Cedar Haven Operations Llc Dba Lake Forrest Health
Cedar Haven Operations LLC DBA Lake Forrest Health in Smithfield, RI — inspection on November 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Haven Operations LLC Dba Lake Forrest Health
180 Log Road Smithfield, RI 02917
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Haven Operations LLC Dba Lake Forrest Health
180 Log Road Smithfield, RI 02917
SUMMARY STATEMENT OF DEFICIENCIES
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
jeopardy to resident health or safety
Facility ID: