Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Northbridge during CMS and state inspections, most recent first.
A resident with DM and a G-tube did not have ongoing blood glucose monitoring after readmission, and routine orders for blood sugar checks were not maintained. The resident later had HI blood sugars, received correctional insulin, became lethargic with low SpO2, and was transferred to the ED with subsequent hospitalization for metabolic encephalopathy. A second resident with abnormal posture, cognitive impairment, and pressure injury risk did not have an individualized 24-hour positioning plan for a custom tilt-in-space wheelchair, and the record lacked staff education and ongoing wheelchair evaluation documentation; observations showed the resident in bed while staff described an informal out-of-bed routine.
Resident room fans in multiple rooms were observed with gray, fuzzy material on the blades, enclosure, and grills over 3 consecutive survey observations, while several fans were running. Staff gave conflicting accounts of whether Housekeeping or Maintenance was responsible for cleaning the fans, and the room routine audit form and cleaning policy did not direct fan cleaning.
A resident with dementia, anxiety, and depressive symptoms had psychiatry orders to change psychotropic medications after worsening inappropriate sexual behaviors, but nursing staff did not transcribe the paper orders into the EHR. As a result, the medication changes were not administered, and the resident continued to have behavioral incidents including slapping, scratching, yelling, and agitation. Interviews with an LPN, the DON, and the psychiatry APRN confirmed the facility’s paper-to-EHR transcription process and that the orders were not entered.
A resident’s meds were left in a cup on the bedside tray table after an LPN was called out of the room before seeing the resident take them, and the resident said he/she was unaware the meds had been left there. In a separate observation, a medication cart was found unlocked and unattended in a hallway, contrary to facility policy requiring meds and controlled substances to be stored securely and carts to remain locked when not in use.
Failure to Honor Resident Preference for Oral Hygiene: A dependent resident with quadriplegia and contractures requested teeth brushing 3 times daily, but staff did not follow the care plan or Resident Care Card directing oral care 3 times per day. The NA acknowledged the resident was dependent for mouth care and documentation showed oral hygiene was provided only about once daily on average, despite the resident’s stated preference and the facility’s resident rights and mouth care policies.
A resident with severe weight loss and malnutrition and another resident with dementia and poor oral intake had physician-ordered weights that were not consistently obtained. The record also showed IV hydration was given, but the MAR and intake/output records did not document the fluid amounts or complete intake/output data as required. Staff and the DON/DNS could not explain the missing weights or incomplete documentation.
Failure to consistently document an ordered fluid restriction for a resident with ESRD receiving hemodialysis. The resident had a strict 1000 mL daily fluid limit with shift parameters, but nursing records showed missed intake documentation on many opportunities. Staff stated NAs reported intake, LPNs/RNs recorded totals in the intake and output binder, and dietary provided set fluid amounts on meal tickets, yet the DON could not explain why monitoring was not consistently completed.
Unclean garbage and refuse storage area: During a kitchen and dumpster area tour, surveyors observed used gloves, surgical masks, cigarette butts, wrappers, paper, wet cardboard, and multiple cardboard boxes scattered around the dumpster area, with dumpster #3 open and a trash bag protruding from the lid. The FSD, Administrator, and Asst. Maintenance Director stated the condition was not acceptable and identified housekeeping and maintenance as responsible for keeping the area clean; the facility policy for garbage and refuse removal was not provided.
Infection Control Failure During Wound Dressing Change: An LPN failed to follow wound care infection control practices while changing a resident’s pressure ulcer dressing. After removing the contaminated dressing with gloved hands, the LPN applied the new clean dressing without removing the gloves or performing hand hygiene first. The resident had a stage 3 coccyx PU and required daily wound treatment per APRN order, and the facility’s wound policy required handwashing, glove removal, and clean gloves before applying the new dressing.
Missing Annual Nurse Aide In-Service Documentation: The facility failed to verify completion of the required annual 12-hour NA training for one NA, including abuse prevention, dementia care, effective communication, infection control, resident rights, and behavioral health. The Staff Development RN could not locate the required competency records, and the Administrator identified an inconsistent signature on the NA’s abuse education documentation that did not match other records signed by the NA.
MDS coding and submission errors occurred for two residents. One resident with diabetes, malnutrition, and anemia had a documented stage 2 pressure ulcer on the R lower leg that was not coded on the quarterly MDS, while another resident with adult failure to thrive, dementia, and palliative care had a death in facility tracking form completed but not submitted through IQIES on time.
A resident with a history of behavioral issues and prior altercations was placed on 1:1 monitoring but was left unsupervised when the assigned NA left the room. During this time, the resident entered a common area and physically assaulted another resident with hemiplegia, causing distress and anxiety. Staff interviews and documentation confirmed that required supervision was not maintained, leading to the incident.
A resident who was alert, oriented, and able to communicate was restricted from going outside after a conservator revoked outdoor privileges, despite prior assessments indicating no elopement risk and facility policy supporting resident rights. Staff enforced the restriction, leading to increased agitation and aggressive behavior from the resident, without updating the care plan or conducting a new elopement assessment.
A resident with diabetes, anxiety, depression, and mobility issues, who was cognitively intact and independent, did not have a timely or documented discharge plan despite an active discharge goal and referral to a community program. The care plan lacked discharge planning details, and there was no evidence of follow-up on referrals or alternative discharge options, contrary to facility policy.
Two residents with intact cognition and court-appointed conservators maintained a close relationship, including private visits, but staff failed to document or implement a care plan addressing their interactions. Despite staff awareness and facility policy requiring individualized care plans, no interventions or monitoring guidance were included, resulting in a deficiency.
Two residents with intact cognition and independent mobility, one with a history of trauma and the other with prior inappropriate sexual behavior, were allowed to visit unsupervised in a private room. Staff, including NAs, social workers, and the DON, were aware of these unsupervised visits but did not monitor or intervene, despite the known risk. One resident later reported non-consensual sexual contact during these visits, and documentation confirmed that no preventive measures were in place.
A resident with multiple medical conditions sustained a first-degree burn during a shower and did not immediately inform staff. When the injury was later identified, the RN supervisor was notified only by a vague text message and did not follow up, resulting in no timely RN assessment being completed. The administrator confirmed that an RN assessment should have occurred and documentation was lacking.
A resident with cognitive impairment and multiple diagnoses was subjected to verbal abuse by a NA, who responded to the resident's use of foul language with similar expletives. Although the resident did not report feeling offended, the exchange was overheard and confirmed through interviews and documentation, constituting a failure to protect the resident from verbal abuse as required by facility policy.
