Forest Haven Nursing and Rehabilitation Ctr

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a safe, clean, comfortable, homelike environment. This was evident pervasively throughout all resident floors of the facility's building.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1.) ensure proper sanitation and food handling practices, 2.) properly monitor the temperatures of nourishment refrigerators, and 3.) ensure labeling and dating of food products and monitoring for expiration of food product. This was evident during the surveyor's tours of the facility's kitchen during the facility's recertification survey.

Inspectors wroteBased on observations, staff interviews and review of facility documents, it was determined the facility failed to implement, complete and accurately reflect a Facility Assessment regarding the facility's physical environment, equipment, and other physical plant considerations that are necessary to care for its population, as well as an evaluation of the facility building maintenance capital improvements, or structures. This was evident during survey with the potential to affect all residents.

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to: 1) ensure clean linen was handled and transported in a safe and sanitary manner. The was evident for 1 clean linen transportation cart observed; and 2) establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice was evident for the Water Management Plan investigated during the survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to: 1) maintain laundry equipment in safe operating conditions. This deficient practice was evident for 1 of 4 washers and 4 of 5 dryers within the Laundry Room; and 2) maintain patient care equipment in a safe operating condition. This was evidence for 1 out of 4 Automatic External Defibrillators reviewed.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 2 resident rooms (room [ROOM NUMBER] and #218) out of 17 rooms observed at Station 4 and 3 resident rooms (room [ROOM NUMBER], #2 and #8) out of 13 rooms observed at Station 1.

Inspectors wroteBased on observation, record review, and interviews with staff, it was determined that the facility failed to ensure the exterior facility environment was maintained to be safe, sanitary. This was evident throughout the surveyors' tour of the exterior facility.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a handrail was firmly secured. This was evident for one handrail during a random observation on Station 3 during the surveyor's initial tour of the facility.

Inspectors wroteBased on observation, record reviews and interviews, it was determined that the facility failed to ensure resident self-determination for bathing preferences such as methods and times. This was evident for 1 (#114) resident out of 8 residents investigated during the survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to notify the medical director of recent testing results of the facility when there was a need to alter treatment or testing significantly. This was evident for 2 (#113 and #1) residents out of 6 residents investigated during the survey.

Inspectors wroteBased on record review, observation, and interviews, it was determined that the facility failed to ensure resident personal and medical information was not publicly disclosed without consent. This deficient practice was evident for 3 of 3 residents reviewed (Residents #20, #45, and #65).

Inspectors wroteBased on review of the facility's Facility Reported Incidents and interviews, it was determined that the facility failed to timely report an allegation of abuse (Resident #54). This was evident for 1 out of 7 residents reviewed for abuse during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to provide the written notification of transfer to the resident representative, provide written notification of the facility's bed hold policy upon transfer to the hospital to the resident representative, and ensure the local ombudsman was notified of a facility-initiated transfer to the hospital. This was evident for 1 (Resident #15) out of 4 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and including the right to refuse treatment. This was evident for 1 (#1) resident out of 3 residents investigated for complaints during the facility's annual survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to facilitate timely care plan meetings after a resident's quarterly assessment. This was evident for 1 (Resident #14) out of 4 residents reviewed for care planning during the annual survey.

Inspectors wroteBased on record review and interviews with staff, it was determined that the facility failed to complete residents Pre-admission Screening and Resident Review (PASRR) forms according to professional standards of practice. This was evident for 1 (Resident #2) out of 6 resident PASRR's reviewed during the annual survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed: 1) to ensure Resident (#117) was provided assistance necessary for an activity of daily living necessary to maintain proper nutrition. This was evident during a random observation; and 2) ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. This was evident for 1 (#114) resident out of 8 residents investigated during the survey.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an environment that is free from risks of accident hazards. This was evident for 1 (Resident #110) out of 6 residents reviewed during the survey. On 9/04/25 at 8:34 AM, during observation rounds, the surveyor observed Resident #110's toilet leaking water from the base. There was a large puddle of water on the bathroom floor surrounding the toilet. Also, the bathroom floor was slippery when walking on it. On 9/04/25 at 10:10 AM, the Director of Nursing staff #13 was interviewed. During the interview, the surveyor made staff #13 aware that Resident #110's toilet was leaking water from the base, and that there was a large puddle of water on the floor surrounding the toilet. Staff #13 mentioned that she would have maintenance repair Resident #110's toilet, and the puddle of water mopped from the floor.

