Inspection Reports for Cedar Haven Operations Holdings LLC DBA Valley View Health & Rehabilitation LLC
4 ST JOSEPH STREET, RI, 02895
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Inspection Report
Annual Inspection
Census: 185
Capacity: 200
Deficiencies: 8
Feb 24, 2025
Visit Reason
The annual Federal Life Safety Code survey and a recertification and complaint survey were conducted to determine compliance with federal regulations and state requirements for long-term care facilities.
Findings
Deficiencies were cited related to unsafe water temperatures, employment of staff with disqualifying backgrounds, accuracy of resident assessments, medication administration, wound care, infection control, food safety, and life safety code violations including kitchen hood maintenance and emergency power supply testing.
Complaint Details
The survey included a complaint investigation related to quality of care and medical workup concerns reported to the Rhode Island Department of Health on 2/28/2025.
Deficiencies (8)
| Description |
|---|
| Unsafe water temperatures exceeding 120 degrees Fahrenheit were observed in multiple resident rooms and common areas. |
| Employment of a maintenance assistant with a disqualifying criminal background was identified. |
| Failure to ensure accurate resident assessments for dialysis, wounds, and other conditions. |
| Medication administration errors including failure to properly document and administer medications. |
| Inadequate wound care and failure to follow physician orders for wound treatment. |
| Failure to maintain infection control practices including use of gowns and gloves for residents on contact precautions. |
| Food safety violations including improper food temperatures and failure to maintain certified food safety manager. |
| Life safety code violations including failure to maintain kitchen hood suppression system and emergency power supply testing. |
Report Facts
Census: 185
Total Capacity: 200
Water temperature: 137.5
Water temperature: 132
Water temperature: 137.7
Deficiency count: 29
Lab result: 1.8
Lab result: 17.5
Lab result: 15.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Maintenance Assistant | Named in finding related to employment with disqualifying background. |
| Staff F | Licensed Practical Nurse | Named in medication administration and resident care findings. |
| Staff D | Licensed Practical Nurse | Named in medication administration and resident care findings. |
| Staff H | Licensed Practical Nurse | Named in wound care and infection control findings. |
| Staff J | Licensed Practical Nurse | Named in medication administration and training findings. |
| Staff K | Licensed Practical Nurse | Named in wound care and medication administration findings. |
| Staff T | Nursing Assistant | Named in infection control and resident care findings. |
| Staff W | Laundry Aide | Named in infection control and laundry handling findings. |
| Staff X | Dietary Aide | Named in food safety and training findings. |
| Staff Z | Dietary Aide | Named in food safety and training findings. |
Inspection Report
Follow-Up
Deficiencies: 0
May 3, 2024
Visit Reason
A follow-up visit was conducted to verify correction of previous Life Safety Code deficiencies at the facility.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up Life Safety Code survey.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 15, 2024
Visit Reason
A follow-up to a previous recertification survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no deficiencies were identified during this follow-up survey.
Inspection Report
Annual Inspection
Census: 141
Capacity: 185
Deficiencies: 12
Mar 15, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to Medicaid/Medicare coverage notices, reporting of alleged violations, comprehensive care plans, ADL care, treatment of pressure ulcers, medication errors, infection prevention and control, food safety, resident records, and life safety code violations including fire safety and emergency lighting.
Complaint Details
Complaint investigation was conducted as part of the recertification survey. Allegations included failure to provide proper Medicaid/Medicare notices, failure to report abuse and neglect, inadequate care for pressure ulcers, medication errors, and infection control issues. Some allegations were substantiated as evidenced by cited deficiencies.
Severity Breakdown
Level B: 1
Level D: 4
Level E: 3
Level F: 4
Level G: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to properly provide Medicaid/Medicare coverage notices to residents. | Level B |
| Facility failed to report alleged violations of abuse and neglect timely and appropriately. | Level D |
| Facility failed to ensure services met professional standards of quality for residents with specific medical conditions. | Level D |
| Facility failed to provide adequate ADL care for dependent residents. | Level E |
| Facility failed to provide necessary treatment and services to prevent pressure ulcers and promote healing. | Level E |
| Facility failed to provide adequate pain management services. | Level G |
| Facility failed to maintain medication error rates below 5%. | Level D |
| Facility failed to maintain infection prevention and control program to prevent transmission of communicable diseases. | Level E |
| Facility failed to maintain food safety standards including sanitation and food labeling. | Level F |
| Facility failed to maintain resident records confidential, complete, and accessible. | Level D |
| Facility failed to maintain life safety code compliance including delayed egress locking, emergency lighting, and fire alarm system maintenance. | Level F |
| Facility failed to maintain automatic sprinkler system in accordance with NFPA standards. | Level F |
Report Facts
Capacity: 185
Census: 141
Medication error rate: 8
Residents reviewed: 141
Residents reviewed for nutrition: 11
Residents reviewed for pressure ulcers: 4
Residents reviewed for pain management: 3
Residents reviewed for medication errors: 32
Residents reviewed for infection control: 7
Residents reviewed for ADL care: 32
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 13, 2023
Visit Reason
A revisit survey was conducted on April 13, 2023, for all previous deficiencies cited on March 1, 2023, related to the Re-certification/Licensure Life Safety Code survey.
Findings
All deficiencies have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 4, 2023
Visit Reason
A follow-up to a previous Recertification survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 18
Mar 1, 2023
Visit Reason
A Recertification Survey and complaint investigation survey were conducted from 02/22/2023 through 03/01/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to failure to notify physicians of significant resident changes, failure to provide proper notices to Medicare-eligible residents, failure to report alleged abuse timely, inadequate care for dependent residents, failure to prevent accidents and falls, failure to provide adequate nutrition and hydration, failure to provide proper wound care, failure to ensure proper medication administration and pharmacy services, failure to maintain food safety, failure to maintain accurate resident records, failure to ensure infection prevention and control, failure to maintain call light systems, and failure to maintain life safety code compliance including fire alarm system and emergency power testing.
Complaint Details
The complaint investigation was substantiated with findings of failure to notify physicians of significant resident changes, failure to report alleged abuse timely, failure to provide necessary care and services, and other deficiencies as cited.
Severity Breakdown
Level 3: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician and representative of significant changes in resident condition for 2 of 2 residents reviewed. | — |
| Failure to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) to Medicare Part A residents for 2 of 3 residents discharged. | — |
| Failure to report alleged abuse, neglect, or mistreatment timely for 2 of 3 residents. | — |
| Failure to provide necessary services for dependent residents including nail care for 2 of 3 residents. | — |
| Failure to ensure adequate supervision and assistance to prevent accidents and falls for 2 of 5 residents reviewed. | — |
| Failure to maintain acceptable parameters of nutritional status and hydration for 2 of 9 residents reviewed. | — |
| Failure to provide proper treatment and services to prevent and heal pressure ulcers for 2 of 4 residents reviewed. | Level 3 |
| Failure to ensure medications were administered as ordered and documented for 1 of 26 residents reviewed. | — |
| Failure to obtain laboratory services timely for 1 of 5 residents reviewed. | — |
| Failure to ensure radiology/diagnostic services were obtained and results reported timely for 1 of 1 resident reviewed. | — |
| Failure to ensure oxygen therapy orders were in place and followed for 1 of 1 resident reviewed. | — |
| Failure to ensure medication administration records were accurate and complete for 1 of 26 residents reviewed. | — |
| Failure to ensure self-catheterization was supported by physician orders and care plans for 1 resident. | — |
| Failure to ensure residents received adequate supervision and assistance with call light system for 2 of 26 residents reviewed. | — |
| Failure to maintain food safety standards including proper storage, labeling, and cleanliness in the kitchen. | — |
| Failure to maintain accurate and complete resident records including medication administration documentation for 1 of 26 residents reviewed. | — |
| Failure to establish and maintain an effective infection prevention and control program including antibiotic stewardship. | — |
| Failure to maintain life safety code compliance including fire alarm system initiation and emergency power generator testing. | — |
Report Facts
Residents reviewed: 26
Residents with deficiencies: 2
Residents with falls: 2
Residents with pressure ulcers: 4
Residents with medication issues: 1
Residents with call light issues: 2
Residents with SNFABN issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Lopes | Laboratory Director or Provider/Supplier Representative | Signed Plan of Correction and Life Safety Code survey documents |
