Civita Care Center at Salmon Brook

In the surveyor’s words

From the most serious findings on record at Civita Care Center at Salmon Brook, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 27, 2025

  Based on observations, record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident identified as high risk for wandering received adequate supervision to ensure the resident was not able to leave the facility without staff knowledge, which resulted in the facility unable to locate the resident for 4 hours and 40 minutes. The failures resulted in a finding of Immediate Jeopardy. The findings include: Record review identified Resident #1 had a diagnosis of Alzheimer's disease and delusional disorders, and Resident #1 had a Power of Attorney (POA) for care decisions and finances. […]

• Immediate jeopardy, isolatedF689Apr 27, 2023

  Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were at risk for elopement, a facility receptionist failed to inform either the Charge Nurse, Nursing Supervisor or the Director of Nursing, that Resident #1 exited through the front door and as a result, the resident was not assessed for elopement risk and subsequently eloped again shortly thereafter. This resulted in a finding of Immediate Jeopardy and failed to maintain a list of residents who were at risk for elopement along with current photographs at the receptionist's desk. […]

• Actual harm, isolatedF689Nov 7, 2023

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care to prevent an injury. The finding included: Resident #1 was admitted to the facility with diagnoses that included dementia, Parkinson's disease, atrial fibrillation, and chronic kidney disease. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance with one (1) staff member for transfers. […]

• No harm, potential for more than minimal, widespreadF908Nov 26, 2025

  Based on facility documentation review and interviews, the facility failed to provide sufficient laundry services to ensure resident laundry was completed timely due to broken washing machines. The findings included: Review of a grievance dated 8/4/2025 identified Resident #2 was displeased with the amount of time it was taking his/her personal items to be laundered. The grievance identified Resident #2 had sent personal items to be laundered about one (1) week prior, and was still waiting for them to be washed and returned. The grievance further identified a response from the facility administration indicating the facility was were working on buying a new washing machine. […]

• No harm, potential for more than minimal, widespreadF908May 29, 2025

  Based on observations, facility policy and interviews, the facility failed to ensure that laundry equipment within the facility was maintained timely and in proper working order. The findings include: Interview with Resident #15 on 5/28/25 at 12:19 PM identified staff complain there is not enough washcloths for care, it has taken weeks to get personal laundry back and staff have told him/her the facility has only one (1) working washing machine. Interview with Resident #2 on 5/28/25 at 12:24 PM identified his/her personal laundry was sent to laundry eight (8) days ago, he/she had not received it back, and he/she had to wear dirty clothing because he/she had no clean clothing left to wear. […]