Inspection Reports for
River Ridge at Avon

CT

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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/year

Deficiencies per year

12 9 6 3 0
2018
2019
2021
2022
2023
2024
2025

Census

Latest occupancy rate 81 residents

Based on a October 2023 inspection.

Occupancy over time

72 80 88 96 104 112 Aug 2022 Oct 2023

Inspection Report

Routine
Capacity: 135 Deficiencies: 0 Date: 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
NameTitleContext
Kevin O'ConnellExecutivePersonnel contacted during inspection
Cavalene DeSouzaRNSALSA personnel contacted during inspection
Michael J. SmithRNReport submitted by

Inspection Report

Plan of Correction
Deficiencies: 1 Date: 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)
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantSigned letter and contact for plan of correction response
Doris QuaglianiExecutive DirectorNamed in relation to personnel file review and findings

Inspection Report

Deficiencies: 0 Date: 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
NameTitleContext
Keven O'ConnellAdministratorPersonnel contacted during the inspection
Michael J. SmithSurvey Team LeaderReport submitted by
Liz HeineySupervisorSupervisor of the survey team

Inspection Report

Plan of Correction
Deficiencies: 1 Date: Mar 7, 2024

Visit Reason
An unannounced visit was made to Bal Avon on March 7, 2024, by the Department of Public Health for the purpose of conducting an investigation related to a complaint.

Complaint Details
Complaint CT #38023. The complaint involved allegations of abuse and failure to timely investigate a bruise and rape allegation for Client #1. The complaint was substantiated by the findings.
Findings
The investigation found that the Assisted Living Service Agency (ALSA) failed to complete a timely comprehensive investigation following identification of a bruise and an allegation of rape involving Client #1. The agency delayed initiating the investigation until five days after the initial report, and failed to promptly address the client's injuries and allegations.

Deficiencies (1)
Failure to complete a timely comprehensive investigation following identification of a bruise and allegation of rape for Client #1.
Report Facts
Clients involved: 3 Days delay: 5 Medication dosage: 2.5 Compliance date: May 10, 2024

Employees mentioned
NameTitleContext
Elizabeth T. HeineySupervising Nurse ConsultantAuthor of the plan of correction letter
Kevin O'ConnellAdministratorFacility administrator addressed in the letter

Inspection Report

Follow-Up
Census: 81 Deficiencies: 0 Date: Oct 2, 2023

Visit Reason
On-site review of the plan of correction for complaint investigation CT#33728.

Complaint Details
Complaint investigation CT#33728; the revisit was to review the plan of correction.
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.

Employees mentioned
NameTitleContext
Kevin O'ConnellExecutive DirectorPersonnel contacted during the inspection.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jan 24, 2023

Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #33728.

Complaint Details
Complaint Investigation #33728 was the basis for the visit. Violations were substantiated as indicated by the checked box and attached violation letter.
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.

Report Facts
Inspection dates: Inspection conducted on 1/12/2022, 1/13/2022, 1/17/2022, and 1/24/2023

Employees mentioned
NameTitleContext
Paige MendittoRNPersonnel contacted during inspection
Stephanie Gavitt BonewiczRNPersonnel contacted during inspection
Justin GradyEDPersonnel contacted during inspection
Taisha Shay-OwensRNPersonnel contacted during inspection

Inspection Report

Complaint Investigation
Census: 85 Capacity: 102 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Census: 85 Total Capacity: 102

Employees mentioned
NameTitleContext
Dominick WarnerEDPersonnel contacted during inspection
Robin TentoniSALSAPersonnel contacted during inspection
Karen DonatoRNCReport submitted by

Inspection Report

Complaint Investigation
Census: 85 Capacity: 102 Deficiencies: 0 Date: 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.

Complaint Details
Complaint investigation CT #32591 was the reason for the visit. Violations were identified during the inspection.
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.

Employees mentioned
NameTitleContext
Dominick WarnerEDPersonnel contacted during the inspection
Robin TentoniSALSAPersonnel contacted during the inspection
Karen DonatoRN Nurse ConsultantReport submitted by and signature on inspection report

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantAuthor of the violation letter and contact for plan of correction
Dominick WarnerExecutive DirectorFacility Executive Director addressed in the letter
Robin TentoriRN, SALSAPerson responsible for submitting the plan of correction

Inspection Report

Complaint Investigation
Census: 85 Capacity: 102 Deficiencies: 0 Date: Aug 18, 2022

Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation CT #32591.

Complaint Details
Complaint Investigation CT #32591 was the reason for the visit. Violations were identified during this inspection.
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.

Report Facts
Census: 85 Total Capacity: 102

Employees mentioned
NameTitleContext
Dominick WarnerEDPersonnel contacted during inspection
Robin TentoniSALSAPersonnel contacted during inspection
Karen DonatoRN Nurse ConsultantReport submitted by

Inspection Report

Plan of Correction
Deficiencies: 2 Date: 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.

Complaint Details
Complaint CT #s 30970, 31115 were referenced in the report.
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.

Deficiencies (2)
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantNamed as contact for response to violations
Hospice Registered Nurse #1Assessed and treated Client #4's burns and administered medication
Licensed Practical Nurse #2Observed and reported Client #4's reddened skin
Kitchen Staff #1Observed coffee temperatures and preparation
Supervisor of Assisted Living Services (SALSA)Interviewed regarding client records and investigations

Inspection Report

Complaint Investigation
Deficiencies: 5 Date: 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.

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.
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.

Deficiencies (5)
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 Date: 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.

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.
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.

Deficiencies (6)
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
NameTitleContext
Loan NguyenSupervising Nurse ConsultantSigned the report and referenced in relation to violations and plan of correction

Inspection Report

Renewal
Deficiencies: 0 Date: 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
NameTitleContext
Joanne KuncioSALSAPersonnel contacted during the inspection
Loann D. NguyenSupervisorGranted approval for issuance of license
Robin GirzenReport submitted by

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