Inspection Reports for
River Glen Health Care Center
162 S Britain Rd., Southbury, CT 06488, CT, 06488
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
89% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 107
Capacity: 120
Deficiencies: 4
Date: Sep 16, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for violations previously cited in a violation letter dated July 21, 2025.
Findings
All four violations identified in the prior inspection were confirmed corrected as of August 14, 2025. The Director of Nursing was notified of the corrections on September 16, 2025.
Deficiencies (4)
Violation #1
Violation #2
Violation #3
Violation #4
Report Facts
Violations corrected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Arteaga | Director of Nursing | Notified of correction of all violations on September 16, 2025 |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as part of the annual survey of River Glen Health Care Center to assess compliance with regulatory requirements and evaluate resident care and facility operations.
Findings
The facility was found deficient in multiple areas including medication management, advanced directives consistency, resident assessments, care planning, nursing services quality, fall prevention, respiratory care, pharmaceutical services, and infection control practices. Several residents' care plans and assessments were inaccurate or incomplete, and staff failed to follow policies for medication self-administration, CPAP orders, and enhanced barrier precautions.
Deficiencies (10)
Allow residents to self-administer drugs if determined clinically appropriate; failure to properly store medication and obtain physician order for self-administration assessment.
Failed to ensure advanced directives were consistent; resident had conflicting DNR and Full Code orders.
Failed to ensure accurate Minimum Data Set (MDS) assessments for hearing aids, range of motion, position/mobility, and falls.
Failed to develop and implement a comprehensive care plan addressing hearing aids, refusals of care, and functional limitations.
Failed to update care plan after change in advance directives for a resident with comfort measures only and DNR order.
Registered Nurse Pronouncement (RNP) assessment incomplete; missing blood pressure and pupillary reaction documentation upon resident death.
Failed to provide adequate supervision to prevent falls for a resident requiring assistance and supervision, resulting in a fall with injury.
Failed to obtain physician's order for resident's use of CPAP machine; resident used CPAP nightly without order.
Failed to conduct bi-monthly narcotic audits to monitor for possible drug diversion.
Failed to implement Enhanced Barrier Precautions for a resident with a Stage 3 pressure ulcer; staff did not wear gowns during wound care and PPE signage and supplies were inadequate.
Report Facts
Deficiencies cited: 10
Residents reviewed: 4
Residents reviewed: 3
Residents reviewed: 3
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Nursing Supervisor | Identified lack of physician order for CPAP and self-administration assessment; involved in medication and respiratory care findings |
| LPN #3 | Licensed Practical Nurse | Observed unsecured Albuterol inhaler and lack of physician order for self-administration; involved in respiratory care findings |
| RN #1 | MDS Coordinator | Responsible for MDS assessments and care plan updates; acknowledged inaccuracies in assessments and care plans |
| RN #5 | Registered Nurse | Performed incomplete Registered Nurse Pronouncement assessment upon resident death |
| LPN #4 | Licensed Practical Nurse | Assisted resident with CPAP use without physician order; aware of missing order |
| APRN #2 | Advanced Practice Registered Nurse | Wrote progress notes regarding CPAP use and advanced directives; attempts to interview unsuccessful |
| NA #4 | Nurse Aide | Witnessed resident fall; provided statements regarding resident's mobility and care |
| OT #2 | Occupational Therapist | Provided therapy notes and identified contracture and palm guard use |
| PT #1 | Physical Therapist | Provided input on resident mobility and assistance levels |
Inspection Report
Renewal
Census: 107
Capacity: 120
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a licensing inspection with a renewal focus and included review of a complaint investigation #2589534.
Complaint Details
Complaint investigation #2589534 was reviewed during this inspection; no substantiation status is provided.
Findings
The report indicates that the inspection included licensing and renewal processes along with a complaint investigation. No explicit findings or violations are detailed on this page.
Report Facts
Licensed Bed Capacity: 120
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gwendolyn Brown | RN | Survey Team Leader and report submitter |
Inspection Report
Renewal
Census: 107
Capacity: 120
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included a complaint investigation #2589534.
Complaint Details
Complaint investigation #2589534 was conducted; substantiation status is not explicitly stated.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, with an attached violation letter dated 2025-09-16. Approval for issuance of license was granted.
