River Glen Health Care Center

In the surveyor’s words

From the most serious findings on record at River Glen Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Jul 13, 2026

  . Based on observation, review of the clinical record, facility documentation and facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision to prevent a resident from leaving the facility without staff knowledge after they were notified the resident was planning to leave the facility, and failed to ensure a complete investigation was completed after a resident left the facility without staff knowledge. The facility failed to implement appropriate interventions after they became aware of the resident's intent to leave the facility, resulting in the resident exiting the building unescorted and without staff knowledge. […]

• No harm, potential for more than minimal, isolatedF554Aug 15, 2025

  Based on observation(s), review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #118) reviewed for respiratory care, the facility failed to properly store medication and obtain a physician order with completion of a self administration assessment for a resident with chronic obstructive pulmonary disease (COPD). The findings include:Resident #118's diagnoses included COPD, chronic respiratory failure with hypoxia, emphysema, and pneumonia. A physician's order dated 7/16/25 directed Ventolin HFA (a bronchodilator used to treat asthma) aerosol solution 108mcg/act (Albuterol Sulfate HFA) 2 puffs inhaled orally every 4 hours as needed for shortness of breath.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was… […]

• No harm, potential for more than minimal, isolatedF578Aug 15, 2025

  Based on review of the clinical record, facility policy and interviews for the 1 of 32 sampled residents (Resident #2) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent. The findings include:Resident #2's was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, acute respiratory failure with hypercapnia (retention of carbon dioxide) and chronic kidney disease. A State of Connecticut Department of Public Health transfer of Do Not Resuscitate (DNR) order form signed by the physician on [DATE] indicated Resident #2 had a valid DNR order which was written on [DATE] and was retained in the resident's medical record. […]

• No harm, potential for more than minimal, isolatedF656Aug 15, 2025

  Based on observations, review of the clinical record, interviews and facility policy for the only resident reviewed for communication/sensory (Resident #8), for 1 of 3 sampled resident (Resident #32) reviewed for pressure ulcers, for the only sampled resident reviewed for positioning (Resident #90), the facility failed to ensure a comprehensive care plan was in place for hearing (Resident #8), for refusals of care (Resident #32) and for functional limitation in range of motion (Resident #90). The findings include: 1.Resident #8 diagnoses included failure to thrive, heart failure, and osteoarthritis. A facility contracted audiology consult form dated 9/17/24 identified that Resident #8 had a right and left hearing aid from another company. […]

• No harm, potential for more than minimal, isolatedF657Aug 15, 2025

  Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #15) reviewed for advance directives, the facility failed to update the resident care plan (RCP) for a resident with comfort measures only (CMO) and no intravenous hydration (IVs). The findings include:Resident #15 had diagnoses that included dementia, anemia, and hypertension.A Do Not Resuscitate Consent Form dated [DATE] identified do not resuscitate (DNR) was discussed with Resident #15's responsible party by the Advanced Practice Registered Nurse (APRN) #4 and Resident #15's responsible party signed the form in agreement with changing Resident #15 to DNR.An APRN #4's progress note dated [DATE] at 11:53 AM identified Resident #15's code status/advance directives was changed by probate… […]