The Haven on the River

In the surveyor’s words

From the most serious findings on record at The Haven on the River, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 6, 2026

  Based on interview and record review, the facility failed to follow physician's orders and failed to assess and monitor a resident's declining condition for 1 of 3 residents (R1) reviewed for quality of care in a sample of 18. This failure resulted in R1's hospital admission for acute kidney injury and hyperkalemia requiring emergent dialysis and subsequent death.This failure resulted in Immediate jeopardy, which was identified to have begun on 12/28/25 when the facility failed to obtain physician ordered labs of CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and TSH (Thyroid-stimulating hormone) for R1. The facility failed to follow up on UA (Urinalysis) and Culture and Sensitivity lab results that was ordered for R1 on 12/28/25. […]

• Actual harm, isolatedF600Jun 3, 2026

  Based on interview and record review, the facility failed to ensure residents are free from neglect for 1 of 6 residents (R1) reviewed for neglect in the sample of 12. The failure resulted in R1 not receiving an immediate nursing assessment and treatment for a fall resulting in a hip fracture.Findings include:R1's Face Sheet documented an admission Date of 3/18/26, and listed Diagnoses including Vascular Dementia, Atherosclerotic Heart Disease, and Chronic Obstructive Pulmonary Disease.R1's Minimum Data Set, dated [DATE], documented R1 had moderate deficits in cognition. R1's Care Plan, dated 4/30/26, documented a problem area, The resident is moderate risk for falls related to history of falls, poor safety awareness, impulsivity; resident sometimes crawls out of bed. […]

• Actual harm, isolatedF697Apr 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure pain medication was available for 1 of 3 (R1) residents reviewed for pain in the sample 10. This failure resulted in R1's pain not being controlled post knee replacement surgery, causing R1 to become restless and anxious. R1 stated when he doesn't have the pain medication he doesn't move as much because of the pain.Findings Include:R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE], with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures.R1's Minimum Data Set (MDS), dated [DATE], documents a… […]

• Actual harm, isolatedF684Dec 3, 2025

  Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that includes post fall assessment and treatment, monitoring, reporting, and investigating for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6. This failure resulted in R1 falling and sustaining a hip and femur fracture without timely assessment and treatment after the fall. A reasonable person would experience feelings of discomfort and distress due to not receiving timely after fall care. […]

• Actual harm, isolatedF697Dec 3, 2025

  Based on interview and record review, the facility failed to ensure that a resident was properly assessed for injury and pain and to address resident complaints of pain post fall for 1 of 3 (R1) residents reviewed for pain in a sample of 6. R1 fell and sustained a hip and femur fracture without proper assessment of injury/pain. A reasonable person would experience feelings severe pain and discomfort due to not receiving pain relief medication. Findings include:R1's Transfer/Discharge report dated 12/2/25 documents an admission date of 12/3/2021 and a discharge date of 11/20/2025.R1's diagnosis report, dated 12/3/25, documents the following diagnoses fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, muscle weakness (generalized), other… […]