A resident with cognitive impairments and a history of elopement risk exited a facility without staff knowledge and was found by law enforcement 0.6 miles away. The facility failed to reapply a wander guard bracelet upon the resident's readmission and did not follow protocols for missing residents. Staff did not communicate the resident's elopement risk effectively, and the equipment to monitor wander guards was not functioning. These lapses resulted in a finding of Immediate Jeopardy.
The facility failed to document competencies for Nurse Aides and Licensed Nurses from 2022 to the present, despite completing mandatory in-service training. The absence of a Staff Development Coordinator since March 2023 contributed to this deficiency, with the Administrator and other staff continuing in-servicing without documented competencies.
The facility failed to consistently document the pH levels of the manual sanitizer in the kitchen's three-bay sink, essential for ensuring proper sanitizing levels. A dietary aide struggled to demonstrate the procedure and interpret test results due to a vision problem. The logs showed missing documentation on several occasions, which the Dietary Director attributed to staff possibly forgetting to record results.
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training. Documentation lacked details on training duration and conductors, and there was no tracking system in place. The absence of a Staff Development Coordinator since March 2023 further contributed to this deficiency.
The facility failed to maintain CPR certification for several staff members and did not complete Code Blue logs for two residents who required CPR. This lack of documentation and certification violates facility policy and potentially compromises emergency care quality.
A resident with pneumonia, COPD, and asthma was found unresponsive, leading to CPR initiation. An NA, uncertified in CPR, took over from an LPN, contrary to facility policy allowing only certified personnel to perform CPR. The facility confirmed the NA was not trained or certified, breaching protocol.
A resident with diabetes, arthritis, and depression was not assessed for self-medication administration, despite requesting to have medications left at their bedside. The resident separated the medications into two cups, indicating which they intended to take. An LPN left the medications with the resident without confirming an evaluation for self-administration had been conducted. The DON confirmed no evaluation had been done, contrary to facility policy requiring such an assessment and nurse supervision during medication administration.
A resident with dementia and osteoporosis experienced a fall and subsequent pain, but the LTC facility failed to notify the physician promptly. Despite orders to assess and manage pain, the resident's moderate pain was not communicated to the physician until hours later. Nursing staff did not immediately assess or report the pain, and interviews revealed a lack of recall about the incident.
A resident with a history of depression was verbally abused by an LPN, who called them derogatory names. The incident was reported, and an investigation was initiated, leading to the LPN's removal from the facility. The facility's abuse prohibition policy was not upheld, as residents have the right to be free from abuse.
A facility failed to report a verbal abuse allegation involving a resident to an outside state agency in a timely manner. The resident, with a history of depression and other medical conditions, was verbally abused by an LPN. Although the incident was reported to the police, the facility did not notify the required state agency as per their policy.
A facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with cognitive impairments, eloped due to the lack of a wander guard bracelet after hospital readmission. Another resident's care plan was not updated to reflect a change to Full Code status, despite physician orders and discussions with the responsible party. These oversights highlight the facility's failure to ensure timely care plan revisions.
The facility failed to timely evaluate a resident's significant weight loss, assess another resident's safe food consumption with broken dentures, apply ACE wraps as prescribed, and communicate a change in code status to hospice. These deficiencies highlight lapses in following medical orders and ensuring resident safety.
A resident experienced a significant weight loss, but the facility failed to obtain a re-weight and did not evaluate the resident's nutritional needs promptly. The LPN documented the weight discrepancy but did not recall taking further action, and the dietitian was not informed until nine days later. The facility's policy required immediate re-weight and notification of the dietitian, which did not occur, leading to a delay in addressing the resident's nutritional needs.
The facility failed to change and label oxygen tubing weekly for three residents requiring oxygen therapy, as per its policy. Observations revealed undated tubing for residents with conditions such as congestive heart failure and respiratory failure. Interviews with LPNs confirmed the policy requirement, which was not adhered to.
A resident with severe cognitive impairment and under hospice care was not appropriately medicated for pain despite exhibiting daily indicators of discomfort. Physician orders required hourly pain assessments and medication as needed, but records showed consistent zero pain levels until a day when moderate pain was noted multiple times without adequate intervention. The DNS acknowledged the need for better pain management and investigation following the resident's recent fall and hip fracture.
A resident with dementia and dysphagia had broken dentures, and despite a request from the responsible party for evaluation, the facility failed to provide necessary dental services. Dental consults noted the issue but did not recommend repair or replacement. Interviews revealed a lack of communication and follow-up, with the DNS and Medical Records Associate unaware of the request. The facility's policy required prompt referral for dental services, which was not followed.
A resident with a stage 3 pressure ulcer and ESBL resistance received wound care without proper infection control practices. An LPN and NA failed to wear gowns and did not perform hand hygiene between glove changes, despite facility policies and signage indicating the need for enhanced barrier precautions. The LPN admitted to oversight and lack of awareness regarding hand hygiene requirements.
The facility did not effectively communicate its Compliance and Ethics program to all staff. The Administrator could not find records of initial or annual in-service training for the Corporate Compliance program, and 4 out of 6 employee files lacked the Compliance Certificate Statement, indicating missing documentation of compliance training.
Failure to Provide Ordered Blood Glucose Monitoring and Individualized Wheelchair Positioning
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice and the residents’ care plans for two sampled residents. For one resident with dysphagia, a G-tube, and type 2 DM with hyperglycemia, the record showed an admission order for NPH insulin every 12 hours and an order for daily blood sugar checks, but after hospitalization and readmission there were no active routine or recurring blood glucose monitoring orders documented. The resident’s care plan identified the resident as insulin dependent and directed blood sugar checks per physician order and insulin administration as ordered, yet the clinical record did not maintain ongoing orders for routine monitoring after readmission. When the resident later had a blood sugar reading of HI, the value was rechecked and remained HI, indicating a level greater than 600 mg/dL. The APRN was notified and ordered immediate Lispro insulin and a repeat blood sugar in 1 hour. The repeat blood sugar was 586 mg/dL, and another provider order directed additional Lispro, another recheck in 2 hours, and notification if the result remained above 400. A subsequent order directed blood sugar checks twice daily before meals. Shortly after, the resident was observed lethargic with an oxygen saturation of 88% on room air, was placed on supplemental oxygen, and was transferred by ambulance to the ED. The record also noted the resident was later discharged from the hospital with metabolic encephalopathy. For the second resident, the record identified abnormal posture, arthritis, diabetes mellitus, moderate cognitive impairment, dependence on staff for toileting, transfers, and dressing, and risk for pressure ulcers/injuries. The resident’s care plan addressed skin breakdown risk with an air mattress, weekly skin inspections, and turning and repositioning every 2 hours and as needed. OT documentation described the resident as unable to reposition self, with decreased trunk control and weakness, and noted the resident was in a tilt-in-space custom wheelchair. A physician order directed the resident to be out of bed in the wheelchair after morning care and back to bed before evening care, with tilting to tolerance for pressure relief, but the order did not specify timeframes. Observations showed the resident in bed in the supine position on multiple occasions, and a nurse aide stated the resident was usually gotten up right before lunch and returned to bed around 2:30 PM for incontinent care. The resident care card did not include directions for an out-of-bed schedule, tilt-in-space schedule, or positioning plan. The DON and PT were unable to provide documentation of staff education, quarterly or monthly wheelchair evaluation notes, or a customized 24-hour positioning plan for the wheelchair. The vendor stated that a positioning schedule, staff education, and ongoing evaluation are strongly recommended, and that the resident’s position plan was too open ended and should have included specific times or time frames for out of bed, back to bed, and tilting.
