Inspection Report Summary
Most inspections found deficiencies related primarily to resident care and staff compliance with regulations, including failure to provide care according to service plans, delayed responses to client needs, inadequate staff training, and issues with investigations following allegations of abuse. Several complaint investigations were substantiated, notably a delayed investigation of a client injury with an allegation of rape in March 2024 and confirmed incidents of staff misconduct in 2022. The facility did not have any fines, license suspensions, or immediate jeopardy findings listed in the available reports. The most recent inspection on February 10, 2025, was clean with no deficiencies identified, indicating improvement since prior reports. Earlier issues around physicals for aides and timely investigations were isolated, and recent compliance suggests corrective actions have been effective.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81 residents
Based on a October 2023 inspection.
Census over time
Inspection Report
Routine
Capacity: 135
Deficiencies: 0
Feb 10, 2025
Visit Reason
Routine onsite inspection conducted for licensure category ALSA 135, including verification of Alzheimer's special care units and infection prevention requirements.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin O'Connell | Executive | Personnel contacted during inspection |
| Cavalene DeSouza | RN | SALSA personnel contacted during inspection |
| Michael J. Smith | RN | Report submitted by |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 4, 2024
Visit Reason
An unannounced visit was made to River Ridge at Avon concluding on December 4, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of a licensing inspection renewal.
Findings
The agency failed to ensure annual physicals were completed by two of two Assisted Living Service Agency (ALSA) aides, with last physicals dated in 2021 and 2022, not meeting the Regulations of Connecticut State Agencies.
Deficiencies (1)
| Description |
|---|
| The agency failed to ensure annual physicals were completed for two ALSA aides as required by regulations. |
Report Facts
Date of inspection visit: Dec 4, 2024
Compliance date a: Apr 16, 2025
Compliance date c: May 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter and contact for plan of correction response |
| Doris Quagliani | Executive Director | Named in relation to personnel file review and findings |
Inspection Report
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was conducted to identify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies at the facility.
Findings
Violations were identified at the time of this inspection, as indicated by the checked box on the report form.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keven O'Connell | Administrator | Personnel contacted during the inspection |
| Michael J. Smith | Survey Team Leader | Report submitted by |
| Liz Heiney | Supervisor | Supervisor of the survey team |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 7, 2024
Visit Reason
An unannounced visit was made to Bal Avon on March 7, 2024 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint.
Findings
The agency failed to complete a timely comprehensive investigation following identification of a bruise to a client with an allegation of rape. The investigation was delayed by 5 days after the initial report. The client had multiple bruises and reported being raped. The agency and involved staff failed to initiate a timely investigation and medical examinations were refused by the client and family member.
Complaint Details
Complaint CT #38023 involved one of three clients who received services at the Assisted Living Service Agency. The complaint was substantiated by findings that the agency delayed investigation of injury and rape allegations by 5 days and failed to initiate timely investigation procedures.
Deficiencies (1)
| Description |
|---|
| Failure to complete a timely comprehensive investigation following identification of a bruise and allegation of rape to a client. |
Report Facts
Days delay in investigation: 5
Client move-in date: Apr 30, 2022
Medication dosage: 2.5
Compliance date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the plan of correction letter and contact for response |
| Kevin O'Connell | Administrator | Facility administrator addressed in the letter |
Inspection Report
Follow-Up
Census: 81
Deficiencies: 0
Oct 2, 2023
Visit Reason
On-site review of the plan of correction for complaint investigation CT#33728.
Findings
A revisit was conducted on 10/02/2023 to review the plan of correction submitted by the agency. Based on interviews, facility tour, documentation review, and audits, no violations were identified.
Complaint Details
Complaint investigation CT#33728; the revisit was to review the plan of correction.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin O'Connell | Executive Director | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #33728.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, with an attached violation letter dated 2023-03-21.
Complaint Details
Complaint Investigation #33728 was the basis for the visit. Violations were substantiated as indicated by the checked box and attached violation letter.
