Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Salmon Brook during CMS and state inspections, most recent first.
Failure to assess, measure, and document pressure ulcer care: A resident with an unhealed stage 4 pressure ulcer, bowel and bladder incontinence, and limited mobility did not receive required Braden Scale assessments, weekly skin checks, or weekly wound measurements/documentation. Although the resident was also seen by an outside wound clinic, facility LPNs did not continue the required wound assessments, and an as-needed dressing change order was not in place until later.
Delayed Resident Laundry Due to Broken Washing Machines: A resident’s personal items remained unlaundered for about a week, and resident council minutes showed ongoing complaints about delayed laundry service. Staff reported that multiple washers were broken for long periods, leaving only one functioning machine at times, with outsourcing of soiled clothing starting later and NAs sometimes retrieving clothes from lost and found bins for residents without clean clothing.
A resident with intact cognition and independent wheelchair mobility was denied access to an enclosed courtyard because the facility key was lost and no spare key was available. Staff stated the courtyard door remained locked to prevent elopement, and the resident’s grievance noted the resident was withheld from outdoor access until the key was later found.
Medication Prepared by One Nurse and Administered by Another: An LPN administered a PRN morphine dose to a resident with anxiety, major depressive disorder, and chronic back pain after an RN had prepared the medication. The RN signed the TAR as if she had administered it, while interviews confirmed the medication was prepared by one nurse and given by another, contrary to facility policy requiring the same licensed person to prepare and administer medications.
The facility did not provide evidence of a completed background check for a Recreation Aide. Interviews and document reviews revealed that the employee's file lacked the required background check, and facility staff were unable to produce the documentation despite multiple attempts.
The facility failed to keep laundry equipment in working order, leading to ongoing shortages of clean washcloths and towels and significant delays in returning personal laundry to residents. Multiple residents and staff reported that only one washing machine was consistently operational for months, with other machines and a dryer out of order for extended periods. Staff described hazardous workarounds and repeated, unaddressed requests for more linens and repairs, while administrative staff did not arrange for alternative laundry solutions or regular linen audits.
The facility failed to maintain laundry equipment and ensure an adequate supply of linens, resulting in residents experiencing delays in receiving clean personal laundry and a shortage of washcloths and towels for care. Staff and residents reported ongoing issues with laundry turnaround and linen availability, with only one washing machine functioning for months and some equipment out of order for years. Despite repeated reports to administration, the facility did not take effective action to address the shortages or utilize alternative solutions.
A resident identified as high fall risk experienced a fall out of bed, and although the care plan called for a floor mat to be placed to the left side of the bed, there was no immediate physician order or documentation on the MAR/TAR to confirm the intervention was implemented. The order for the floor mat was delayed, and staff interviews confirmed that the intervention should have been initiated and documented right after the fall.
A resident admitted with a stage 2 pressure injury and high risk for further skin breakdown did not receive timely or documented interventions such as an air mattress or scheduled turning and repositioning, as required by facility policy. The resident's wounds worsened and new pressure injuries developed, with staff unable to explain the lack of orders or documentation for these preventative measures.
A resident with dementia and other complex needs, who required staff assistance for ADLs, did not have consistent or complete Nurse Aide documentation for care tasks over a two-month period. Observations showed the resident was well cared for, but documentation for essential care activities was missing or inconsistent on most days. The DNS was unaware of these documentation lapses, and no facility policy for Nurse Aide documentation was provided.
A resident with diabetes and neuropathy developed an infection in the left great toe, prompting an APRN to order antibiotics and a priority podiatry consult. Despite these orders and communication attempts, the resident was not added to the podiatrist's priority list and was not seen as scheduled, due to a failure in the facility's scheduling process.
A resident with Alzheimer's and a high risk for wandering was unaccounted for over four hours due to inadequate supervision and security measures. The resident exited through an unalarmed door and was found outside near the kitchen entrance. Despite previous reports of wandering behavior and broken locks, the facility failed to implement effective interventions, resulting in Immediate Jeopardy.
The facility failed to timely obtain physician orders for wander guard bracelets for two residents identified as high wander risks. One resident with Alzheimer's disease did not have a wander guard applied until 12 days after being assessed as high risk. Another resident with Parkinsonism and dementia lacked a current order to check the wander guard's function nightly, contrary to facility policy.
