Inspection Reports for
Riverside Health and Rehabilitation Center

The complaint investigation substantiated that Resident #1 was physically abused by Resident #2 on 12/7/25, resulting in injuries including open fractures and hematomas. Resident #2 was removed from the facility following the incident.

The investigation found that Resident #1 was punched multiple times in the face by Resident #2 following a verbal altercation, resulting in physical injuries requiring hospital transfer. The facility identified deficient practices related to abuse prevention and implemented an immediate plan of correction including audits, staff education, and behavioral monitoring.

One violation was identified and corrected as of 2025-11-25. No new non-compliance was found, and the facility is in compliance with all regulations.

The complaint investigation was substantiated based on review of clinical records, facility documentation, and interviews. Resident #1 exhibited wandering and agitation behaviors, and the facility failed to complete a timely reassessment of elopement risk despite these behaviors. The resident eloped from the facility but was found without injury and returned safely.

The facility failed to reassess Resident #1's elopement risk in a timely manner despite changes in condition and wandering behaviors, leading to the resident leaving the facility unsupervised. The resident was found outside the building without injury, and corrective actions including a new elopement evaluation, application of a wander guard bracelet, and one-to-one observation were implemented.

Violations #1 and #2 were identified as corrected as of September 25, 2025. The facility administrator was notified of the corrections on September 26, 2025.

The facility failed to ensure that care plans were reviewed and revised appropriately for a resident with suicidal ideations and intent, including failure to mitigate environmental hazards and implement adequate safety interventions. Multiple hospitalizations and emergency transfers occurred without timely updates to the care plan or removal of safety risks such as access to knives and corded call lights.

The facility failed to ensure Resident #2 received required supervision during meals, resulting in a choking incident causing actual harm. Communication failures between speech therapy and nursing staff led to inadequate implementation of the care plan. The facility initiated a Plan of Correction including staff training, care plan revisions, and audits to prevent recurrence.

The facility failed to ensure that the physician's orders for Resident #2, a readmission after a hospital stay, were accurately transcribed. The hospital discharge order to administer Quetiapine at night was incorrectly transcribed to be given at 9:00 AM, leading to medication administration errors and subsequent resident lethargy requiring emergency evaluation.

The investigation was complaint-driven, related to complaints #37241 and #43229. The report does not explicitly state substantiation status.

Violations of Connecticut State Agencies regulations and statutes were identified during the visits, including a medication transcription error involving Resident #2, where the medication administration time was incorrectly transcribed, leading to potential medication errors. The facility was found to have policy gaps in double-checking medication orders prior to transcription.

The complaint investigation focused on allegations that Resident #1's low blood sugar episodes were not properly reported to the provider, Resident #4 was neglected in toileting and transfer assistance, and clinical documentation was incomplete. The investigation confirmed these issues with findings of failure to notify providers, neglect in toileting and transfers, and incomplete documentation.

The facility failed to timely notify the provider of low blood sugar episodes for Resident #1, failed to provide timely toileting hygiene and proper transfer assistance for Resident #4, and failed to maintain accurate and complete clinical documentation for Resident #1's hypoglycemia management. The facility identified past non-compliance and initiated corrective actions including education and audits.

Complaints #42538 and #42720 triggered the investigations.

Violations of the Regulations of Connecticut State Agencies and/or General Statutes were noted during the visits, including issues related to timely notification of physicians and families, neglect in toileting assistance, and failure to ensure timely interventions for residents with low blood sugar. The facility submitted plans of correction addressing these violations with specific corrective actions and monitoring plans.

The facility was found deficient in multiple areas including failure to follow physician orders for medication monitoring, inadequate pressure ulcer care and prevention, lack of podiatry services, unsafe fall prevention practices, missing physician orders for oxygen therapy, inaccurate controlled substance counts, expired and improperly stored medications, improper food storage and hygiene practices, and incomplete hospice documentation.

