Cedar Haven Operations Llc Dba Lake Forrest Health
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident ID #2 was interviewed in the presence of the Social Worker and the Administrator and reports that Staff C is .crazy and doesn't belong here. Additionally, the report revealed that the facility apologized to the resident and reassured him/her that Staff C will not be returning to the facility.During a surveyor interview
on 11/18/2025 at 2:28 PM, with the DNS revealed that Staff C was added to a Do Not Return list and reported to the State Licensing Department and Agency that she was employed by. Additionally, she was unable to provide evidence that the facility kept Resident ID #2 free from sexual abuse.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Haven Operations LLC Dba Lake Forrest Health
180 Log Road Smithfield, RI 02917
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0726
F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
vitamins.Record review of an undated written statement authored by CMT, Staff A, revealed that on the morning of 11/16/2025 she was preparing medications when the nurse gave her a cup of medications to administer to Resident ID #2. When she went into Resident ID #2's room s/he was sleeping. She then placed the prepared cup of medications for Resident ID #2 in the drawer of the medication cart and started to prepare Resident ID #1's medications. She revealed at this time she was distracted and placed Resident ID #1's medication cup down to assist another resident. When she returned, she retrieved Resident ID #2's medications and administered them to Resident ID #1 in error. Record review of a written statement dated 11/16/2025 authored by Registered Nurse, Staff B, revealed that on the morning of 11/16/2025 she signed off narcotics for Resident ID #2 and then gave them to the CMT to administer. She then indicated the medications were subsequently given to Resident ID #1 by Staff A. Resident ID #1 was observed in his/her wheelchair with pinpoint pupils, lethargic and unresponsive. She administered two emergency doses of Narcan and called EMS.During a surveyor interview on 11/17/2025 at 2:04 PM with Staff A, she revealed that on 11/16/2025 during the morning medication pass she was distracted and inadvertently gave Resident ID #1 another resident's medications. She further revealed, the medications included Scheduled II narcotics that Registered Nurse, Staff B, had given to her to give to another resident. Additionally, she acknowledged that she should not have given the narcotics, and she should not have had Resident ID #2's medications pre-poured in the medication cart.During a surveyor interview on 11/17/2025 at 2:33 PM with Staff B, she indicated that on the morning of 11/16/2025 she retrieved Resident ID #2's narcotics that included, 10 mg of Oxycontin ER, 5 mg of Oxycodone and 50 mg of Lyrica from the locked narcotic box and then gave them to Staff A to administer to Resident ID #2 with his/her additional prescribed medications. She further revealed that approximately 30 minutes later Staff A told her that she accidently gave all Resident ID #2's medications to Resident ID #1. She went to assess Resident ID #1 who appeared lethargic, unresponsive with pinpoint pupils and administered two doses of 4 mg of Narcan and called 911.During a surveyor interview on 11/17/2025 at 2:45 PM, with the Director of Nursing Services, she acknowledged that Staff B should not have been pouring medications then having Staff A administer them.
Her expectation would be that the nurse administers narcotics, and it would be out of the CMT's scope of practice to administer to the resident. She further acknowledged that medications for Resident ID #2 should not have been pre-poured and left in the medication cart by Staff A.The failure of the facility to ensure that nursing staff followed established medication administration protocols, adhered to scope-of-practice requirements, and maintained safe medication-handling practices resulted in significant medication errors that placed Resident ID #1 in immediate jeopardy. This failure contributed to the resident receiving multiple medications not prescribed to him/her, requiring emergency intervention and hospital transfer. Cross reference F-F760
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Haven Operations LLC Dba Lake Forrest Health
180 Log Road Smithfield, RI 02917
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760
exhibiting adverse effects which resulted in Resident ID #1 being admitted to a hospital, where s/he required treatment for a drug overdose Cross reference F 726
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Cedar Haven Operations LLC DBA Lake Forrest Health in Smithfield, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Smithfield, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cedar Haven Operations LLC DBA Lake Forrest Health or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.