Report Facts
Licensed Bed Capacity: 120
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Urbanski | Administrator | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Aug 15, 2025
Visit Reason
Unannounced visits were made to River Glen Health Care Center which concluded on August 15, 2025, for the purpose of conducting an investigation and a licensing renewal inspection.
Findings
The report details multiple violations of Connecticut State Agencies regulations related to medication storage and administration, advanced directives consistency, medical record accuracy, respiratory care, fall prevention, and infection control. The facility failed to properly store medications, ensure consistent advanced directives, accurately code Minimum Data Set (MDS) assessments, and provide adequate supervision and care in several areas.
Deficiencies (10)
Failed to properly store medication and obtain a physician order with completion of a self-administration assessment for a resident with COPD.
Failed to ensure advanced directives were consistent for a resident.
Failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for hearing aids, range of motion, and falls for multiple residents.
Failed to update the resident care plan for a resident with comfort measures only and no intravenous hydration.
Failed to ensure Registered Nurse Pronouncement was comprehensive for a resident's death.
Failed to provide supervision for a resident who required assistance with toileting and ambulation, resulting in a fall.
Failed to obtain a physician's order for a resident utilizing a CPAP machine and failed to ensure proper use and supervision.
Failed to ensure bi-monthly narcotic audits were completed to monitor for possible drug diversion.
Failed to comply with controlled substance inventory and documentation requirements.
Failed to ensure residents with pressure ulcers were placed on Enhanced Barrier Precautions and observed compliance with PPE use.
Report Facts
Residents reviewed: 32
Residents reviewed for falls: 3
Residents reviewed for communication/sensory: 1
Residents reviewed for pressure ulcers: 1
Residents reviewed for position/mobility: 1
Residents reviewed for accidents: 1
Residents reviewed for respiratory care: 4
Residents reviewed for death: 1
Residents audited for medication at bedside: 10
Residents audited for self-administration compliance: 5
Residents audited for MDS accuracy: 5
Residents audited for narcotic audits: 8
Residents audited for Advanced Directives: 8
Residents audited for Enhanced Barrier Precautions: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the initial letter and involved in complaint investigation |
| Linda Urbanski | Administrator | Facility administrator addressed in the notice |
| RN #2 | Registered Nurse Supervisor | Identified issues with medication self-administration and respiratory care |
| LPN #3 | Licensed Practical Nurse | Observed medication storage and administration issues |
| NA #3 | Nurse Aide | Observed medication administration and storage issues |
| RN #1 | Registered Nurse | Interviewed regarding hearing aids and MDS assessments |
| RN #5 | Registered Nurse | Involved in death pronouncement and fall incident |
| RN #6 | Registered Nurse | Interviewed regarding advance directives and care plan updates |
| RN #7 | Registered Nurse | MDS Coordinator involved in assessments and audits |
| LPN #1 | Licensed Practical Nurse | Observed wound care and PPE use |
| LPN #4 | Licensed Practical Nurse | Assisted resident with CPAP machine |
| LPN #5 | Licensed Practical Nurse | Charted refusals of care |
| APRN #2 | Advanced Practice Registered Nurse | Provided progress notes and orders for respiratory care |
| APRN #3 | Advanced Practice Registered Nurse | Provided progress notes for wound care |
| APRN #4 | Advanced Practice Registered Nurse | Involved in DNR order changes |
| OT #1 | Occupational Therapist | Provided mobility directions and therapy notes |
| OT #2 | Occupational Therapist | Provided therapy notes and assessments |
| NA #2 | Nurse Aide | Primary aide for resident with hearing impairment |
| NA #4 | Nurse Aide | Witnessed fall incident |
| NA #5 | Nurse Aide | Witnessed fall incident and assisted resident |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 7, 2025
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse, involuntary seclusion, and failure to timely report and document an allegation of abuse involving Resident #1 by staff member LPN #1 during the early morning of 6/16/2025.
Complaint Details
The complaint involved allegations that LPN #1 verbally abused Resident #1 by telling the resident to fall and break their hip and barricaded the resident in bed with wheelchairs and a nightstand, constituting involuntary seclusion. The facility investigation initially did not substantiate the verbal abuse allegation but later the Director of Nursing Services substantiated it. The allegation was reported late to the State Agency. Interviews revealed failure of timely reporting by NA #1 and RN #1.
