Fair Haven of Forest City: Missing Care Plans - NC
Fair Haven of Forest City failed to create care plans for two residents receiving high-risk medications, according to a federal inspection completed April 2, 2025. One patient with chronic obstructive pulmonary disease and recurrent pneumonia had no respiratory care plan. Another resident taking blood-thinning medication after a heart attack had no anticoagulant care plan.
The temporary MDS nurse, interviewed April 1 at 10:30 AM, said he had only held the role for a few weeks. He explained that Resident #1 had diagnoses of COPD, respiratory failure and recurrent pneumonia. "COPD should be included in Resident #1's care plan since it was a long-term issue," he told inspectors, but said he was "unsure why one was not in place."
Resident #32 presented a similar gap. Admitted with myocardial infarction and chronic atrial fibrillation, the patient received Apixaban 2.5 milligrams twice daily since October 11, 2025. Medication records showed consistent administration through March 31, 2026.
Yet no care plan addressed the anticoagulant use.
The temporary nurse acknowledged that Resident #32's quarterly assessment accurately documented anticoagulant use, "but her care plan did not address the use of anticoagulant medications." He told inspectors that anticoagulant medications "were considered high-risk medications and should be care planned."
Director of Nursing interviews revealed management expectations that contradicted facility practice. During a 12:14 AM interview April 2, the DON said she "expected the residents' care plans to be accurate and reflect care concerns." She stated that Resident #1 "should have a respiratory care plan in place due to her ongoing impaired respiratory status."
The DON attributed the oversight to staffing disruption. She indicated "the MDS Nurse who was responsible for updating care plans had recently quit and this may have contributed to the overlooking Resident #1's respiratory care plan."
Regarding the anticoagulant case, the DON told inspectors during a 1:45 PM interview that she "did not know why Resident #32's anticoagulant medication was not care planned." She said she "expected that all high-risk medications be care planned including anticoagulant medications."
Administrator interviews on separate days revealed similar gaps between policy and practice. On August 28, 2025, at 4:02 PM, the administrator stated "the care plans should reflect the clinical condition of the residents, including respiratory symptoms or diagnoses."
Months later, on April 2, 2026, at 2:45 PM, the same administrator told inspectors she "did not know why Resident #32's anticoagulant medication was not care planned." She said she "expected all resident care plans to be reflective of the resident's clinical condition including the use of anticoagulant medications."
The administrator acknowledged "that an anticoagulant care plan should have been implemented for Resident #32."
The facility lacked an MDS Coordinator during the inspection period. The Informatics Nurse said "the facility did not currently have an MDS Coordinator and he had been temporarily filling in for the past couple of weeks."
Resident #32's comprehensive care plan, initiated October 17, 2025, and last revised January 21, 2026, contained no focus areas or interventions related to anticoagulant medication use. This occurred despite the patient's January 16, 2026, quarterly assessment correctly indicating anticoagulant use.
The inspection found that management at multiple levels expected care plans to address residents' medical conditions and high-risk medications. Yet two residents continued receiving daily medications without written plans addressing their specific clinical needs.
Fair Haven is disputing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Haven of Forest City, LLC from 2026-04-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Fair Haven of Forest City, LLC in Forest City, NC was cited for violations during a health inspection on April 2, 2026.
One patient with chronic obstructive pulmonary disease and recurrent pneumonia had no respiratory care plan.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.