Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Meadowbrook during CMS and state inspections, most recent first.
A non‑ambulatory, cognitively impaired resident, fully dependent on staff and a Hoyer lift for transfers, was care planned and ordered for two‑person mechanical lift transfers and bed‑level ADL and toileting care. During morning care, the resident suddenly screamed in pain when socks were applied, and staff notified LPNs but proceeded with Hoyer lift transfers to and from a wheelchair, reporting no issues and administering scheduled acetaminophen. The next day, the resident exhibited increased body and lower extremity pain, with a swollen, tender left leg, and was again observed in a wheelchair before being returned to bed for further assessment. Imaging subsequently showed displaced proximal tibia/fibula fractures and a right femur fracture requiring surgery; providers reported no known trauma or falls and, based on the resident’s dependence and injury pattern, one APRN identified the probable cause as related to mechanical lift transfers, while the medical director noted possible osteoporosis‑related fragility fractures potentially associated with lift use.
A resident with advanced dementia and schizoaffective disorder, who had severely impaired cognition (BIMS score of 0) and was rarely/never understood, had documented needs for emotional support, care coordination, and advocacy, as well as care plan interventions for expression of thoughts and feelings and provision of psychiatric services. However, required SW documentation was missing, including quarterly progress notes for an eight-month period and an annual assessment for over a year, with the sole SW acknowledging these were missed due to oversight and no SW documentation/assessment policy provided when requested.
Two residents experienced deficiencies in care due to failures in medication reconciliation and adherence to physician orders. One resident received medications not included in their hospital discharge instructions because of incorrect transcription and lack of proper verification by nursing staff. Another resident did not receive timely administration of a prescribed bowel regimen following a syncopal episode and signs of constipation, with significant delays in following the facility's bowel protocol. These events occurred despite established facility policies intended to prevent such errors.
A resident admitted after a hospital stay with elevated kidney function labs did not have hydration needs properly assessed or documented. Required intake and output (I&O) monitoring was incomplete, estimated fluid needs were not consistently recorded, and no hydration or nutritional assessment was completed after admission or following a syncopal episode. Staff interviews confirmed that facility policy for hydration assessment and documentation was not followed.
Code Status Order Did Not Match Signed Advance Directive: A resident with atrial flutter, Type 1 DM with hyperglycemia, and mild intellectual disability had a signed advance directive form indicating DNR/DNI, but the physician order, care plan, and EMR banner listed Full Code/CPR. The POA stated DNR was the resident’s wish, and an LPN and nursing leadership confirmed the discrepancy between the signed form and the active order.
Controlled drugs in a unit 3 med cart were not secured under double lock. An LPN was able to unlock the cart and lift the compartment door containing the controlled meds, and the DNS stated controlled drugs should have been secured in the lock box inside the cart. The facility policy required controlled drugs to be stored in a 2-door double locked cabinet with 2 separate keys.
Expired orange juice and yogurt were found in the first-floor nourishment room refrigerator during an observation. The FSD stated the prep cook was responsible for daily refrigerator checks and removing expired items, and confirmed the items should have been removed. Facility policy assigned dietary staff responsibility for checking nourishment refrigerators daily and following food safety standards.
The facility failed to ensure the state Ombudsman received required monthly notices of resident transfers and discharges. One resident with cancer, heart failure, aphasia, and moderate cognitive impairment was sent to the hospital for respiratory distress, and another resident with impaired cognition and major mobility assistance needs was discharged AMA. The SW and Administrator confirmed the monthly reports had not been submitted for several months because the SW had fallen behind with workload, despite policy requiring Ombudsman notification.
Missing Annual Performance Evaluations for Nurse Aides: The facility failed to ensure annual performance appraisals were completed and available in personnel files for 2 nurse aides reviewed. HR could not locate the missing reviews, and the DNS stated she completes nursing evaluations and sends them to HR after employee signatures, but was unsure why they were not filed. The facility policy required supervisors to complete appraisals by the anniversary date and place the signed evaluation in the employee file.
A resident with a history of diabetes, hypertension, and dementia was admitted with a rib fracture, but the facility failed to develop a baseline care plan addressing this condition. Despite hospital documentation indicating a rib fracture, the facility did not document or manage the resident's pain effectively, nor did they inform the rehabilitation department. The resident experienced falls, and staff interviews revealed an expectation for a care plan that was not met, highlighting a lapse in the facility's care planning policy.