The complaint involved a verbal altercation where Nurse Aide #2 used inappropriate language, including telling Resident #1 to 'shut the f_ _k up.' The incident was reported by staff and resident interviews confirmed the event. Nurse Aide #2 was terminated following the investigation.

The facility failed to ensure the resident was treated with respect and dignity, as a nurse aide used inappropriate language, including profanity, directed at Resident #1 during an incident on 10/24/2023. The nurse aide was subsequently removed from the floor and terminated for poor customer service.

Complaint investigation #36450 was substantiated with findings including inappropriate language used by a nurse aide and staffing deficiencies. The nurse aide involved was terminated for poor customer service.

Violations of Connecticut State regulations were identified during the inspection, including inappropriate language used by a nurse aide towards a resident and failure to maintain staffing levels according to minimum requirements. The facility was required to submit a plan of correction.

The complaint investigation focused on Resident #1 who had dysphagia and a history of aspiration. The facility failed to implement required aspiration precautions and one-to-one supervision during meals. Resident #1 choked while eating without supervision, required CPR, and was transferred to the hospital. Interviews revealed failures in communication and order transcription by nursing and speech therapy staff.

The facility failed to transcribe physician orders for one-to-one assistance and aspiration precautions, and the speech therapist failed to enter full supervision recommendations as physician orders. This failure led to inadequate supervision during meals, resulting in a resident choking and requiring CPR and emergency transfer to the hospital. Immediate jeopardy was identified due to these deficiencies.

Complaint Investigation #33851 was conducted. The investigation found deficiencies related to abuse allegations involving Residents #1, #2, #3, and #4. The facility failed to protect residents from abuse, failed to notify the State Agency timely, and failed to investigate allegations thoroughly. The facility was required to submit a plan of correction by March 9, 2023.

Violations of Connecticut State regulations were identified involving failure to protect residents from alleged sexual abuse and failure to notify the State Agency timely of abuse allegations. Deficiencies were found related to supervision, investigation, and reporting of abuse incidents involving multiple residents.

The complaint investigation involved allegations of sexual abuse by Resident #3 towards Resident #2, physical aggression by Resident #2 towards Resident #4, and failure by the facility to timely report and investigate these abuse allegations. The investigation found substantiated issues of abuse and inadequate facility response.

The facility failed to protect residents from alleged sexual abuse by Resident #3, failed to timely notify the State Agency of abuse allegations, and failed to conduct thorough investigations of abuse allegations involving Residents #2 and #4. Several residents were found exposed and upset after Resident #3 was unsupervised in their rooms. The facility also lacked documentation of incident reports and investigations for some abuse incidents.

Complaint 32400 triggered the investigation. The complaint involved an alleged resident-to-resident sexual abuse incident. The facility could not substantiate abuse but identified concerns with staff actions and resident safety. The complaint was investigated with interviews, video review, and policy review.

The investigation focused on a potential resident-to-resident sexual abuse incident involving Residents #1 and #2. The facility was unable to substantiate abuse as no physical contact was observed, but identified deficiencies in staff response and resident safety monitoring. A plan of correction was submitted addressing safety measures and staff education.

Complaint #31314 was investigated. The facility was found noncompliant with regulations related to abuse and mistreatment of Resident #10. The complaint was substantiated based on review of clinical records, interviews, and facility documentation.

The facility failed to report an allegation of mistreatment in a timely manner and failed to initiate and thoroughly investigate the allegation of mistreatment involving Resident #10. Documentation was lacking to reflect statements obtained from the resident's caregivers as part of the investigation.

The complaint investigation was substantiated with findings that the facility failed to timely report and properly investigate an allegation of abuse involving Resident #10. The resident reported being struck and pushed by a nurse aide, and the facility failed to obtain a resident statement and was unaware of a police report related to the incident.

