at the time, while another resident’s LAL mattress was repeatedly found set far above the ordered weight despite a stage 3 coccyx wound and high Braden risk. A third resident with a stage 3 buttock ulcer and other wounds also had the pressure mattress set at 320 lbs instead of the ordered setting, even though staff signed the treatment as completed.
A resident with dementia and mobility needs slid from a wheelchair during transport when the leg rests were not confirmed in place, and another resident with nicotine dependence repeatedly smoked on facility grounds despite a no-smoking policy and prior education. Documentation and staff interviews showed the first resident required staff assistance with wheelchair mobility, while the second resident had multiple smoking-related incidents and continued non-compliance with the facility's smoking rules.
Failure to complete annual performance evaluations for two NAs was identified during review of personnel files, facility policy, and staff interview. One NA had no documented yearly evaluation for multiple years after the last review on file, and another NA had no documented yearly evaluations for several years after the last review on file. The DNS stated evaluations were due yearly based on the hire date anniversary and that HR was responsible for notification and filing, but the facility did not currently have an HR person.
Controlled substance receipt and disposition records were not accurately reconciled. The DON/DNS reported biweekly narcotic audits, but duplicate controlled-drug forms in the reconciliation binder remained outstanding and were not used as the guide for reconciliation. Of 30 flagged forms, 25 were later found in destruction logs or documented as destroyed, while several controlled meds, including hydromorphone, pregabalin, oxycodone, clonazepam, and amphet/dextrin, could not be located or reconciled.
Expired medications were found on a medication cart, including Lisinopril and multiple Gabapentin supplies with past expiration dates. Staff gave mixed accounts of who was responsible for removing expired or discontinued meds, with an LPN, RN supervisor, DNS, and pharmacist describing different practices and expectations. Facility policy and state guidance stated outdated, discontinued, or no longer needed medications should be removed from nursing unit locations and handled appropriately.
Inaccurate meal tray tickets and missing fruit were observed for two residents with therapeutic diets. Both residents had diabetes and were ordered regular consistency, carbohydrate-controlled diets, and both tray tickets listed a banana, but no banana was on the tray. The FSD stated bananas and oranges were always available, but also acknowledged the facility had run out of bananas and had reduced the banana order because they frequently went bad.
A resident with Alzheimer's disease, acute kidney failure, and anxiety disorder was found to have severely impaired cognition, and the MDS showed the pneumococcal vaccine had not been offered. The clinical record lacked documentation that the resident was offered or received any pneumococcal vaccine at the facility, and there was no record of prior pneumococcal vaccination history. The RN and DNS stated residents are assessed and offered the vaccine on admission and when a new series is available, with the admitting nurse obtaining consent and the IP nurse obtaining the physician order.
Failure to Offer COVID-19 Booster Vaccine: A resident with Alzheimer's disease, acute kidney failure, and anxiety disorder had severely impaired cognition and was documented as not up to date with COVID-19 vaccination. Review of immunization consent records and the preventative health care report did not show that the COVID-19 booster was offered. The IP and DNS stated residents are assessed and offered the COVID-19 vaccine on admission and with each new series, and that a new consent form is provided annually with the influenza vaccine.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
Staff did not consistently provide care in accordance with physician orders or the resident’s stated preferences and goals, resulting in treatment that was not individualized or aligned with the resident’s needs.
Two residents with severe cognitive impairment and known wandering behaviors were not adequately supervised, resulting in one resident entering another's room and sitting on their lap with undergarments lowered, while the other resident attempted to push them away. Staff were unaware of the residents' locations at the time, despite care plans and facility policy requiring close monitoring and redirection.
A resident with chronic venous ulcers and a history of accusatory behaviors alleged that a nurse punctured their leg during a dressing change. The nurse did not immediately report the allegation to facility leadership as required by policy, resulting in a delay of two days before the DON was notified.
Multiple residents with psychiatric and cognitive disorders experienced verbal and physical abuse from another resident with a history of aggressive behavior. Despite requests for room changes and ongoing verbal altercations, staff failed to document or act on concerns, leading to physical assaults and psychological trauma. Inadequate supervision and lack of timely interventions allowed repeated incidents involving both residents and staff.
The facility did not ensure that physician visits were conducted at the required intervals for several residents with various chronic conditions, resulting in missed or delayed evaluations as mandated by state regulations and facility policy.
Two residents were affected when staff failed to implement a care plan intervention requiring a stop sign banner on a doorway following a physical altercation. Despite the care plan directive, the stop sign was not in place, and staff confirmed responsibility for its maintenance, resulting in a deficiency.
Two residents did not receive care as ordered: one did not receive the full prescribed dose of a psychiatric medication due to missed labwork required for dispensing, and another did not receive daily wound care for a Stage III pressure ulcer, with no documentation or explanation for the missed treatment.
A resident with severe cognitive impairment and multiple diagnoses did not have their activities of daily living (ADLs) consistently documented each shift, as required by facility policy. Staff failed to record essential information such as support provided for eating, meal intake, and toileting, partly due to agency nurse aides lacking access to the electronic charting system.
