A list of the most recent deficiencies for Civita Care Center at West River. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-19 | 2023-03-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-19 | 2023-03-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-19 | 2023-03-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-19 | 2023-03-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-26 | 2023-03-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-26 | 2023-03-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-26 | 2023-03-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-26 | 2023-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-03-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-26 | 2023-03-09 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-26 | 2023-03-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-18 | 2022-11-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-14 | 2022-04-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-14 | 2022-04-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-08-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-14 | 2020-03-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-14 | 2020-03-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-14 | 2020-03-24 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-14 | 2020-03-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-10 | 2020-03-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-12-13 | 2019-02-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-12-13 | 2019-02-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-13 | 2019-02-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-12-13 | 2019-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-13 | 2019-02-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-12-18 | 2019-01-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-18 | 2019-01-29 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide or obtain dental services for each resident. | Health | 2018-12-18 | 2019-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-18 | 2019-01-29 | N |