Inspectors wroteBased on observations, record review, and interview with staff, it was determined that the facility failed to ensure that residents were properly assessed for the safe use of bedrails, failed to obtain consent from the resident or resident representative prior to use of bedrails, and failed to complete a device assessment for the use of bedrails. This was evident for 2 (Resident #15 and # 65) out of 8 residents reviewed for accidents during the survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure medications were administered in accordance with physician orders for 2 of 26 opportunities reviewed. This deficient practice resulted in residents receiving medications contrary to physician orders and a medication error rate of 7.69%.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure medications and resident information were secured to prevent unauthorized access. This deficient practice was evident for 1 of 6 medication carts observed during the facility's recertification survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure a resident who requires dental services on a routine basis received necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #15) reviewed for dental services during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the residents' right to make personal dietary choices. This was evident for 1 (#112) resident out of 8 residents investigated during the survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the accuracy of medical records for a resident. This was evident for 1 (#71) out of 14 residents reviewed for advanced directives during the facility's recertification survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that facility failed to ensure regular inspections of all bedrails being used by residents. This was evident for 2 (Resident #15 and #65) out of 8 residents reviewed for accidents during the survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to have multiple-resident bedrooms that measure 80 square feet per resident. This was evident for 4 resident rooms (Room # 1, #5, #6 and #9) observed during the survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that resident rooms are equipped to provide visual privacy for each resident. This was evident for 2 resident rooms (Room # 1 and 8) observed during the survey. On 9/15/25 at 9:43 AM, during observation rounds with the Nursing Home Administrator staff #3 and the Maintenance Director staff # 18, the surveyor observed a missing privacy curtain for bed A in room [ROOM NUMBER]. On 9/15/25 at 9:44 AM, staff #3 and staff # 18 were interviewed. During the interview, staff #3 agreed that there was not a privacy curtain for bed A in room [ROOM NUMBER]. On 9/15/25 at 3:05 PM, during observation rounds with staff # 18, the surveyor observed a privacy curtain that did not pull across completely for bed A in room [ROOM NUMBER]. On 9/15/25 at 3:06 PM, staff #18 was interviewed. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the current nurse staffing assignments and ratios for each shift was posted daily in a clear and visible place on each nursing unit. This deficient practice was evident on 7 of 8 survey days on Unit Station 2B and 6 of 8 survey days on Units 2A, 4, and 2B during the recertification survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to have the most recent survey results posted and accessible to residents, family members, and legal representatives of residents. This had the potential to affect all residents and visitors within the facility.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility staff failed to ensure 1) adequate supervision while positioning a resident in bed during the provision of care and 2) residents did not have access to medications. This was evident for 2 of 30 residents (#13 and #26) reviewed for complaints and resulted in harm to Resident #13.

Inspectors wroteBased on review of employee files and interviews with staff it was determined the facility staff failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. This was evident during review of 1 (#12) of 7 residents reviewed for abuse.

Inspectors wroteBased on review of employee files and interviews with staff it was determined the facility Administration failed to complete performance review of every nurse aide at least once every 12 months and provide regular in-service education that was based on the outcome of the reviews. This was evident during review of 1 (#12) of 7 residents reviewed for abuse.

Inspectors wroteBased on observation during the initial tour of the main kitchen with facility staff it was determined that the facility staff failed to store food items in a manner that maintains professional standards of food service safety and prepare food under sanitary conditions. This was evident during 2 of 2 tours of the kitchen.

Inspectors wroteBased on observation during tour of the facility's dumpster area, and smoking area it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents. .