Failure to Supervise Aggressive Resident During Room Maintenance Leads to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safety planning for a resident with known aggressive behaviors during a scheduled room maintenance activity that required removal from the resident’s room. Resident #1 had diagnoses including dementia, schizoaffective disorder, depressive type, and adjustment disorder, and was identified on the MDS as severely cognitively impaired. The resident’s care plan documented psychotropic medication use, a history of refusal of care, paranoia/delusions, hitting, and prior resident-to-resident altercations, with interventions that included keeping the resident in a visible area when out of bed and monitoring for behaviors such as hitting and paranoia. Despite these identified risks and interventions, the resident was displaced from his/her room for a thorough cleaning and placed in a common area without an individualized, established supervision plan specific to this situation. On the day of the incident, housekeeping staff stripped the floors and washed the walls of Resident #1’s room, requiring the resident to be removed from the room from before 10:00 AM until between 3:00 PM and 4:00 PM. The Assistant Director of Nursing stated that the plan was for Resident #1 to attend activities from 10:00 AM to 11:30 AM, then sit in a chair outside the room for lunch, and then return to activities after lunch. LPN #3 reported that Resident #1 was moved into the hallway while cleaning took place and was to be monitored by NAs assigned to that wing. However, during the time of the incident, NAs were passing lunch trays and LPN #3 was performing blood glucose monitoring, and therefore was unable to monitor Resident #1. Resident #1, who preferred to stay in his/her room and was not known to wander, was not continuously observed during this period. During this lapse in supervision, Resident #1 entered another resident’s room (Resident #2). Resident #2, who had diagnoses including disorganized schizophrenia, schizoaffective disorder, and generalized anxiety disorder, was moderately cognitively impaired and independent with activities of daily living, with a care plan addressing mood and behavior issues such as agitation and yelling. A reportable event documented that Resident #2 reported being struck by Resident #1 and then pushed Resident #1, causing Resident #1 to fall. Staff responded after hearing commotion in Resident #2’s room and found Resident #1 on the floor, bleeding from a laceration to the right eyebrow. Resident #1 was later found to have sustained a laceration to the right eye and a closed fracture of the right maxillary sinus. This sequence of events demonstrates that the facility did not implement adequate supervision or a specific safety plan for Resident #1 during the room maintenance displacement, resulting in a resident-to-resident altercation with injury. The report also describes a prior incident involving Resident #1 and another resident, Resident #5, on a secured memory care unit. Resident #1’s care plan at that time identified severe cognitive impairment, psychotropic medication use, dementia diagnosis, and behaviors requiring staff intervention and redirection for safety, including wandering, exit seeking, and intrusive behaviors. Resident #5 had vascular dementia, schizoaffective disorder, bipolar type, and an unspecified head injury, was severely cognitively impaired, dependent with bathing, toileting, and personal hygiene, and able to ambulate independently, with a care plan directing staff to intervene and redirect when wandering or when behaviors became intrusive or affected other residents. On the day of that earlier event, NA #1 observed Resident #5 walking down the hallway on the side of Resident #1’s room; as Resident #5 approached the doorway, Resident #1 stepped out and punched Resident #5 in the face under the eye. Resident #5 sustained mild facial swelling, and staff removed Resident #5 from the area and notified the nurse. This prior altercation further reflects that Resident #1 had a documented history of aggressive behavior toward other residents that required close supervision and redirection, which was not effectively implemented during the later room maintenance event. The facility’s own policy on residents’ right to freedom from abuse, neglect, and exploitation stated that residents have the right to be free from abuse and that the facility has zero tolerance for abuse of any kind. Despite this, Resident #1, with a known history of hitting and resident-to-resident altercations, was not provided with adequate supervision or a clearly defined, individualized supervision plan during the extended period out of his/her room for cleaning. The lack of effective monitoring and failure to ensure that staff were available and actively supervising during a known high-risk situation directly preceded the resident’s unsupervised entry into another resident’s room and the resulting altercation and injuries.
Care Plan Not Updated After Room Change Following Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive, person-centered care plan after a significant change in room assignment from a secured memory care unit to a non-secured unit following a resident-to-resident physical altercation. The resident had diagnoses including dementia, schizoaffective disorder (depressive type), and adjustment disorder, and was identified on a quarterly MDS as severely cognitively impaired with a BIMS score of 00, dependent for bathing, requiring substantial assistance with toileting and personal hygiene, and able to ambulate with supervision or touch assistance. The existing Resident Care Plan, dated 8/16/25, documented that the resident received psychotropic medications related to dementia, depression, schizoaffective disorder, anxiety, and insomnia, and had a history of refusal of care, paranoia/delusions, and hitting. It also identified the resident as living on a secured memory care unit due to behaviors requiring staff intervention and redirection for safety, with interventions to monitor for depression and intervene and redirect for wandering, exit seeking, or intrusive behaviors affecting other residents. A Reportable Event Form dated 10/11/25 documented that another resident was struck in the face by this resident, resulting in mild swelling to the other resident’s face. Following this incident, the resident was moved from the secured unit to a non-secured unit on 10/11/25. A nurse’s note by the Assistant DON on 10/12/25 indicated the resident continued on one-to-one monitoring, appeared to be adjusting to the room change, and to continue with the plan of care. However, review of the Resident Care Plan showed no revisions after the move from the secured to the non-secured unit. The DON confirmed the room change date and the lack of care plan revisions, and the social worker reported that the IDT would typically meet to discuss needs and develop a plan of care prior to a room change, or as soon as practicable after a safety-related move, which did not occur for this resident. This was inconsistent with the facility’s Comprehensive Care Planning policy requiring development and implementation of a comprehensive care plan with measurable objectives and timetables based on data gathering and clinical decision making.
Failure to Obtain Timely Psychiatric/Harm Clearance After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not obtaining a harm/psychiatric clearance prior to a resident’s return following a physical altercation. Resident #1, who had dementia, schizoaffective disorder (depressive type), adjustment disorder, severe cognitive impairment (BIMS of 4), dependence with toileting and lower body dressing, and a history of refusal of care, paranoia/delusions, hitting, and resident-to-resident altercations, was care planned to receive psychotropic medications and to be monitored for depression and aggressive behaviors. On 3/16/26, an unwitnessed incident occurred between Resident #1 and Resident #2 in which Resident #2 reported being struck by Resident #1 and then pushing Resident #1, causing Resident #1 to fall. Resident #1 was found lying on the floor, reported being struck in the face, and had a laceration to the right eyebrow. An APRN evaluated Resident #1 that afternoon and recommended transfer to the emergency department for evaluation. The hospital discharge summary documented that Resident #1 sustained a right eye laceration and a closed fracture of the right maxillary sinus but did not indicate that a psychiatric evaluation had been completed. Resident #1 returned to the facility at 11:30 PM on 3/16/26. Facility documentation did not show that a no-harm letter or psychiatric clearance was obtained for Resident #1 related to the altercation before or at the time of readmission. A subsequent note by an APRN at 7:25 AM on 3/17/26 documented that Resident #1 was evaluated after the altercation and was not considered a danger to self or others, but this occurred nearly eight hours after the resident’s return. Interviews with facility leadership confirmed that the readmitting RN was responsible for reviewing hospital paperwork and addressing missing documentation, and that the hospital had not completed the psychiatric evaluation as expected. The facility did not have a policy specific to psychiatric evaluations or one-to-one assignments for residents involved in physical altercations.