The facility failed to ensure only authorized personnel had access to medication keys and did not maintain proper storage for controlled drugs. An RN left keys in an unlocked drawer, accessible to others, and a medication refrigerator was found unsecured. The DNS was unaware of the proper procedures, and the facility lacked a policy for narcotic storage.
The facility failed to effectively manage resources and provide proper administrative oversight, resulting in multiple deficiencies. There was no Governing Body, and the Medical Director was not appointed by one. The facility did not notify the State Agency of a reportable event timely, and clinical records were incomplete. A resident with a known wander risk accessed an unlocked egress, and medication security was inadequate. Annual in-service training and policy reviews were not completed timely, leading to differing policies. Interviews revealed a lack of oversight processes, compromising resident well-being.
The facility failed to establish a governing body responsible for management and operation, as evidenced by missing documentation and inconsistent Elopement Policies. Interviews confirmed the absence of a governing body and lack of annual policy reviews, despite existing By-Laws outlining these responsibilities.
A resident with Alzheimer's and delusional disorders, identified as an elopement risk, was found outside the facility after being reported missing. Despite the facility's interventions, there was no documented RN assessment following the incident, violating the facility's documentation policy.
The facility did not ensure that two nurse aides hired in 2023 received the required 12 hours of annual in-service training. One aide only received education on IV therapy, while the other had training on resident rights, abuse/retaliation, and dementia, but neither met the 12-hour requirement. The DNS confirmed the training shortfall but could not explain the deficiency.
A staff member recorded and posted videos of a resident with Alzheimer's and other residents on social media, capturing unprofessional interactions and personal care without consent. This violated facility policies on privacy and abuse, as the residents' rights to confidentiality and dignity were not protected.
A resident with severe cognitive impairment and behavioral issues was found to have a right wrist fracture of unknown origin. The facility did not complete a thorough investigation, as required by policy, by failing to conduct a 72-hour look back and limiting staff interviews to only one shift.
The facility did not complete or document required neurological assessments after unwitnessed falls for two residents, and failed to document wrist stabilization as recommended by an APRN for another resident with a fracture. Despite facility policies mandating neurological checks and adherence to treatment recommendations, these protocols were not followed or documented in the cited cases.
Annual performance evaluations were not conducted for two nurse aides, as required, with the last documented evaluations occurring nearly a year prior. Administrative changes and lack of communication contributed to the oversight, and no evaluation policy was provided when requested.
A resident with significant mobility impairments and a care plan requiring frequent repositioning and assistance out of bed did not receive timely care after using the call bell for an extended period. The facility failed to conduct a thorough investigation into the resident's allegation of neglect, did not collect statements from all involved staff, and lacked documentation of care provided during the shift.
A resident with significant mobility and continence needs was not provided with required turning, repositioning, or incontinent care for over three hours, despite activating the call bell and having care needs documented in the care plan and physician orders. Staffing shortages contributed to the delay, and care was not documented or provided as required during the morning shift.
A resident with spina bifida and neurogenic bladder did not receive required turning, repositioning, or incontinence care for several hours due to insufficient staffing. The resident's call bell went unanswered for an extended period, and only one NA was present for 22 residents until additional staff arrived later in the morning. As a result, the resident had to move themselves to the bathroom and developed a stage 3 pressure ulcer. Staff interviews and documentation confirmed that the facility was understaffed and unable to meet the resident's care needs as outlined in the care plan and physician orders.
Failure to Assess, Measure, and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate assessment, monitoring, and treatment for a resident with an unhealed stage 4 pressure ulcer involving the sacrum/coccyx, left buttocks, and right buttocks. The resident had diagnoses including spinal stenosis of the lumbar region, spina bifida with hydrocephalus, muscle weakness, anxiety disorder, and major depressive disorder. The record showed the resident was incontinent of bowel and bladder, used a wheelchair, required assistance with bed mobility, hygiene, and transfers, and was identified as at risk for pressure ulcer development. The resident was also followed weekly by an outside community wound clinic and had a care plan addressing pressure ulcer prevention and treatment. The clinical record failed to show Braden Scale assessments were completed in accordance with facility policy for a period of more than five months. The record also failed to show weekly skin assessments were completed as required by physician order and facility policy, with gaps in documentation and a fully completed Skin Observation Tool assessment not identified until weeks after the last completed assessment. In addition, the record failed to identify facility-completed weekly pressure ulcer assessments and wound measurements from 2/26/26 through 5/21/26, including wound stage, surrounding skin condition, tissue condition, drainage, and other required wound documentation. The resident’s wound treatment orders directed cleansing, application of zinc oxide paste, Iodosorb, calcium alginate, and dressings changed every shift, but the TARs did not identify an as needed dressing change order until 4/16/26. Interviews with the wound care nurse, DON, and Regional Nurse confirmed licensed nursing staff should have continued weekly wound assessment, measurement, and documentation even though the resident was seen by an outside wound clinic, and that an as needed dressing change order should have been in place earlier. The resident stated he or she had not refused dressing changes or wound measurements at the facility.
