River Haven Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one out of five sampled residents (Resident (R)2). Review of the Diabetes Mellitus Care Plan for R2, revealed the care plan included interventions to provide regular podiatry care as ordered by the medical doctor (MD), which was not implemented.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received proper treatment and care to maintain good foot health. Additionally, the facility failed to provide foot care and treatment for Resident (R) R2 in accordance with professional standards of practice that included preventing complications from the resident's medical condition(s), assisting the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments, if needed for one of five sampled Residents (R2). An observation on 05/11/2026 at 4:08 PM revealed R2's left great toenail was thick, long, and curved to the left halfway over and was touching the 2nd digit.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the mechanical lift slings were retired in accordance with the manufacturer's recommendations. Per the sewn-on manufacturer's label, the working life is six months. One sling out of six slings inspected in the 100 Hall had a legible date handwritten in black, which had expired, and there were no legible handwritten dates on all seven slings located in the 200 Hall.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents had a right to a safe, clean, comfortable, and homelike environment which had the potential to affect all of the facility's 81 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an alleged violation of abuse related to an allegation that occurred on or around 03/10/2025 for 1 of 5 residents sampled for abuse out of the total 26 sampled residents, (Resident (R)8).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to thoroughly investigate an alleged abuse violation related to an allegation that occurred on or around 03/10/2025 for 1 of 5 residents sampled for abuse out of the total sample of 26, (Resident (R)8).

Inspectors wroteBased on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect eighty-two (82) of eighty-eight (88) residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 2 of 21 sampled residents (Resident (R)39 and R42). 1. R39 developed a facility acquired stage 4 pressure ulcer in 05/2024. However, there was no documented evidence the facility reviewed and further developed R39's care plan with additional interventions. Further, R39's comprehensive care plan (CCP) did not include measurable data elements to monitor progress towards the expected outcomes and goals. 2. R42 received tube feeding and was care planned to have the head of bed (HOB) elevated. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 21 sampled residents (Resident (R)43, and R54). 1. R43 was tested for symptoms of a urinary tract infection (UTI) on 10/13/2024 and the laboratory (lab) results were finalized on 10/16/2024. However, the facility failed to ensure the lab results were received resulting in R43 not receiving the necessary treatment for a UTI until 10/23/2024, seven days later. 2. R54 received a recommendation for a gradual dose reduction on 09/15/2024. The recommendation was approved and signed by the facility Nurse Practitioner on 09/17/2024. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure residents received care consistent with professional standards for 1 of 3 residents sampled as at risk for developing pressure ulcers out of the total sample of 21 (Resident (R)39). In interview on 10/22/2024 at 9:48 AM, R39 stated she had been at the facility since January and had a wound on her foot. Observation, at the time of interview, revealed R39 lying on her back on an alternating pressure mattress (APM), with two wedge cushions and a heel boot stored on a shelf in the corner of the room. R39 stated she received the heel boot for her left heel at the hospital; however, staff removed it when she returned to the facility. She stated the left heel boot had not been placed back on her since. R39 stated staff did not utilize wedge cushions or pillows for positioning her. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure a resident fed by enteral means (feeding tube) received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia for 2 of 7 residents receiving enteral feeding (Resident (R)39, R42). In interview the Director of Nursing (DON) stated it was a standard of practice for a resident's head of bed (HOB) to be elevated during (tube) feedings and for the tube feeding to be changed every 24 hours. 1. However, observation on 10/21/2024 at 1:15 PM, revealed R42's HOB was flat when the resident was receiving enteral feeding. Additionally, the enteral feeding R42 was receiving was dated 10/20/2024 at 10:08 AM (over 24 hours). Observation revealed R42 continued lying flat two hours later at 3:18 PM. [...]

Inspectors wroteBased on observation, interview and review of the facility policy, it was determined the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 21 sampled residents (Resident (R)39). Observation on 10/24/2024 at 11:20 AM, during the left heel dressing change for R39 revealed the resident had a grimace on her face prior to being turned by staff. R39 was observed placing the neckline of her gown in her mouth and biting down to keep from yelling out. R39 had tense facial expressions, facial grimacing and verbalizations of oh, oh, oh me during the dressing change. The State Survey Agency (SSA) Surveyor requested the wound care halted and R39 be assessed for pain. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure drugs and biologicals used in the facility were safely stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on [DATE] of the 300 hall medication storage room revealed multiple expired medical supplies. Observation further revealed a small refrigerator utilized for storage of milk and beer with the temperature reading out of the acceptable range according to the internal thermometer of the device.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Observations of Certified Nursing Assistant (CNA) 10 on 10/22/2024 at 11:40 AM, revealed she pulled gloves from a box sitting on top of a medication cart and placed them in her pants pocket prior to entering Resident 7 ' s room to provide care.