Resident Struck by Unit Door and Sustains Nasal Fracture
Penalty
Summary
Staff failed to safely open an access door to a secured resident unit, resulting in a resident being struck by the door and falling. The resident involved had diagnoses including Alzheimer's disease, dementia with behaviors, and osteoarthritis, and was care planned as a fall risk. A recent MDS assessment documented severe cognitive impairment, independent ambulation with set-up assistance, and no falls in the prior 90 days. On the evening of 1/14/2026, the resident was positioned near the corner of the wall and the double doors at the secured unit entrance when a nursing assistant opened the door from the hallway side. The door had a push bar and a clear glass window above it that allowed visibility into the area where the resident was standing. According to nursing documentation and facility incident reports, the nursing assistant did not recognize that the resident was behind the door when she opened it, and the door hit the resident, causing a fall. The resident was found with a nosebleed and facial discoloration but with range of motion at baseline and no reported loss of consciousness. The APRN ordered transfer to the hospital for facial x‑rays, and the resident was diagnosed with a closed nasal bone fracture. Interviews with the DNS, RN, and the nursing assistant confirmed that the resident often paced close to the walls, that multiple residents on the unit wandered or paced near doors, and that the nursing assistant either did not see or did not adequately identify the resident through the door window before pushing the door open, leading to the accident.
Failure to Maintain Complete Medical Record for Post‑Surgical Therapy and Orthopedic Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who had complex medical needs, including neurogenic bladder, a stage 4 sacral pressure ulcer, chronic pain, contractures, an indwelling catheter, an ostomy, a feeding tube, and dependence for all care. The resident’s MDS showed intact cognition with a BIMS score of 14, and the care plan identified the need for bilateral elbow extension splints and a custom tilt-in-space wheelchair with gentle range of motion and therapy screening as needed. An APRN progress note documented that the resident was seen by a bone/joint specialist for hand contractures and had a right wrist carpectomy without complications, with left wrist/hand surgery scheduled. A nursing note later documented the resident’s return from a surgical appointment with a left wrist dressing that was clean, dry, and intact and no acute distress. A grievance filed by the resident stated that he/she reported to a hospital bone and joint institute that physical therapy was not being received. The grievance response stated that after the wrist surgery, the required therapy was specialized and could not be completed at the facility, that attempts to arrange outside therapy were complicated by the resident’s special needs, and that therapy had thoroughly evaluated the resident and determined he/she was not appropriate for therapy pending removal of a wrist splint by the orthopedist. However, record review did not identify any therapy notes or records related to the wrist surgery, any documentation of the orthopedic procedure on the left wrist, or any outside consultations prior to a specified date. The facility was unable to provide any therapy documentation for 2021 or outside consultations before that date. In interviews, the APRN and DON both stated that documentation of the orthopedic procedure, therapy evaluations, any therapy provided, or reasons therapy was not provided, and orthopedic consultations/surgeries should have been included in the resident’s medical record, consistent with the facility’s Charting Documentation Policy requiring all services and changes in condition to be documented.
Failure to Prevent Elopement Due to Inadequate Supervision During High Visitor Volume
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and a known history of wandering was not adequately supervised during a period of increased visitor activity. The resident was independent with ambulation and transfers, and care plans identified wandering behaviors with interventions to redirect and provide structured routines. Despite these interventions, the resident was able to leave the secured memory care unit unsupervised while visitors were entering and exiting the unit in large groups. On the day of the incident, there were several out-of-state visitors unfamiliar with the facility, as well as ongoing construction and a social worker present, contributing to a busier environment than usual. Staff interviews revealed that the resident likely exited the secured unit alongside visitors when the door was opened for them. The staff member responsible for entering the secure door code did not remain at the door to ensure no residents exited, as required by facility policy. The resident then proceeded through two hallways and exited the main facility entrance without being noticed by the receptionist or other staff. The facility was unaware that the resident had left until notified by the police, who found the resident 0.4 miles away from the facility. Documentation and interviews confirmed that staff did not provide the necessary supervision or monitoring at exit points during peak visitor times, as outlined in the facility's elopement prevention policy. This lapse in supervision allowed the resident to leave the secured area and the facility without detection.
Failure to Complete Post-Fall Risk Assessment
Penalty
Summary
A deficiency was identified when a resident with a history of falls, dementia with behavioral disturbances, and Parkinson's disease experienced a fall. The resident's care plan indicated interventions such as keeping the call light within reach, encouraging the resident to call for assistance, and providing help with bed mobility, transfers, and ambulation. After the fall, the resident was found sitting on the floor, assessed for injuries, and assisted back to bed. Documentation showed no injuries or distress following the incident. However, a review of the clinical record revealed that the required fall risk assessment, specifically the Morse Fall Scale, was not completed after the fall as mandated by facility policy. The next documented fall risk assessment occurred four months later. Interviews with the DON and Regional Nurse confirmed that the Morse Fall Scale should have been completed after the fall, in accordance with policy, but this was not done. Facility policy directs that a fall risk assessment must be completed and documented in the medical record after any fall.
