Civita Care Center at Danbury

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and staff interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to appropriately respond to an emergency situation in which a resident experienced a medical emergency, and failed to provide interventions when the resident was identified to be unresponsive and had a respiratory rate of three (3) breaths per minute, resulting in a finding of Immediate Jeopardy.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for resident rights, the facility failed to honor the resident's right for self-determination and honor the resident's right to make choices about his/her lift to interact and participate in community activities outside the facility, and failed to honor the resident's right for leave of absence (LOA) privileges upon readmission.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure a quarterly Minimum Data Set (MDS) and a Discharge MDS assessment were completed and transmitted timely.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for professional standards of care, the facility failed to ensure a licensed nurse remained with Resident #1 when staff identified a change in condition that included the resident was unresponsive with agonal respirations at a rate of three (3) per minute, until Emergency Medical Services (EMS) arrival.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 residents (Resident #34) who expressed the desire to self-administer medications, the facility failed to complete a self-administration assessment and obtain a physician's order, according to facility policy, to ensure the resident was safe to self-administer medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #34 and 59) reviewed for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops), the facility failed to ensure the resident's wishes for code status were honored.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for pressure ulcers, the facility failed to ensure that the physician and resident representative were notified following a newly identified skin issue.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #79 and 87) reviewed for abuse, the facility failed to ensure the residents were free from verbal and physical abuse by another resident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #34) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to incorporate the PASARR recommendations from the Level 2 determination into the resident's assessment and plan of care. Notice of PASARR dated 7/16/24 identified Resident #34 had a diagnosis of depression, anxiety, and Bipolar. Resident #34 was not on any antidepressants, mood stabilizers, antipsychotics, or other health medications prescribed currently, or other mental health medications prescribed currently or within the last 6 months. Resident #34 received a Level 2 approval with no specialized services needed. The PASARR did not reflect Resident #34 had opioid dependance. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for 1 of 5 residents (Resident #13) reviewed for PASARR, the facility failed to notify the state designated authority when Resident #13 received a new mental health and intellectual disability diagnosis.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #91) reviewed for abuse, the facility failed to ensure interventions, including enhanced monitoring, were in place for a resident with a documented history of combative behavior towards staff, who later acted as the aggressor in a resident-to-resident physical altercation.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #7) reviewed for unnecessary medications, the facility failed to follow the physician's orders for lab monitoring following the start of a new medication, and for Resident #46 the facility failed to obtain physician's orders for the use of oxygen post hospitalization.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #13) reviewed for accidents, the facility failed to ensure the resident was transferred per the physician's orders resulting in a fall, for 1 resident (Resident #27) reviewed for smoking, the facility failed to ensure the resident was supervised and redirected when necessary to smoke in a safe manner, and the facility failed to ensure that smoking materials were accounted for, equipment in the smoking area was inspected at least monthly, and smoking materials were secured.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #34) reviewed for a specialized medical procedure, the facility failed to ensure consistent monitoring and documentation of intake and output for a resident on fluid restriction.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure that a discrepancy for a controlled medication was investigated and resolved in a timely manner, failed to ensure that an individual use medication was labeled and dated, and failed to ensure that the controlled drug change of shift audits were completed.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for pressure ulcers, the facility failed to document weekly assessments and/or healing of a newly identified non-blanchable area of redness on the sacrum.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #163) reviewed for infection control, the facility failed to ensure a resident with an indwelling medical device was placed on enhanced barrier precautions (EBP).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 8 residents (Resident #1, 7, 13 and 82) reviewed for pneumococcal vaccinations, the facility failed to ensure that pneumococcal vaccines were offered timely.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #46 and Resident 50) reviewed for hospitalization, the facility failed to provide written notice of the bed hold policy to the resident representative when the resident was transferred to the hospital.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews for 1 of 3 certified nurse aide personnel files reviewed, the facility failed to complete annual employee performance reviews at least every twelve months.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1), reviewed for accidents, the facility failed to ensure that staff provided the required assistance with a resident transfer which resulted in a fall with injuries.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1), reviewed for accidents, the facility failed to ensure when the resident had a fall with injury failed to ensure an RN assessment was conducted prior to transferring the resident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for abuse, the facility failed to ensure the resident was free from abuse.

Inspectors wroteBased upon clinical record review, facility documentation review, and staff interviews for one of three residents (Resident #3) reviewed for quality of care, the facility failed to ensure the residents medical record was complete and accurate to include documentation of foley output.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 20 of 28 sampled residents (Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who were reviewed for the accuracy of their clinical records, the facility failed to ensure licensed staff documented at the time when the medications were administered in accordance with professional standards.