Delayed Resident Laundry Due to Broken Washing Machines
Penalty
Summary
The facility failed to provide sufficient laundry services to ensure resident laundry was completed timely because multiple washing machines were broken and remained unrepaired or unreplaced for extended periods. A grievance dated 8/4/2025 documented that Resident #2 had sent personal items to be laundered about one week earlier and was still waiting for them to be washed and returned. The grievance also noted that facility administration stated they were working on buying a new washing machine. Vendor documentation showed a 60-pound washing machine was purchased on 8/14/2025 and due to the facility on 8/29/2025, and resident council minutes from 8/29/2025 and 9/25/2025 showed residents remained displeased with delays in having personal items laundered. Interviews on 10/1/2025 showed the laundry system had been operating with reduced equipment for a prolonged period. The Environmental Services Director stated two of the three washing machines that broke down were irreparable because replacement parts were unavailable, and one broken machine had been replaced about six weeks earlier. Laundry staff reported that one machine had been broken for over two years and another for about one year, leaving only one functioning washer for resident laundry and causing delays. Laundry Technician #2 stated the facility had only one functioning washer for approximately six months before a second washer was added, and outsourcing of soiled clothing began two months earlier at a rate of one time per week. The Central Supply Manager stated nurse aides sometimes had to retrieve clothes from lost and found bins to provide clean clothes to residents who did not have any clean clothes because of the laundry delays. The Administrator acknowledged awareness that two of the three washing machines were not working and that only one machine had been replaced as of 10/1/2025.
Resident Denied Access to Courtyard Due to Missing Key
Penalty
Summary
The facility failed to allow an alert and oriented resident access to an enclosed courtyard. Resident #1 had diagnoses including spina bifida with hydrocephalus, osteoarthritis, anxiety, and major depressive disorder. The resident’s care plan identified that he or she met emotional, intellectual, physical, and social needs by socializing with peers, going outside when it was nice out, and dining in the Rosewood dining room for lunch, with interventions directing the resident to go outdoors and on short trips when able. The annual MDS identified a BIMS score of 13, indicating intact cognition, and the resident was independent with wheelchair mobility. A grievance dated 9/27/2025 stated the resident was withheld from access to the outdoor Recreational Courtyard because a facility key was lost. The Recreation Director stated residents could not use the courtyard that day because the door was locked and no other copies of the key existed in the facility; the key was later located on 9/28/2025. During observation and interview, the Administrator and Recreation Director stated the key had been missing for an undetermined length of time before 9/27/2025, the nursing supervisor did not have a spare key, and the courtyard door remained locked until another staff member arrived and the key was found. The Administrator stated the door was kept locked to prevent elopement and that the facility did not want residents sitting outside the building, and also stated residents should be able to access the courtyard without needing staff to unlock the door. The facility did not have a policy regarding courtyard access.
Medication Prepared by One Nurse and Administered by Another
Penalty
Summary
The facility failed to ensure that the nurse who prepared a medication was the same nurse who administered it, as required by facility policy. Resident #1 had diagnoses including anxiety and major depressive disorder, a care plan addressing chronic back pain and pain medication therapy, and an MDS indicating a BIMS score of 13 with pain medication use. A physician ordered Morphine Sulfate (Concentrate) Solution 20 mg/mL, 10 mg by mouth every 4 hours as needed for pain, and the narcotics log documented that 10 mg was administered at 4:00 AM on 9/30/2025. Interview statements showed that RN #1, who was assigned to Resident #1, poured and prepared the morphine dose, but LPN #1 administered it to the resident. RN #1 signed the TAR indicating the medication had been administered, even though LPN #1 stated she gave the dose and that it was acceptable to administer medication prepared by another nurse. The DNS stated resident medications were to be prepared and administered by the same licensed person, and the facility policy for Administration of Medications directed that medications should always be prepared and administered by the same licensed person.