Report Facts
Inspection dates: Inspection conducted on 1/12/2022, 1/13/2022, 1/17/2022, and 1/24/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Menditto | RN | Personnel contacted during inspection |
| Stephanie Gavitt Bonewicz | RN | Personnel contacted during inspection |
| Justin Grady | ED | Personnel contacted during inspection |
| Taisha Shay-Owens | RN | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 102
Deficiencies: 0
Aug 18, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint CT #32591 and to identify any violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Verification of Alzheimer's special care units or programs and full-time Infection Prevention and Control Specialist requirements were also confirmed.
Complaint Details
Complaint Investigation CT #32591 was the basis for the visit. Violations were identified during the inspection as noted in the attached violation letter dated 8/31/22 and 9/12/22.
Report Facts
Census: 85
Total Capacity: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominick Warner | ED | Personnel contacted during inspection |
| Robin Tentoni | SALSA | Personnel contacted during inspection |
| Karen Donato | RNC | Report submitted by |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 102
Deficiencies: 0
Aug 18, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Connecticut complaint CT #32591, including verification of Alzheimer's special care units and compliance with infection prevention and control requirements.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of inspection. The report notes the presence of violations but does not provide detailed findings or deficiency descriptions in the provided text.
Complaint Details
Complaint investigation CT #32591 was the reason for the visit. Violations were identified during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominick Warner | ED | Personnel contacted during the inspection |
| Robin Tentoni | SALSA | Personnel contacted during the inspection |
| Karen Donato | RN Nurse Consultant | Report submitted by and signature on inspection report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 18, 2022
Visit Reason
An unannounced visit was made to Bal Avon on August 18, 2022 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint CT #32591.
Findings
The Assisted Living Services Agency (ALSA) failed to ensure a client's needs were met and failed to ensure clients were free from abuse and neglect. Specifically, ALSA aide #1 used profanity and was terminated for violating policies on conduct and discourteous treatment of clients.
Complaint Details
Complaint CT #32591. The complaint was substantiated as the ALSA aide was found to have used profanity towards the client and was terminated for violating conduct policies.
Deficiencies (1)
| Description |
|---|
| ALSA failed to ensure the client's needs were met and failed to ensure the client was free from abuse. |
Report Facts
Complaint number: 32591
Date of visit: Aug 18, 2022
Date of client admission: Sep 25, 2021
Date of incident: Mar 6, 2022
Date of phone interview: Mar 6, 2022
Date of aide termination: Mar 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Author of the violation letter and contact for plan of correction |
| Dominick Warner | Executive Director | Facility Executive Director addressed in the letter |
| Robin Tentori | RN, SALSA | Person responsible for submitting the plan of correction |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 102
Deficiencies: 0
Aug 18, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation CT #32591.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Verification of Alzheimer's special care units and full-time infection prevention and control specialist requirements were also confirmed.
Complaint Details
Complaint Investigation CT #32591 was the reason for the visit. Violations were substantiated as violations were identified at the time of inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominick Warner | ED | Personnel contacted during inspection |
| Robin Tentoni | SALSA | Personnel contacted during inspection |
| Karen Donato | RN Nurse Consultant | Report submitted by |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 12, 2021
Visit Reason
Unannounced visits were made to Bal Avon by representatives of the Department of Public Health for the purpose of conducting multiple investigations with additional information received through December 31, 2021.
Findings
Violations of Connecticut State Agencies regulations were identified, including failure to protect a client from physical injury and failure to implement safety interventions, improper medication administration, and failure to update service plans timely. The facility submitted a Plan of Correction outlining measures to prevent recurrence and monitor quality assurance.
Complaint Details
Complaint CT #s 30970, 31115 were referenced in the report.