Resident Room Fans Not Kept Clean
Penalty
Summary
The facility failed to ensure fans in resident rooms were maintained in a clean manner, affecting rooms 411, 412, 415, 416, 417, 418, 419, 420, and 422. On three consecutive days, survey observations identified gray, fuzzy material on the edges of fan blades, the bottom of the fan enclosure, and in the grills of fans in those rooms. Fans were observed running in several of the rooms during the survey, including rooms 411, 412, 415, 416, 417, 418, 419, 420, and 422. Interviews showed conflicting understanding among staff about who was responsible for cleaning resident room fans. A housekeeper stated she had never been instructed to clean fans and believed Maintenance was responsible, while the Assistant Maintenance Director stated Housekeeping was responsible and had been for 8 years. The Housekeeping Director stated Maintenance was responsible, and the Administrator also identified Housekeeping as responsible but could not explain why the fans were not cleaned. Review of the Daily Resident Room Routine Audit form did not direct staff to clean resident fans, and the facility's Cleaning and Disinfecting Resident Rooms policy did not identify fan cleaning as part of the procedure.
Failure to Transcribe Psychiatry Medication Orders
Penalty
Summary
The facility failed to ensure physician’s orders for psychotropic medications were transcribed and implemented for a resident with unspecified dementia with behavioral disturbances, anxiety disorder, and adjustment disorder. The resident’s quarterly MDS showed moderate cognitive impairment, dependence on staff for transfers and dressing, a high likelihood of depression, and physical behavioral symptoms directed toward others occurring 1-3 days per week. The care plan identified anxiety and depressive disorder and included administering anti-anxiety medications per physician orders, monitoring effectiveness, and providing psychiatry follow-up as needed for medication management and counseling. A psychiatry prescriber note and physician’s order sheet in the paper record documented worsening inappropriate sexual behaviors and orders to discontinue Zoloft 125 mg, start Zoloft 75 mg daily for anxiety, start Prozac 10 mg daily for anxiety, and start Trazodone 25 mg daily prior to care for dementia with agitation. The resident continued to have behavioral incidents after that, including slapping a nurse aide during incontinent care, disruptive yelling and profanity during activities, agitation in the dining room, and grabbing and scratching staff during care. Review of the electronic health record did not identify the 12/2/25 medication change orders as transcribed. Interviews with an LPN, the DNS, and the psychiatry APRN identified the facility practice was for providers to write orders on paper and for nursing staff to transcribe them into the electronic record so medications would be administered. The DNS and APRN both identified that the 12/2/25 psychiatry orders had not been transcribed, and there were no nursing notes showing attempts to notify the POA or complete the transcription. The APRN stated she expected nursing to have notified the POA and transcribed the orders by the next psychiatry visit, but the orders remained unimplemented months later.
Unattended bedside medications and unlocked medication cart
Penalty
Summary
Medications were left unattended at Resident #64’s bedside during medication administration. Resident #64 had diagnoses including type 2 diabetes mellitus with diabetic neuropathy and peripheral vascular disease, and the quarterly MDS identified the resident as independent with decision-making and daily tasks. During observation, 4 medications were found in a medication cup on the resident’s bedside tray table next to personal belongings and breakfast, and the resident stated he/she was unaware the medications were there and must have been asleep when the nurse passed them. LPN #3 stated he/she had passed the medications around 8:00 AM but was called out of the room by a NA, leaving the medications on the tray table without seeing the resident take them. Medication storage was also not maintained according to policy on a medication cart in the Beardsley Park area. The cart was observed unlocked in a resident hallway between a resident room and the game room with no nurse in sight. LPN #1 stated the charge nurse should always keep the medication cart locked when not in use and that it should not have been left unlocked and unattended. Facility policy stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, that compartments containing drugs and biologicals are locked when not in use, and that unlocked medication carts are not left unattended. The Controlled Substances Policy also directed compliance with laws and regulations related to handling and storage of controlled medications.
Failure to Honor Resident Preference for Oral Hygiene
Penalty
Summary
The facility failed to honor a dependent resident’s preference for oral hygiene. Resident #38 had diagnoses including quadriplegia, contractures of multiple sites, and injury of unspecified nerves of the neck, and was totally dependent on staff for oral hygiene, personal hygiene, and all activities of daily living. The resident’s care plan identified oral/dental health problems due to poor oral hygiene and directed staff to brush the resident’s teeth 3 times daily after meals per the resident’s request. The Resident Care Card also directed mouth care 3 times a day, and the physician’s order directed assistance with ADLs at the bedside due to total dependence. The resident stated that although he/she had requested teeth brushing 3 times per day, staff were not following the request. The NA who was the primary caregiver acknowledged the resident was dependent for oral care and that the care card directed oral hygiene 3 times daily, including twice during the day shift, but could not explain why mouth care had not been provided as directed. Review of the resident’s documentation showed oral care was being provided, on average, once per day rather than 3 times per day. Facility policy required oral hygiene to be documented, including the date and time provided and any refusal, and the resident rights policy stated residents had the right to self-determination and participation in treatment.