Failure to Provide Background Check Documentation for Employee
Penalty
Summary
The facility failed to provide evidence that a background check had been conducted for one employee, specifically a Recreation Aide. During interviews and a review of facility documents, it was determined that no background check information was found in the employee's file. The current Human Resource Manager, who had recently started, noted that several files were missing background checks and explained that the previous Human Resource Manager worked remotely and did not print or file the necessary forms. Despite attempts by the Administrator and Assistant Director of Nursing Services to locate or obtain the background check, no documentation was produced for the Recreation Aide.
Failure to Maintain Laundry Equipment Results in Linen Shortages and Delayed Personal Laundry
Penalty
Summary
The facility failed to maintain laundry equipment in proper working order, resulting in significant shortages of clean linens and delays in returning personal laundry to residents. Multiple residents reported not receiving their personal laundry for extended periods, with some having to wear dirty clothing due to the lack of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with some staff resorting to using sheets as towels and having to rush to secure available linens at the start of their shifts. Observations confirmed that linen carts and closets were frequently empty or inadequately stocked during care times. Interviews with staff revealed that only one washing machine was consistently operational for several months, while other machines and a dryer remained out of order for extended periods—up to two years for one washer and four years for a dryer. Laundry aides reported that the turnaround time for personal laundry far exceeded the expected 24 hours, often taking up to 72 hours or more, and that they were unable to keep up with the facility's laundry needs due to equipment limitations. Staff also described hazardous workarounds, such as using a pen to operate a broken washing machine latch, and reported that repeated requests for additional linens and equipment repairs were not addressed in a timely manner. Administrative staff acknowledged the ongoing equipment issues and linen shortages, citing delays in obtaining parts and a lack of alternative arrangements, such as sending laundry to outside facilities or borrowing linens from sister facilities. There was no evidence of regular audits of linen levels prior to the survey, and maintenance staff were unclear about the status of equipment repairs and linen inventory. The facility's own infection control policy required the maintenance supervisor to ensure the safe status of equipment, which was not upheld in this instance.
Failure to Maintain Laundry Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to maintain building equipment and provide adequate linens, resulting in a lack of a clean, comfortable, and homelike environment for residents. Multiple residents reported significant delays in receiving their personal laundry, with some waiting over a week and being forced to wear dirty clothing due to the unavailability of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with staff sometimes resorting to using sheets for bathing and being unable to provide proper care due to insufficient linens. Observations confirmed that linen carts and closets were frequently empty or severely understocked during care shifts. Staff interviews revealed that the facility had only one consistently functioning washing machine for several months, making it impossible to keep up with both facility linens and residents' personal laundry. Laundry aides reported that the turnaround time for personal laundry was significantly delayed, often taking up to 72 hours instead of the expected 24 hours. Despite repeated reports of linen shortages and equipment failures to the Administrator and Director of Housekeeping, no effective action was taken to resolve the issues, and the facility did not utilize available options such as sending laundry to outside facilities or borrowing linens from sister facilities. Further investigation found that some laundry equipment had been out of order for extended periods, with one washing machine nonfunctional for almost two years and a dryer for nearly four years. The Director of Housekeeping was unaware of the full extent of the equipment failures and did not have authority over repairs or purchasing. The facility also lacked policies addressing residents' rights to a clean, homelike environment and did not provide requested policies on laundry or environmental standards.
Failure to Timely Implement and Document Fall Prevention Intervention
Penalty
Summary
A resident with diagnoses including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure was identified as a high fall risk and experienced a fall out of bed. The resident's care plan specified interventions such as ensuring the call bell was within reach, encouraging its use, and placing a floor mat to the left side of the bed. Despite these interventions being documented in the care plan and accident investigation, there was no evidence that a physician's order for the floor mat was obtained or transcribed immediately after the fall. The order for the floor mat was not entered until six days after the incident, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to confirm that nursing staff ensured the mat was in place as required. Interviews with facility staff, including the Director of Nursing Services (DNS) and a regional nurse, confirmed that the expected protocol was to obtain and transcribe a physician's order for the intervention immediately after the fall and to ensure it was reflected on the TAR for staff accountability. The facility's Accident and Incident Investigation policy also required that interventions to prevent further incidents be identified and implemented promptly. The failure to timely implement and document the fall intervention according to the care plan and physician order constituted the deficiency.
Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with multiple diagnoses, including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure, was admitted to the facility with a stage 2 pressure injury to the coccyx. Upon admission, the resident was assessed as high risk for pressure injuries using the Braden Scale and required substantial assistance for bed mobility, personal hygiene, and transfers. Despite these findings, there was no evidence that preventative interventions, such as an air mattress or a scheduled turning and repositioning regimen, were initiated or documented in the days following admission, as required by facility policy. The resident's care plan, initiated five days after admission, included interventions for pressure injury prevention and treatment, but physician orders and nursing documentation did not reflect the implementation of these interventions. The pressure injury progressed to an unstageable wound, and a new facility-acquired unstageable pressure injury developed on the resident's left heel. Throughout the resident's stay, there was a lack of documentation indicating that an air mattress was provided or that a turning and repositioning schedule was followed, even after the wounds worsened and new wounds developed. Additionally, weekly skin observation tools were either not completed or not documented as required by facility policy. Interviews with facility staff, including the DNS, wound physician, and wound nurse, confirmed that interventions such as air mattress placement and frequent turning and repositioning should have been implemented immediately upon admission and after wound deterioration. Staff were unable to explain why these interventions were not ordered or documented. The facility's policy clearly directed these interventions for residents with stage 2 or greater pressure injuries, but the required actions were not taken or recorded, leading to the identified deficiency.
Failure to Ensure Complete and Accurate Nurse Aide Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation by Nurse Aides for a resident with multiple diagnoses, including dementia, altered mental status, anxiety disorder, and malnutrition. The resident was assessed as having moderately impaired cognition and required staff assistance for activities of daily living (ADLs), including eating, personal care, bed mobility, and transfers. Observations confirmed that the resident appeared clean, well-dressed, and had access to water and reading material. However, a review of Nurse Aide documentation for April and May revealed significant inconsistencies in recording care tasks such as behavior symptoms, transferring, bed mobility, bowel movements, toileting hygiene, intake and output, toilet use, oral hygiene, personal hygiene, showering/bathing, snacks, eating, and amount eaten. Documentation was incomplete for the majority of days reviewed in both months. During an interview, the Director of Nursing Services (DNS) was unaware of the inconsistent documentation and acknowledged that Nurse Aides should be documenting all tasks every shift. The facility was unable to provide a policy for Nurse Aide documentation when requested. The deficiency centers on the lack of consistent and complete documentation of care provided to a dependent resident, as required by accepted professional standards.
Failure to Ensure Timely Podiatry Care for Resident with Toe Infection
Penalty
Summary
A resident with diabetes and polyneuropathy, who was dependent on staff for personal care and had a history of memory recall deficits, developed redness, swelling, and pain in the left great toe. The care plan required daily foot checks and prompt reporting of any abnormalities. After a family member reported the toe issue, an Advanced Practice Registered Nurse (APRN) evaluated the resident, diagnosed an infection, and ordered antibiotics, warm soaks, and a podiatry consult. The APRN also directed that the resident be placed on the podiatrist's priority schedule for an upcoming visit. Despite these orders, the facility failed to ensure the resident was added to the podiatrist's priority list. Although the scheduling secretary reported emailing the podiatry office to include the resident, the facility's podiatry list for the scheduled visit did not reflect the resident's name. As a result, the resident was not seen by the podiatrist as intended. Interviews with facility staff and the podiatrist confirmed that the resident should have been prioritized and that Medicare coverage was not a barrier to timely care.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified as high risk for wandering, resulting in the resident being unaccounted for over four hours. The resident, diagnosed with Alzheimer's disease and delusional disorders, was known to have exit-seeking behaviors and had previously been found wandering in unauthorized areas. Despite being identified as a high wander risk, the resident's care plan interventions, such as using a wander guard bracelet and offering diversions, were insufficient to prevent the resident from leaving the facility unnoticed. On the day of the incident, the resident was last seen by a nursing assistant at 3:15 AM, and it was discovered that the resident was missing at 4:00 AM. The facility's search efforts were delayed, and the police were not notified until 6:00 AM, contrary to the facility's policy of notifying authorities within 5 to 7 minutes if a resident is not located. The resident was eventually found outside near the rear kitchen entrance, having exited through an unalarmed and unlocked door, and was believed to have been in a dryer service room that was also unlocked. Interviews and observations revealed that several doors within the facility, including those leading to the kitchen and laundry areas, had broken locks or were unalarmed, allowing the resident to exit the building. Staff had previously reported the resident's wandering behavior and the broken locks, but no room change or additional monitoring orders were implemented. The facility's failure to maintain secure exits and promptly address the resident's wandering risk resulted in a finding of Immediate Jeopardy.
