Inspection Reports for
River Haven Nursing and Rehabilitation Center
867 MCGUIRE AVE., PADUCAH, KY, 42001
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
74% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Abbreviated Survey
Census: 76
Deficiencies: 0
Date: Nov 17, 2025
Visit Reason
An Abbreviated Survey investigating KY2614785 was initiated on 2025-10-22 and concluded on 2025-11-17 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies cited related to KY2614785.
Report Facts
Sample Size: 11
Supplemental Residents: 0
Inspection Report
Complaint Investigation
Capacity: 81
Deficiencies: 3
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to maintain a safe, clean, and homelike environment, specifically mold in shower rooms, and to investigate an alleged sexual abuse incident involving a resident and a staff member.
Complaint Details
The complaint investigation involved allegations of mold and unsanitary conditions in shower rooms affecting all residents, and an alleged sexual abuse incident on or around 03/10/2025 involving Resident R8 and Certified Nurse Aide (CNA) 6. The facility failed to report the abuse properly to authorities and did not conduct a thorough investigation. The allegation was ultimately unsubstantiated due to lack of evidence and conflicting statements. The facility's administration was dismissive and failed to maintain proper documentation or follow policy.
Findings
The facility failed to ensure a safe, clean, and homelike environment due to mold and unsanitary conditions in shower rooms affecting all 81 residents. Additionally, the facility failed to properly report and investigate an alleged sexual abuse incident involving a resident and a staff member, with inadequate documentation and dismissive responses from administration.
Deficiencies (3)
F 0584: The facility failed to provide a safe, clean, and homelike environment, with mold and unsanitary conditions observed in shower rooms affecting all 81 residents.
F 0609: The facility failed to timely report suspected abuse and report investigation results to proper authorities regarding an alleged sexual abuse incident involving one resident.
F 0610: The facility failed to thoroughly investigate an alleged sexual abuse violation involving one resident, with no documented investigation and dismissive administrative response.
Report Facts
Residents affected: 81
Residents sampled for abuse: 26
Residents sampled for abuse with allegation: 5
Brief Interview for Mental Status (BIMS) score: 13
Care plan dates: Mar 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nurse Aide | Named in alleged sexual abuse incident with Resident R8 |
| CNA 5 | Certified Nurse Aide | Interviewed regarding Resident R8's reports of alleged abuse |
| Maintenance Director | Interviewed about mold conditions and facility maintenance | |
| Housekeeper 1 | Housekeeper | Reported mold presence and cleaning challenges |
| Housekeeper Supervisor | Housekeeping Supervisor | Reported staffing and cleaning schedule issues related to mold |
| Director of Nursing | Director of Nursing | Interviewed about abuse reporting policies and mold awareness |
| Administrator | Facility Administrator | Interviewed about abuse investigation and mold issue management |
| Social Services Director | Social Services Director | Interviewed about abuse reporting and resident interactions |
| Department for Community Based Services 2 | APS Worker | Conducted investigation and interviews related to abuse allegation |
| Former Administrator | Former Facility Administrator | Interviewed about prior knowledge and handling of abuse allegation |
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 2
Date: Aug 26, 2025
Visit Reason
An Abbreviated Survey was conducted from 08/19/2025 to 08/26/2025 to investigate multiple complaint allegations and assess compliance with regulatory requirements.
Complaint Details
The survey was complaint-related, investigating allegations of abuse, neglect, and mistreatment involving specific residents. The facility failed to investigate and report alleged abuse incidents timely and adequately. The complaint was substantiated with deficiencies issued.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Regulatory deficiencies were issued with the highest scope and severity cited as a "D". Deficiencies related to safe, clean, comfortable, and homelike environment, and reporting and investigation of alleged violations including abuse were identified.
Deficiencies (2)
Failure to maintain a safe, clean, comfortable, and homelike environment, including mold issues in shower rooms and inadequate housekeeping.
Failure to thoroughly investigate and report allegations of abuse, neglect, exploitation, or mistreatment in a timely manner.
Report Facts
Survey Census: 81
Sample Size: 26
Supplemental Residents: 0
Survey Dates: 08/19/2025-08/26/2025
Inspection Report
Abbreviated Survey
Census: 72
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
An Abbreviated Survey was conducted to assess the facility's compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies cited related to the specified tags.
Report Facts
Sample Size: 10
Inspection Report
Routine
Deficiencies: 8
Date: Oct 25, 2024
Visit Reason
Routine inspection of River Haven Nursing and Rehabilitation Center to assess compliance with regulatory standards including care planning, treatment, medication management, infection control, and food safety.
Findings
The facility failed to develop and implement comprehensive, measurable care plans for residents, delayed treatment and medication administration, failed to ensure proper pressure ulcer care and prevention, did not maintain appropriate infection control practices, and had issues with medication and food storage safety.
Deficiencies (8)
F 0656: The facility failed to develop and implement complete, measurable care plans for 2 of 21 residents, including timely updates for new conditions and adherence to physician recommendations.
F 0684: The facility failed to provide timely treatment and care according to orders and resident preferences for 2 of 21 residents, including delayed antibiotic treatment for UTI and delayed medication order implementation.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention for 1 of 3 residents at risk, including failure to use prescribed devices and update care plans with wound physician recommendations.
F 0693: The facility failed to ensure feeding tubes were used appropriately and residents' heads of bed were elevated during tube feeding for 2 of 7 residents receiving enteral feeding.
F 0697: The facility failed to provide safe, appropriate pain management for 1 of 21 residents, including failure to administer pain medication prior to wound care and inadequate pain assessment documentation.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, including expired medical supplies and improper refrigerator temperature control.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and expired food items in the kitchen.