Inspectors wroteBased on tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 3 of 5 residents (Resident #50, 56, and 80) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure that PASARR screenings and re-screenings were completed timely.

Inspectors wroteBased on tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #41) reviewed for advance directives, the facility failed obtain a physician's order for DNR to ensure the residents wishes were honored.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #53 and 67) reviewed for care planning, the facility failed to develop a care plan related to an antibiotic therapy and failed to develop a care plan with interventions to address the resident's refusals to get out of bed.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #33 and 73) reviewed for medication administration, the facility failed to ensure licensed staff followed the five rights of medication administration.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #14) reviewed for hospitalization, the facility failed to ensure a registered nurse completed an assessment of the resident's condition when the resident verbalized he/she was not feeling well, felt weak and requested to go to the hospital and for 1 resident (Resident #21) reviewed for mood and behavior, the facility failed to ensure that staff administered a medication according to the physician's order.

Inspectors wroteBased on staff interview, clinical record review, facility documents, and facility policy for 1 of 1 sampled resident (Resident #51) reviewed for smoking, the facility failed to complete smoking assessments and complete a Review of the Smoking Policy document when Resident #51 began smoking, per facility policy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #22) reviewed for pain management, the facility failed to provide the recommended intervention of a back brace in a timely manner.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 resident (Resident #21) reviewed for mood and behavior, the facility failed to ensure the proper disposition of a controlled medication and for 1 of 4 residents (Resident #72) observed during medication administration, the facility failed to ensure an antidepressant was available for Resident #72 as per physician orders.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #38, 39 and 60) reviewed for unnecessary medications, the facility failed to respond to pharmacy recommendations.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #38 and 39) reviewed for unnecessary medications and who were receiving antipsychotic medications, the facility failed to monitor for behaviors.

Inspectors wroteBased on observation for 1 of 2 medication storage rooms and staff interview, the facility failed to remove expired supplies from the medication room and failed to ensure the refrigerator was clean.

Inspectors wroteBased on review of the clinical record, and interviews for 1 of 2 residents (Resident #236) reviewed for rehabilitation and restorative services, the facility failed to ensure the resident received rehabilitation services as ordered.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure the hallway tiled floor in the corridor where deliveries occur was in good repair and the housekeeping closet in that corridor was clean.

Inspectors wroteBased on clinical record, reviews, review of facility documentation, review of facility policy, and interviews for 9 residents (Residents #9, #14, #15, #21, #35, #49, #65, #66, and #79) reviewed for Pneumococcal Vaccines, the facility failed to educate and offer the vaccines to the residents and/or resident representatives.

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 2 of 3 residents (Residents #9 and # 12) reviewed for Advanced Directives, the facility failed to ensure the resident or resident's representative were able to make their own Advanced Directive known and followed by the facility.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #37) reviewed for pressure ulcers, the facility failed to notify the responsible person of the development of a Deep Tissue Injury (DTI).

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 2 of 4 residents (Resident #9 , #79) reviewed for Abuse and one resident (Resident # 60) reviewed for injury of unknown origin , the facility failed to ensure the allegation of verbal abuse was immediately reported to the State Agency in accordance with State Law and/ or that the results of the outcome of the investigation was reported to the state agency within 5 working days.

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 3 of 4 residents (Resident #9 #79 and # 60) reviewed for Abuse, the facility failed to ensure the allegation of verbal abuse and injuries of unknown origin were thoroughly investigated.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one resident (Resident #18) reviewed for oxygen, the facility failed obtain a physician's order for oxygen.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to store emergency medications and solutions in the emergency medication box to ensure that the medications were stored with appropriate expiration dates to meet professional standards.

Inspectors wroteBased on review of facility documentation and facility policy, interview and reviewed of the facility Infection Control Program, the facility failed to at least annually review and approve the Infection Control Policy and Procedure Manual, Intravenous Therapy Policy and Procedure Manual, and the Nursing Policy and Procedure Manual by the Medical Director, Director of Nursing and Administrator.

Inspectors wroteBased on interviews, review of the facility Personal Funds Accounts for petty cash and review of policy for 6 days out of 20 weeks, the facility failed to ensure that residents could readily access petty cash when needed.

Inspectors wroteBased on review of the clinical records, interviews and review of the RAI manual, for 3 of 6 residents reviewed for PASARR, (Residents #22, Resident #28 and Resident #39), the facility failed to ensure the resident's MDS accurately reflected the resident's current status .