Failure to Timely Obtain and Implement Wander Guard Orders for High-Risk Residents
Penalty
Summary
The facility failed to obtain timely physician orders for wander guard bracelets for two residents identified as high wander risks. Resident #1, diagnosed with Alzheimer's disease and delusional disorders, was assessed on 1/10/2025 as a high wander risk with a score of 12. Despite this assessment, a physician order for a wander guard bracelet was not obtained until 1/22/2025, 12 days later. The Director of Nursing Services (DNS) believed a wander guard was applied earlier, but no documentation supported this. The facility's wander guard tracking book also lacked evidence of a bracelet being signed out for Resident #1 before 1/22/2025. Similarly, Resident #2, with diagnoses including Parkinsonism and dementia, was also identified as a high wander risk with a score of 12 on 1/13/2025. Although a physician order was eventually obtained on 1/22/2025 to verify the placement and function of the wander guard bracelet, there was no current order directing staff to check the bracelet's function nightly. The DNS acknowledged the absence of such an order, which contradicted the facility's policy requiring nightly checks by the 11 PM to 7 AM supervisor.
Unauthorized Access to Medication Keys and Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to keys for medication storage, including medication rooms and carts, and did not maintain separately locked, permanently affixed compartments for controlled drugs. During an observation, a registered nurse (RN) was found to not carry the nursing supervisor keys on her person due to their weight, instead keeping them in an unlocked drawer in the supervisor's office. This office was located on a different wing and was accessible to others, including a resident who was present in the office at the time of the observation. The RN demonstrated that the keys provided access to all areas of the facility, including medication storage areas. Further observations revealed that the medication room on the B-unit was unattended, and the refrigerator meant for storing controlled emergency medications was not properly secured. The keypad lock intended for the refrigerator was found sitting on top of it, leaving the refrigerator unlocked. Inside, a locked box containing controlled substances like liquid Morphine and Ativan was chained to the refrigerator. The Director of Nursing Services (DNS) was unable to explain why the RN did not have control of the keys and incorrectly believed that the lock's placement on top of the refrigerator was acceptable. The facility's policy on controlled pharmaceuticals required that keys to controlled substance containers be maintained separately, but there was no policy for the storage of narcotic/controlled medications.
Deficiencies in Administrative Oversight and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and ensure proper administrative oversight, leading to several deficiencies. There was no Governing Body in place, and the Medical Director was not appointed by such a body. The facility did not notify the State Agency in a timely manner about a reportable event. Clinical records were incomplete and lacked documentation or an RN assessment. A resident with a known wander risk had access to an unlocked egress, and the orders for a wander guard bracelet were neither accurate nor timely. Medications were not secured properly, and unauthorized staff had access to keys. Additionally, annual in-service training was not completed on time, and facility policies were not reviewed or approved annually, resulting in differing and duplicate policies. The facility had three different Elopement Policies in effect, none of which matched, and it was unclear which policy staff had been educated on prior to an elopement incident. Interviews with the DNS, Administrator, and Regional Nurse revealed a lack of process for administrative oversight regarding the Governing Body, Medical Director appointment, medication storage, notification of reportable events, annual training, policy review, physician orders, and resident access to unlocked egress. The facility's failure to utilize resources effectively compromised the residents' well-being, and no facility policy was provided for review.
Lack of Governing Body and Policy Oversight
Penalty
Summary
The facility failed to establish a governing body or designate individuals to function as a governing body responsible for the management and operation of the facility. This deficiency was identified through a review of facility documentation, which did not reveal the existence of a governing body. Additionally, the Administrator's employee file lacked evidence of appointment by a governing body. The facility's policy and procedure manual also failed to show that an annual review of policies was conducted, which is a requirement for maintaining effective management and operation. Further investigation revealed inconsistencies in the facility's Elopement Policies, with three different versions in effect, each from different sources, and no clear indication of which policy staff had been educated on. Interviews with the Director of Nursing Services (DNS), Administrator, and Regional Nurse confirmed the absence of a governing body and the lack of annual policy reviews. Despite the presence of Governing Body By-Laws, which outline the responsibilities of the governing board, the facility did not adhere to these guidelines, leading to a lack of oversight and management of the facility's operations.
Failure to Document RN Assessment After Resident Elopement
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident following an elopement incident. The resident, diagnosed with Alzheimer's disease and delusional disorders, was identified as an elopement risk and had interventions in place, such as a wander guard bracelet. Despite these measures, the resident was reported missing from their room early in the morning. The facility staff, along with local police, conducted a search and eventually found the resident outside near the rear kitchen entrance, with dryer lint on their clothes, indicating they had been in the laundry area. The deficiency arose because there was no documented RN assessment following the resident's elopement, as required by the facility's Charting and Documentation policy. Although the Director of Nursing Services (DNS) stated that an RN assessment was completed, they could not provide documentation to support this claim. The absence of this documentation in the resident's medical record constitutes a failure to maintain complete and accurate records, as per accepted professional standards.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides, hired in 2023, received the required 12 hours of annual in-service training. The review of the employee file for one nurse aide, hired on August 10, 2023, showed that the only education provided was on Intravenous (IV) therapy, with no additional or general orientation education documented for 2023, 2024, and up to February 27, 2025. Another nurse aide, hired on July 20, 2023, had annual education that included resident rights, abuse/retaliation, and dementia, but still did not meet the 12-hour requirement. An interview with the Director of Nursing Services (DNS) confirmed that all nurse aides should have a minimum of 12 hours of annual in-service training, but the DNS could not explain why the required training was not completed for these two aides. The facility's assessment tool from August 2024 outlined topics for annual education, including abuse, resident rights, confidentiality, and infection control, among others, which were not fully addressed in the training provided to these aides.
Staff Recorded and Posted Inappropriate Resident Videos on Social Media
Penalty
Summary
A staff member at the facility recorded videos of residents, including one resident with Alzheimer's disease, depression, and agitation, who was dependent on staff for transfers, personal hygiene, and dressing. The videos captured the staff member interacting with residents in an unprofessional manner, such as speaking inappropriately to a resident while they were rummaging through bins in the recreation room and referring to the resident as 'thieving.' Other videos included footage of a resident's legs during personal care and a resident being told they were banned from the dining area and recreational activities. These videos were posted on social media without the residents' consent. The facility's policies on resident privacy and abuse explicitly prohibit such actions, stating that residents have a right to privacy and confidentiality and that abuse includes actions facilitated through technology. The incident was brought to the attention of the DON by another staff member, who reported the existence of the videos. The DON reviewed the videos and confirmed the inappropriate conduct and unauthorized recording and posting of residents, which constituted a failure to protect residents from abuse and to uphold their rights to privacy and dignity.
Failure to Conduct Thorough Investigation for Injury of Unknown Origin
Penalty
Summary
A resident with dementia, behavioral issues, and severe cognitive impairment was admitted to the facility and required significant assistance with daily activities. The resident was noted to have a history of physical aggression and attempts to get up unassisted. On a specified date, the resident was found to have increased pain, swelling, and decreased range of motion in the right wrist, which was later diagnosed as a fracture of the right ulnar styloid process. The injury was of unknown origin, and there was no documentation of negative behaviors or incidents in the days leading up to the discovery of the injury. The facility failed to conduct a thorough investigation into the cause of the resident's injury as required by its policy. Specifically, a 72-hour look back was not completed, and staff interviews were limited to only those working one shift on the day before the injury was identified. No staff from other shifts were interviewed, and the investigation did not include a comprehensive review of possible causes. The Director of Nursing acknowledged that the required 72-hour look back was not performed.