| Staff H | Nursing Assistant | Interviewed regarding resident menstrual bleeding and condition changes |
| Staff E | Registered Nurse | Interviewed regarding notification of resident bleeding and medication administration |
| Staff A | Nursing Assistant | Involved in abuse allegation incident with resident |
| Director of Nursing | DON | Interviewed regarding notification of bleeding, abuse allegations, and medication administration |
| Staff F | Licensed Practical Nurse | Interviewed regarding resident self-catheterization and medication administration |
| Staff C | Registered Nurse | Interviewed regarding resident use of off-loading boots |
| Staff D | Nursing Staff | Interviewed regarding wound care and pressure ulcer treatment |
| Staff I | Licensed Practical Nurse | Interviewed regarding x-ray results reporting |
| Staff K | Licensed Practical Nurse | Interviewed regarding x-ray results reporting |
| Staff L | Food Service Director | Interviewed regarding food safety observations |
| Staff M | Licensed Nurse | Interviewed regarding resident call light use |
| Staff N | Certified Nursing Assistant | Interviewed regarding resident call light placement |
| Staff O | Nurse Practitioner | Interviewed regarding notification of resident bleeding |
| Staff J | Nursing Assistant | Interviewed regarding resident weight measurement |
| Staff E | Registered Nurse | Interviewed regarding resident ambulation and oxygen therapy |
| Staff F | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff I | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff K | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff B | Nurse Practitioner | Interviewed regarding wound care recommendations |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 29, 2022
Visit Reason
An off-site desk audit was conducted on March 29, 2022 for all previous deficiencies cited on February 24, 2022.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Life Safety
Deficiencies: 0
Feb 24, 2022
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, as referenced in 42 CFR 483.90 (a-d) - Physical Environment. Additionally, an Emergency Preparedness Survey was conducted on the same date.
Findings
The facility was found to be in compliance with the Life Safety Code and with 42 CFR §483.73 related to Emergency Preparedness. No deficiencies were cited in either survey.
Inspection Report
Complaint Investigation
Deficiencies: 8
Feb 24, 2022
Visit Reason
A Recertification and Complaints Investigation Survey was conducted at Trinity Health and Rehabilitation Center from 02/21/2022 through 02/24/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to failure to develop baseline care plans within 48 hours of admission, failure to meet professional standards for services provided, failure to ensure adequate supervision to prevent accidents, failure to provide necessary treatment and services for pressure ulcers, failure to properly label and store drugs and biologicals, failure to provide routine and emergency dental services, failure to maintain accurate resident records, and failure to provide required in-service training for nurse aides.
Complaint Details
The survey included a complaints investigation with ACTS Reference Numbers 80900, 80901, 81435, 8717, 82761, and 82889. The investigation found deficiencies related to care planning, supervision, treatment of pressure ulcers, medication management, dental services, resident records, and staff training.
Deficiencies (8)
| Description |
|---|
| Facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 1 new admission reviewed, Resident ID #281. |
| Facility failed to ensure services provided met professional standards for 4 of 25 residents reviewed (Residents #48, 62, 73, and 81). |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents for 4 of 9 residents reviewed (Residents #58, 63, 120, and 281). |
| Facility failed to provide necessary treatment and services to prevent and treat pressure ulcers for 1 of 5 residents reviewed, Resident ID #90. |
| Facility failed to ensure proper labeling, storage, and disposal of drugs and biologicals; expired medications found and medications not dated after opening. |
| Facility failed to provide routine and emergency dental services for 1 of 1 resident reviewed, Resident ID #62. |
| Facility failed to maintain accurate and complete resident records for 2 of 25 residents reviewed (Residents #47 and 90). |
| Facility failed to provide required in-service training for nurse aides; 23 staff failed to receive required dementia training and 40 staff failed to receive required abuse, resident rights, and trauma-informed care training. |
Report Facts
Residents reviewed: 25
Residents with inadequate supervision: 4
Residents with pressure ulcer treatment issues: 1
Staff failing dementia training: 23
Staff failing abuse training: 40
Staff members: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Staff B | Nursing Supervisor | Developed resident baseline care plan; acknowledged failure to provide hospitalization-related information |
| Director of Nursing Services | Director of Nursing Services | Unable to provide evidence of baseline care plan development within 48 hours; acknowledged failure to follow physician orders for bed cradle; oversaw corrective action processes |
| Nurse Staff C | Nurse | Acknowledged order transcription errors and failure to complete treatments; provided information on call light issues |
| Staff A | Certified Nursing Assistant (CNA) | Provided personal care to resident during observation |
| Staff F | Certified Medication Technician (CMT) | Observed medication storage and labeling issues |
| Assistant Director of Nursing Services | Assistant Director of Nursing Services | Unable to provide evidence that required in-service trainings were provided to all staff |
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