Civita Care Center At Newington
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
phone call from the police inquiring if a resident was missing from the facility. RN #1 identified Resident #1 was not on the secured memory care unit and then went with a police officer to assist the resident back to
the facility. RN #1 identified Resident #1 had a history of wandering throughout the secured memory care unit and walked up and down the halls. RN #1 identified that on 11/19/25 from 7 AM to 3 PM, there were several out-of-state visitors, unfamiliar with the facility, who were entering and exiting the secured memory care unit in groups of six (6) to eight (8) at a time. RN #1 further identified Resident #1 likely walked off the unit with exiting visitors. In addition to the visitors, a Social Worker was visiting the unit and construction was occurring in the building. RN #1 identified secure door codes should not be given to visitors. Interview with NA #2 on 12/18/25 at 11:10 AM identified he/she worked the 7 AM to 3 PM shift on 11/19/25. NA #2 identified she did not give the secure door code to visitors and that staff were responsible for escorting visitors in and out of the secured memory care unit and ensuring the door shuts and locks once visitors pass through the door. NA #2 further identified the secured memory care unit was busier than usual on 11/19/25 due to several visitors entering and exiting. NA #2 saw Resident #1 ambulating in the hallway around 1 PM and did not recall assisting any visitors out of the secured memory care unit. Observation of
the secured memory care unit and interview with the DON on 12/18/25 at 2 PM identified that when visitors enter and exit the secured memory care unit, staff should enter the secured door code to assist visitors in and out. The DON identified staff should stay at the door as visitors pass through the doorway, then close
the door and ensure the door is secured, which is indicated by a light illuminating red above the door. Staff should not give the door security code to visitors or residents. On 11/19/25 Resident #1 was last seen seated in the lounge area adjacent to the locked exit door. The DON identified the facility investigation revealed Resident #1 likely exited the secured unit when visitors entered/exited and further identified there were multiple unfamiliar visitors on the secured memory care unit on 11/19/25. The facility was unable to identify which staff member assisted the visitors in or out when Resident #1 exited. The DON indicated that
the staff member who entered the secure door code must not have remained at the door to ensure no residents exited and that after exiting the secured memory care unit, Resident #1 proceeded to exit the facility's main entrance unseen by the receptionist. The facility Elopement Prevention and Door Safety Policy identified residents with a history of dementia and wandering were at increased risk of elopement.
The policy further identified large groups of visitors presented a risk for unnoticed residents to exit the locked unit and staff should monitor exit doors more closely during peak visitor times and to ensure residents do not exit with visitors. Review of facility documentation identified that a Plan of Correction was initiated immediately to include:Staff training was completed and included review of the Elopement Prevention and Door Safety Policy, rounding expectations, visual oversight of residents, alarm response and visitor monitoring.Random audits were completed daily for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly for one (1) month to ensure Wader Guard devices were in place and functional, door alarms were operational, care plans were accurate, and staff followed visitor exit-monitoring procedures to ensure no residents exited unsupervised and the door was secured before leaving/entering
the area.Audits will be reviewed at the monthly QAPI meetings.The Administrator and DON were responsible for the Plan of Correction with a compliance date of 11/22/25. The Plan of Correction was reviewed by the State Agency during an on-site visit on 12/19/25 and the facility met all components for past non-compliance.
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CIVITA CARE CENTER AT NEWINGTON in NEWINGTON, CT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEWINGTON, CT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CIVITA CARE CENTER AT NEWINGTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.