A resident receiving IV therapy for recurrent UTIs had critical lab values that were not communicated to the physician in a timely manner. The lab results, which included elevated BUN, creatinine, and Vancomycin trough levels, were reported to the facility but not acted upon until 28 hours later. The delay resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility lacked a specific policy for reporting critical lab results, and the responsible staff failed to notify the physician as required.
A resident with multiple diagnoses, including a methicillin-resistant staphylococcus aureus infection, did not receive IV Vancomycin as ordered, with doses administered outside the prescribed time frame. Additionally, Vancomycin was not discontinued as per new physician orders, with evidence suggesting a potential extra dose was given. The facility lacked a policy on IV administration, contributing to the deficiency.
A resident with multiple health conditions was not properly monitored for intake and output (I & O) as required by physician orders. The facility failed to provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite this, a dehydration evaluation was not conducted as required by the facility's policy. Interviews with the DON and ADON revealed a lack of awareness and adherence to the facility's hydration policy.
Inadequate Protection of Dependent Resident During Mechanical Lift Transfers Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate protection from injury for a non‑ambulatory, cognitively impaired resident who was totally dependent on staff and a mechanical lift for transfers. The resident had dementia with severely impaired cognition (BIMS score of 0), was always incontinent, and was care planned and ordered for Hoyer lift transfers with assist of two staff, and assist with ADLs and toileting at bed level. The resident’s care plan and orders specified non‑ambulatory status, total lift use, and a customized wheelchair with headrest and bilateral leg rests. Prior to the incident, an APRN documented baseline confusion, no pain, movement of all extremities, and bilateral knee contractures, and a skin check shortly before the event showed no new skin impairments. On one day, a nursing assistant reported that during morning care when applying socks, the resident suddenly began screaming, prompting the NA to stop care and notify the night‑shift LPN and the day‑shift LPN. The resident, who had baseline lower extremity edema but no noted discoloration or bruising the prior day, was nonetheless transferred with a Hoyer lift and two‑person assist to a wheelchair and later back to bed, with staff reporting no issues during the transfers and that the resident appeared comfortable after receiving scheduled acetaminophen. The following morning, the charge nurse was notified that the resident had increased generalized body pain, including lower extremity pain, and was uncomfortable during personal care. At that time, the resident’s left leg was noted to be swollen and painful to touch, though the skin was intact, and the resident was observed in the dining room in a wheelchair appearing uncomfortable. Subsequent assessment by an APRN led to orders for a Doppler ultrasound to rule out DVT and an x‑ray of the lower left extremity. Imaging revealed displaced, angulated, recent‑appearing proximal tibial and fibular fractures, and the resident was transferred to the ED, where additional right femur fracture was identified, requiring surgical intervention. The physician and APRNs noted there was no known trauma or recent falls, and one APRN stated that, given the resident’s dependence and lack of reported falls, the injuries were unlikely to have occurred from rolling in bed or an unwitnessed fall, and identified the probable cause of injury as related to use of the Hoyer lift during transfers. The medical director, after reviewing hospital documentation, stated there was no clear etiology but that the injuries could represent osteoporosis‑related fragility fractures potentially associated with mechanical lift transfers.
Failure to Provide and Document Required Social Work Services
Penalty
Summary
The facility failed to provide and document medically-related social services for a resident with dementia and schizoaffective disorder. The resident had a POA for health decisions and was documented in an annual social work (SW) assessment as being primarily alert to self with cognitive deficits related to place and time, as well as confusion. The annual assessment noted that the SW was available for emotional support and for concerns or complaints. A subsequent SW quarterly assessment documented that the resident continued to have severe cognitive impairment due to advanced dementia, with stable mood, calm and friendly affect, and poor insight and judgment, and stated that the SW would remain available for ongoing support, care coordination, and advocacy for the resident’s needs and comfort. The resident’s MDS showed severely impaired cognition with a BIMS score of 0 and that the resident was rarely or never understood. The resident’s care plan identified long-term care needs and psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with interventions including encouraging the resident to express thoughts and feelings, providing support and validation as needed, and providing psychiatric services within the facility. Despite these identified needs and planned interventions, the clinical record lacked required SW documentation. There were no SW quarterly progress notes for an eight-month period following the last note dated 7/2/25, and no SW annual assessments for a period of one year and four months following the last annual assessment dated 11/13/24. The DNS confirmed there were no additional SW notes in the resident’s record. In an interview, the sole facility SW acknowledged that the resident’s annual and quarterly progress notes had been missed due to an oversight, noted that the electronic medical record did not prompt her to document, and stated that progress notes should be completed at least quarterly and annually. When requested, the facility did not provide a SW documentation and assessment policy.