Missed Weights and Incomplete Intake/Output Documentation for Residents Receiving IV Fluids
Penalty
Summary
The facility failed to follow physician orders for weights and failed to maintain intake and output documentation for residents receiving IV fluids. Resident #15 had diagnoses including acute cholecystitis, diabetes, and encephalopathy, and the record showed significant weight loss with poor oral intake, vomiting, low albumin, and severe protein calorie malnutrition. After a physician ordered reweighing and later daily weights because of abnormal weight loss, the resident was not weighed on all ordered days. The record also showed that the resident was receiving IV normal saline for severe malnutrition and acute kidney injury, but the MAR and intake/output binder did not reflect documentation of oral intake or IV fluid amounts during the period the fluids were administered. Resident #15’s clinical record included APRN and dietitian notes describing ongoing decline, poor appetite, refusal of most protein shakes, and a loss of 37 pounds in less than 2 months. The physician ordered daily weights due to abnormal weight loss, but the facility missed ordered weights on multiple days. During the same period, IV fluids were administered through a midline, including normal saline at different rates and volumes, yet the MAR failed to indicate monitoring of fluid intake related to the IV administration and the intake/output binder did not contain a flow sheet for the resident. Nursing staff and the DNS were unable to explain why the required intake/output documentation and ordered weights were not present. Resident #122 had diagnoses including Alzheimer’s dementia, pneumonia, and severe protein calorie malnutrition, and was described as being at the end of life with decline in overall status anticipated. The resident had physician orders for admission and weekly weights because of poor oral intake, but weekly weights were not obtained as ordered. The resident was also receiving IV therapy for hydration, with orders for IV fluids and intake/output monitoring, yet the MAR did not identify the quantity of IV fluids administered and the intake/output flowsheets contained blank output entries for multiple days. Staff interviews confirmed that NAs were responsible for documenting intake and output, but the DNS stated she was not aware that the output flowsheets had no urine output documentation and could not explain the missing IV fluid administration amounts or blank output records.
Failure to Consistently Document Ordered Fluid Restriction
Penalty
Summary
The facility failed to consistently maintain a physician-ordered 1000 mL daily fluid restriction for a resident with ESRD who was receiving hemodialysis. The resident’s record showed diagnoses including ESRD, cirrhosis of the liver, low sodium, and dependence on hemodialytic treatments. The quarterly MDS identified the resident as cognitively intact and requiring substantial to maximum assistance with toileting, bathing, dressing, and personal hygiene, with set-up assistance for eating and oral care. The care plan and physician’s order both directed a strict 1000 mL fluid restriction with specific shift limits and an additional 400 mL from dietary. During interview and record review, nursing staff stated that NAs were to report fluid intake and licensed nursing staff were to record it in the intake and output binder at the end of each shift. The binder showed that 54 of 198 opportunities to record fluid intake had been missed since 1/11/26. The Nursing Supervisor stated that nursing and dietary were both responsible for monitoring fluid intake, with nursing obtaining intake information from NAs, adding medication pass fluids, and documenting totals each shift. The Dietician stated dietary provided a specific amount of fluid on meal tickets and nursing was responsible for administering and monitoring other fluids. The DON stated nursing was responsible for monitoring fluid intakes, restriction, and documentation, but could not explain why the resident’s fluid intake was not consistently monitored.
Unclean garbage and refuse storage area
Penalty
Summary
The facility failed to maintain the garbage and refuse storage area in a clean manner during a tour of the kitchen and dumpster area. In the corner of the ramp down to the garbage dumpster area, surveyors observed a pair of used clear gloves turned inside out and two blue surgical masks on the stone to the left of the ramp. In the dumpster area, a pair of used clear gloves, a blue surgical mask, and multiple cigarette butts were observed. There were three dumpsters in a row, identified as trash dumpster #1, trash dumpster #2, and recycling dumpster #3. The lid and side panel to dumpster #3 were open, and a trash bag was visibly coming out of the side of the closed lid. Multiple wrappers and pieces of paper were scattered around the two trash dumpsters to the front, side, and behind. Two wet pieces of cardboard were wedged under dumpster #1, cigarette butts were scattered around the entire garbage disposal area, and ten cardboard boxes were strewn around dumpster #3 from the curb throughout the disposal field. A black copy machine with the cord placed on top was slightly to the front of dumpster #3, and the debris field of trash and cardboard extended 15 feet from the lid opening of the dumpsters. The FSD, Administrator, and Assistant Maintenance Director all acknowledged the condition was not acceptable and identified housekeeping and maintenance as responsible for the area; the facility policy for garbage and refuse removal was not provided.
Infection Control Failure During Wound Dressing Change
Penalty
Summary
The facility failed to maintain appropriate infection control practices during a dressing change for a resident with a stage 3 pressure ulcer of the coccyx. The resident’s diagnoses included a stage 3 PU of the coccyx, fracture of the right lower leg, and generalized muscle weakness. The quarterly MDS identified the resident as moderately cognitively impaired and requiring supervision for eating and substantial assistance for bathing, toileting, and personal care. The care plan identified the resident as having a PU on the coccyx, requiring a mechanical lift for transfer, assist of 1 for care, being a fall risk, and being able to consent for self. An APRN order directed staff to cleanse the wound with betadine, apply a sterile antibacterial foam dressing, cover with a dry clean dressing, and change daily and as needed. During observation of the dressing change, the LPN removed the old contaminated dressing with gloved hands and then placed a new clean dressing over the pressure ulcer without removing the gloves, sanitizing or washing hands, or applying a new pair of clean gloves. The LPN stated she had not followed the facility wound policy for glove use and hand sanitizing. The Infection Prevention Nurse and the DON both stated that gloves should be changed and hand hygiene performed between removal of the dirty dressing and application of the clean dressing. The facility wound policy directed staff to wash and dry hands, place exam gloves, remove the dressing, discard it appropriately, wash and dry hands thoroughly, and then place on clean gloves.
Missing Annual Nurse Aide In-Service Documentation
Penalty
Summary
The facility failed to ensure that required annual in-service training was completed for 1 of 5 nurse aides. Review of the facility’s mandatory yearly in-service records showed that the required 12 hours of nurse aide training for 2025, including abuse prevention, dementia care, effective communication, infection control, resident rights, and behavioral health, was not completed for NA #3. The facility’s annual training documentation also showed that staff competencies were expected to be provided upon hire, annually, and as needed, and that the topics included dementia care, abuse prevention, infection control/hand hygiene, resident rights, compliance and ethics, behavioral health, abuse, neglect, and exploitation. During interview, the Staff Development Nurse stated she was unable to locate the required educational in-service documentation and competencies for NA #3 in the areas of Abuse/Neglect, Resident Rights, Dementia Care, Infection Control, Effective Communication, and Behavioral Health. She said she stored nursing staff competencies in monthly binders in the Staff Development office and was unsure why the documents were missing. The Administrator later identified an inconsistent signature on NA #3’s yearly in-service abuse education and prevention documentation and stated she had not reviewed the document before providing it, noting that the signature and date did not match other documentation signed by NA #3.
