Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair Haven Of Forest City, Llc during CMS and state inspections, most recent first.
The facility failed to obtain and document informed consent, including discussion of risks and benefits, before initiating or increasing psychotropic medications for three residents receiving antianxiety and antidepressant drugs. Cognitively intact residents reported that no provider or staff discussed side effects or risks and benefits when their alprazolam, sertraline, Xanax, or Zoloft were started or increased, and a responsible party for a severely cognitively impaired resident did not recall any discussion when buspirone was initiated. Records lacked documentation of informed consent, while interviews with the NP, Medical Director, Rounding Nurse, DON, Informatics Nurse, and Consulting Pharmacist revealed that nursing staff were expected to handle psychotropic consents, but consents were only being obtained for new antipsychotic orders and not for residents admitted on psychotropics or for antidepressant and antianxiety medications, despite policy defining these as psychotropics.
A resident admitted with an active diagnosis of bipolar disorder had only a Level I PASRR completed prior to admission, and the facility did not request a required Level II PASRR evaluation. The resident’s MDS assessments documented severe cognitive impairment and an active bipolar disorder diagnosis, with ongoing treatment using mirtazapine and Lamictal and a care plan addressing depression and bipolar disorder. The SW acknowledged knowing about the bipolar diagnosis but did not submit a Level II PASRR referral, believing the existing Level I PASRR was sufficient, while the Administrator recognized that Level II evaluations are important for residents who meet criteria.
Surveyors found that the facility failed to include key clinical issues in the comprehensive care plans for two residents. One resident with severe COPD, chronic respiratory failure, recurrent pneumonia, and ongoing respiratory symptoms had no respiratory-focused care plan despite repeated physician documentation, pulmonology consultation, and continued respiratory treatments. Another resident receiving the high-risk anticoagulant Apixaban for cardiac conditions and DVT prevention had no anticoagulant-related focus or interventions in the care plan, even though anticoagulant use was accurately coded on the MDS and the medication was administered consistently over several months.
A resident with limited mobility and cognitive impairment was improperly transferred by a nurse aide without using the required mechanical lift, as specified in the care plan. The aide attempted a stand and pivot transfer, resulting in the resident being lowered to the ground without injury. The incident was observed by a nurse who confirmed the improper transfer method.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent, including discussion of risks and benefits, before initiating or increasing psychotropic medications for multiple residents. For one cognitively intact resident with panic disorder, depression, and anxiety, the NP increased alprazolam from twice daily to three times daily and later increased sertraline in two separate dose changes. Physician orders and MARs showed these medications were administered as ordered over several months, but the medical record contained no documentation that the resident was informed in advance of the risks and benefits of these dose increases. In an interview, this resident reported that no provider at the facility had discussed side effects or the risks and benefits of taking or increasing alprazolam or sertraline. Another resident, who was severely cognitively impaired and admitted with anxiety disorder and major depressive disorder, was started on buspirone per physician order, and the MAR confirmed ongoing administration. The record contained no evidence that the responsible party was informed in advance of the risks and benefits of initiating buspirone. In a telephone interview, the responsible party did not recall any discussion with the provider or facility staff about the risks and benefits of this antianxiety medication at the time of admission. A third cognitively intact resident with anxiety disorder and major depressive disorder had orders for Xanax three times daily and Zoloft at bedtime, with MARs confirming administration, but the medical record lacked documentation that the resident was informed in advance of the risks and benefits of initiating either medication. This resident also did not recall any discussion with providers or staff about side effects or risks and benefits. Interviews with facility staff and leadership showed systemic gaps in the process for obtaining psychotropic medication consents. The NP stated that psychotropic consents were handled by nursing, and the Consulting Pharmacist confirmed that antidepressants and antianxiety medications are psychotropics requiring consent when initiated or increased but did not review consents during monthly medication reviews. The Medical Director reported not recalling discussions of risks and benefits for residents admitted on psychotropics and believed floor nurses and the Rounding Nurse notified residents and representatives of medication changes, expecting consents to be completed when psychotropics were initiated or increased. The Rounding Nurse stated she was responsible for obtaining psychotropic consents but only did so for residents started on antipsychotics after admission, not for residents admitted on psychotropics or for antidepressant and antianxiety medications, as she did not know these were considered psychotropics. The DON confirmed the Rounding Nurse’s role, acknowledged that all entered orders are new orders (including pre-admission medications), and stated she did not know antianxiety and antidepressant medications required consent when initiated or increased. The Informatics Nurse indicated the psychotropic policy definition, which includes antidepressants and antianxiety medications, had not changed and that nurses should know which medications are psychotropics, while the Administrator stated an expectation that psychotropic consents be obtained.