Failure to Remove Soiled Linen and Incontinent Brief from Resident's Room
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for personal hygiene and activities of daily living was found to have dirty linen and a soiled incontinent brief left on top of the dresser and overbed table in their room. The resident had diagnoses including dementia with behavioral disturbances and Parkinson's disease, and was noted to have significant cognitive impairment, requiring substantial assistance for bed mobility, transfers, and was incontinent of bowel and bladder. Observations on the morning of the survey revealed that soiled items remained on furniture surfaces in the resident's room for at least ten minutes. During interviews, the assigned nurse aide explained that the soiled linen and brief were left on the furniture because the soiled linen cart was unavailable in the hallway, and acknowledged that the items should have been bagged and removed immediately. The Regional Nurse (LPN) confirmed that staff should never place dirty linens or incontinent briefs on furniture surfaces and that proper procedures were not followed. The facility was unable to provide a policy on infection control practices related to the disposal of soiled linens and incontinence supplies when requested.
Unsafe and Unclean Resident Areas
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable environment. On the first-floor resident unit, survey observations identified a urine odor in the hallway, rust-colored stains and peeling wallpaper on the walls and baseboards, sticky floors in some areas, and standing brownish-black water in the hallway water fountain drain. Several resident rooms, including rooms 101, 104, 105, 108, 110, 118, 119, and 238, had peeling wallpaper with a black substance on the back of the wallpaper and on the wall, black substance beneath AC units, exposed inner wall and insulation around AC units, missing molding exposing insulation and wiring, detached baseboard covers, and holes in the wall with exposed insulation and black substance. During interviews, an LPN stated the water fountain had not worked since prior to COVID and was not cleaned regularly, and noted that the unit had residents with wandering and other behaviors that made it difficult to keep up with cleaning. An RN stated she noticed the floor was sticky in some areas and had addressed it with housekeeping. The Administrator observed the fountain and stated it would be removed that day, noting the standing water could be a safety concern for ambulatory residents with lower cognitive status or safety awareness. The Administrator was also shown the black growth, exposed insulation, and residue on the walls and molding during the unit tour. The report also identified a resident lounge on the Chateaux unit that was warm and humid because the wall AC was not functioning and the television was out of order. A resident stated the lounge had been too hot for residents to use for relaxation or watching TV and said the condition had been present for greater than two months. A maintenance director from another Civita facility stated he was aware of the broken AC and had told the resident it was an electrical issue requiring an electrician. The Administrator stated the AC had been broken for several weeks, that a new unit had not been installed because of the electrical issue, and that they were working on quotes. A maintenance assistant stated there had been HVAC problems in the building and that the lounge AC had been out for a couple of months, with the breaker tripping when reset.
Secured Unit Placement Lacked Assessment, Consent, and Least-Restrictive Documentation
Penalty
Summary
The facility failed to assess, care plan, demonstrate that the secured unit was the least restrictive setting, and obtain consent for residents selected to reside on the secured unit. Four sampled residents on the secured unit were reviewed for involuntary seclusion, and the clinical records for each failed to show documentation of the criteria for placement, physician involvement in the decision, or consent from the resident and/or responsible party. The facility assessment and interviews also showed that the secured unit had keypad-controlled entry and exit, with staff allowing access from the nursing station. Resident #32 had diagnoses including Parkinson's disease, psychosis, PTSD, anxiety, and dementia with behavioral disturbances. The quarterly MDS identified intact cognition and independence with toileting, hygiene, dressing, transfers, and ambulation, and the care plan did not address residence on the secured unit. Social work notes documented that the resident kept the room door closed because of anxiety when other residents entered the room. The resident stated that no one had discussed placement on the secured unit and that many residents wandered into rooms, took items, and were disruptive. The record did not identify why the resident required the secured unit, that it was the least restrictive environment, or that consent had been obtained. Resident #69 had diagnoses including dementia with behavioral disturbances, depression, and adjustment insomnia. The annual MDS identified intact cognition, no wandering or rejection of care behaviors, and independence with mobility and transfers. The care plan addressed mild cognitive decline and helping other residents without permission, but the record did not identify criteria for secured unit placement, least restrictive setting, physician involvement, or consent. The resident stated that a rolling walker had been taken from the room by another resident and that residents wandered into the room, and the family member stated there was no need for the resident to be on a secured unit and that the placement had not been discussed. Resident #161 had diagnoses including Alzheimer's disease, anxiety, and chronic pain syndrome, and the admission MDS identified severely impaired cognition, no wandering behaviors, and use of a manual wheelchair with partial/moderate assistance for mobility. The care plan described dementia-related decline and agitation but did not document placement on the secured unit. The record failed to show documentation of placement discussion, least restrictive setting, or consent. Resident #173 had diagnoses including dementia, anxiety disorder, and depression; the admission MDS identified intact cognition and no wandering behaviors, while later assessments conflicted regarding elopement risk. The resident described confusion about placement, inability to leave, and stress related to other residents entering the room and taking items. The record again failed to show documentation supporting secured unit placement, least restrictive setting, or consent.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed timely for 6 of 6 sampled residents reviewed for resident assessment. Resident #31, #45, #49, #56, #62, and #64 each had a quarterly MDS assessment that established an ARD and a required completion window, but the next quarterly assessments were completed after the 14-day timeframe allowed by the RAI 3.0 user manual. The assessments were late by 35 days, 37 days, 40 days, 57 days, 21 days, and 29 days, respectively. During interview, the LPN MDS Coordinator stated she was responsible for completing the MDS sections, while the RN Regional MDS Coordinator was responsible for signing the RN MDS completion and submitting the completed MDS. She acknowledged the quarterly assessments were late because the full-time RN MDS coordinator had left 2 months earlier and she was only receiving 6 to 8 hours per week of remote help from another MDS coordinator, which she said was not enough to complete the assessments timely. She also stated the RN Regional MDS Coordinator was aware she was getting behind with completion of the MDS assessments.