The facility failed to report an allegation of mistreatment in a timely manner and failed to initiate and thoroughly investigate the allegation. Resident #10 alleged being struck on the back of the head and pushed into side rails by a nurse aide. The facility did not obtain a statement from the resident as part of the investigation and was unaware of a police call related to the resident's safety concerns.

The visit was complaint-related, investigating complaints CT31206 and CT31251. Violations were substantiated as noted in the attached violation letter dated 12/27/21.

Violations of Connecticut State regulations were identified related to failure to notify responsible parties about pressure ulcers and failure to implement interventions to prevent pressure ulcer development. The facility was found deficient in documentation and notification practices concerning a resident with a pressure ulcer.

The facility was found to have multiple deficiencies including failure to ensure call bells were within reach, unclean resident equipment, failure to follow grievance procedures, unsafe smoking supervision, improper respiratory care, expired medications and improper medication storage, inadequate food labeling and infection control practices during food preparation, and failure to perform hand hygiene during meal delivery.

The report details multiple violations of Connecticut state regulations related to resident care, facility cleanliness, grievance processes, smoking policies, respiratory care, medication management, dietary services, and infection control. The facility was found deficient in ensuring resident safety, proper equipment maintenance, grievance handling, medication expiration management, and staff compliance with infection control policies.

Multiple deficiencies were identified including failure to ensure call bells were within reach, inadequate cleaning of feeding tube equipment, failure to follow grievance procedures, unsafe smoking supervision, improper oxygen tubing changes, expired medications and improper medication storage, undated and unlabeled food items, improper use of PPE in food preparation, and failure to perform hand hygiene during meal delivery.

The investigation was complaint-related, focusing on the failure to report and document an incident involving a resident who displayed a danger to self. The complaint was substantiated based on the findings.

The facility failed to report and document an investigation for one resident who displayed a danger to self, including failure to complete a reportable event form and notify the State agency. Additionally, the clinical record for a resident was incomplete, lacking specific details of the incident and required notifications. The facility's policies on accident and incident reporting were found insufficient in some areas.

The investigation was complaint-related, focusing on Resident #1's change in condition, wound care, and infection control practices. The complaint was substantiated by findings including failure to notify responsible parties, incomplete wound assessments, and infection control breaches.

The facility failed to notify the responsible party when a change in condition was identified and new treatment was initiated for Resident #1. The facility also failed to ensure a wound assessment was conducted when a new skin condition was identified, resulting in an unstageable pressure ulcer and hospital transfer for sepsis. Additionally, the facility failed to adhere to infection control practices by allowing clean linen carts into residents' rooms, risking contamination.

Deficiencies were identified related to failure to notify responsible parties of changes in resident condition and new treatments, failure to conduct wound assessments for new skin conditions, and failure to adhere to infection control practices regarding clean linen handling.

The facility failed to adhere to its Communal Dining Plan and CDC social distancing guidelines during a pandemic, as residents were observed seated less than six feet apart and sharing food in the dining room. Nursing staff acknowledged social distancing was an oversight during the meal, and the facility's communal dining policy was not followed.

The facility failed to adhere to the Communal Dining Plan and CDC social distancing guidelines during a pandemic, with residents seated less than six feet apart in the dining room. Interviews with staff confirmed the lack of designated seating arrangements and oversight of social distancing.

The facility failed to adhere to infection control practices and CDC guidelines while handling a contaminated surgical mask, specifically involving improper glove use and mask handling by a nurse aide.

The facility failed to adhere to infection control practices and CDC guidelines while handling a contaminated surgical mask, specifically involving improper handling and contamination by a Nursing Assistant. The facility was cited for violations related to infection control and Director of Nurses responsibilities.

Complaint CT#28320 was investigated, focusing on the delay in reporting a reportable event. The complaint was substantiated by findings.

The facility failed to timely report a reportable event involving Resident #1 becoming unresponsive and subsequent death. The event was reported 22 days after occurrence, and the Director of Nursing acknowledged a delay in reporting.