Inspectors wroteBased on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure the person centered comprehensive care plan was implemented for one (1) of four (4) sampled residents (Resident #1). The facility care planned Resident #1 as a choking risk due to behaviors of reaching and grabbing food not on his/her diet, The resident required a pureed diet. In addition, one to one (1:1) supervision, when out of bed. The facility failed to implement the nursing care plan interventions to prevent Resident #1 from getting food not on his/her diet, nor the 1:1 supervision when out of bed. On 08/07/2020, Resident #1 obtained a peanut butter sandwich from the snack tray on the medication cart. Resident #1 grabbed and consumed half of the half of peanut butter sandwich before staff intervention and choked. [...]

Inspectors wroteBased on observation, interview, record review, hospital record review, review of Nurse's book, Staff Assignment Sheet, and facility education review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision to prevent accidents. The facility assessed Resident #1 required one to one (1:1) supervision when out of bed; however, the facility did not ensure this assessed need was met. Interviews and record review revealed, on 08/07/2020, there was no staff to provide 1:1 supervision. One Certified Nurse Aide (CNA) was outside providing supervision during the residents' smoke break, one CNA was providing resident care in a resident room, and the nurse was administering medication. Resident #1 was sitting beside the medication cart while the nurse prepared medication to administer to a resident. [...]

Inspectors wroteBased on interview, record review, review of the Staff Assignment Sheet, facility education documentation, hospital records, and facility policy review, it was determined the facility failed to ensure sufficient staff had the appropriate competencies and skill sets to provide nursing and related services to ensure one (1) of four (4) sampled residents (Resident#1) safety as determined by resident assessments and care plans. The facility assessed and care planned Resident #1 with a history of grabbing food off trays, was at risk for choking, and required 1:1 supervision when out of bed. However, on 08/07/2020, the facility did not assign staff to provide 1:1 supervision, due to insufficient staffing. [...]

Inspectors wroteBased on observation, interview, facility menu review, and review of facility policy, it was determined the facility failed to follow the standardized four (4) week cycle menus as determined by menu changes not assessed by the Dietitian for prior approval.

Inspectors wroteBased on observation and interview, it was determined the facility failed to prepare food under sanitary conditions. Observation during initial kitchen tour revealed dusty ceiling vents over the production area.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies/procedures, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to prevent the possible spread of COVID-19. Observations revealed personal protective equipment (PPE) was not available on hall, and multiple staff failed to don PPE prior to entering residents' rooms who were on isolation precautions (due to being newly admitted and/or possibly exposed to COVID-19). In addition, one staff failed to remove PPE prior to exiting resident room.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to treat three (3) of twenty (20) sampled residents (Residents #30, #39, and #52) with respect, dignity, and provide care in a manner that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. Staff failed to ensure Resident #30's name was not displayed on his/her clothing visible to others, failed to answer Resident #39's call light in a timely manner which caused the resident to be incontinent, and failed to meet Resident #52's grooming needs to remove facial hair including mustache.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for one (1) of twenty (20) sampled residents (Resident #45). Observations revealed Resident #45's call light was not accessible to him/her.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to provide housekeeping services necessary to maintain a clean, comfortable, and homelike interior in two (2) of fourteen (14) residents' rooms on the one-hundred (100) hall. Observations, of rooms #113-B and 117-A, on 09/01/2020 and 09/02/2020, revealed debris and dried matter on the floors.

Inspectors wroteBased on interview, record review, review of facility investigation, and facility policy review, it was determined the facility failed to conduct interviews with staff who worked with the alleged perpetrator or might have knowledge of the incident related to an allegation of abuse to ensure a thorough investigation was completed for one (1) of three (3) sampled residents (Resident #2).

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of twenty (20) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Resident #18). The facility inaccurately coded Resident #18's Section E of the admission Minimum Data Set (MDS) Assessment as a 1, indicating Resident #18's behavior had improved as compared to the previous assessment when there was no previous assessment.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles. On 09/02/2020, observation of medication room refrigerator revealed a medication vial with an open date of 07/17/2020, was still available for use.

Inspectors wroteBased on observation, interview, record review, dietary meal slip review, and facility policy review, it was determined the facility failed to honor one (1) of twenty (20) sampled residents meal preferences (Resident #52). The facility identified Resident #52 disliked green beans, green peas, spinach, and greens; however, served the resident lima beans, on 09/01/2020.

Inspectors wroteBased on observation, interview, record review, and Dietary Meal Slip review, it was determined the facility failed to ensure adaptive equipment was provided to two (2) of twenty (20) sampled residents (Resident #36 and Resident #372). Observations revealed the facility failed to provide a black-foam built up utensils for Resident #372 and double handed cup for Resident #36.