Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Haven Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Implement Podiatry Care in Resident Care Plan: A resident with DM, an above-the-knee amputation, and ESRD had a care plan that included regular podiatry care, but the service was not implemented as planned. The resident missed podiatry visits because they were scheduled on dialysis days, staff did not successfully arrange the appointment, and the resident’s toenail remained thick, overgrown, and touching the adjacent toe. Interviews showed the resident, dialysis staff, the podiatry MD, and facility staff all identified the missed podiatry care and the ongoing scheduling problem.
A resident with DM, ESRD, and an above-knee amputation had a thick, long, curved great toenail that was touching the second toe, yet staff did not ensure timely podiatry care despite weekly nail checks and a care plan for regular podiatry. The resident said no one tried to cut the nail, the dialysis nurse repeatedly called about the need for podiatry, and staff gave conflicting accounts about scheduling and follow-up when the resident missed visits because of dialysis or refusal.
Mechanical lift slings were not retired in accordance with manufacturer guidance. In the 100 Hall, one sling had an expired handwritten date, another had apparent fabric damage, and two had illegible safety labels. In the 200 Hall, all seven slings lacked legible handwritten dates, and several had unreadable manufacturer tags. Staff could not explain the sling inspection log, did not track sling age or inspections, and the DON/Administrator reported no written guidance for sling use, maintenance, or cleaning.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with observations of mold in shower rooms, dirty linens, and inadequate cleaning. Housekeeping and maintenance staff confirmed the presence of mold and cited short staffing and lack of reporting as reasons for inaction. Two residents reported seeing mold but did not report it, believing staff were already aware or would not address it. The DON and Administrator were unaware of the extent of the issue, and the deficiency had the potential to affect all residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to store and label food items in accordance with professional standards, as observed during a kitchen tour. Items in the walk-in cooler were found unlabeled and undated, including raw potatoes and red peppers, while prepared apple crisp exceeded the storage duration policy. Interviews with the CDM and Administrator highlighted expectations for proper labeling and dating, which were not met by the contracted kitchen staff.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in care. One resident developed a new stage 4 pressure ulcer without updated interventions, while another's care plan for tube feeding was not followed, resulting in the bed being flat during feeding. Staff interviews revealed a lack of communication and responsibility in updating and following care plans.
Two residents in a LTC facility experienced delays in receiving appropriate treatment and care due to communication failures. One resident's UTI lab results were not obtained for seven days, delaying antibiotic treatment. Another resident's medication dose reduction was delayed by 33 days due to a lack of follow-up on a pharmacist's recommendation. These deficiencies were identified through observations, interviews, and record reviews, revealing failures in following facility policies for lab and pharmacy practices.
A resident at risk for pressure ulcers was not provided with necessary interventions, such as heel boots and wedge cushions, despite having a history of multiple pressure ulcers. The facility's care plan lacked evidence of these measures, leading to the development of a new stage 4 pressure ulcer. Staff interviews revealed a lack of awareness and implementation of pressure ulcer prevention policies.
The facility failed to provide appropriate care for residents receiving enteral feeding, leading to deficiencies in treatment and services. Observations showed that a resident's head of bed was not elevated during feeding, and feeding bottles were not changed within the required timeframe. Interviews with staff revealed a lack of clear policies and procedures for managing enteral feeding, contributing to these deficiencies.
A resident with chronic pain syndrome and wounds did not receive appropriate pain management during a dressing change, as staff failed to administer prescribed pain medication. Despite displaying non-verbal signs of pain, the resident had not received medication since two days prior, contrary to the facility's pain management policy. Interviews revealed communication lapses among staff, leading to delayed pain relief.
The facility failed to properly store and label drugs and biologicals, as observed in the 300 hall medication room. Expired medical supplies were found, and a refrigerator used for milk and beer was at an unacceptable temperature. The DON highlighted the risk of false readings from expired supplies and emphasized the UM's role in monthly checks, with night shift nurses responsible for monitoring refrigerator temperatures.
The facility failed to maintain an effective infection control program, as observed when a CNA placed gloves in her pocket before providing care, and a PPE bin lacked necessary supplies. Interviews revealed unclear responsibility for PPE stocking, with staff acknowledging the issue but unsure of current roles. The deficiency highlights a breakdown in communication and responsibility for infection control measures.