F 0880: The facility failed to maintain an infection prevention and control program, including inadequate PPE availability and staff placing gloves in pockets, risking contamination.
Report Facts
Residents sampled: 21
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Expired supplies: 9
Residents affected: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM 1 | Unit Manager | Named in pain management and care plan deficiencies |
| DON | Director of Nursing | Interviewed regarding care plans, infection control, and medication management |
| SDC | Staff Development Coordinator | Interviewed regarding training and policies for feeding tubes and pain management |
| NP | Nurse Practitioner | Interviewed regarding medication orders and expectations |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding resident care and pain observations |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding resident care and pain observations |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding feeding tube care |
| RN 8 | Registered Nurse | Interviewed regarding pain assessment and care |
| CDM | Certified Dietary Manager | Interviewed regarding food storage and safety |
| IP/ADON | Infection Preventionist/Assistant Director of Nursing | Interviewed regarding infection control practices |
| Administrator | Facility Administrator | Interviewed regarding overall expectations for care and compliance |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Sep 15, 2020
Visit Reason
Annual inspection of River Haven Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care planning, staffing, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, inadequate 1:1 supervision leading to a choking incident with serious injury, failure to follow dietary menus and honor resident food preferences, inadequate infection control practices, and improper medication storage.
Deficiencies (13)
F 0550: Staff failed to treat three residents with dignity by displaying a resident's name on clothing, delayed answering call lights causing incontinence, and not meeting grooming needs including facial hair removal.
F 0558: Facility failed to reasonably accommodate resident needs and preferences when a resident's call light was not accessible, being wrapped around the bed rail.
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment in two resident rooms with debris and dried matter on floors.
F 0610: Facility failed to conduct thorough abuse investigations by not interviewing all staff who worked with the alleged perpetrator.
F 0641: Facility failed to ensure accurate resident assessments when one resident's behavior was incorrectly coded as improved without prior assessment for comparison.
F 0656: Facility failed to implement a comprehensive care plan for a choking risk resident requiring 1:1 supervision, resulting in choking, CPR, intubation, and ventilator placement.
F 0689: Facility failed to provide adequate supervision to prevent accidents for a resident requiring 1:1 supervision, resulting in a choking incident and serious injury.
F 0725: Facility failed to ensure sufficient nursing staff with appropriate competencies to provide required 1:1 supervision for a high-risk resident, contributing to a serious choking incident.
F 0761: Facility failed to ensure drugs were labeled and stored according to professional standards when an opened medication vial was kept beyond its expiration date.
F 0803: Facility failed to follow standardized four-week cycle menus and obtain dietitian approval for menu changes.
F 0810: Facility failed to provide required adaptive eating equipment for two residents as indicated on dietary meal slips.
F 0812: Facility failed to prepare food under sanitary conditions as evidenced by dusty ceiling vents in the kitchen production area.
F 0880: Facility failed to implement infection prevention and control program properly, including lack of PPE availability, staff failure to don PPE before entering isolation rooms, and failure to remove PPE before exiting rooms, risking COVID-19 spread.
Report Facts
Residents sampled: 20
Residents affected by dignity deficiency: 3
Residents affected by call light deficiency: 1
Residents affected by housekeeping deficiency: 2
Residents affected by abuse investigation deficiency: 1
Residents affected by assessment deficiency: 1
Residents affected by care plan deficiency: 1
Residents affected by supervision deficiency: 1
Residents on mechanical altered diets reviewed: 17
Residents affected by adaptive equipment deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in choking incident and supervision deficiency |
| CNA #2 | Certified Nurse Aide | Named in call light and adaptive equipment findings |
| Administrator | Named in multiple interviews related to deficiencies and corrective actions | |
| Director of Nursing | DON | Named in multiple interviews related to deficiencies and corrective actions |
| Regional Quality Manager | Provided education on 1:1 supervision and snack pass process | |
| Dietary Manager | Named in menu and adaptive equipment findings | |
| Staff Development Coordinator | SDC | Named in education and infection control findings |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 11, 2019
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations for nursing home operations, including medication administration, bed hold policies, and facility safety.
Findings
The facility failed to provide written bed hold notices for residents transferred to the hospital, did not administer medications according to physician orders by leaving medications unattended, failed to label multi-dose medication vials with the date opened, and did not maintain a safe environment by leaving medications accessible to residents.
Deficiencies (4)
F 0625: The facility failed to provide written bed hold notices to residents or their representatives for two residents transferred to the hospital, contrary to facility policy.
F 0658: The facility failed to administer medications according to physician orders for one resident by leaving medication cups with Aspirin and Tylenol on the bedside table.
F 0761: The facility failed to label a multi-dose insulin vial with the date opened as required by policy and professional standards.
F 0921: The facility failed to maintain a safe environment by leaving medications unattended in a resident's room, accessible to other residents.
Report Facts
Residents sampled: 18
Residents affected: 1
Residents affected: 2
Medication cups observed: 2
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Business Office Manager | Interviewed regarding failure to provide bed hold notices | |
| Administrator | Interviewed regarding responsibility for bed hold notices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding medication administration to Resident #58 | |
| Unit Manager | Interviewed regarding medication administration and staffing | |
| Director of Nursing (DON) | Interviewed regarding medication administration policies and expectations | |
| Staff Development Coordinator (SDC) | Interviewed regarding medication labeling expectations | |
| Registered Nurse (RN) #4 | Attempted contact regarding medication administration but no response |
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