Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fresh River Healthcare during CMS and state inspections, most recent first.
A resident with multiple medical and cognitive conditions was discharged without confirmation that home nursing services were established, despite requiring assistance with medication management, wound care, and activities of daily living. The facility did not provide documentation that discharge paperwork was sent to the home care agency or that the resident was accepted for services, and the agency was unaware of any request for renewed services prior to discharge.
A resident with atrial fibrillation and a recent hip fracture experienced a sudden change in condition, including confusion and a rapid, irregular pulse. An LPN identified the issue and notified the RN supervisor, but the transfer to the hospital was delayed by approximately forty-five minutes due to the supervisor prioritizing paperwork and not immediately calling 911, despite facility policy and physician expectations for urgent action.
The facility did not promptly notify the State Agency after a resident-to-resident physical altercation, delaying the report by over nine hours, and also failed to report or investigate a resident's grievance alleging verbal abuse by staff. In both cases, required procedures for reporting and investigating abuse allegations were not followed.
A resident with a history of mental health conditions reported concerns about the conduct of two staff members after requesting bathroom cleaning. Although a grievance was filed and the resident described instances of being verbally reprimanded and spoken to in a condescending manner by an LPN and an RN, the facility did not investigate the allegations as required by policy. Documentation focused on housekeeping actions, and there was no evidence that staff statements were obtained or that the resident's concerns about staff conduct were addressed.
A resident with Huntington's disease and chorea, who was at risk for skin injuries, did not receive care plan interventions such as padded siderails and long sleeves as documented. Instead, pillows were used in place of proper padding, and the resident was observed with multiple bruises and skin injuries. Staff interviews confirmed awareness of the care plan but uncertainty about the lack of appropriate equipment.
A resident with fragile skin and cognitive impairment was found with multiple bruises, scabs, and scratches that were not properly documented or monitored by nursing staff. Despite care plan interventions for skin integrity, staff failed to record the location, appearance, and size of new skin alterations, and no assessments were initiated. The DNS was unable to explain the discrepancies or provide a relevant facility policy.
Failure to Establish Home Nursing Services Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident had home nursing services established upon discharge. The resident, who was admitted with multiple diagnoses including infection following a procedure, surgical wound dehiscence, Alzheimer's, and anxiety disorder, was assessed as cognitively intact but required partial assistance with activities of daily living and mobility. The care plan identified deficits in self-care and mobility, and interventions were in place to support the resident's needs. Documentation indicated that the resident was discharged as independent with activities of daily living and was to receive home health care for medication delivery and wound care. However, interviews and record reviews revealed that the facility did not provide confirmation that the resident's discharge packet was sent to the home care agency or that the resident was accepted back for services. The home health agency reported that the resident's previous certification for services had expired and that they were not aware of a request for renewed services prior to or upon discharge. The agency also indicated that the resident's care needs had increased beyond what they could provide, and no evaluation or arrangements were made for the required medical services before discharge. The facility's discharge planning policy required social work staff to assist with referrals for post-discharge services, but this was not documented as completed for this resident.
Delayed Transfer to Higher Level of Care Following Change in Condition
Penalty
Summary
A resident with a history of atrial fibrillation and a recent femoral neck fracture was admitted to the facility and prescribed apixaban. The resident was cognitively intact at baseline but required assistance with activities of daily living. On the evening in question, the resident exhibited a sudden change in condition, including restlessness, lethargy, increased confusion, and an elevated, irregular pulse rate of 156 BPM, which was a significant deviation from previous stable vital signs. The LPN on duty recognized the resident's altered mental status and abnormal vital signs, promptly notifying the RN supervisor. Despite the urgency, the LPN reported that it was not within her authority to initiate a hospital transfer and that she had to follow up multiple times with the supervisor. The supervisor assessed the resident, confirmed the abnormal findings, and began preparing transfer paperwork, which delayed the call to 911. The supervisor eventually contacted the physician, who instructed immediate transfer, but by this time, approximately forty-five minutes had elapsed from the initial recognition of the change in condition to the call for emergency services. Interviews with facility staff and review of policies revealed that the process for transferring residents to a higher level of care was not followed in a timely manner. The facility's policy and the expectations of the Medical Director and Director of Nursing indicated that emergency services should be contacted immediately in such situations, and paperwork should not delay transfer. However, in this case, the resident's transfer was delayed due to adherence to paperwork procedures and lack of prompt action, despite clear signs of a significant change in condition.