Medication Reconciliation and Bowel Regimen Protocol Failures
Penalty
Summary
The facility failed to ensure accurate medication reconciliation and adherence to physician orders for two residents. For one resident admitted with multiple fractures, delirium, glaucoma, GERD, depression, and dementia, the hospital discharge summary listed specific medications to be continued. However, during the admission process, two medications—gabapentin and senna-s—were incorrectly transcribed into the electronic physician's orders, despite not being included in the hospital discharge instructions. The resident subsequently received two doses of gabapentin and one dose of senna-s before the error was identified. The medication reconciliation process required a second nurse to verify the accuracy of transcribed orders, but this verification failed, allowing the error to proceed undetected until after administration. For another resident admitted with a cervical spine fusion, cognitive communication deficit, and weakness, the facility did not follow the prescribed bowel regimen as per physician order and facility policy. The resident, who was receiving scheduled oxycodone, had not had a bowel movement for several days. Although a bowel regimen was ordered after the resident experienced a syncopal episode and was found to have a firm, distended abdomen, the medications were not administered according to the protocol. There were significant delays between the ordering and administration of each step in the bowel regimen, with the first medication given 17 hours after the order and subsequent steps delayed further, contrary to the facility's bowel evacuation protocol. Interviews with nursing staff revealed lapses in the medication reconciliation and bowel regimen processes. The admitting nurse acknowledged accidentally transcribing incorrect medications, and the verifying nurse failed to catch the error. In the case of the bowel regimen, staff could not recall whether medications were administered as ordered, and documentation did not support timely administration. The facility's policies for medication reconciliation and bowel management were not followed, resulting in medication errors and delayed care.
Failure to Assess and Document Resident Hydration Needs
Penalty
Summary
A deficiency was identified regarding the facility's failure to adequately assess and document the hydration needs of a resident following admission. The resident, who had recently been discharged from the hospital with a noted increase in creatinine and BUN levels, was admitted with multiple diagnoses including cervical spine fusion, cognitive communication deficit, and weakness. Upon admission, the resident was alert and oriented, with normal abdominal findings and independence in eating. However, the medical provider's note did not specify fluid intake goals, and a physician's order was issued to monitor intake and output (I&O) every shift for 72 hours and document it on the appropriate flowsheet. Review of the I&O documentation revealed significant gaps. There was no I&O documentation for the day of admission, and incomplete records for the following day, with missing entries for several hours and no 24-hour estimated fluid needs recorded. Over the subsequent days, the resident's total fluid intake was consistently below the estimated needs, and the required estimated fluid needs were not documented until several days after admission. Additionally, there was no evidence of a nursing hydration assessment or a nutritional assessment after admission or following a syncopal episode and findings of constipation and abdominal distension. Interviews with facility staff confirmed that hydration assessments should be completed on admission and readmission, and that both nursing and dietary staff are responsible for calculating and documenting fluid needs. The dietitian acknowledged that she may not have assessed the resident due to her limited schedule and the resident's hospital stay. The facility's hydration policy requires at-risk residents to be reviewed and provided with interventions to promote hydration, and mandates that I&O be documented for each shift for 72 hours post-admission. These requirements were not met in this case, resulting in the identified deficiency.
Code Status Order Did Not Match Signed Advance Directive
Penalty
Summary
The facility failed to ensure that Resident #4’s physician order matched the resident’s wishes for code status. Resident #4 had diagnoses including atrial flutter, Type 1 diabetes mellitus with hyperglycemia, and mild intellectual disability, and the quarterly MDS identified intact cognition, moderate assistance with personal hygiene, independence with bed mobility, and walker use. The resident’s physical chart contained an Advanced Directives Declaration Code Status form indicating DNR and DNI, signed by the resident’s POA and dated [DATE], but the form was not signed by the physician. The care plan identified the resident as full code, and the physician’s orders for [DATE] to [DATE] also directed Full Code/CPR. During interview, the POA stated that DNR had been elected because it was the resident’s wishes and that this had been discussed with the facility. The charge nurse reviewed the chart and noted the discrepancy between the signed advance directive form, the physician’s order, and the EMR banner, which showed full code while the advance directive form showed DNR. Nursing leadership stated that code status is obtained on admission, readmission, and change in condition, and that a telephone physician order is used until the provider signs the form, but they were unable to explain why the most recent advance directive consent had not been reflected in the physician order.
Controlled Drugs Not Secured Under Double Lock
Penalty
Summary
Controlled drugs were not secured under double lock in the unit 3 medication cart. During observation on 12/1/25 at 11:10 AM, an LPN used a key to unlock the medication cart and was then able to lift the door to the compartment containing the controlled medications, showing the controlled medications were not double locked. When interviewed, the LPN stated that sometimes the drawer does not click shut because of the cards in the drawer, but also stated the drawer closed and locked when she tried to secure it and that the lock does work and is not broken. The DNS later stated that controlled drugs should be secured under double lock in the medication cart and that the nurse should have secured the lock box inside the cart; the DNS also stated she had not heard of any issue with the medication cart having difficulty locking. Review of the facility's Control Substance Handling policy stated that all controlled drugs shall be stored in a 2-door double locked cabinet with 2 separate keys designed for that purpose, separate from all other drugs.
Expired Food Left in Nourishment Refrigerator
Penalty
Summary
Expired food items were found stored in the first-floor nourishment room refrigerator during observation. The refrigerator contained 14 individual 4-ounce containers of orange juice with an expiration date of 11/7/25, 3 individual 4-ounce containers of orange juice with an expiration date of 11/19/25, and one container of yogurt with an expiration date of 11/15/25. During interview, the Food Service Director stated the prep cook was responsible for checking the refrigerators daily, removing expired items, and restocking the refrigerators, and confirmed that the orange juice and yogurt should have been removed. The facility’s Personal Food Policy stated dietary aides were responsible for checking nourishment refrigerators daily, and the Food Brought in From Visitors policy required dietary staff to follow food safety standards and applicable regulations.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman’s office received required notification of resident transfers and discharges for two sampled residents. Resident #86 had diagnoses including malignant neoplasm of the brain and lung, hypertensive heart disease with heart failure, and aphasia, and the admission MDS identified moderate cognitive impairment. On 9/2/25, RN #2 documented that the resident was observed in respiratory distress with oxygen saturation in the 70s, placed on a non-rebreather oxygen mask at 6 liters, and sent to the acute care hospital. The Director of Social Service documented the resident was transferred out to the hospital with no anticipated return date. Resident #88 was admitted with diagnoses including fusion of the cervical spine, cognitive communication deficit, and weakness, and the 5-day MDS identified moderately impaired cognition with substantial/maximal assistance needed for bed mobility and bed/chair transfers. A nursing note documented that the resident was discharged from the facility against medical advice. Interviews with the Social Worker and Administrator confirmed that monthly transfer and discharge reports were supposed to be sent to the state Ombudsman, but the reports had not been submitted since May 2025 because the Social Worker had fallen behind with workload. The facility policy stated the Ombudsman would receive copies of notices and/or a monthly listing of residents transferred to the hospital on an emergency basis, and the facility later updated the Ombudsman with discharges and transfers after surveyor inquiry.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed and available for review for 2 of 3 Nurse Aides reviewed. Review of personnel records showed NA #1 had an evaluation dated 11/20/24 and was due for another in 11/2025, but no evaluation could be located in the personnel record for review. NA #2 had an evaluation completed on 10/9/25, but no 2024 evaluation was available in the personnel record or could be located for review. During interviews, Human Resources stated he started in May 2025 and was unable to locate the missing reviews. He reported that the DNS completed nursing performance reviews and had recently completed some before going on leave, but the evaluations for NA #1 and NA #2 could not be found. The DNS stated she completes nursing reviews, sometimes over the phone, asks the employee to come into HR to sign them, and then gives the evaluations to HR, but was unsure why they were not placed in the employee files. The facility policy stated department heads and supervisors will complete performance appraisals prior to the anniversary date of employment, and once complete, the employee and supervisor will sign and date the review and it will be placed in the employee's file.