Infection Control Program Documentation and Water Management Failures
Penalty
Summary
The facility failed to ensure that infection prevention and control program activities were completed and documented as required. Review of environmental round documentation for the prior two years showed no documentation for monthly environmental rounds for October 2024 and January 2025. The Infection Preventionist RN and the DNS stated they were unable to locate documentation for those months, and identified that environmental rounds are completed monthly. The facility policy stated that the infection control professional or designee, charge nurses, supervisors, and department heads complete environmental rounds on a regular basis, and that the worksheets are retained for review. The facility also failed to provide documentation that monthly infection surveillance reports and infection trend analyses were completed for January 2024 through May 2024 and July 2024 through September 2024. The Infection Preventionist RN and the DNS stated they could not locate the monthly surveillance infection reports and analysis for those periods after searching throughout the facility. The Infection Preventionist stated the monthly report and analysis data included healthcare/facility acquired infections and community acquired infections, and that the monthly infection rate is calculated using a formula. The surveillance policy required monthly collection of infection reports, line listing of infections by resident, and monthly/quarterly identification of predominant pathogens or sites of infection. The facility also did not follow its water management plan for preventing Legionella and other waterborne pathogens in the building water system. The plan identified flushing of not regularly used water pipes and locations, including the soiled utility room, medication room sinks, and shower tubs twice monthly, along with annual water sampling and daily water temperature checks. Review of the flushing log showed no documentation that flushes were completed twice for January 2025, February 2025, and July 2025 in the identified locations. Staff stated the flushing plan changed in January 2025 from monthly to twice monthly, and the Administrator stated he was unable to say why the flushes were not completed. The facility also could not provide the contracted company water management binder referenced in the annual water management plan revision and update.
Missing Antibiotic Surveillance Tracking and Quarterly Review Documentation
Penalty
Summary
The facility failed to ensure antibiotic surveillance tracking reports of antibiotic usage and outcomes were collected and documented for analysis as part of its antibiotic stewardship program. During review of the program with the Infection Preventionist (RN #7) and the DNS, no documentation could be provided for antibiotic surveillance data from January 2024 through May 2024 or from July 2024 through September 2024. The facility also could not provide documentation showing that quarterly reviews of antibiotic usage for the first, second, and third quarters of 2024 and the first and second quarters of 2025 were presented at the quarterly medical staff meeting. During interview, RN #7 and the DNS stated they were not working at the facility during the earlier time frame and were only able to locate the monthly antibiotic surveillance tracking report for June 2024 and for October through December 2024. The DNS further stated she could not locate any infection control reports that included the antibiotic stewardship program presentation at the quarterly medical staff meetings held in the first, second, and third quarters of 2024 and the first and second quarters of 2025. RN #7 stated the antibiotic surveillance report is tracked monthly as part of the infection surveillance report and is presented at the quarterly medical staff meeting by the infection preventionist, and that the previous IP would have been responsible for completing the monthly antibiotic surveillance usage report.
Medication Left at Bedside and Incorrect eMAR Documentation
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for a resident who was cognitively intact but dependent on staff for most ADLs and transfers. The resident was observed in bed with a medication cup left on an overbed table in front of him/her while the nurse was not in the room, and the resident then self-administered the medications. The resident stated that the nurse leaves the medications at the bedside because it takes a long time to take them one at a time. The LPN confirmed she had poured the medications, left them at the bedside, and left the room to heat cereal, and also acknowledged the resident had not been assessed to self-administer medications. The medications prepared for that resident included gabapentin, cholecalciferol, dexamethasone, acidophilus, vitamin C, a multivitamin with minerals, Prevagen, aspirin, and linezolid. The nursing supervisor stated the LPN was distracted and nervous, mistakenly left the medications at bedside, and should have asked a NA to reheat the cereal while medication administration was in progress. The supervisor also stated medications should not be left at the bedside and that the nurse should observe the resident taking the medications that were poured. The facility also failed to ensure documentation on the eMAR was accurate for a resident receiving alprazolam ER for anxiety disorder. The resident’s order was for alprazolam ER 1 mg daily at 9:00 AM, but the eMAR showed it was administered by the charge nurse before the medication had been delivered to the facility. The controlled disposition record showed the medication was delivered the following day, the emergency medication inventory did not list alprazolam ER, and the controlled medication transactions did not identify any resident with an order for that medication during the relevant period. The charge nurse could not identify where the medication came from or whether it was actually administered, and the DNS confirmed the eMAR entry was incorrect because the medication was not available and was not part of the facility’s emergency supply.
