Inspection Reports for Cedar Haven Operations Holdings LLC DBA Valley View Health & Rehabilitation LLC

The complaint was submitted to the Rhode Island Department of Health on 7/30/2025 alleging that Resident ID #1 was left unattended outside the facility for an unknown amount of time on 7/30/2025, found unconscious without a pulse, and required CPR. The resident was hospitalized for suspected heat stroke and cardiac arrest.

The facility failed to keep Resident ID #1 free from neglect, as the resident was left unattended outside for approximately 3 hours and 20 minutes during a heat advisory, resulting in cardiac arrest and hospitalization. Additionally, the facility failed to follow physician's orders for medication administration, including insulin and other prescribed medications, leading to significant medication errors.

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 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.

The facility was found to have immediate jeopardy related to unsafe water temperatures exceeding 120°F on all floors, placing residents at risk of serious injury. Additional deficiencies included failure to obtain timely laboratory tests for residents on anticoagulation therapy and with elevated white blood counts, and failure to provide food at safe and appetizing temperatures.

The facility was found deficient in multiple areas including unsafe water temperatures posing immediate jeopardy, employment of a disqualified staff member, inaccurate resident assessments, failure to review and revise care plans, medication errors, inadequate wound care, improper infection control practices, food safety violations, and insufficient staff training.

The visit was complaint-related based on community complaints alleging mold causing illness. The complaint was substantiated by surveyor observations of environmental hazards including mold-like stains, feces in shower, and maintenance failures.

Surveyor observations and interviews revealed multiple environmental deficiencies including stained ceiling tiles, heavy dust accumulation on vents, rust on metal ceiling frames, broken door frame with protruding metal, and presence of feces in a shower stall. Maintenance records did not document these issues, and staff including nurses were unaware of these conditions. The Administrator acknowledged these deficiencies during the survey.

The complaint investigation found that the resident, identified as Resident ID #1, left the secured unit and exited the facility unsupervised on 11/11/2024. The facility was unaware of the elopement until the hospital notified them. The resident was found approximately 1.5 miles away by a jogger and was transported to the hospital for safety. The facility failed to follow their wandering policy and implement appropriate interventions.

The facility failed to implement interventions for a cognitively impaired resident identified as a moderate risk for wandering, did not follow their wandering policy, and did not provide adequate supervision, resulting in the resident leaving the secured unit unsupervised and being found offsite. The facility was unaware of the elopement until notified by the hospital.

Complaint received by Rhode Island Department of Health on 6/19/2024 alleging Resident ID #1 did not receive methadone and other medications for two days. The resident attempted to address this with facility staff who responded they were checking with the pharmacy. Investigation confirmed missed doses due to pharmacy delivery delays.

The facility failed to ensure nursing staff had appropriate competencies for PICC line care and IV therapy, with only 6 of 60 nurses trained. Additionally, the facility failed to provide pharmaceutical services to meet resident needs, resulting in Resident ID #1 missing five doses of methadone over three days due to pharmacy delivery issues. Medication errors were confirmed for the same resident.

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.

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.

The facility was found deficient in multiple areas including failure to provide proper Medicare coverage notices, timely reporting of injuries, adherence to physician orders for treatments and devices, inadequate incontinence care, failure to follow shower schedules, improper wound care and infection control practices, medication errors and omissions, inaccurate medical record documentation, and food safety violations.

The facility failed to provide necessary incontinence care and follow the scheduled shower regimen for multiple residents, resulting in minimal harm or potential for harm. Additionally, the facility failed to provide appropriate pressure ulcer care for one resident and failed to maintain acceptable nutritional status for two residents.

The visit was complaint-related based on two community complaints alleging mice presence. The complaint was substantiated by surveyor observations and staff interviews confirming mouse droppings and ongoing pest issues.

Surveyor observations and interviews confirmed the presence of mouse droppings in multiple resident rooms across two floors, with residents and staff expressing concerns about sanitation. The facility acknowledged ongoing issues with mice despite a recent change to a new pest control company.

The complaint investigation found that the resident eloped from a secured unit despite wearing a wanderguard bracelet. The resident was found outside in cold weather, posing immediate jeopardy to health and safety. The facility was unable to provide evidence of adequate supervision during the incident.

The facility failed to provide adequate supervision for one resident identified as an elopement risk, who left the secured unit wearing a wanderguard bracelet and was found outside the building in cold weather. Multiple staff interviews and record reviews confirmed the resident's elopement and inadequate supervision despite functioning safety systems.

The investigation was complaint-related, focusing on substantiated failures to follow weight monitoring policies for Residents #2 and #3, including lack of re-weighing and failure to notify physicians after significant weight changes.

The facility failed to follow its weight monitoring policy for two residents who experienced significant weight loss without appropriate re-weighing, physician notification, or progress notes. Staff acknowledged these failures during interviews, and the facility could not provide evidence of physician contact after weight changes exceeding policy thresholds.

The facility failed to provide necessary treatment and services to promote wound healing and prevent new ulcers from developing for one resident with a stage 4 pressure ulcer. The wound care physician recommended a change in wound dressing, but the facility did not implement this recommendation prior to the surveyor's intervention.

Complaint investigation triggered by a community reported complaint dated 7/26/2023 regarding Resident ID #1's significant weight gain and failure to return to the facility post-hospitalization. The complaint was substantiated with findings of failure to notify the physician and implement interventions.

The facility failed to immediately consult with the physician regarding a significant weight gain of Resident ID #1, who gained 58 pounds between 4/8/2023 and 4/12/2023. There was no evidence that the physician or dietitian were notified, no intervention was implemented, and the resident's plan of care was not updated.

The complaint investigation found that the facility did not monitor or report the resident's respiratory distress and change in condition, including hallucinations and abnormal vital signs, to the physician until many hours later. The resident was transferred to the hospital for respiratory failure after an unwitnessed fall and ultimately expired.

The facility failed to promptly notify the physician or reassess the resident's condition after the resident was found on the floor with hallucinations and abnormal vital signs. The resident was transferred to the hospital with respiratory failure and subsequently expired. The Director of Nursing Services confirmed the lack of immediate consultation and reassessment.

The complaint was substantiated that Resident ID #2 removed Resident ID #1's supplemental oxygen, leading to Resident ID #1's death. The facility failed to provide adequate supervision and respiratory care, contributing to serious harm and death.

The facility failed to protect Resident ID #1 from physical abuse by Resident ID #2, who repeatedly removed Resident ID #1's oxygen supply. The facility also failed to provide adequate supervision and appropriate interventions for both residents despite known behavioral issues. Additionally, the facility failed to provide respiratory care consistent with professional standards, including improper use of non-rebreather masks and failure to administer prescribed nebulizer treatments, contributing to the deaths of Residents #1 and #6.

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.

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.

The facility was found deficient in multiple areas including failure to notify physicians and resident representatives of significant changes in resident condition, failure to timely report suspected abuse, inadequate catheter care, failure to monitor fluid intake and output, failure to obtain timely laboratory services, and failure to notify providers of resident refusals of care.

The facility was found deficient in multiple areas including failure to notify physicians of significant resident changes, inadequate notification of Medicare coverage changes, failure to timely report abuse allegations, inadequate care for pressure ulcers, insufficient fall prevention measures, improper catheter care, failure to maintain accurate medical records, lack of timely laboratory services, failure to monitor antibiotic use, food safety violations, and inadequate call light accessibility for residents.

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 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.