Findings
The facility substantiated the allegations of verbal mistreatment and involuntary seclusion of Resident #1 by LPN #1, who was verbally abusive and barricaded the resident in bed with furniture. However, the facility failed to timely report the abuse allegation and failed to document the incident properly in the medical record. The facility identified past non-compliance and initiated staff education and audits.
Deficiencies (4)
Failed to ensure Resident #1 was free from verbal mistreatment by staff.
Failed to ensure Resident #1 was free from involuntary seclusion by barricading the resident in bed with furniture.
Failed to timely report an allegation of abuse to proper authorities.
Failed to maintain complete and accurate medical records including documentation of the abuse allegation.
Report Facts
BIMS score: 6
BIMS score: 15
Incident report time: 2
Incident report time: 9.4
Date of staff education: 6.18
Date of audits initiation: 6.24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in verbal abuse and involuntary seclusion findings |
| RN #1 | Registered Nurse / RN Supervisor | Responded to incident, helped remove barricades, failed to timely report abuse |
| NA #1 | Nursing Assistant | Witnessed incident, reported verbal abuse and barricading, failed to timely report abuse |
| Director of Nursing Services | DNS | Substantiated abuse allegation and provided interview |
| Social Worker #1 | Social Worker | Interviewed regarding Resident #2's report of verbal abuse |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 31, 2025
Visit Reason
The inspection was conducted due to a complaint alleging that a nurse aide treated Resident #1 roughly and caused a painful abrasion on the resident's right buttock during care.
Complaint Details
The complaint was unsubstantiated. Resident #1 alleged rough treatment by NA #1 on 3/13/2025, including forceful pulling of the blanket causing an abrasion and disrespectful communication. The facility investigated, notified the physician and police, and suspended NA #1 pending outcome. NA #1 was ultimately terminated for lack of respectful and dignified care.
Findings
The investigation found that Resident #1 reported rough treatment by NA #1, including forcefully pulling the blanket and causing an abrasion. The allegation of abuse was unsubstantiated, but NA #1 was found to have not treated the resident with respect and dignity and was subsequently terminated.
Deficiencies (1)
Failure to ensure the resident was treated in a respectful and dignified manner.
Report Facts
Date of incident: Mar 13, 2025
Date of complaint report: Mar 14, 2025
Date of investigation completion: Mar 31, 2025
Length of slit wound: 3
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Named in complaint for rough treatment and disrespectful behavior toward Resident #1; suspended and later terminated |
| RN #1 | Registered Nurse | Nursing supervisor who interviewed Resident #1 and notified DNS of complaint |
| DNS | Director of Nursing Services | Took over investigation, interviewed Resident #1, and terminated NA #1 |
| LPN #3 | Licensed Practical Nurse | Notified nursing supervisor of Resident #1's complaint |
| LPN #4 | Licensed Practical Nurse | Performed Resident Evaluation on admission noting wound |
| MD #1 | Physician | Notified of the incident |
| APRN #1 | Advanced Practice Registered Nurse | Notified of the incident |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards, including resident rights, pre-admission screening, staff competency, and medication administration.
Findings
The facility was found deficient in ensuring a dignified dining experience due to use of Styrofoam containers and plastic utensils related to kitchen understaffing, failure to complete timely PASRR Level II assessments for residents with psychiatric diagnoses, failure to ensure nursing assistants completed required annual dementia care training, and a medication error rate exceeding 5 percent due to incorrect medication administration.
Deficiencies (4)
Failure to ensure a dignified dining experience; use of Styrofoam containers and plastic utensils due to kitchen understaffing.
Failure to request and complete timely PASRR Level II assessments for residents with qualifying psychiatric diagnoses.
Failure to ensure nursing assistants completed annual competency training for dementia care and failure to suspend staff not completing required training.
Medication error rate exceeded 5 percent due to incorrect medication administration observed during survey.