MDS Coding and Submission Errors
Penalty
Summary
Resident #3’s quarterly MDS assessment failed to code a stage 2 pressure ulcer on the right lower leg. The resident’s diagnoses included diabetes, moderate protein calorie malnutrition, and anemia. The admission quarterly MDS identified the resident as having a BIMS score of 15, no cognitive impairment, independence with eating, hygiene, bed mobility, and transfer, and being at risk for pressure ulcers but without a current pressure ulcer. However, the skin assessment documented a stage 2 pressure ulcer blister on the right lower leg with an onset of 1/18/26, and a wound progress note described the blister as measuring 1 cm by 0.5 cm by 0.1 cm deep. Resident #101’s death in facility MDS tracking form was completed but was not submitted through IQIES. The resident’s diagnoses included adult failure to thrive, dementia, and palliative care. The discharge MDS tracking form dated 12/13/25 showed that although the death in facility MDS had been completed, it was never submitted through the IQIES system. The IQIES validation report later identified the death tracking form as submitted late. The RAI manual cited in the report directed that the death in facility tracking record must be completed within 7 days after death and submitted within 14 days after death.
Failure to Provide Adequate Supervision During 1:1 Monitoring Results in Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from mistreatment and did not ensure adequate supervision of a resident who was on one-to-one (1:1) observation, resulting in a resident-to-resident physical altercation. One resident with a history of anxiety, combative behaviors, and prior incidents of resident-to-resident abuse was placed on 1:1 monitoring following multiple behavioral incidents, including altercations and attempts to remove safety devices. Despite these interventions, the resident was left unattended by the assigned staff member, who left the room to obtain coffee, leaving the resident unsupervised. During this period of unsupervised time, the resident left their room and entered the dining area, where another resident with hemiplegia and hemiparesis was present. The unsupervised resident approached and struck the other resident in the face, knocking off their glasses and using derogatory language. The incident was witnessed by staff and reported by the affected resident, who expressed feeling unsafe and anxious following the event. Facility documentation and interviews confirmed that the staff member responsible for 1:1 monitoring was not present with the resident at the time of the incident, contrary to facility policy and the intended purpose of continuous observation. The affected resident, who was dependent on assistance for activities of daily living due to stroke-related impairments, reported increased anxiety and distress as a result of the altercation. Facility records and staff interviews corroborated that the assigned staff member failed to maintain constant visual supervision, which directly led to the opportunity for the physical assault to occur. The facility's policies on 1:1 monitoring and abuse prevention were not followed, resulting in a failure to protect the resident from mistreatment.
Failure to Honor Resident's Right to Self-Determination and Outdoor Access
Penalty
Summary
The facility failed to honor a resident's right to self-determination and a dignified existence by not allowing an alert and oriented resident to leave the facility at will. The resident, who had diagnoses including dementia, sensorineural hearing loss, anxiety, and depression, was assessed as alert and oriented with a BIMS score of 15/15 and was able to communicate daily needs using a communication board. The care plan and physician orders permitted the resident to go on leave of absence with medications and a responsible party, and the resident was not considered at risk for elopement. Despite this, after an incident where the resident attempted to board a city bus, the court-appointed conservator revoked outdoor privileges, and facility staff subsequently restricted the resident from going outside, even though the resident had previously been allowed to do so to feed birds and had not attempted to leave the premises before. Facility documentation and interviews confirmed that staff, including the DON and social worker, enforced the conservator's directive to restrict the resident from going outside, despite acknowledging the resident's rights and alert status. The restriction led to increased agitation and aggressive behaviors from the resident, culminating in a physical altercation and transfer to the hospital. The facility did not update the resident's care plan or conduct a new elopement and wandering assessment after the change in outdoor privileges. The facility's own policy states that residents have the right to make choices about their activities and participate in community life both inside and outside the facility, but this was not upheld in this case.
Failure to Develop and Implement Timely Discharge Plan
Penalty
Summary
A deficiency was identified regarding the facility's failure to develop and implement a timely discharge plan for a resident with diagnoses including diabetes mellitus, anxiety, depression, and difficulty walking. The resident was cognitively intact and independent with personal care, transfers, and ambulation. Although the Minimum Data Set (MDS) indicated an active discharge plan and a referral to the local contact agency, the resident's care plan did not include a discharge plan, and there was no documentation of referrals for potential discharge to another level of care. The interdisciplinary care plan meeting marked discharge planning as not applicable, with only a handwritten note referencing Money Follows the Person (MFP). Interviews revealed that a referral to MFP was made approximately 20 months prior, but the resident remained in the facility without further discharge planning or follow-up contacts regarding MFP or alternative settings. When the resident later requested a transfer to another nursing home, a referral was made and the resident was placed on a waiting list, but no additional follow-up was documented. The facility's discharge planning policy requires that discharge planning be addressed upon admission and throughout the resident's stay, particularly for those expressing a desire to return to the community, which was not consistently followed in this case.
Failure to Develop and Implement Care Plan for Resident Relationship
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the relationship between two residents, both of whom had intact cognition and court-appointed Conservators of Person (COP). One resident had a history of trauma and the other had a prior incident of allegedly inappropriate touching of a peer. Despite staff awareness of the ongoing friendship and frequent private visits between the two residents, there was no documentation in either resident's care plan addressing their relationship or providing guidance for staff on monitoring or managing their interactions. Multiple staff members, including nursing assistants, social workers, LPNs, and the administrator, confirmed knowledge of the residents' friendship and private visits, often with the door closed and without staff monitoring. Both residents' COPs were aware of the relationship, and one resident reported feeling uncomfortable after previously consenting to intimate contact. Facility policy required care plans to reflect resident preferences and needs, but no care plan interventions were documented to address the relationship, resulting in a deficiency.
Failure to Supervise Residents with Known Risk Leading to Sexual Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident involving two residents, both of whom had intact cognition and were independently mobile. One resident had a history of trauma and the other had a documented prior incident of inappropriate touching of another resident. Despite this history, both residents were allowed to visit each other unsupervised in a private room with the door closed, and staff were aware of these visits but did not monitor or check on them during these times. Multiple staff members, including nursing assistants, social workers, and the Director of Nursing, acknowledged awareness of the friendly relationship and unsupervised visits between the two residents. Staff interviews revealed that no interventions were implemented to prevent inappropriate contact during these visits, even though one resident had a known history of inappropriate sexual behavior. The facility's abuse prohibition policy defined sexual abuse as non-consensual sexual contact of any type with a resident, yet there was a lack of preventive measures in place. The incident came to light when one resident reported feeling uncomfortable and stated that the other resident had touched them in a manner they did not consent to, despite having previously had a consensual relationship. The resident reported telling the other to stop, but the inappropriate touching continued. Documentation and interviews confirmed that staff were aware of the risk factors and the unsupervised nature of the visits but failed to implement or explain any interventions to ensure resident safety during these interactions.
