Civita Care Center At Milford

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

event summary dated 7/20/2025 indicated Resident #3 reported NA #1 spoke inappropriately to Resident #2 on 7/14/2025 and NA #1 was removed from the schedule on 7/15/2025 when the allegation was made.

The summary further indicated when the facility interviewed NA #1, he stated he had notified the assigned NA when Resident #2 rang the call bell. NA #1 stated Resident #2 rang again and was agitated. NA #1 stated Resident #2 called him names, said he/she was not playing games and made a verbal threat to NA #1. The summary further indicated based on findings from interviews conducted during the investigation,

the facility has concluded that abuse could not be substantiated, however, facility identified that there was a lack of judgement by NA #1 regarding expectations of customer service and the code of conduct when interacting with the resident. Interview with LPN #1 on 8/19/2025 at 2:15 PM identified on 7/14/2025 during

the 3 PM to 11 PM shift, LPN #1 was at the nurse's station while NA #1 was also at the nurse's station talking to someone. LPN #1 was unaware who NA #1 was talking to, and thought he was on his cellphone and heard NA #1 say f*** you, I am not coming and felt that NA #1's demeanor was very harsh and intimidating. LPN #1 identified she realized NA #1 was speaking into the (call bell) intercom feature. LPN #1 stated she was unable to confirm who NA #1 was talking to, and she did not report the incident since she was aware who was on the other end of the intercom conversation. Interview with Resident #2 on 8/19/2025 at 9:30 AM identified on 7/14/2025 during the 3 PM to 11 PM shift when he/she rang the call bell, NA #1 spoke through the intercom and on the second time, they exchanged words. NA #1 stated I'll take your call bell away and to change myself, I'm the supervisor, NA, Administrator and this is why your garbage, and you can't walk, and care was provided by another NA. Interview with NA #1 on 8/19/2025 at 10:40 AM identified on 7/14/2025 during the 3 PM to 11 PM shift, NA #1 was at the nurse's station when Resident #2 rang the call bell for assistance. NA #1 utilized the intercom system and told Resident #2 that he/she will have to wait for their assigned NA and NA #1 will let them know. NA #1 indicated Resident #2 called again soon after, where Resident #2 then started making statements at NA #1 saying stop playing games and using multiple profanities and racial threats. NA #1 identified he lost it and indicated he shouldn't have said what he said, but indicated he did state to Resident #2 you can go change yourself and if you keep calling, I will come and take your call bell, and denied any other comments. Interview with Resident #4 on 8/19/2025 at 12:00 PM identified on 7/14/2025, he/she heard NA #1 say to Resident #2

during the 3 PM to 11 PM shift, go and change yourself and I'll take your call bell away. Record review identified Resident #4 was alert and oriented (BIMS 14). Although attempted, an interview with Resident #3, and LPN #1 was unable to be obtained during the survey. Interview with the DON (Director of Nursing)

on 8/19/2025 at 2:35 PM identified on 7/15/2025, Resident #3 reported an allegation of abuse; alleged NA #1 spoke inappropriately to Resident #2. The DON stated the facility interviewed staff and residents, and concluded that abuse could not be substantiated. The DON stated it was a lack of judgement by NA #1 regarding customer service the facility code of conduct. The DON stated NA #1 did admit he told Resident #2 to change him/herself and that he'll take the call bell away and NA #1 was terminated from his position.

Review of the undated Abuse, Neglect, and Exploitation Policy directed in part, it was the facility policy to protect residents for the health, welfare and rights of residents. The Policy further directed abuse is defined as the means of willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse. Verbal abuse was defined as the use of oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Civita Care Center at Milford

2028 Bridgeport Ave Milford, CT 06460

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Interview with DON (Director of Nursing) on 8/19/2025 at 2:35 PM identified Resident #1 received Nyzalim instead of the Narcan as instructed by APRN #1. APRN #2 informed the hospital staff of the medication error, and Resident #1 did not sustain any adverse effects from the incident. The DON stated LPN #1 and LPN #2 both should have checked the medication label before administration to ensure they were administering the correct medication. Review of the Five Rights of Medication Administration Policy dated 10/1/24 identified the facility will ensure safe, accurate, and consistent medication administration to residents in accordance with federal and state regulations, facility standards, and accepted nursing practice. All licensed nurses and authorized medication personnel must adhere to the Five Rights of Medication Administration to minimize errors and promote resident safety. The Five Rights are identified as: Right Resident, Right Medication, Right Dose, Right Route, and Right Time. Review of facility documentation identified nursing staff education was initiated on 8/4/2025 regarding the Five Rights of medication administration and a new coloring system for the medication packaging for Nyzalim and Narcan.

A QAPI meeting was held on 8/4/2025, and audits of medication administration were initiated on 8/5/2025.

Based on review of facility documentation, past non-compliance was identified.

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