Forest Haven Nursing and Rehabilitation CTR

In the surveyor’s words

From the most serious findings on record at Forest Haven Nursing and Rehabilitation CTR, in the surveyor’s own words.

• Actual harm, isolatedF689May 1, 2025

  Based 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. The findings include: 1. On 4/21/25 at 9AM, a record review was conducted which revealed that Resident #13 had diagnoses which included, but were not limited to, respiratory failure with hypoxia, heart failure, wedge compression fracture of fourth thoracic vertebra, Hospice, and dementia. The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified. […]

• Actual harm, isolatedF600May 30, 2024

  Based 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. The findings include: Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. […]

• Actual harm, isolatedF600Aug 2, 2022

  Based 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. The findings include: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few) to be addressed. […]

• No harm, potential for more than minimal, widespreadF584Sep 15, 2025

  Based 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.The findings include: 1. On 9/4/25 at 8:14AM the surveyor observed ripped areas in the flooring material in resident room # 202.2. On 9/4/25 at 8:26AM the surveyor observed resident room [ROOM NUMBER] with windows with a cloudy, unclean appearance and chipping wall paint.3. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2025

  Based 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. The findings include: 1. On 9/4/25 at 7:46AM the surveyor conducted an initial tour of the facility's kitchen. On 9/4/25 at 7:47AM the surveyor observed the reach in refrigerator with an unclean appearance. […]