Report Facts
Medication error rate: 8
Number of residents with Alzheimer's or Dementia: 31
Days past PASRR Level II expiration: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #9 | Nursing Assistant | Identified as not completing annual dementia care competency training and working shifts despite incomplete training. |
| LPN #1 | Licensed Practical Nurse | Observed administering incorrect medication doses leading to medication errors. |
| Director of Dietary | Interviewed regarding kitchen understaffing and use of Styrofoam containers and plastic utensils. | |
| ADNS | Assistant Director of Nursing Services | Interviewed about staff training requirements and consequences for incomplete training. |
| Facility Educator | Interviewed about nurse aide training and responsibility for ensuring training completion. | |
| SW #1 | Social Worker | Interviewed regarding PASRR screening responsibilities and oversight. |
| SW #2 | Social Worker | Interviewed regarding PASRR screening and referral process. |
| NA #1 | Nursing Assistant | Interviewed about use of plastic utensils and Styrofoam containers during meals. |
| NA #2 | Nursing Assistant | Interviewed about use of plastic utensils and Styrofoam containers and concerns about choking risk. |
Inspection Report
Renewal
Census: 164
Capacity: 120
Deficiencies: 0
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as a renewal visit for licensure of the facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Ucbanik | Administrator | Personnel contacted during the inspection. |
| Florida Doko | ADNA | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Aug 31, 2021
Visit Reason
The inspection was conducted based on allegations of abuse, skin integrity issues, quality of care concerns, physician service deficiencies, medical record accuracy, and vaccination policy compliance at River Glen Health Care Center.
Complaint Details
The complaint investigation was triggered by allegations of abuse, failure to notify family of skin condition changes, failure to implement care plans, inadequate physician services, inaccurate medical records, and vaccination policy noncompliance.
Findings
The facility failed to provide dignified care to Resident #69, timely notify family of skin condition changes for Resident #27 and #28, implement care plans properly, conduct timely RN assessments, obtain physician orders before treatments, ensure application of ted stockings per orders for Resident #89, complete timely physician admission history and physical for Resident #298, maintain accurate medical records, and properly educate and offer pneumococcal vaccines to residents.
Deficiencies (7)
Failed to provide care and assistance in a dignified manner to Resident #69, including verbal abuse by a nurse aide and failure to follow care plan requiring two staff for assistance.
Failed to ensure timely notification to resident's representative when a change in skin condition was identified for Resident #27 and #28.
Failed to implement Resident #69's plan of care related to staff provision of care requiring two staff members.
Failed to conduct RN assessment, obtain practitioner order prior to treatment, and follow facility policy for skin tears and minor breaks for Resident #28; failed to ensure ted stocking applied daily per physician orders for Resident #89.
Physician failed to conduct admission History and Physical timely and sign admission orders timely for Resident #298.
Failed to maintain accurate medical records for Residents #27, #28, and #89 including wound documentation and treatment records.
Failed to educate and offer pneumococcal vaccines timely to residents and/or their representatives for Residents #1, #8, and #27.
Report Facts
Wound measurement: 1.2
Wound measurement: 1
Wound measurement: 1.5
Wound measurement: 1.5
Wound measurement: 6
Wound measurement: 6
Treatment duration: 10
Treatment duration: 7
Admission delay: 12
Date of survey completion: Aug 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Named in verbal abuse allegation toward Resident #69 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #69's verbal abuse allegation |
| RN #3 | Registered Nurse Supervisor | Interviewed regarding Resident #69's verbal abuse allegation and investigation |
| DNS | Director of Nursing Services | Interviewed regarding multiple findings including Resident #69 abuse allegation and physician services |
| LPN #2 | Licensed Practical Nurse | Involved in wound care and notification for Resident #27 |
| RN #2 | Registered Nurse | Involved in wound care and notification for Resident #27 |
| RN #7 | Registered Nurse | Previous ADNS/Wound RN involved in wound care for Resident #27 |
| LPN #1 | Licensed Practical Nurse | Wrote order and applied treatment for Resident #28's hand wound |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding wound care for Resident #28 |
| RN #5 | Registered Nurse | Interviewed regarding Resident #89's ted stocking application |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding Resident #89's ted stocking availability |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding Resident #89's ted stocking availability |
| MD #1 | Physician | Interviewed regarding admission History and Physical for Resident #298 |
| Infection Control Nurse | Interviewed regarding pneumococcal vaccine policy and resident vaccine status |
Inspection Report
Renewal
Census: 87
Capacity: 120
Deficiencies: 0
Date: Aug 29, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The facility was found to be in compliance with visitation requirements.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 87
Inspection Report
Routine
Census: 99
Capacity: 120
Deficiencies: 0
Date: Sep 8, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Census: 104
Capacity: 120
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey.