Failure to Implement Podiatry Care in Resident Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for one resident with diabetes mellitus, an above-the-knee right leg amputation, and end stage renal disease. The resident was cognitively intact with a BIMS score of 15 out of 15. The resident’s diabetes care plan, established after admission and later reviewed, included an intervention for regular podiatry care as ordered by the MD. The resident’s record showed a general physician order for consults with podiatry and other specialties, and a weekly nursing order to assess the resident’s finger and toenails. The TAR documented weekly assessments of the finger and toenails during the reviewed period. However, the podiatry intervention in the care plan was not carried out as intended. Progress notes showed the resident complained that her great toenail was rubbing against her second toe after a fall, and the resident stated she missed a podiatry visit because she was at dialysis. Another note documented that dialysis staff contacted the facility and asked that an appointment be made with podiatry, with a nurse responding that she would make the appointment the next week. A later note showed the facility sent a referral and requested an appointment, with the podiatry office to contact the facility once approved. At the time of observation, the resident was sitting in a wheelchair and her left foot showed extremely dry, flaky skin, with a thick brown great toenail growing sideways and touching the second toe. During interview, the resident stated no one at the facility had tried to cut the toenail and that staff knew it was long and touching the second toe. Staff interviews showed the podiatry visits were missed because they were scheduled on dialysis days, that the resident had wanted to use a different provider, and that the facility had not successfully arranged the podiatry service despite repeated contact from the dialysis center and the podiatry company. The podiatry MD stated the visits could have been rearranged to accommodate the resident’s needs, and the resident’s dialysis nurse stated she repeatedly called the facility about the podiatry referral status.
Failure to Provide Timely Foot Care and Podiatry Follow-Up
Penalty
Summary
The facility failed to ensure proper foot care and treatment for a resident with diabetes mellitus, an above-the-knee right leg amputation, and end stage renal disease. On observation, the resident’s left great toenail was thick, long, curved sideways, and touching the second toe, and the left foot skin was extremely dry and flaky. The resident stated that no one at the facility had tried to cut the toenail and that staff knew it was long and touching the second toe. Record review showed the resident had a care plan that included regular podiatry care as ordered by the MD, and physician orders included consults with podiatry and weekly assessment of finger and toenails by a nurse. The TAR documented weekly nail assessments, but the resident’s toenail remained elongated and deformed. A progress note documented the resident complaining that the great toenail was rubbing against the second toe after a fall, and the resident reported missing a podiatry visit because she was at dialysis. Another progress note documented dialysis staff asking the facility to make a podiatry appointment, with nursing stating it would be made the next week. Interviews showed the podiatry company could have scheduled the resident on a different day and had previously placed her on the list to be seen, but she was at dialysis or had refused when they came. The dialysis nurse stated she repeatedly called the facility about the need for podiatry referral after foot checks. Facility staff gave differing accounts about who was responsible for scheduling and following up, and the DON stated the resident was on the podiatry list, had refused, and later the facility tried to arrange in-house and outside podiatry. The Administrator stated staff were expected to reach out to the podiatrist to schedule evaluation and treatment and to follow the resident’s care plan.
Mechanical lift slings not retired per manufacturer guidance
Penalty
Summary
The facility failed to ensure that mechanical lift slings were retired in accordance with the manufacturer’s recommendations. During observation, one sling out of six inspected in the 100 Hall had a legible handwritten date that had expired, and there were no legible handwritten dates on all seven slings located in the 200 Hall. Several slings also had manufacturer tags that were not legible, including three slings in the 200 Hall and two slings in the 100 Hall. One sling in the 100 Hall had what appeared to be cigarette holes in the fabric. Review of the sling wash and inspection log showed the last signature had been entered on [DATE] at 10:15 AM, and Laundry #13 could not explain why the log had not been completed since that time or identify its purpose. Maintenance #9 stated he maintained the hoist but did not do anything related to the slings and was not aware of sling recommendations. Central Supply #12 stated she did not track sling age, cleaning, or inspection, was unsure who was responsible for inspections, and could not state how long the service life was for resident lift slings until reading a new sling label that showed a 6-month lifespan. The Administrator stated there was no policy or written guidance related to sling use, maintenance, or cleaning and was unaware of the service life of the slings used in lifting residents.
