Cedar Haven Operations Holding LLC Valley View Hea

In the surveyor’s words

From the most serious findings on record at Cedar Haven Operations Holding LLC Valley View Hea, in the surveyor’s own words.

• Immediate jeopardy, patternF584Mar 3, 2025

  Based on surveyor observation, resident, and staff interview, it has been determined that the facility failed to ensure a safe environment was maintained relative to unsafe water temperatures, for 4 of 4 floors observed. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 8/8/2024, states in part, .Some States have regulations regarding allowable maximum water temperature .Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. […]

• Immediate jeopardy, patternF695Jul 6, 2023

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed who received oxygen therapy via a nonrebreather mask, Resident ID #s 1 and 6. Findings are as follows: According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. […]

• Immediate jeopardy, patternF726Jul 6, 2023

  Based on record review and staff interview it has been determined that the facility failed to ensure its nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 of 6 licensed nursing staff reviewed for competencies relative to the use of non-rebreather masks, Staff A, B, C, E, F and G. […]

• Immediate jeopardy, isolatedF600Aug 5, 2025

  Based on record review, staff and resident interview it has been determined that the facility failed to keep a resident free from neglect relative to 1 of 1 resident reviewed who was left unattended outside of the facility for approximately 3 hours and 20 minutes during a heat advisory resulting in cardiac arrest, Resident ID #1. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/30/2025 alleged that Resident ID #1 was left unattended outside of the facility for an unknown amount of time on 7/30/2025. The complaint further alleged that the resident was found unconscious, without a pulse and required cardio-pulmonary resuscitation (CPR). […]

• Immediate jeopardy, isolatedF689Nov 20, 2024

  Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was assessed to be a moderate risk for wandering, previously displayed exit seeing behavior and was able to successfully elope from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled Elopement dated 4/10/2018, states in part, .Elopement - leaving the facility without permission and/or notification to the facility .An assessment will be completed within 24-hours of admission. 1. A re-assessment will be completed for any resident who demonstrates any of the following: Verbalizing a desire to leave the building .exit seeking .A resident assesses to be at risk. […]