Failure to Ensure Timely RN Assessment After Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the RN supervisor and completion of an RN assessment after a resident experienced a change in condition. The resident, who had diagnoses including type 2 diabetes, anemia, and Charcot's joint, independently showered and sustained a first-degree burn to the right lower extremity after using a hot washcloth during a shower. The resident did not immediately report the injury to staff and later requested lotion for the affected area. Upon identification of the burn by staff, the RN supervisor was notified only via a non-urgent text message, which did not specify the nature of the incident. The RN supervisor did not follow up, and no RN assessment was completed at the time the burn was discovered. The administrator confirmed that an RN assessment should have been performed and that there was no documentation of such an assessment when the injury was first identified. The facility was unable to provide an assessment policy for review.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with Parkinson's disease, unspecified dementia, and generalized anxiety disorder, who was moderately cognitively impaired and required assistance with activities of daily living, was subjected to verbal abuse by a nursing assistant (NA). The incident occurred when the resident, who was incontinent and dependent on staff for transfers, repeatedly requested to get out of bed. The NA responded to the resident's requests with foul language after the resident used similar language towards the NA. Facility documentation and interviews confirmed that the NA replied to the resident with the same expletive the resident had used, and this exchange was overheard by staff. Interviews with the resident, the NA, and other staff revealed that such exchanges were not uncommon between the resident and the NA, and the resident did not express feeling offended or fearful. However, the facility's investigation substantiated that verbal abuse had occurred, as the NA engaged in inappropriate language with the resident, contrary to facility policy prohibiting abuse, neglect, and exploitation. The incident was documented in the nurse's notes and corroborated by multiple interviews and facility records.
Failure to Implement Elopement Interventions Leads to Resident's Unauthorized Exit
Penalty
Summary
The facility failed to implement necessary interventions for a resident identified at risk for elopement, resulting in the resident exiting the facility without staff knowledge and being found 0.6 miles away by law enforcement. The resident, who had diagnoses including paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was moderately cognitively impaired according to a recent assessment. Despite being identified as at risk for elopement, the resident's care plan interventions, such as the application of a wander guard bracelet, were not effectively implemented. On the day of the incident, the resident's wander guard was removed prior to a hospital transfer, and upon readmission, the facility failed to reapply the wander guard or implement other measures to monitor the resident's location. The facility's investigation revealed multiple lapses in protocol and communication. Staff did not follow the facility's policy to page a Dr. Hunt when the resident was identified as missing. The wander guard bracelet was not reapplied upon the resident's readmission, and there was no evidence of physician orders for its reapplication. Additionally, the receptionist, who was responsible for monitoring exits, did not notice the resident leaving the building, and the dietary aide who accompanied the resident on the elevator did not recognize the resident as being at risk for elopement. Interviews with staff indicated a lack of awareness and adherence to the facility's elopement policies. The charge nurse and RN supervisor failed to communicate the resident's elopement risk and need for a wander guard to the appropriate parties. The facility's transmitter used to check the function of wander guard bracelets had been broken for several months, and there was a delay in obtaining a replacement. These failures in communication, policy adherence, and equipment maintenance contributed to the resident's elopement and the subsequent finding of Immediate Jeopardy.
Deficiency in Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that competencies were conducted for Nurse Aides and Licensed Nurses to confirm that staff was competent to provide care for and meet the needs of all residents. During interviews and reviews of facility documentation, it was revealed that while mandatory in-service training was completed for all staff in 2022 and 2023, the facility was unable to provide any competencies for Nurse Aides or Licensed Nurses from 2022 to the present. The Administrator acknowledged the absence of a Staff Development Coordinator since March 2023, despite ongoing efforts to fill the position. The Administrator, along with the nursing supervisor and the Infection Preventionist, continued monthly and annual in-servicing. However, the lack of documented competencies persisted, indicating a deficiency in ensuring staff competency as required by the facility's assessment.
Inconsistent Documentation of Sanitizer pH Levels in Kitchen
Penalty
Summary
The facility failed to consistently document the pH levels of the manual sanitizer used in the kitchen's three-bay sink, which is essential for ensuring that sanitizing levels are adequate to effectively remove harmful bacteria on food contact surfaces. During a kitchen tour, it was observed that a dietary aide was unable to explain or demonstrate the procedure for checking the sanitizer concentration without prompting. The dietary aide also had difficulty interpreting the results of the pH test strip due to a vision problem, which was noted by the Dietary Director. A review of the daily temperature logs revealed that pH testing of the manual sanitizer was not documented on several occasions, including specific meals on multiple days. The Dietary Director acknowledged that there would have been pots to sanitize on those days and suggested that staff might be forgetting to record their results. The facility's policy requires staff to perform pH tests and record the results to ensure proper sanitizing levels, but this was not consistently followed, leading to the deficiency.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that all nurse aides received at least 12 hours of annual in-service training, as required. During an interview and review of facility documentation with the Administrator, it was identified that while in-service training sessions were conducted, many of the in-service sheets lacked details such as the duration of the training and the identity of the person who conducted it. Furthermore, the facility did not have a system in place to track or monitor whether each nurse aide completed the required annual training hours. Additionally, the facility had been unable to fill the Staff Development Coordinator position since March 2023, despite ongoing efforts to advertise the vacancy. This lack of a dedicated staff development coordinator contributed to the failure in monitoring and ensuring compliance with the training requirements for nurse aides.
Deficiencies in CPR Certification and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and certification for CPR among its staff, which is a critical component of emergency response in a healthcare setting. Specifically, the facility did not have a copy of the CPR certification card for several licensed staff members, including LPN #4 and NA #1, as required by facility policy. LPN #4's CPR certification had expired, and there was no evidence of renewal, while NA #1 could not confirm their certification status. Additionally, LPN #13 was not certified at the time of the incident but was scheduled to attend a CPR class. The facility's practice of discarding CPR certifications upon employee termination further complicated the issue, as it hindered the ability to verify staff qualifications. The report also highlights the facility's failure to complete the Code Blue transcription log for residents who required CPR, which is a breach of their own policy. For Resident #286, who was a full code and required CPR after being found unresponsive, the facility did not maintain a Code Blue log in the resident's file. Similarly, for Resident #288, who was also a full code and required CPR, the Code Blue log was missing from the clinical documentation. This lack of documentation is contrary to the facility's CPR policy, which mandates that a Code Blue log be completed and included in the resident's clinical record. These deficiencies were identified through clinical record reviews, facility documentation, policy review, and staff interviews. The absence of proper documentation and certification not only violates the facility's policies but also potentially compromises the quality of care provided to residents in emergency situations. The facility's failure to adhere to its own policies regarding CPR certification and documentation reflects a significant oversight in maintaining professional standards of quality care.