Failure to Obtain Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to obtain a Level II PASRR evaluation for a resident admitted with an active diagnosis of bipolar disorder. A Level I PASRR was completed prior to admission, dated 03/20/18, and the resident was admitted with diagnoses including bipolar disorder. Review of the medical record showed no evidence that a Level II PASRR evaluation had ever been completed. The admission MDS documented an active diagnosis of bipolar disorder and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. A subsequent quarterly MDS showed the resident was severely cognitively impaired, had no behaviors or signs of depression, but continued to have an active diagnosis of bipolar disorder and was receiving anticonvulsant and antidepressant medications daily. Physician orders confirmed ongoing treatment with mirtazapine 15 mg by mouth at bedtime for depression and appetite, and Lamictal 25 mg by mouth daily as a mood stabilizer for bipolar disorder. The active care plan included a focus area for antidepressant medications with indications of depression and bipolar disorder, with a goal for the resident to remain free from side effects and interventions to administer medications as ordered and monitor for adverse effects. During interview, the Social Worker stated that because a Level I PASRR had already been completed prior to admission, she did not submit a referral for a Level II PASRR evaluation and was not aware that she was required to do so, despite knowing the resident had a bipolar disorder diagnosis. In a separate interview, the Administrator acknowledged the importance of completing Level II PASRR evaluations for residents who meet criteria so they can receive needed services.
Failure to Care Plan for Respiratory Conditions and Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to develop individualized, person-centered comprehensive care plans addressing significant clinical conditions and treatments for two residents. For the first resident, who had chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and recurrent pneumonia including MRSA pneumonia, the quarterly MDS documented these respiratory diagnoses. However, review of the active comprehensive care plan last updated on 09/30/25 showed no care plan addressing COPD, respiratory failure, or pneumonia, despite ongoing respiratory issues. Physician orders since September 2025 showed daily and PRN medications for COPD and chronic respiratory symptoms and multiple courses of antibiotics for pneumonia, and multiple physician progress notes documented respiratory complaints, hospitalizations for pneumonia, dyspnea, and continued aggressive treatment. Further documentation for this resident included a pulmonology consult following a recent hospitalization for right lower lobe pneumonia, noting ongoing chest congestion, cough, wheezing, and possible bronchiectasis with mucus impaction, with a recommendation to continue antibiotics. During an interview and observation, the resident had a current cough and slightly labored breathing and reported ongoing respiratory issues. The Medical Director described the resident’s COPD as severe and chronic, requiring frequent monitoring and respiratory symptom management by staff. Despite these documented conditions and treatments, there was no corresponding respiratory care plan in the resident’s comprehensive care plan. The second resident had diagnoses including myocardial infarction and chronic atrial fibrillation and was receiving an anticoagulant, Apixaban 2.5 mg by mouth twice daily, for history of myocardial infarction and deep vein thrombosis prevention. The quarterly MDS assessment indicated anticoagulant use, and the MAR confirmed that the resident consistently received Apixaban as ordered from 01/01/2026 through 03/31/2026. However, the active comprehensive care plan, initiated in October 2025 and last revised in January 2026, did not contain any focus area or interventions related to anticoagulant therapy. Interviews with the Informatics Nurse, DON, and Administrator confirmed that anticoagulant medications are considered high-risk and should be care planned, and they could not explain why this resident’s anticoagulant use was not addressed in the care plan.
Improper Transfer of Resident Without Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for Resident #344, who was supposed to be transferred using a mechanical lift. On the morning of 6/14/24, Nurse Aide (NA) #1 attempted a stand and pivot transfer with Resident #344, which was not in accordance with the resident's care plan. This resulted in Resident #344 being lowered to the ground without injury. The resident had been admitted with diagnoses including heart failure, lumbago with sciatica, and alveolar hypoventilation, and was noted to have moderate cognitive impairment and dependence for chair to bed transfers. The Comprehensive Care Plan for Resident #344, dated 6/4/24, specified that the resident required a mechanical lift for transfers due to limited physical mobility. Despite this, NA #1 attempted to assist the resident without the proper equipment. NA #1 stated that she intervened when she saw the resident attempting to get out of bed, claiming she was not trying to transfer the resident. However, Nurse #1, who responded to NA #1's call for help, observed NA #1 attempting a stand and pivot transfer without the mechanical lift. Interviews with other staff members, including NA #2, NA #3, NA #4, and the Therapy Manager, confirmed that the transfer status of residents was typically posted inside the closet door, and that staff were trained to use mechanical lifts. The Director of Nursing and the Administrator acknowledged the incident and agreed that staff should follow proper transfer procedures. The incident highlighted a failure in adhering to the established care plan and ensuring the safety of Resident #344 during transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Forest City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Haven Home Inc | 5.5 mi | ★★★★★ | 2 | 0 |
| Willow Ridge Of Nc | 6 mi | ★★★★★ | 5 | 0 |
| Oak Grove Healthcare | 7.1 mi | ★★★★★ | 1 | 0 |
| Hilltop Health And Rehabilitation | 7.7 mi | ★★★★★ | 2 | 0 |
| Willowbrooke Court Sc Ctr At Tryon Estates | 17.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.