Forest Haven Nursing & Rehab Ctr, LLC

In the surveyor’s words

From the most serious findings on record at Forest Haven Nursing & Rehab Ctr, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 24, 2026

  Based on observation and interview the facility failed to ensure the kitchen prepared and served food in accordance with professional standards for food service safety. This had the potential to affect 121 diets served from the kitchen.Findings:On 06/22/2026 at 10:25 a.m. observation of the lunch meals revealed they were serving herb baked chicken, riced dressing, squash and zucchini and chocolate and strawberry cake. Observation of the alternate foods available revealed they had a choice of pulled pork, mashed potatoes and cabbage.For the mechanical chopped meat, residents were served chopped chicken.On 06/22/2026 at 11:30 a.m. S5Production Manager began serving trays from the steam table. […]

• No harm, potential for more than minimal, patternF604Apr 30, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#112) of 2 (#58 and #112) residents reviewed for restraints. The facility failed to identify that resident #112 had a wheelchair seatbelt in place. Findings: Review of the facility's undated Physical Restraint Policy revealed the following, in part: A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. […]

• No harm, potential for more than minimal, patternF689Apr 30, 2025

  Based on observation, record review, and interviews, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible; and each resident received assistance devices to prevent accidents by failing to ensure a thorough investigation and appropriate interventions were initiated after each incident for 1 (#49) of 4 (#38, #49, #81, #107) sampled residents revealed for accidents. Findings: Review of the undated facility Accident/Incident Reports: Resident policy revealed the following, in part: Purpose: To assure appropriate follow-through on all accident/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action. Procedure: 10. […]

• No harm, potential for more than minimal, patternF690Apr 30, 2025

  Based on observations, interviews, and record review, the facility failed to ensure that an indwelling catheter was not used unless there is valid justification for catheterization and the catheter was discontinued as soon as clinically warranted for 1 (#70) of 3 (#70, #68, and #78) residents reviewed for urinary catheter or urinary tract infection. Findings: Review of the facility's undated Catheterization, Urinary: In and out, indwelling and suprapubic (Male and Female) Policy revealed the following, in part: an indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary dysfunction. Examples of clinical conditions demonstrating that catheterization may be unavoidable include: . , 2. […]

• No harm, potential for more than minimal, patternF695Apr 30, 2025

  Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#70, #76, #120) of 3 (#70, #76, #120) residents reviewed for respiratory care. The facility failed to ensure: 1) water in the humidifier bottle on the oxygen concentrator was changed weekly and oxygen tubing was stored properly for resident #70), 2) nebulizer hand pipe was dated and stored properly for resident #76, and 3) oxygen tubing was dated and oxygen concentrator filter was clean for resident #120. Findings: Review of the facility's undated Oxygen Administration (Concentrator or Tank) Policy revealed that humidifier bottles, cannulas, and Oxygen (O2) tubing will be changed at least once weekly and dated. […]