Complaint #27907 triggered the investigation. The complaint was substantiated based on review of records, interviews, and documentation showing delays and lack of communication in discharge planning.

The facility failed to discharge a resident in a timely manner due to inadequate follow-up on the discharge plan involving the resident's family and outside agencies, resulting in a delay of discharge. Documentation and communication deficiencies were noted regarding the discharge process.

The investigation was in response to allegations of abuse, neglect, exploitation, or mistreatment related to an injury of unknown origin for Resident #1. The facility did not thoroughly investigate the alleged violation, failed to interview involved nursing assistants, and did not report the injury as potential abuse to the state agency. The deficiency was substantiated as the investigation was incomplete.

The facility failed to complete a full investigation according to standards of practice for an injury of unknown origin involving Resident #1. The investigation lacked interviews from key nursing assistants and was not reported to the state agency as potential abuse. The Director of Nursing could not locate investigative interviews, indicating the investigation was not comprehensive. No deficiencies were cited related to infection control.

Complaint #27681 triggered the investigation. The complaint involved failure to properly investigate an injury of unknown origin for one resident. The investigation was found not comprehensive and the injury was not reported as potential abuse.

The facility failed to complete a full investigation for injury of unknown origin for one resident, Resident #1, who had dependent edema and swelling. The investigation lacked interviews with key staff and was deemed not comprehensive. The Director of Nursing did not consider the injury to be of unknown origin and did not report it as potential abuse to the state agency.

The facility failed to ensure proper personal protective equipment (PPE) was utilized according to CDC guidelines by staff on COVID-19 positive units, including improper use and lack of fit testing for N95 masks. The facility had adequate PPE supplies and initiated re-education and audits to address the deficiencies.

The facility failed to ensure proper personal protective equipment (PPE) was utilized according to CDC guidelines, with multiple staff members observed wearing masks incorrectly or not wearing N95 masks when required. The facility had adequate PPE supplies and planned re-education and fit testing for staff to correct deficiencies.

The facility failed to notify the state agency of a newly identified fracture in a resident, which was initially misclassified as a Class E event but later reclassified as a Class D event and reported. The facility submitted a plan of correction addressing the reporting requirements and monitoring procedures.

The complaint investigation was substantiated with violations identified, including failure to notify the state agency of a newly identified fracture and misclassification of incident reports as Class E instead of Class D.

Violations were identified during the complaint investigation, including failure to notify the state agency of a newly identified fracture, misclassification of incident reports, and deficiencies in resident care and facility policies. The facility submitted plans of correction for the identified violations.

The complaint investigation focused on allegations that the facility failed to provide timely wound care and RN assessments, failed to supervise a resident with a history of elopement and smoking violations, and failed to maintain proper food safety and sanitation standards.

The facility failed to provide timely wound care and RN assessments for residents with pressure ulcers and changes in condition. The facility also failed to provide adequate supervision to a cognitively impaired resident who repeatedly violated smoking policies and left the facility unsupervised. Additionally, the facility failed to properly monitor dishwasher sanitizing solution levels and ensure proper storage of juices prior to serving.

The facility failed to ensure the accuracy and consistency of the MDS assessments for Resident #316, particularly regarding hospice care status and prognosis documentation. The coding errors were acknowledged by staff, and the facility did not meet the requirement for accurate resident assessment documentation.

The facility was found deficient in quality of care related to timely RN assessments and pressure ulcer care for two residents, failure to provide adequate supervision to a resident with a history of elopement and smoking policy violations, and food safety issues including inadequate monitoring of dishwasher sanitizing solution and improper storage of juices prior to serving.

The report identifies multiple violations of Connecticut General Statutes and Regulations related to clinical record accuracy, timely nursing assessments, resident supervision, smoking policy compliance, and food service sanitation. The facility failed to ensure accurate Minimum Data Set assessments, timely care for pressure ulcers, adequate supervision of residents with a history of non-compliance, and proper sanitizing solution levels for dishwashers.