Inspectors wroteBased on record review and interviews it was determined the facility Administration failed to establish and ensure: 1) a system was in place to evaluate staff performance and provide required education as determined by staff performance reviews and the facility assessment; 2) policies and procedures were available and accessible to all staff; 3) the facility had an effective pest control program. This was evident during the complaint survey and has the potential to affect all residents in the facility.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to maintain a quality assessment and assurance committee that included the Medical Director and an Infection Preventionist. This was evident during review of the Quality Assurance Performance Improvement program.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to maintain a safe and homelike environment for their residents. This was evident throughout the facility and had the potential to affect all residents.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to have an effective pest control program to ensure the facility was free of pest. This was evident throughout the facility and had the potential to affect all residents.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to report an allegation of abuse to the State Agency in a timely manner. This was evident for 1 resident (#2) during review of 1 of 9 complaints related to Resident Rights and 2 (#10, #28) of 7 residents reviewed for abuse.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to investigate an allegation of misappropriation of resident property for 1 (#2) of 6 residents reviewed for Resident Rights; and failed to conduct a thorough investigation and prevent other potential abuse or mistreatment while the investigation was in progress for 2 (#12 and #15) of 7 residents reviewed for abuse.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights. This was evident for 2 (#12 and #18) of 16 residents reviewed for Quality of Care.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of the residents and failed to develop a resident centered care plan related to activities with achievable goals and measurable objectives. This was evident for 1 (#11) of 5 residents reviewed for quality of life.

Inspectors wroteBased on medical record reviews and interviews, the facility staff failed to follow physician orders for a resident. This was evident for 1 (#18) of 1 residents reviewed for physician services during a complaint survey.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to implement appropriate individualized interventions for residents identified at risk of developing pressure ulcers. This was evident for 1 (#14) of 16 residents reviewed for Quality of Care.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#11) of 5 residents reviewed for quality of life during a complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to ensure that all medications were stored in a locked compartment that was temperature controlled. This was evident for 1 (26) of 30 residents reviewed for complaints.

Inspectors wroteBased on review on record review of facility documentation and staff interview, it was determined that the facility staff failed to conduct and document an accurate and comprehensive facility-wide assessment. This was evident during a complaint survey and had the potential to affect all residents within the facility.

Inspectors wroteBased on record review, observation and interviews it was determined that the facility failed: 1) to have a process to prepare and update an inventory of all property that the resident brought to the nursing facility. Including whether the resident retained possession of each item or entrusted the item to the facility for safekeeping, and identification of items valued at $100 or more and, 2) to have accurate and complete documentation regarding resident's end of life choices. This was evident for 1 (#2) of 9 residents reviewed for Resident Rights and evident for 1 (#11) of 5 residents reviewed for quality of life during a complaint survey.

Inspectors wroteBased on review of medical records, facility documentation, complaint MD00205968 and staff interviews, it was determined the facility failed to ensure all residents were free from abuse. This was evident for 3 (Resident #2, #3, and #4) of 4 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on reviews of a closed medical record, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, sexual abuse, and misappropriation of resident property, 2) immediately initiate an investigation into the allegations of resident abuse, and 3) report the allegations of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 2 (Resident #1, #3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a closed medical record and staff interview, it was determined the facility failed to initiate an investigation into a reported allegation of abuse. This was evident for 2 (Resident #1, #3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to initiate the process to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to ensure safe and orderly transfer or discharge from the facility. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to send a copy of the facility bed hold policy with a resident when the resident was sent to the emergency room. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to permit a resident to return to the facility after a brief hospitalization. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (Resident #56) from verbal and physical abuse from a facility staff member. This caused harm to Resident #56. This was evident for 1 of 10 residents reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on surveyor observations during tour of the facility and staff interview, it was determined that the facility failed to ensure that Resident #10's and #100's urinary bag were covered from view from people walking past his/her room. This occurred in 2 of 53 sampled residents. The facility failed to ensure that Resident #10 and #100 urinary bag was covered. A urinary catheter is a medical device that bypasses the urethra and drains urine directly from the bladder. It drains into an attached urinary bag made with transparent plastic to allow staff to assess and measure the urine it contains. However, in consideration of a homelike environment, it is appropriate to cover the clear part of the bag with a cloth cover to prevent the resident from feeling exposed and to prevent other residents from feeling discomfort at being able to see another resident's urine. [...]

Inspectors wroteBased on observations and staff interview it was determined the facility failed to provide housekeeping and maintenance services to keep the resident's environment clean and in good repair. This was evident on 5 of 5 nursing units and impacted 9 of 58 residents (Resident # 115, #30, # 107, # 29, #4, #22, #73, #56, #376) reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to notify the state agency in the required allotted time frame after being made aware of an allegation of neglect. This was evident in 1 of 10 residents (Resident #326) sampled for neglect/abuse during the annual survey.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to transmit a resident's Minimum Data Set (MDS) assessment within 7 days after the assessment was completed. This was evident in 1 in 6 (Resident #1) resident charts reviewed during the survey for completed MDS assessments.

