Civita Care Center at West River

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Aug 4, 2021

  Based on review of facility documentation and facility policies, observations, and interviews, the facility failed to implement an effective water management plan to mitigate the risk of Legionella (originally identified in April 2021 water sampling) and other waterborne pathogens which resulted in Immediate Jeopardy that was corrected on August 4, 2021. The findings include: Review of the facility's water culture results from the Laboratory on 04/19/2021 indicated the presence of Legionella species (not pneumophila) in 4 of the 12 samples submitted to the laboratory for analysis for the presence of Legionella. The results were reported to the facility's water management committee for the April 2021 meeting. There was no action taken by the facility on the positive Legionella water sample. […]

• No harm, potential for more than minimal, widespreadF812Aug 20, 2026

  Based on observations, interviews, and review of facility documentation, the facility failed to monitor and maintain dishwasher water temperatures at the appropriate level. The findings include:a. Observation on 08/19/2026 from 11:45 AM to 11:55 AM identified Dietary Aide #1 was in the dish room the only staff present. Dietary Aide #1 was observed handling soiled dishes, placing dish racks into the dishwasher, and, after several dishwasher cycles, moving to the clean side of the dish room to remove clean dishes from the machine to make space for additional loads.b. […]

• No harm, potential for more than minimal, patternF697Aug 20, 2026

  Based on review of clinical records, facility documentation, facility policy, and interviews for 3 of 6 residents (Residents #13, #106, and #121) reviewed for pain management, the facility failed to ensure the residents received care in accordance with professional standards. Specifically, the facility failed to complete pain assessments prior to administering as needed (PRN) pain medications. The findings include:1. Resident #13's diagnoses included displaced intertrochanteric fracture of the right femur, vertebral fracture, and cognitive communication deficit.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had BIMS score of five (5) indicating severe cognitive impairment, required moderate assistance with bed mobility, and required supervision with… […]

• No harm, potential for more than minimal, patternF755Aug 20, 2026

  Based on review of clinical records, interviews, facility documentation and facility policy, for one 5 of 5 residents (Resident #8, Resident #13, Resident #106, Resident #121, and Resident #122) reviewed for medication administration, the facility failed to record the administration of controlled medications on the Medication Administration Records (MAR) and facility failed to document the removal of a controlled medications on the Controlled Substance Distribution Record (CSDR). […]

• No harm, potential for more than minimal, patternF760Aug 20, 2026

  Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #8 and Resident #13) reviewed for medication administration, the facility failed to obtain physician orders before administering controlled medications, resulting in significant medication errors. The findings include:1.Resident #8's diagnoses included anxiety, schizophrenia, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of ten (10), indicating moderate cognitive impairment, required moderate assistance with bed mobility, and was independent with eating.The Resident Care Plan (RCP) dated 5/10/2026 identified Resident #8 had schizophrenia. […]