Failure to Timely Report and Investigate Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure timely notification to the State Agency regarding an incident of resident-to-resident physical interaction. One resident with severe cognitive impairment and a history of physical aggression entered another resident's room, resulting in a physical altercation where the second resident punched the first. The incident was discovered by staff, and both residents were assessed, with one resident sustaining scratches and facial swelling. However, the State Agency was not notified until over nine hours after the event, contrary to facility policy requiring immediate reporting. Additionally, the facility did not properly address or report an allegation of verbal abuse and mistreatment made by another resident against two staff members. The resident, who had intact cognition, reported being verbally reprimanded and spoken to in a condescending manner by staff, and filed a grievance with the social worker. The grievance and resident's statement were provided to the Administrator and DON, but no investigation was initiated, and the State Agency was not notified as required for abuse allegations. The Administrator determined the accusations were unsubstantiated due to lack of specific dates, and the DNS acknowledged that an investigation and audits should have been conducted but were not. Facility policy directs that all allegations of abuse or neglect are to be reported to the Department of Public Health immediately, but not later than two hours after the allegation is made, and that investigations should be initiated within 24 hours. In both cases described, the facility failed to follow its own policy and regulatory requirements for timely reporting and investigation of abuse allegations, resulting in deficiencies related to the protection of residents from abuse and the prompt reporting of such incidents.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to investigate an allegation of verbal abuse involving one of three residents reviewed for mistreatment. The resident, who had diagnoses including major depressive disorder, anxiety disorder, and a history of suicidal behavior, reported concerns about the conduct of two staff members after requesting that the bathroom be cleaned. The resident's care plan included interventions to address his or her concerns and to avoid challenging the resident's beliefs, as well as providing opportunities for the resident to discuss issues with the social worker. A grievance was filed by the social worker on behalf of the resident, detailing the resident's complaints about the responses of two staff members when the resident requested cleaning of the bathroom. The grievance documentation focused on housekeeping actions taken but did not address or investigate the staff's responses or the resident's allegations of verbal abuse. The resident's interview statement described specific instances of being verbally reprimanded and spoken to in a condescending manner by staff, and the resident reported that these concerns had not been addressed by facility leadership. Interviews with facility staff revealed that the grievance and the resident's statement were submitted to the Administrator and the Director of Nursing Services (DNS), but there was uncertainty about whether an investigation was initiated or completed. The Administrator and DNS both acknowledged that an investigation should have been conducted, including obtaining statements from the staff members named, but there was no documentation of such an investigation. The facility's policies required prompt and thorough investigation of abuse allegations, but this was not followed in this case.
Failure to Implement Care Plan Interventions for Skin Protection
Penalty
Summary
A deficiency occurred when the facility failed to ensure that interventions for skin protection were followed according to the care plan for one resident with Huntington's disease and chorea, who was at risk for skin injuries. The resident's care plan included interventions such as applying moisturizing lotion, encouraging long sleeves, inspecting skin during care, and ensuring padded siderails with pillows. Despite these documented interventions, observations revealed that the resident was wearing a short-sleeved shirt and did not have padded siderails in place. Instead, pillows were used as a substitute due to the unavailability of proper padding. The resident was observed with multiple bruises, scabs, and scratches on the lower extremities, as well as redness around the eye. Interviews with nursing staff and the DNS confirmed awareness of the care plan requirements for padded siderails but revealed uncertainty about why the padding was not available or in use. Nursing notes documented multiple instances of bruising over a period of time. The facility's care plan policy required the interdisciplinary team to develop and implement individualized interventions based on comprehensive assessments, but the specified interventions for skin protection were not consistently followed for this resident.
Failure to Document and Monitor Skin Alterations
Penalty
Summary
The facility failed to document and monitor alterations in skin integrity for one resident with Huntington's disease and chorea, who was identified as having fragile skin and a history of bruising and skin tears. Despite the care plan indicating the need for regular skin inspections and interventions such as moisturizing lotion and padded siderails, clinical records and skin checks over a three-week period only noted old and new bruises without detailed documentation of the location, appearance, or measurements of the skin alterations. No assessments and interventions (A & I's) were initiated for these findings, and the facility was unable to provide a policy for altered skin integrity when requested. During an observation, the resident was found with multiple scabs, scratches, and a large bruise that were not documented in the clinical record, and the DNS was unable to account for when these injuries occurred or why they were not properly recorded. The DNS confirmed that nursing staff are expected to document all new skin alterations with specific details, but this was not done for the resident in question. The lack of documentation and monitoring of skin alterations upon identification and on a weekly basis until resolution constituted the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Chestnut | 0.6 mi | ★★★★★ | 3 | 0 |
| Bickford Health Care Center | 1.1 mi | ★★★★★ | 51 | 2 |
| St Joseph's Residence | 3.4 mi | ★★★★★ | 0 | 0 |
| Suffield House Rehabilitation And Healthcare Cente | 4.2 mi | ★★★★★ | 2 | 0 |
| Parkway Pavilion Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.