Untrained Staff Administered CPR Against Facility Policy
Penalty
Summary
The facility failed to ensure that an employee who administered CPR was appropriately trained according to facility practice and policy. This deficiency was observed in the case of a resident with diagnoses including pneumonia, COPD, and asthma, who was identified as a full code. The resident was found unresponsive with no pulse, heartbeat, or respiration, prompting the initiation of CPR and a call to 911. However, the nurse aide who took over CPR from the LPN was not certified to perform CPR, as per facility policy, which only allows RNs, LPNs, or any personnel with valid CPR certification to perform such procedures. The nurse aide admitted to not knowing how to call a code and took over CPR from the LPN, despite being aware that nurse aides are not supposed to perform CPR according to facility policy. The facility's administration confirmed that the nurse aide was not trained or certified to perform CPR at the time of the incident. The facility's CPR policy mandates that CPR should be performed by trained registered or licensed practical nurses or any other personnel who have completed CPR training, highlighting a breach in protocol during the incident with the resident.
Failure to Assess Resident for Self-Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-medication administration, which is a requirement when a resident desires to self-administer medications. Resident #99, who has diagnoses including diabetes mellitus, arthritis, and depression, was observed with medication cups containing pills next to their breakfast tray. The resident had requested the medications to be left in their room while eating breakfast and had separated the medications into two cups, one for the medications they intended to take and another for those they did not want to take that morning. An interview with an LPN revealed that the resident had requested the medications be left at the bedside, and the LPN complied with this request without knowing if the resident had been evaluated for self-administration. The Director of Nursing Services confirmed that Resident #99 had not been evaluated for self-administration of medication, which is a necessary step if a resident wants to have their pills at the bedside. The facility's policy requires the nurse to stay with the resident until the medication is swallowed, which was not adhered to in this instance.
Failure to Notify Physician of Resident's Pain Post-Fall
Penalty
Summary
The facility failed to notify the physician of a resident's new and ongoing pain following a fall. Resident #100, who was severely cognitively impaired and receiving hospice care, experienced a fall and subsequent pain that was not promptly communicated to the physician. Despite a physician's order to assess and manage pain, the resident's pain was not adequately addressed, and the physician was not notified until several hours after the resident first exhibited signs of moderate pain. The resident had a history of dementia, repeated falls, and osteoporosis, and was unable to verbalize pain, relying on vocal complaints and protective body movements as indicators. The nursing progress notes revealed that the resident exhibited moderate pain shortly after an unwitnessed fall, but there was no immediate assessment or notification to the physician. The resident's pain was documented at a level of 5 on multiple occasions, yet the nursing staff did not contact the physician or APRN until hours later. Interviews with staff indicated a lack of recall regarding the incident, and attempts to contact certain staff members were unsuccessful. The DNS acknowledged that there should have been an intervention to address the resident's ongoing pain, especially given the recent fall.
Resident Subjected to Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Licensed Practical Nurse (LPN). The resident, who was cognitively intact and had a history of depression, was verbally abused by being called derogatory names by the LPN. This incident was reported in a nursing progress note, and an investigation was initiated, with the police being notified. The facility's abuse prohibition policy mandates that residents have the right to be free from abuse, but this was not upheld in this case. Interviews conducted during the investigation revealed that the psychiatric consultant agency no longer had records of the incident, and the staff who witnessed it were no longer employed there. The Director of Nursing Services, who was not in the position at the time of the incident, confirmed that the facility's procedures were to remove the staff from the resident's care and start an investigation. The Administrator confirmed that the incident was reported by psychiatric consultant staff, and the LPN involved was removed from the resident's care and is no longer employed at the facility due to the substantiated verbal abuse.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to an outside state agency in a timely manner. Resident #189, who was diagnosed with adjustment disorder, type 2 diabetes mellitus, and hypotension, was identified as cognitively intact and required supervision for eating and limited assistance with bed mobility and transfers. The resident's care plan noted a history of depression, with interventions to encourage verbalization of feelings and provide emotional support. On a specific date, a nursing progress note documented that a report was received about verbal abuse by a charge nurse, and an investigation was initiated with the police being notified. The reportable event indicated that an LPN called the resident derogatory names. However, the facility administrator later indicated that the incident was not reported to an outside state agency, as required by the facility's Abuse Prohibition policy, which mandates reporting to the Connecticut Department of Social Service if abuse is confirmed.
Failure to Update Care Plans for Elopement and Code Status
Penalty
Summary
The facility failed to revise the care plan for Resident #8 in a timely manner, which contributed to an elopement incident. Resident #8, diagnosed with paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was identified as moderately cognitively impaired with no wandering behaviors noted during a quarterly assessment. However, the resident's care plan indicated a risk of leaving the facility and a tendency to remove the wander guard bracelet. After being transferred to the hospital for a psychiatric evaluation, the resident was readmitted without the necessary elopement precautions being implemented. This oversight led to Resident #8 being found outside the facility by EMS, indicating a failure to update the care plan and apply a wander guard bracelet as required. In another case, the facility did not update the care plan for Resident #88 to reflect a change in code status. Resident #88, diagnosed with dementia and failure to thrive, was initially under hospice care with a DNR/DNI status. However, after discussions with the responsible party, the code status was changed to Full Code, but this change was not reflected in the resident's care plan. The social worker involved did not follow up on the code status change, and the care plan remained outdated, not matching the physician's orders or the resident's current wishes. These deficiencies highlight the facility's failure to ensure timely updates and revisions to residents' care plans, which are crucial for addressing their current medical and safety needs. The lack of communication and follow-up among staff members contributed to these oversights, resulting in inadequate care planning for both residents.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to timely evaluate the medical needs of Resident #6, who experienced significant weight loss. Despite a documented weight loss of 23.7 lbs, or 17.34%, from the previous month, there was no immediate re-weight or medical evaluation. The Advanced Practice Registered Nurse (APRN) noted the weight discrepancy eight days later, identifying moderate protein-calorie malnutrition. The facility's policy required notification of the interdisciplinary team and implementation of interventions for significant weight loss, which was not promptly followed. Resident #82, who had dementia and dysphagia, was not assessed for safe food consumption while awaiting dental services for broken dentures. Despite a request for a dental evaluation, there was no documented assessment of the resident's ability to eat safely. Interviews revealed that nursing staff could assess chewing and swallowing difficulties, but no such assessment was documented. The facility's policy required prompt referral for dental services and documentation of measures to ensure adequate eating and drinking if the referral was delayed. The facility also failed to apply ACE wraps as prescribed for Resident #126, who had lower extremity edema. Despite a physician's order to apply ACE wraps daily, observations showed the resident without them. An LPN was unaware of the order and could not explain the omission. Additionally, Resident #88's change in code status to Full Code was not communicated to hospice services, as required by facility policy. The Director of Nursing acknowledged the oversight, and the social worker did not follow up on the code status change, leading to a lack of communication with hospice.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's weight was obtained according to policy and did not evaluate the resident's nutritional needs following significant weight loss in a timely manner. Resident #6, who had diagnoses including dementia, anemia, and hypertension, experienced a significant weight loss of 23.7 pounds or 17.34% from the previous month, as documented on 4/16/24. Despite this significant weight discrepancy, there was no documented re-weight, and the issue was not promptly addressed or communicated to the dietitian. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for documenting the weight discrepancy was unable to recall the actions taken to address the issue. The Director of Nursing Services (DNS) and the facility's policy indicated that a re-weight should have been conducted immediately, and the dietitian should have been notified. However, the dietitian was not informed of the weight discrepancy until nine days later, and there was no documented re-weight or immediate dietary intervention. The facility's policy required that any significant weight loss be reviewed by the dietary team, with the interdisciplinary team, dietitian, physician, and family notified. However, the dietitian, who provided services only one day a week, was not informed of the weight discrepancy in a timely manner, and Resident #6's nutritional needs were not addressed promptly. The delay in addressing the weight loss was attributed to the lack of immediate communication and the limited availability of the dietitian.