Skin checks, wound follow-up, and mattress settings were not carried out as ordered
Penalty
Summary
The facility failed to ensure skin checks were completed before a pressure ulcer was identified, failed to ensure assessment and provider follow-up after a skin issue was found, and failed to ensure a low air loss mattress was set according to physician orders for three residents. Resident #1 had diagnoses including muscle weakness, hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, and difficulty walking. The resident was cognitively intact, did not ambulate, used a wheelchair, and required substantial assistance with mobility and personal care. The care plan identified the resident as at risk for skin breakdown and directed skin checks and skin treatment as ordered, and a physician order directed weekly skin checks. Review of skin assessments did not identify weekly skin checks completed prior to the 11/19/24 assessment, which documented no skin issues. A nurse note on 11/10/24 documented an open area on the right inner buttocks measuring 1 cm by 1 cm with no drainage, but no treatment order was found after that identification. Interviews showed the open area was not handled consistently with the facility’s wound process. RN #6 did not recall being notified of the open area and stated that if she had been notified she would have contacted the on-call provider and documented an assessment in a progress note. APRN #2 stated she would frequently be updated when something needed to be seen or treated before the wound physician came to the facility, but the first time she noted the wound in a note was not until 12/20/24. MD #2 stated the wound management detail showed the right buttock area as stage III on 11/10/24 and healed by 11/22/24, but he would not have healed an area he had not yet consulted on and did not order it healed. He further stated the wound was not mentioned in his notes until 12/8/24, when it was identified as a new pressure wound to the right buttock, measuring 1.5 cm by 1.5 cm by 0.2 cm with moderate serous exudate. The facility policy directed that changes in skin condition be documented and that MD notification be documented when a new skin alteration was noted. Resident #66 had Alzheimer’s disease, dementia with agitation, and depression, was severely cognitively impaired, nonverbal, non-ambulatory, dependent for transfers, and at high risk for pressure ulcers by Braden score. A physician order directed the resident’s air mattress be set at 160 lbs and checked every shift, and the care plan included the reopened stage 3 coccyx wound with the same mattress setting. However, observations showed the low air loss mattress was set at 360 lbs on two occasions and 125 lbs on another occasion. RN #3 confirmed the order was for 160 lbs, while LPN #2 stated she checked that the mattress was inflated but did not look at the settings and had signed it off in the TAR. Resident #123 had a stage 3 pressure ulcer to the buttocks, a left upper arm wound, protein-calorie malnutrition, and anemia. The resident was cognitively intact, required moderate assistance with care and mobility, and used a manual wheelchair. A physician order directed the air mattress to be set at 150 lbs and checked every shift, but the resident’s weight was 119 lbs and observations showed the mattress set at 320 lbs on multiple occasions. Although the wound nurse documented the buttock stage 3 as resolved, the resident still had a cancerous left upper arm wound and remained on the pressure redistribution mattress. LPN #5 signed that the mattress was set at 150 lbs on the eMAR/eTAR, but later observed it at 320 lbs and thought it was correct. RN #7 and MD #2 both stated the mattress setting should be based on the resident’s weight and that a setting of 320 lbs was inappropriate because it made the mattress hard and not effective.
Wheelchair positioning and smoking supervision failures
Penalty
Summary
The facility failed to ensure a wheelchair leg rest was in place during transport for a resident with Alzheimer's disease, CHF, and Parkinson's disease who had moderate cognitive impairment and required extensive assistance with transfers and wheelchair mobility. The resident slid from the wheelchair to the floor while being transported to the bathroom by a nurse aide. The record noted the resident did not sustain injuries and denied pain, and therapy documentation identified that the wheelchair leg rests should be used to help maintain proper positioning and prevent sliding from the wheelchair. The facility also failed to provide adequate supervision to prevent repeated smoking on the facility grounds by a resident with stomach cancer, malnutrition, bipolar disorder, and nicotine dependence. The resident was cognitively intact, independent with ambulation, and had a care plan addressing smoking-related concerns, including room searches, 1:1 supervision if searches were refused, smoking education, and a non-smoking policy review. Nursing notes documented multiple episodes in which the resident was observed smoking outside on facility grounds, including incidents where cigarette smoke was smelled in the room, smoking materials were found or suspected, and the resident was educated about the non-smoking policy. Despite repeated non-compliance with the non-smoking policy, the resident was again observed smoking on the facility grounds after returning from leave of absence. The record shows the resident had acknowledged the facility's strict non-smoking policy and that repeated non-compliance could lead to discharge, yet the resident continued to smoke on the property. The facility documentation and interviews confirmed the resident's ongoing smoking-related non-compliance and the facility's awareness that smoking was not allowed within the facility or on the property.
Failure to Complete Annual Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two nurse aides, NA #4 and NA #5, based on review of personnel records, facility policy, and staff interviews. NA #4’s personnel file showed a hire date of 1/31/22, and the last performance evaluation on file was completed on 5/26/23; no yearly performance evaluation was identified for 2024 or 2025. NA #5’s personnel file showed a hire date of 8/14/2002, and the last performance evaluation on file was dated 8/20/2018; no yearly performance evaluations were identified for 2023, 2024, or 2025. During interview, the DNS stated that each employee should have a performance evaluation completed yearly based on the date of hire anniversary, that Human Resources was responsible for notifying staff when evaluations were due and ensuring they were completed and filed, and that the facility did not currently have a Human Resources person. The facility policy stated that performance evaluations include review and summary of employee counseling sessions, review of job description performance ratings with the employee, and filing the evaluation in accordance with facility policy.
Controlled Substance Reconciliation Records Not Properly Maintained
Penalty
Summary
The facility failed to ensure a system of records for the receipt and disposition of all controlled drugs was in place to allow accurate reconciliation of controlled medications. The DNS stated she conducted biweekly audits of narcotic signature sheets, and review of the audit sheets showed she completed all audits from April through August. However, observation and review of the narcotic reconciliation binders with the DNS on 8/21/25 showed the facility kept duplicate copies of controlled drug receipt/proof of use/disposition forms to compare against narcotics in use, and the duplicate forms in the binder ranged from 2023 through 8/20/25 without being reconciled, appearing to remain outstanding. The DNS stated the reconciliation process was to take the duplicate binder to each medication cart, count the carts, and verify the medication sheets in the carts were also present in the duplicate binder, but she did not use the duplicate binder as a guide when completing reconciliations and did not know the status of the outstanding duplicate sheets. Of 30 randomly selected controlled substance forms, 25 were later identified as located in narcotic destruction logs sent home with residents or destroyed, while 6 medications could not be located or reconciled, including amphet/dextrin cap 50 mg ER, hydromorphone HCL 2 mg tab, pregabalin cap 150 mg, oxycodone IR 5 mg tabs, and clonazepam 0.5 mg tabs. The facility policy required unannounced documented audits of all controlled substance stock at least twice a month and separate maintenance of receipt, disposition, and destruction records.