Failure to Maintain Clean and Homelike Environment Due to Mold and Poor Housekeeping
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required by its own policies and federal regulations. Observations revealed a dirty adult brief on a shower chair, a pile of dirty linens on the floor, a toilet full of feces, and a mold-like substance on the ceiling and wall tiles in the shower room. Housekeeping staff confirmed the presence of mold throughout the facility and stated that they had not reported it, citing short staffing and limited time to complete cleaning tasks. The housekeeping supervisor acknowledged awareness of the mold issue but indicated that no action had been taken to address it, also attributing the problem to staffing shortages and time constraints. Interviews with residents confirmed that mold was present in the shower rooms, with one resident stating it was all over the walls, ceiling, and floors, but residents had not reported it because they believed staff were already aware or would not address it. The Maintenance Director admitted to noticing the mold recently and had attempted to address it superficially but had not investigated the cause due to time constraints and lack of reports from staff. The DON was unaware of the mold issue and acknowledged the potential health risks, while the Administrator stated that maintenance was responsible for identifying and addressing such issues, expecting staff to follow policy and guidelines. The failure to maintain cleanliness and address environmental hazards had the potential to affect all 81 residents in the facility.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Adhere to Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. The walk-in cooler contained several items that were not labeled or dated, including a large container of cut-up raw potatoes in water and a small container of red peppers. Additionally, a container of prepared apple crisp was found with a date range that exceeded the facility's policy for storing leftovers. These observations were made in the presence of the Certified Dietary Manager (CDM), who subsequently removed the items from the cooler. Interviews with the CDM and the Administrator revealed expectations for kitchen staff to follow guidelines for labeling and dating food items. The CDM stated that items should be used in the order they were opened and that leftovers should be stored for no more than three to four days. The Administrator noted that the kitchen staff were contracted and were expected to comply with these labeling and dating procedures. These failures in food storage practices had the potential to affect a significant number of residents who consumed food from the facility's kitchen.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, R39 and R42, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For R39, who was admitted with multiple pressure ulcers and developed a new stage 4 pressure ulcer, the facility did not update the care plan with additional interventions or include the Wound Physician's recommendations for turning and offloading the wound. Despite the presence of a care plan for impaired skin integrity, it lacked specific interventions such as the use of wedge cushions or heel boots, and the care plan was not reviewed or updated following the development of the new pressure ulcer. R42, who received tube feeding and required the head of the bed to be elevated, was observed with the bed flat on two occasions. The care plan for R42 included the need for the head of the bed to be elevated during tube feeding, but this was not consistently followed. Interviews with staff revealed a lack of awareness and communication regarding the specific interventions required for R42, indicating a disconnect between the care plan and the care provided. Interviews with various staff members, including CNAs, the MDS Nurse, and the DON, highlighted a lack of communication and responsibility in updating and following care plans. The MDS Nurse was responsible for updating care plans, but there was confusion about who should ensure that care plans reflected current conditions and interventions. The Administrator expected staff to follow care plans, but the lack of updates and communication led to deficiencies in care for both residents.
Delayed Treatment and Care Due to Communication Failures
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For one resident, identified as R43, the facility did not receive and act upon laboratory results for a urinary tract infection (UTI) in a timely manner. R43 was tested for UTI symptoms on 10/13/2024, and the lab results were finalized on 10/16/2024, showing a heavy growth of Escherichia coli. However, the facility did not obtain these results until 10/23/2024, resulting in a delay of seven days before the resident received the necessary antibiotic treatment. Interviews with staff revealed that the pending lab results were not added to the tracking board, and the Unit Manager failed to follow up on the results as required. Another resident, identified as R54, experienced a delay in the implementation of a pharmacist's recommendation for a gradual dose reduction of Alprazolam. The recommendation was made on 09/15/2024 and approved by the Nurse Practitioner on 09/17/2024. However, the facility did not initiate the dose reduction until 10/18/2024, 33 days after the recommendation was made. The delay was attributed to a lack of communication and follow-up between the Consultant Pharmacist, the Director of Nursing, and the Unit Manager responsible for entering the order into the electronic medical record. The deficiencies in both cases were identified through a combination of observation, interviews, and record reviews. The facility's policies for lab and diagnostic practices and pharmacy recommendations were not followed, leading to delays in treatment and care for the residents. Interviews with the facility's staff, including the Unit Manager, Assistant Director of Nursing, Director of Nursing, and Administrator, highlighted the breakdown in communication and tracking of pending results and recommendations, which contributed to the deficiencies.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident at risk of developing pressure ulcers. The resident, who had been at the facility since January, was observed lying on her back on an alternating pressure mattress without the use of prescribed heel boots or wedge cushions, which were stored unused in her room. Despite having a history of multiple pressure ulcers and being assessed as dependent on staff for repositioning, the facility did not implement necessary interventions to prevent further skin breakdown. The facility's Comprehensive Care Plan for the resident included interventions such as pressure reduction cushions and mattresses, but there was no evidence of additional measures like the use of wedge cushions or heel boots. The resident developed a new stage 4 pressure ulcer on her left heel, which was initially documented as moisture-associated skin damage. Observations revealed that staff did not consistently use devices to relieve pressure, and the resident remained in a supine position for extended periods. Interviews with staff, including the Director of Nursing and Unit Manager, indicated a lack of awareness and implementation of pressure ulcer prevention policies. Staff were unsure of the interventions listed in the resident's care plan and did not consistently reposition the resident due to her preference to lie on her back. The facility did not have a specific policy on pressure ulcer prevention, and staff were not fully informed of the necessary interventions to prevent the worsening of the resident's condition.