Fair Haven Forest City: PASRR Evaluation Failure - NC
The facility failed to submit a Level II PASRR evaluation request for Resident #14, who was admitted with an active bipolar disorder diagnosis and received daily psychiatric medications, federal inspectors found in April.
Resident #14 entered Fair Haven on an unspecified date with multiple diagnoses including bipolar disorder. A Level I PASRR screening had been completed before admission on March 20, 2018, but no follow-up Level II evaluation was ever requested.
The resident's medical records showed he was severely cognitively impaired by his most recent quarterly assessment. Despite having no behavioral issues or signs of depression, he remained on two psychiatric medications: mirtazapine 15 milligrams daily for depression and appetite, and Lamictal 25 milligrams daily as a mood stabilizer for bipolar disorder.
His care plan from June 17, 2025 focused specifically on antidepressant medication management, with a stated goal that he "would remain free from side effects of the medication." Staff were directed to administer medications as ordered and monitor for adverse effects.
The Social Worker told inspectors on April 2 that she knew Resident #14 already had a Level I PASRR when he was admitted. She said that because the initial screening existed, "she did not submit a referral for a Level II PASRR evaluation and was not aware she had to."
She acknowledged knowing about the resident's bipolar disorder diagnosis.
PASRR evaluations are federal requirements designed to ensure nursing home residents with mental illness receive appropriate specialized services. Level II evaluations provide comprehensive assessments that can unlock access to psychiatric treatment and support services.
The Social Worker's admission revealed a fundamental gap in understanding the screening process. Level I evaluations are preliminary screenings, while Level II evaluations provide the detailed assessments needed to connect residents with mental health services.
Administrator interviews on April 2 confirmed the facility understood the importance of proper PASRR evaluations. The Administrator told inspectors "it was important that level II PASRR evaluations were completed for residents who met criteria so they could receive the services they needed."
The contradiction was stark: leadership recognized the evaluations' importance for connecting residents to needed services, while the Social Worker responsible for initiating them didn't understand when they were required.
Resident #14's case highlighted the consequences of this knowledge gap. Despite having an active bipolar disorder diagnosis, receiving daily psychiatric medications, and being severely cognitively impaired, he had gone without the comprehensive mental health assessment that could have connected him to specialized psychiatric services.
The facility's medical records showed careful attention to medication management and side effect monitoring. Staff tracked his psychiatric medications meticulously, noting dosages and indications. But they failed to pursue the evaluation that could have expanded his access to mental health support.
Federal regulations require nursing homes to ensure residents with mental illness receive appropriate treatment and services. The PASRR process serves as a gateway to these specialized resources, but only when facilities properly navigate the evaluation requirements.
Fair Haven is disputing the citation, according to inspection records.
The case represents more than administrative oversight. For Resident #14, the missing evaluation meant potential years without access to psychiatric services that could have enhanced his care and quality of life, despite his facility's recognition that such evaluations were important for residents to "receive the services they needed."
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
- View all inspection reports for Fair Haven of Forest City, LLC
- Browse all NC nursing home inspections
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: June 15, 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.
Resident #14 entered Fair Haven on an unspecified date with multiple diagnoses including bipolar disorder.
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.
Frequently Asked Questions
- What happened at Fair Haven of Forest City, LLC?
- Resident #14 entered Fair Haven on an unspecified date with multiple diagnoses including bipolar disorder.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Forest City, NC, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Fair Haven of Forest City, LLC or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 345314.
- Has this facility had violations before?
- To check Fair Haven of Forest City, LLC's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.