Failure to Change and Label Oxygen Tubing Weekly
Penalty
Summary
The facility failed to adhere to its policy of changing and labeling oxygen tubing weekly for three residents who required oxygen therapy. Resident #69, diagnosed with acute on chronic congestive heart failure, pneumonia, and acute and chronic respiratory failure, had a physician's order for oxygen administration via nasal cannula. Observations on June 12, 2024, revealed that the oxygen tubing was not dated, and the Treatment Administration Record indicated that the tubing should be changed every Sunday night shift starting June 23, 2024, after surveyor inquiry. Similarly, Resident #84, with diagnoses including congestive heart failure, cardiomyopathy, and end-stage renal disease, was observed on June 12, 2024, with undated oxygen tubing. Resident #126, diagnosed with heart failure, hypertension, and edema, also had undated oxygen tubing, with no evidence of tubing change on June 9, 2024, as per the Treatment Administration Record. Interviews with LPNs confirmed the requirement to change and document the oxygen tubing weekly, as per the facility's policy updated in 2024, which was not followed in these cases.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was severely cognitively impaired and unable to verbalize pain. The resident, who had a history of dementia, repeated falls, and osteoporosis, was under hospice care and exhibited daily indicators of pain. Despite physician orders to assess the resident's pain every hour and medicate as needed, the Medication Administration Record (MAR) showed that the resident's pain was consistently recorded as zero from the beginning of the month until mid-month. However, on the day of the incident, the resident was evaluated as having moderate pain multiple times during the early morning hours, yet only received a scheduled dose of Morphine at 4:00 AM. The nursing progress notes indicated that the resident exhibited symptoms of pain, such as holding their left leg and facial expressions of pain, but there was a lack of timely intervention. An LPN noted difficulty in contacting hospice services for further guidance. The Director of Nursing Services (DNS) acknowledged that there should have been an intervention to address the resident's ongoing pain, especially considering the recent fall and subsequent hip fracture identified by an x-ray. The failure to adequately manage the resident's pain and investigate the cause of increased pain led to the deficiency identified in the report.
Failure to Provide Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident with broken dentures, despite a request from the responsible party. The resident, who had diagnoses including dementia, anorexia, and dysphagia, was identified as severely cognitively impaired and independent with activities of daily living. The resident's care plan noted the use of partial dentures and required monitoring for dental issues. On a specific date, the responsible party requested an evaluation for the resident's broken dentures, but the facility did not act on this request. Dental consults conducted on various dates noted broken or missing dentures but did not include recommendations for repair or replacement. Interviews with facility staff revealed a lack of communication and follow-up regarding the dental service request. The social worker confirmed that the issue was discussed in a care plan meeting and an email was sent to the Director of Nursing Services (DNS), but no response was received. The DNS acknowledged that requests for specialty services should be acted upon, and the Medical Records Associate, responsible for scheduling specialty services, stated she had not received any requests for dental evaluation or replacement for the resident. The facility's policy required prompt referral for dental services within three days for lost or damaged dentures, which was not adhered to in this case.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a dressing change for a resident with a stage 3 pressure ulcer and a history of ESBL resistance. The resident, who had severe cognitive impairment and required extensive assistance with mobility and toileting, was observed receiving wound care without the staff adhering to enhanced barrier precautions. Specifically, LPN #5 and NA #2 did not wear gowns as required, despite signage indicating the need for gloves and gowns when providing care. Additionally, LPN #5 did not perform hand hygiene between glove changes, which is a part of the facility's hand hygiene compliance policy. During interviews, LPN #5 acknowledged awareness of the enhanced barrier precautions but admitted to not wearing the gown due to oversight and was unaware of the necessity for hand hygiene between glove changes. The DNS confirmed the expectation for staff to follow posted instructions regarding personal protective equipment and emphasized the requirement for gown use during wound care. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, contributing to the deficiency in infection control practices.
Failure to Communicate Compliance and Ethics Program
Penalty
Summary
The facility failed to ensure effective communication of its Compliance and Ethics program standards, policies, and procedures to all staff members. During an extended survey, it was found that the Administrator could not locate records of initial or annual in-service training that included communication of the Corporate Compliance program for all staff. The Administrator acknowledged that annual in-service training was scheduled to begin in 2024 and confirmed that the facility's governing body operates five or more buildings. Additionally, a review of employee files with the Human Resources Director revealed that 4 out of 6 employee files were missing the Compliance Certificate Statement. This statement, which should be kept in the employee's personnel file at the time of hire, indicates that the employee received Corporate Compliance training. This deficiency highlights a lack of documentation and communication regarding compliance training within the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 512 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At 3030 Park, The | 0.9 mi | ★★★★★ | 3 | 0 |
| Mozaic Senior Life | 1.7 mi | ★★★★★ | 34 | 0 |
| Cambridge Health And Rehabilitation Center | 2 mi | ★★★★★ | 2 | 0 |
| Maefair Center For Health & Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| Ludlowe Center For Health & Rehabilitation | 2.6 mi | ★★★★★ | 11 | 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.