Inspection Report
Routine
Census: 107
Capacity: 120
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Census: 99
Capacity: 120
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Census: 98
Capacity: 120
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey conducted on June 3, 2020 at River Glen Health Care Center.
Inspection Report
Renewal
Census: 109
Capacity: 120
Deficiencies: 0
Date: Apr 18, 2019
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations numbered 23340, 24001, and 23784.
Complaint Details
Complaint investigations #23340, #24001, and #23784 were reviewed during the inspection. No substantiation status is provided.
Findings
The report indicates that the inspection was a renewal licensing inspection with complaint investigations reviewed. No violations or citations are explicitly stated in the provided document.
Report Facts
Licensed Bed Capacity: 120
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Murray | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 18, 2019
Visit Reason
Unannounced visits were made to River Glen Health Care Center for the purpose of conducting multiple investigations including a licensure inspection and a certification survey.
Complaint Details
Complaints #23840, #24001, and #23784 triggered the investigation. The report details substantiated findings of noncompliance related to resident care, safety, and documentation.
Findings
The facility was found noncompliant with several regulations including failure to notify attending physician/APRN timely of low blood pressure and pressure ulcers, inconsistent ambulation per physical therapy recommendations, failure to transport residents safely resulting in falls, failure to provide fortified foods as ordered, failure to monitor dialysis access sites, and incomplete clinical records documentation.
Deficiencies (7)
Failure to ensure attending physician/APRN was notified timely of low blood pressure and pressure ulcer for Resident #302.
Failure to ensure Resident #32 was consistently ambulated per physical therapy recommendations.
Failure to transport residents safely resulting in falls for Residents #7, #39, and #69.
Failure to provide fortified foods as per physician's orders and dietician recommendations for Resident #353.
Failure to monitor dialysis access site for Resident #37.
Failure to ensure clinical records were complete and accurate, including documentation of oxygen use and nursing notes for Resident #302.
Failure to treat Resident #356 in a dignified manner.
Report Facts
Dates of clinical records and assessments: Multiple dates from 2018 and 2019 referenced for clinical record reviews and assessments.
Fall risk evaluation score: 13
Fall risk evaluation score: 7
Ambulation opportunities and occurrences: 62
Ambulation occurrences: 30
Ambulation occurrences: 32
Ambulation occurrences: 39
Ambulation occurrences: 11
Distance ambulated: 50
Weight: 106.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the amended violation letter dated June 12, 2019. |
| Judith Birtwistle | Supervising Nurse Consultant | Signed the original violation letter dated May 2, 2019. |
| RN #3 | Interviewed regarding Resident #302's care and documentation. | |
| RN #5 | Interviewed regarding Resident #302's care and oxygen notification. | |
| LPN #4 | Admission nurse for Resident #302. | |
| LPN #1 | Interviewed regarding Resident #7's wheelchair safety and fall. | |
| NA #5 | Interviewed regarding Resident #39's fall incident. | |
| NA #2 | Interviewed regarding Resident #69's fall incident. | |
| RT #1 | Interviewed regarding Resident #302's respiratory therapy. | |
| APRN #1 | Interviewed regarding Resident #302's respiratory care and oxygen orders. | |
| Director of Nursing | Interviewed regarding Resident #7 and Resident #69 care. | |
| Dietician | Interviewed regarding Resident #353's diet and fortified foods. | |
| Rehabilitation Director | Interviewed regarding Resident #32's ambulation. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 120
Deficiencies: 8
Date: Apr 15, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints (#23840, #24001, #23784) concerning resident care and facility compliance.
Complaint Details
The visit was complaint-driven based on complaints #23840, #24001, and #23784. The complaints involved concerns about resident care, including failure to notify responsible parties of changes in condition, inadequate ambulation, and failure to provide ordered treatments. The investigation substantiated multiple deficiencies.