Expired Medications Left on Medication Cart
Penalty
Summary
Expired and discontinued medications were found stored on a medication cart during observation, and the facility failed to ensure they were removed according to its policy. On 8/20/25 at 6:49 AM, the medication cart contained expired Lisinopril 10 mg tablets with an expiration date of 8/1/25, expired Gabapentin 300 mg capsules with an expiration date of 7/1/25, and multiple expired Gabapentin 100 mg supplies with expiration dates of 7/31/25 and 8/1/25, including loose capsules and bubble packs totaling 90 capsules. During interviews, LPN #6 stated someone in the facility was responsible for removing expired medications from the carts, but she was not responsible for doing so. LPN #4 stated the pharmacy consultant goes through the carts monthly and removes expired or discontinued medications. The RN Supervisor was unsure of the protocol for removal of expired medications. The DNS stated the pharmacist visits monthly and removes expired medications if seen, but nurses are responsible for keeping carts in order and removing expired or discontinued medications. The pharmacist stated discontinued, expired, or no longer needed medications should be removed from the cart, but also said medications on hold or discontinued might remain in the cart in case they are needed again; she also stated her last cart audits were completed in June 2025. Facility policy stated discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed, and state guidance stated discontinued, unauthorized, or no longer needed medications should be immediately removed from nursing unit locations.
Inaccurate Meal Tickets and Missing Fruit on Resident Trays
Penalty
Summary
The facility failed to ensure meal tray tickets were accurate and that fruit was available to residents as ordered. Resident #32 had diagnoses including Parkinson disease, dementia, dysphagia, and diabetes mellitus. The quarterly MDS identified the resident as cognitively intact, requiring set-up help for eating, and receiving a therapeutic diet with regular consistency foods. The care plan identified a potential for alteration in nutritional status related to therapeutic diet, dysphagia, and diabetes mellitus, with interventions to ensure the diet was accurate as ordered and to offer snacks as indicated. The current physician’s order directed a regular consistency, carbohydrate-controlled diet. During observation, the resident’s meal ticket listed a banana, but no banana was present on the tray. Resident #172 had diagnoses including dementia, hypertension, and diabetes mellitus. The admission MDS identified moderate cognitive impairment, set-up help with eating, and a regular consistency therapeutic diet. The care plan identified a potential for alteration in nutritional status related to therapeutic diet and weight loss, with interventions to ensure the diet was accurate as ordered and to offer snacks as indicated. The current physician’s order directed a regular consistency, carbohydrate-controlled diet. During observation, the resident’s meal ticket also listed a banana, but no banana was present on the tray. The Food Service Director stated bananas and oranges were always available and that the tray ticket indicated whether a banana and/or orange was requested, but also stated the facility had run out of bananas and that the banana order had been reduced from 80 pounds to 60 pounds because they frequently went bad.
Failure to Assess and Offer Pneumococcal Vaccine
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to offer and/or assess for pneumococcal immunizations for one sampled resident. Resident #59 had diagnoses including Alzheimer's disease, acute kidney failure, and anxiety disorder, and the annual MDS identified severely impaired cognition. The MDS also indicated the resident had not received the pneumococcal vaccine because it was not offered. Review of the clinical record with the Infection Preventionist failed to identify documentation that the resident had been offered or received any pneumococcal vaccines while at the facility, and the record also lacked documentation of any past pneumococcal vaccination history. During interview, the RN and DNS stated residents are assessed and offered the pneumococcal vaccine on admission and when there is a new series, and the RN identified that the admitting nurse obtains consent while the IP nurse reviews the consent and obtains the physician order; the RN also stated she was not working at the facility at the time and that the prior IP nurse would have been responsible for assessing and offering the vaccine.
Failure to Offer COVID-19 Booster Vaccine
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccination was offered and/or assessed for Resident #59, whose diagnoses included Alzheimer's disease, acute kidney failure, and anxiety disorder. The annual MDS assessment identified the resident had severely impaired cognition and was not up to date with the COVID-19 vaccination. Review of the resident's immunization consent records and preventative health care report with the Infection Preventionist failed to identify that the COVID-19 booster vaccine had been offered to the resident. During interview, the Infection Preventionist and DNS stated residents are assessed and offered the COVID-19 vaccine on admission and whenever there is a new series, and that a new COVID-19 vaccine consent form is provided annually with the influenza vaccine for the current/new COVID-19 booster vaccine. The Infection Preventionist also stated she began in March 2025 and that the previous infection preventionist nurse was responsible for offering the current COVID-19 vaccine to the resident. The facility's COVID-19 vaccination policy stated the vaccine will be offered to all residents unless medically contraindicated or previously immunized.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Provide Adequate Supervision for Residents with Wandering Behaviors
Penalty
Summary
The facility failed to provide adequate supervision for two residents with known wandering behaviors, resulting in a resident-to-resident interaction. Both residents had diagnoses of dementia and severe cognitive impairment, with one also diagnosed with bipolar disorder and schizoaffective disorder. Care plans for both residents identified risks related to wandering and directed staff to redirect and encourage recreational activities as diversions. Despite these interventions, one resident was found in another resident's room, sitting on the lap of the other resident with their undergarment around their ankles, while the other resident attempted to push them away. Staff had last observed the residents separately less than half an hour before the incident, but were unaware of their whereabouts at the time of the event. Facility documentation and interviews confirmed that both residents had a history of wandering, and the incident occurred in a room equipped with a video camera. The facility's policy required staff to monitor for behaviors that could provoke reactions, including sexually aggressive behavior, and to take steps to protect residents from abuse. However, the report did not identify how the residents were able to access another resident's room without staff knowledge, indicating a lapse in supervision and monitoring as required by the residents' care plans and facility policy.
Failure to Timely Report Alleged Abuse
Penalty
Summary
A deficiency occurred when staff failed to report an allegation of abuse in a timely manner for a resident with chronic venous ulcers and a history of accusatory and manipulative behaviors. The resident, who was cognitively intact and independent in ADLs, alleged that a registered nurse punctured their leg with scissors during a dressing change. The nursing note documented the allegation and minimal bleeding, but no other signs of injury were observed at the time. Despite the facility's policy requiring immediate reporting of all alleged abuse to the administrator or designee, the registered nurse did not report the allegation on the day it was made. Instead, the Director of Nursing Services (DNS) was informed two days later, after the resident reiterated the accusation. Interviews confirmed the delay in reporting, with the DNS acknowledging that the nurse should have reported the allegation immediately, regardless of the presence or absence of injury.
