Fresh River Healthcare: Discharge Planning Failure - CT
That is what a federal inspection completed August 13, 2025 found at the skilled nursing facility. The inspection, triggered by a complaint, examined how the facility handled the discharge of Resident #4, whose name was withheld in the report. What inspectors documented was a breakdown between the facility's social worker and the home care agency that had previously served the resident, a breakdown that left the resident without medical support at the moment of discharge.
The social worker, identified in the report as SW #1, could not produce a fax confirmation showing the discharge packet had been sent to the home care agency. She could not show the agency had agreed to accept the resident back. Her contact at the agency was the intake manager for behavioral services, identified in the report as Person #2.
Person #2 told inspectors she had never received any discharge paperwork. No fax. No request for services. She was not aware, she said, that the facility had ever asked the agency to take the resident back at all.
What Person #2 did know, and what made the gap more significant, was that she had already communicated with the facility. Within a week of Resident #4's admission to the skilled nursing facility, she had told staff the agency could not accept the resident back. The reason: the resident now required a higher level of care than the agency could provide. That was the agency's position going in.
Person #2 also told inspectors she had left the door open. If the resident's needs changed by the time discharge approached, she said, the case could be reviewed. That review never happened, at least not in any documented way. The facility discharged Resident #4 without circling back to find out whether the agency's position had changed, without sending paperwork, and without securing a commitment that services would be in place.
The resident went home without support.
After inspectors surfaced what had happened, the home care agency made an exception. Person #2 indicated the agency agreed to accept the resident back and took steps to recertify the resident for services. That recertification happened after discharge, not before.
The facility's own discharge planning policy directed social work staff to assist with referrals to community-based agencies for post-discharge services. SW #1's inability to produce a fax confirmation, combined with Person #2's account that no paperwork ever arrived, placed the gap squarely in the space between what the policy required and what actually occurred.
Federal inspectors tagged the deficiency under F0628, which covers discharge planning and the requirement that facilities ensure residents are discharged with adequate post-discharge support. The level of harm was cited as minimal harm or potential for actual harm. Few residents were listed as affected.
The citation is on the lower end of the severity scale. But Resident #4's situation illustrates what that category can look like in practice: a person with active wound care needs, multiple medications to manage, a physical therapy regimen, and daily personal care requirements, discharged into a gap that existed, in part, because a fax was never confirmed and a follow-up call was never made.
The home care agency caught it after the fact. The resident was eventually recertified. But for the period between discharge and the agency's after-the-fact intervention, Resident #4 was home with needs that a skilled nursing facility had deemed significant enough to document in a discharge packet, and no confirmed plan for meeting them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fresh River Healthcare from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 23, 2026 · Our methodology
FRESH RIVER HEALTHCARE in EAST WINDSOR, CT was cited for violations during a health inspection on August 13, 2025.
That is what a federal inspection completed August 13, 2025 found at the skilled nursing facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.