Failure to Develop Baseline Care Plan for Resident with Rib Fracture
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident with fractured ribs. The resident, who had a history of diabetes, hypertension, metabolic encephalopathy, and dementia with behavioral disturbances, was admitted with a nondisplaced left posterior 10th rib fracture, pleural effusion, and suspected malignancy. Despite these conditions being identified in the hospital's discharge summary, the facility did not document or address the rib fracture in the resident's care plan, nor did they communicate this critical information to the hospital upon the resident's transfer. The resident's clinical records and staff interviews revealed that the facility did not adequately assess or manage the resident's pain related to the rib fracture. A handwritten note in the resident's file incorrectly identified a right rib fracture, and subsequent evaluations by medical staff failed to address the left rib fracture. The resident exhibited non-verbal signs of pain, and although Tylenol was administered, there was no comprehensive plan to manage the rib fracture or associated pain. The rehabilitation department was not informed of the rib fracture, which could have influenced the resident's therapy and care. The facility's failure to communicate and document the resident's rib fracture led to inadequate care planning and pain management. The resident experienced two falls while at the facility, and the lack of a care plan addressing the rib fracture meant that appropriate interventions were not in place. Interviews with facility staff, including the ADNS and RN, indicated that there was an expectation for a care plan to be developed, but this was not done. The facility's care planning policy requires an interim plan of care within 24 hours of admission, but this was not adhered to in this case.
Failure to Timely Notify Physician of Critical Lab Values
Penalty
Summary
The facility failed to notify the physician of critical lab values in a timely manner for a resident receiving intravenous therapy for recurrent urinary tract infections. The resident had several diagnoses, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician order required weekly lab work, including a Vancomycin trough, to be conducted on Mondays. On a Monday, the resident's lab results showed critical values, including a BUN of 77, creatinine of 4.1, and a Vancomycin trough greater than 50. These results were reported to the facility but not acted upon until 28 hours later. The facility's documentation and interviews revealed that the critical lab results were not communicated to the physician or the infectious disease office in a timely manner. The RN supervisor was responsible for handling incoming lab results, but there was no documentation that the physician was notified before 1 PM the following day. The facility was unable to verify who received the lab results, as the person named in the report did not exist in their records. The infectious disease office was unaware of the critical lab values until contacted by an external person, who then informed the facility. The delay in notifying the physician resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility's Physician Notification Policy required lab results to be reported to the physician, but there was no specific policy for reporting critical lab results. Interviews with the ADON and DON confirmed that the physician should have been contacted regarding the critical lab values, but no explanation was provided for the delay.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer IV antibiotics to a resident in accordance with physician orders, leading to a deficiency in the quality of care provided. The resident, who had diagnoses including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression, was receiving Vancomycin IV therapy for recurrent UTIs. The physician's order specified that Vancomycin should be administered every 18 hours. However, the electronic medication administration record (eMAR) showed that the doses were not administered within the prescribed time frame, with one dose being an hour late and another being administered one hour and 47 minutes early. The Director of Nursing (DON) confirmed that medications should be administered within one hour before or after the scheduled time but could not explain the discrepancies. Additionally, there was a failure to discontinue Vancomycin as ordered by the physician. Despite a new order to discontinue Vancomycin and start Daptomycin, an empty Vancomycin IV bag was found labeled with a date six days after the discontinuation order. Interviews with the Assistant Director of Nursing (ADON) and the DON revealed uncertainty about whether an extra dose was administered, but the presence of labeled IV bags suggested a potential error. The facility did not provide a policy regarding IV administration, further highlighting the deficiency in adhering to physician orders and ensuring proper medication management.
Failure to Monitor Resident Hydration
Penalty
Summary
The facility failed to ensure proper monitoring of intake and output (I & O) for a resident with multiple health conditions, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician's order required monitoring of I & O every shift for 72 hours upon admission or readmission, with documentation on an I & O paper flowsheet. However, the facility did not provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite these deficiencies, the facility did not conduct a dehydration evaluation as required by their policy when a resident's intake is below the estimated needs for three consecutive days. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy did not include performing a dehydration risk evaluation upon admission. Instead, nursing staff used other assessment measures to determine dehydration risk. The DON was unaware of the missing I & O flowsheets and could not explain why the low intake levels were not addressed. The facility's Hydration Policy required residents at risk for dehydration to be on I & O monitoring until adequate hydration status is achieved, but this was not followed for the resident in question.
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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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Nursing homes near Granby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mclean Health Center | 5.8 mi | ★★★★★ | 1 | 0 |
| Ark Healthcare & Rehabilitation At Governors House | 6.5 mi | ★★★★★ | 13 | 0 |
| Bickford Health Care Center | 8.9 mi | ★★★★★ | 51 | 2 |
| Suffield House Rehabilitation And Healthcare Cente | 9.3 mi | ★★★★★ | 2 | 0 |
| Touchpoints At Chestnut | 9.4 mi | ★★★★★ | 0 | 0 |
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