Failure to Protect Residents from Abuse and Inadequate Intervention for Resident Altercations
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both physical and psychosocial abuse, as evidenced by several incidents involving altercations between residents. In one case, a resident with schizoaffective and bipolar disorder, who was cognitively intact and independent with ADLs, repeatedly made negative and racist remarks to a non-ambulatory roommate with a history of stroke and adjustment disorder. Despite the roommate's request for a room change due to feeling unsafe and uncomfortable, the social worker did not facilitate the move, citing a lack of available rooms, although rooms were in fact available. The ongoing verbal altercations were not documented, and the situation escalated to a physical assault, resulting in injury to the non-ambulatory resident. Another incident involved a resident with schizophrenia and anxiety disorder who was physically assaulted by another resident with a history of aggressive behavior. The aggressor, who had previously attacked both staff and residents, was able to break free from staff supervision and physically attack another resident, causing significant distress and ongoing psychological trauma. Staff interviews confirmed that the resident was not adequately supervised, and interventions to prevent further incidents were insufficient, as the resident was able to continue aggressive behaviors after returning from hospitalization. A third incident involved a resident with disorganized schizophrenia and impaired cognition who was physically attacked in the hallway by another resident. The altercation was witnessed by staff, and both residents were sent to the emergency room for evaluation. The facility's failure to implement and document effective interventions, as well as the lack of communication and follow-through on resident concerns, contributed to an environment where residents were not protected from abuse, in violation of facility policy and regulatory requirements.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that physician visits for seven of fifteen residents reviewed were conducted in accordance with state agency requirements and the facility's own policy. Specifically, the clinical record reviews revealed that several residents with diagnoses such as Alzheimer's Disease, seizure disorder, schizoaffective disorder, diabetes mellitus, anxiety, depression, heart failure, and other chronic conditions did not receive physician evaluations at the required intervals. For example, some residents were not evaluated by a physician every sixty days as mandated, and in some cases, there were gaps in documentation of physician visits for several months. Additionally, for newly admitted residents, the required monthly evaluations for the first ninety days were not consistently maintained. The facility's policy and the Connecticut Public Health Code require that each resident be examined by their personal physician at least once every thirty days for the first ninety days following admission, and at least every sixty days thereafter unless otherwise justified in the medical record. Despite these requirements, documentation for multiple residents showed missed or delayed physician visits, with some residents not being seen within the required timeframes. Interviews with facility staff confirmed that the standard of practice was not consistently followed, resulting in noncompliance with both facility policy and state regulations.
Failure to Implement Care Plan Intervention for Resident Safety
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a stop sign banner was in place on the doorway of a resident with diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease. The resident was assessed as cognitively intact and independent with activities of daily living. Following a physical altercation in which another resident entered the room and was struck, the care plan was updated to include the placement of a stop sign banner across the resident's doorway as an intervention. However, during observation and interview, it was found that the stop sign banner was missing from the resident's door, and staff confirmed that all were responsible for maintaining its presence as directed by the care plan. The facility's care plan policy requires that interventions be implemented as described to address identified problem areas and prevent further incidents. Despite this, the intervention to place a stop sign banner was not followed, as confirmed by both staff observation and interview with the regional clinical consultant. This failure to implement the care plan intervention contributed to the deficiency cited during the review.
Failure to Administer Psychiatric Medication and Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, bipolar disorder, and schizophrenia did not receive their prescribed psychiatric medication as ordered. The resident was supposed to have monthly Absolute Neutrophil Count (ANC) bloodwork completed and faxed to the pharmacy to allow for the dispensing of clozapine. The required labwork was not completed as ordered, resulting in the pharmacy not dispensing the full prescribed dose of clozapine. As a result, the resident only received a partial dose of the medication until the labwork was completed and the medication was supplied. Documentation did not provide an explanation for the missed labwork, and the facility's policy required medications to be administered according to physician orders. Another deficiency was identified when a resident with neurocognitive disorder with Lewy bodies, anxiety, and major depressive disorder, who had a Stage III pressure ulcer, did not receive wound care as ordered. The resident's care plan and physician's order specified daily wound care to the coccyx, including cleansing with normal saline, application of Dakin's solution, and a foam dressing. On one occasion, the treatment was not signed off as administered, and facility staff could not identify why the wound care was missed. The facility's policy required pressure ulcer treatments to be administered in accordance with physician orders.
Failure to Document Activities of Daily Living Each Shift
Penalty
Summary
The facility failed to document activities of daily living (ADLs) for one of three residents reviewed, specifically for a resident with neurocognitive disorder with Lewy bodies, anxiety, and major depressive disorder. The resident was assessed as severely cognitively impaired and required substantial assistance with toileting, as well as support with dressing, hygiene, and bathing. The care plan directed staff to assist with turning, repositioning, skin care after incontinence, and ADLs as needed. However, review of the Point of Care History for May and June 2024 showed that staff did not consistently document the resident's ADLs each shift, including support provided for eating, meal consumption, toileting, and related care. Interviews revealed that the facility's practice was to document ADLs each shift, but agency nurse aides did not have access to the charting system, resulting in incomplete documentation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 801 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
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Nursing homes near Newington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bel-air Manor Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Grandview Rehabilitation And Healthcare Center | 2.4 mi | — | 14 | 1 |
| Jefferson House | 2.4 mi | ★★★★★ | 0 | 0 |
| Ledgecrest Health Care Center | 3 mi | ★★★★★ | 4 | 0 |
| Monsignor Bojnowski Manor | 3.1 mi | ★★★★★ | 3 | 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.