Deficiencies (2)
| Description |
|---|
| The Assisted Living Service Agency (ALSA) failed to protect Client #4 from physical injury and failed to implement safety interventions after the Client's physical injury occurred. |
| ALSA failed to ensure Client #1's Service Plan was updated every 120 days, and/or ALSA nursing staff failed to administer medications in accordance with physician orders, and/or ALSA aides failed to apply stockings in accordance with the service plan. |
Report Facts
Date of visit: Nov 12, 2021
Medication dosage: 0.25
Coffee temperature: 207.5
Coffee temperature: 171.3
Response times: 28
Response times: 15
Response times: 14
Response times: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Named as contact for response to violations |
| Hospice Registered Nurse #1 | Assessed and treated Client #4's burns and administered medication | |
| Licensed Practical Nurse #2 | Observed and reported Client #4's reddened skin | |
| Kitchen Staff #1 | Observed coffee temperatures and preparation | |
| Supervisor of Assisted Living Services (SALSA) | Interviewed regarding client records and investigations |
Inspection Report
Complaint Investigation
Deficiencies: 5
Dec 27, 2019
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit on November 27, 2018 and December 27, 2019 by the Department of Public Health to review violations of Connecticut State regulations at BAL Avon Assisted Living Services Agency.
Findings
The investigation found multiple violations including failure to provide assistance according to client service plans, failure to consider client dignity, delayed responses to client calls, inadequate staff training on dementia and pain recognition, and failure to complete annual performance evaluations for aides. The facility was cited for noncompliance with state statutes and regulations.
Complaint Details
The visit was complaint-related under investigation number 26431. Violations were substantiated as indicated by the issuance of a violation letter dated 2020-01-22.
Deficiencies (5)
| Description |
|---|
| Failure to ensure assistance was provided in accordance with agency policies and client service plans, and failure to consider client's dignity during care delivery. |
| Failure to identify proper response to client needs for elimination considering dignity and self-esteem. |
| Failure to identify accuracy of client service plan describing incontinence and failure to acknowledge client's ability to verbalize elimination needs. |
| Failure to provide aides with required education on dementia and pain recognition. |
| Failure to complete annual performance evaluations for aides. |
Report Facts
Inspection dates: Unannounced visits on 2018-11-27 and 2019-12-27
Response times: Client call bell response times ranged from over 20 minutes to over 44 minutes on multiple occasions.
Training hours: 2
Training hours: 8
Audit percentages: 10
Audit percentages: 25
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 27, 2019
Visit Reason
Unannounced visits were made to BAL Avon on November 27, 2018 and December 27, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
Violations of Connecticut State Agencies regulations were identified related to failure to provide assistance in accordance with agency policies, failure to consider client dignity during care, inadequate staff training on dementia and pain recognition, failure to complete annual performance evaluations, and delayed responses to client call bells.
Complaint Details
The investigation was complaint-related, triggered by concerns about client care and response times. The report details substantiated violations including failure to provide care according to plans and dignity considerations, inadequate staff training, and delayed call bell responses.
Deficiencies (6)
| Description |
|---|
| Failure to ensure assistance was provided in accordance with agency policies, client service plan, and consideration of the person's dignity during care. |
| Failure to identify proper response to client needs or elimination in consideration of client's dignity and self-esteem. |
| Failure to provide required education on dementia and/or pain recognition to aides assigned to specialized dementia unit. |
| Failure to complete annual performance evaluations for certain aides. |
| Failure to identify accuracy of client service plan describing incontinence and client ability to verbalize elimination needs. |
| Failure to identify adherence to agency policies and procedures regarding delayed responses to client call bell and failure of Executive Director to follow up on causes of delay. |
Report Facts
Response time to call bell: 44
Training hours: 2
Training hours: 8
Date of visits: Nov 27, 2018
Date of visits: Dec 27, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the report and referenced in relation to violations and plan of correction |
Inspection Report
Renewal
Deficiencies: 0
Nov 27, 2018
Visit Reason
The inspection was conducted as a licensing renewal inspection for an assisted living facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, as indicated by the attached violation letter. Approval for issuance of license was granted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanne Kuncio | SALSA | Personnel contacted during the inspection |
| Loann D. Nguyen | Supervisor | Granted approval for issuance of license |
| Robin Girzen | Report submitted by |
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