Findings
The investigation identified multiple violations related to resident care, including failure to ensure proper notification of low blood pressure, inadequate documentation of oxygen use, failure to provide fortified foods as ordered, and insufficient monitoring of residents' mobility and safety. Several residents were found to have unmet care needs and documentation deficiencies.
Deficiencies (8)
Failure to ensure responsible party was notified of low blood pressure in a timely manner.
Failure to ensure resident was consistently ambulated per physical therapy recommendations.
Failure to ensure a resident assessment was reviewed by a Registered Nurse upon admission and for respiratory care.
Failure to provide fortified foods as per physician's orders and dietician recommendations.
Failure to monitor a dialysis resident's AV fistula site as per facility policy.
Failure to ensure clinical record was complete and accurate regarding oxygen use and physician orders.
Failure to provide adequate assistance to residents at risk for falls and to implement fall prevention interventions.
Failure to ensure proper documentation and notification of changes in residents' medical conditions.
Report Facts
Licensed Bed Capacity: 120
Census: 109
Complaint Numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Murray | Director of Nursing (DNS) | Named in relation to findings regarding resident care and documentation. |
| Mary Noonan | Administrator | Facility administrator involved in the inspection process. |
| Kevin Antolini | ADNS | Contacted during inspection related to plan of correction review. |
| Lore A. Martinez | Facility Educator | Contacted during inspection related to plan of correction review. |
| Terri D. McNeil | RNC | Reported on follow-up visit findings. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed official correspondence related to complaints and violations. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 120
Deficiencies: 6
Date: Apr 15, 2018
Visit Reason
The inspection was conducted as a licensing inspection with renewal and complaint investigations for complaint numbers 23540, 24001, 23784, 23163, 23191, and CT 21818. Additional visits were made to review the implementation of the Plan of Correction for a violation letter dated 3/15/18.
Complaint Details
Complaint investigations were conducted for multiple complaint numbers including 23540, 24001, 23784, 23163, 23191, CT 21818, and 21818. Violations were identified in some investigations and plans of correction were submitted. Some citations were verified as corrected. The facility was re-educated on policies and procedures related to the complaints.
Findings
The facility was found to have no violations at the time of the inspection for some visits, while other visits identified violations related to inadequate supervision, staffing shortages on the night shift, failure to prevent falls, medication administration errors, failure to provide timely nutrition assessments, and failure to ensure proper dental care. Some citations were verified as corrected. The facility submitted plans of correction and was re-educated on various policies.
Deficiencies (6)
Facility failed to maintain adequate staffing on the night shift contributing to resident falls.
Failure to provide adequate supervision and care to prevent falls for residents #1 and #2.
Failure to provide care and services for dental issues for resident #47.
Failure to ensure timely assessment and evaluation of residents with significant weight loss.
Failure to ensure resident #364 was free from significant medication error.
Failure to identify and provide information regarding advance directives for resident #32.
Report Facts
Licensed Bed Capacity: 120
Census: 109
Inspection Dates: 2018-04-15 to 2018-04-18
Citation Number: 201813
Number of Residents Reviewed: 7
Number of Staff Re-education Weeks: 3
Number of Random Audits: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Noonan | Administrator | Contacted personnel and named in relation to findings and plans of correction. |
| Nathalie Murray | Director of Nursing Services (DNS) | Contacted personnel and named in relation to findings and plans of correction. |
| Karen Gworek | Supervising Nurse Consultant | Signed narrative report and correspondence related to complaint investigations. |
| Lida S. Bayona | RN - FLIS | Named in report summary and findings. |
Inspection Report
Follow-Up
Census: 104
Capacity: 120
Deficiencies: 0
Date: Apr 17, 2017
Visit Reason
An unannounced visit was made to review the implementation of the Plan of Correction for the violation letter dated 2/23/17.
Findings
Staffing was reviewed for a 2 week period and met the minimum qualifications of the State of Connecticut Public Health Code. Violations #1 to #4 were reviewed, corrected, and put back in compliance as of the Plan of Correction date of 3/20/17.
Report Facts
Licensed Bed Capacity: 120
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Noonan | Administrator | Personnel contacted during inspection |
| Nathalie Murray | DNS | Personnel contacted during inspection |
| Judy Birtwistle | RN | Report submitted by |
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