Failure to Complete Neurological Assessments and Follow Treatment Recommendations After Accidents
Penalty
Summary
The facility failed to complete required neurological assessments following unwitnessed falls for two residents and did not document wrist stabilization as recommended by an APRN for another resident with a fracture. For one resident with dementia and a history of falls, there was no documentation of neurological checks after an unwitnessed fall, despite facility policy requiring such assessments. The Director of Nursing Services (DNS) confirmed the absence of documentation and could not explain why the assessments were not completed. Another resident with severe cognitive impairment and a right wrist fracture did not have documentation showing that the APRN's recommendation to stabilize the wrist was followed. Although the APRN directed wrist stabilization and pain management, there was no evidence in the nursing notes, physician orders, or treatment records that the wrist was immobilized or how it was stabilized prior to the resident being sent to the emergency room for further evaluation. A third resident with Parkinson's disease and a history of falls experienced multiple unwitnessed falls. Neurological assessments were either incomplete or missing for several shifts following these incidents, contrary to facility policy. The DNS acknowledged that neurological checks were not consistently documented or performed as required after unwitnessed falls. Facility policies clearly directed staff to perform and document neurological checks after any unwitnessed fall, but these protocols were not followed in the cited cases.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for two out of four nurse aides reviewed. Personnel files showed that the last performance evaluations for both nurse aides were completed nearly a year prior to the review. Interviews with the Regional Clinical Nurse and the Administrator confirmed that annual evaluations were expected but had not been completed due to administrative changes and lack of awareness by the current leadership. Additionally, the facility was unable to provide an employee performance evaluation policy when requested.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an allegation of neglect for a resident with spina bifida, neurogenic bladder, and spinal stenosis. The resident was care planned to be turned and repositioned every two hours and to be assisted out of bed before breakfast. On the date in question, the resident reported using the call bell for one and a half hours without receiving assistance, ultimately moving themselves from bed to wheelchair despite having no feeling from the waist down. The grievance form documented the resident's complaint but did not include a resolution or a comprehensive investigation, such as obtaining statements from all relevant staff or reviewing care provided during the shift. Documentation for the shift lacked evidence of care provided, and interviews revealed confusion regarding staff assignments and care responsibilities. The only NA on the floor was not assigned to the resident and was not interviewed about the incident. The LPN and administrator acknowledged the resident's concerns but did not ensure a thorough investigation or confirm that care was provided as required by the care plan. The facility's abuse reporting policy requires all alleged violations to be reported and investigated, but this process was not followed in this case.
Failure to Provide Timely Incontinent Care and Repositioning
Penalty
Summary
A resident with spina bifida, neurogenic bladder, and spinal stenosis, who was non-ambulatory and incontinent, required extensive assistance with activities of daily living, including turning and repositioning every two hours and timely incontinent care, as documented in the care plan and physician orders. On the morning in question, the resident activated the call bell at 8:33 AM to request incontinent care, but did not receive assistance until between 10:30 and 11:00 AM, resulting in a delay of approximately two hours. During this period, the resident was not turned, repositioned, or provided with incontinent care from the start of the shift at 7:00 AM until care was finally given, totaling a lapse of 3.5 hours. Documentation for the shift did not reflect care provided, and the resident was not assisted out of bed for breakfast as per their care plan. Staff interviews revealed that only one NA was present for 22 residents on the unit until 9:00 AM, and the assigned NA did not provide care to the resident during the relevant period. The resident reported having to move themselves to their wheelchair, despite being assessed as unable to do so due to lack of sensation from the waist down. The facility was also found to be understaffed on the day in question, with a deficit of 23 nursing and NA hours for the census. The failure to provide timely care and assistance was confirmed by staff and resident interviews, review of care documentation, and facility records.
Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of a resident with significant medical conditions, including spina bifida, neurogenic bladder, and spinal stenosis. Physician orders and the resident's care plan required turning and repositioning every two hours, early morning care before breakfast, and prompt incontinence care to prevent pressure ulcers. On the day in question, the resident activated the call bell for assistance at 8:33 AM but did not receive care until after 10:30 AM, despite repeated requests. Documentation showed no care was provided from the start of the shift at 7:00 AM until 10:30 AM, and the resident had to move themselves to the bathroom due to lack of assistance. Staffing records revealed only one nursing assistant was present for 22 residents on the resident's unit until 9:00 AM, and overall facility staffing was below the required hours per state regulations. Interviews with staff confirmed that the assigned nursing assistant was not available for the resident, and the replacement did not arrive until later in the morning. The resident was not turned, repositioned, or provided incontinence care for at least 3.5 hours, contrary to the care plan and physician orders. The resident subsequently developed a stage 3 pressure ulcer. The facility's documentation and staff interviews corroborated that the lack of sufficient staffing directly resulted in unmet care needs for the resident, including delayed response to call bells and failure to provide timely incontinence and mobility assistance.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 725 citations issued within 25 miles in the last 12 months — including the 9 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glastonbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glastonbury Center For Health & Rehabilitation | 2 mi | ★★★★★ | 12 | 0 |
| Apple Rehab Rocky Hill | 4.1 mi | ★★★★★ | 1 | 0 |
| Riverside Health & Rehabilitation Center | 4.1 mi | ★★★★★ | 15 | 0 |
| Touchpoints At Manchester | 4.2 mi | ★★★★★ | 16 | 0 |
| Westside Care Center | 4.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.