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that residents receiving enteral feeding were provided with appropriate treatment and services to prevent complications such as aspiration pneumonia. Specifically, two residents, R39 and R42, were identified as not receiving proper care. Observations revealed that R42's head of bed (HOB) was flat during enteral feeding, contrary to the standard practice of elevating the HOB to prevent aspiration. Additionally, R42's feeding bottle was not changed within the required 24-hour period, as it was observed to be dated over 32 hours old. Similarly, R39's room contained a piston syringe dated several days prior, indicating a failure to change it daily as required. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), and the Unit Manager (UM), revealed a lack of clear policies and procedures regarding the management of enteral feeding and gastrostomy tubes. The DON and other staff members acknowledged that there was no formal policy in place, and practices were based on what they considered standard procedures. The staff also indicated that they were not aware of specific guidelines or reference materials that the facility used to ensure compliance with best practices. The facility's failure to have a policy on enteral feeding and gastrostomy tubes, combined with inconsistent staff training and competency checks, contributed to the deficiencies observed. The lack of a structured approach to managing enteral feeding led to deviations from standard care practices, such as not elevating the HOB during feeding and not changing feeding bottles and syringes as required. These oversights were noted during the survey, highlighting the need for improved protocols and staff education to ensure resident safety and compliance with care standards.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R39, who required such services. R39 was observed during a dressing change for a left heel wound, displaying non-verbal signs of pain such as facial grimacing and biting down on her gown. Despite the Unit Manager's claim that R39 had received pain medication prior to the procedure, a review of the narcotic sign-out sheet revealed that R39 had not received any pain medication since two days prior. This discrepancy was confirmed by the resident herself, who stated she had not received any pain medication. Further investigation revealed that the facility's pain management policy, which required pain management to be consistent with professional standards and the resident's care plan, was not followed. The policy emphasized the need for both pharmacological and non-pharmacological interventions and required pain assessments before and after interventions. However, the staff failed to administer the prescribed Oxycodone/Acetaminophen to R39 before the dressing change, despite the resident's evident pain and the physician's order for pain medication every six hours as needed. Interviews with staff, including the Staff Development Coordinator and the Unit Manager, highlighted a lack of communication and follow-through in administering pain medication. The Unit Manager admitted to requesting pain medication for R39, but it was not administered until several hours later. The Director of Nursing and the Administrator acknowledged the expectation for pain assessments and medication administration before wound care, yet these protocols were not adhered to, resulting in inadequate pain management for R39.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, as observed in the 300 hall medication storage room. Multiple expired medical supplies were found, including glucose test strips, wound cleanser, suction tubing, and tracheostomy tubes. Additionally, a small refrigerator used for storing milk and beer was found to have a temperature reading of 50 degrees Fahrenheit, which was outside the acceptable range. The Unit Manager (UM) acknowledged the issue, attributing the temperature change to a staff member adjusting it after a resident complained about the milk being too cold. During an interview, the Director of Nursing (DON) expressed concerns about the potential for false blood sugar readings if expired supplies were used, particularly for residents with diabetes care plans. The DON stated that it was the UM's responsibility to check for expired supplies monthly, with assistance from pharmacy staff. The expectation was for management to regularly inspect medication rooms and carts for expired items and to discard them. The DON also mentioned that night shift nurses were responsible for monitoring refrigerator temperatures and reporting any unacceptable readings to leadership and management.
Inadequate Infection Control Practices and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by observations and interviews conducted by the State Surveyor Agency. On the date of observation, a CNA was seen pulling gloves from a box on top of a medication cart and placing them in her pants pocket before entering a resident's room to provide care. This practice was identified as a potential infection control issue. Additionally, a PPE bin located in front of two residents' rooms on Enhanced Barrier Precautions was found to contain only face masks, lacking necessary disposable gloves and gowns. Interviews with facility staff, including the CNA, Unit Manager, Infection Preventionist/Assistant Director of Nursing, Director of Nursing, and the Administrator, revealed a lack of clarity and responsibility regarding the stocking and availability of PPE supplies. The CNA expressed that having supplies readily available in residents' rooms would be more convenient, while the Unit Manager and Director of Nursing acknowledged the issue but were unsure of the current responsibility for maintaining PPE supplies. The Infection Preventionist confirmed that staff had been educated on proper glove use, and the Administrator noted that he was not aware of the supply shortages until recently. The deficiency highlights a breakdown in communication and responsibility for ensuring adequate infection control measures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Paducah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Nursing & Rehabilitation Center | 1.5 mi | ★★★★★ | 13 | 0 |
| Stonecreek Health And Rehabilitation | 2 mi | ★★★★★ | 11 | 0 |
| Providence Pointe Healthcare | 5.5 mi | ★★★★★ | 0 | 0 |
| Southgate Health Care Center | 6.4 mi | ★★★★★ | 7 | 1 |
| Metropolis Rehab & Hcc | 7.6 mi | ★★★★★ | 41 | 1 |
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