Inspectors wroteBased on administrative record review and interviews with facility staff, it was determined the facility failed to follow the resident care plan when providing care. This was found to be evident for 1 of 10 (Resident # 3) intakes reviewed for abuse during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations and record reviews and interviews with the facility staff it was determined the facility failed to: 1.) update a care plan for a resident who refuses care (Resident #115) and 2.) update a care plan after a change in status (Resident #10). This was found to be evident for 2 of 59 residents observed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) keep a resident with cognitive impairment from having access to sharp objects that were in the resident room (Resident #226); 2.) ensure that a resident's environment was reasonably free of hazards (Resident #73). This was found to be evident for 2 of 8 residents reviewed for accidents during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to ensure that accurate records were maintained for Resident #50. This was found to be evident while investigating a facility-reported incident (MD00157390) during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation and staff interviews it has been determined that the facility failed to: 1.) follow infection control practices to prevent the spread of COVID-19 as evidenced by facility staff failing to have the needed Personal Protection Equipment (PPE) available in the supply carts in front of the rooms and 2.) ensure the zippered door closure to the COVID 19 Unit was secured to the wall and without compromise in material as evidenced by a large hole in the plastic on the left lower side. This deficient practice was found on 1 of 4 observations of the COVID-19 Unit; 3) ensure that Resident #10 and #100 urinary bags remained off the floor and away from sources of infectious microorganisms. This occurred in two of six residents reviewed for Foley Catheters.

Inspectors wroteBased on observation and staff interviews, it was determined the facility failed to have bedrooms that measure 80 square feet per resident. This was evident in 4 residents' rooms (room [ROOM NUMBER], 5, 6, 9) observed during the survey.

Inspectors wroteBased on observations and interviews it was determined the facility failed to provide a safe, sanitary, and comfortable environment for residents located on Station 1's second and third floors. This has the potential to affect all the residents who reside on Station #1.

Inspectors wroteBased on administrative record review and staff interview, the facility failed ensure that Staff #20 received required yearly abuse, neglect, and exploitation training. This was evident in 1 of 35 employees reviewed during the facility's annual survey.

Inspectors wroteBased on surveyor observation throughout the annual recertification survey, it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior. Issues were identified on all resident units.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to properly store medications. This was observed twice on the station 3 nursing unit during the annual recertification survey.

Inspectors wroteBased on observation of the main kitchen and staff interview, it was determined that the facility failed to follow professional standards for food service safety. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observation, staff interview and record review, it was determined that the facility failed to maintain kitchen and resident equipment in safe operating condition. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observation, staff interview, and record review, it was determined that facility staff failed to ensure the dignity of residents who required assistance with eating during the dining experience. This was evident for 1 (#72) of 11 residents in the dining room.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined the facility staff failed to ensure that resident's call bells were within reach. This was evident for 2 (#18 and #42) of 32 residents observed during initial resident sample observations.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined the facility failed to complete and transmit a discharge MDS assessment timely. This was evident for 1 (#1) of 1 resident reviewed for Resident Assessment. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.

Inspectors wroteBased on record review and interview, it was determine that facility staff failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident to ensure that the resident received appropriate services while in a long term care setting. This was evident for 1 (41) of 3 residents reviewed for accuracy of the PASRR.

Inspectors wroteBased on medical record review and interview with staff, it was determine the facility staff failed to develop and implement a comprehensive person-centered care plan for each resident by failing to follow a plan of care for activities and failing to develop a Hospice plan of care. This was evident for 1 (#42) of 4 residents reviewed for Activities and 1 (#108) of 1 residents reviewed for Hospice. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined the facility staff failed to review and revise resident care plans. This was evident for 1 (#42) of 4 residents reviewed for Activities and 2 (#128 and #50) of 17 resident's reviewed for Accidents. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined the facility failed to maintain complete and accurately documented medical records by failing to document group activities offered and the resident's acceptance or refusal to attend. This was evident for 1 (#42) of 4 residents reviewed for Activities.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to have bedrooms that measured 80 square feet per resident. This was evident for 4 resident rooms observed during the survey.