Cedar Haven Operations Llc Dba Lake Forrest Health
Cedar Haven Operations LLC DBA Lake Forrest Health in Smithfield, RI — inspection on December 1, 2025.
Found 2 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
dignity relative to his/her right to use electronic monitoring equipment.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Haven Operations LLC Dba Lake Forrest Health
180 Log Road Smithfield, RI 02917
SUMMARY STATEMENT OF DEFICIENCIES
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, relative to use of Enhanced Barrier Precautions (EBP, use of gown and gloves for high contact activities) for 1 of 1 resident reviewed, Resident ID #1.
Findings are as follows:Review of a facility policy titled, Guidelines for Management of MDROs [Multi-drug resistant organism] dated 4/15/2024 states in part, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] beyond which exposure to blood and body fluids is anticipated and refers to gown and glove use during high contact resident care.for those with wounds or indwelling medical devices.examples of resident care activities requiring gown and glove use.dressing, bathing/showering.providing hygiene, changing linens, changing briefs.
Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, altered mental status, gastrostomy (an artificial opening used to provide nutrition) status, and seizures.During a surveyor observation on 10/15/2025 at 9:37 AM of Resident ID #1's room revealed signage indicating that the resident is on EBP and staff is to wear a gown and gloves while performing care.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/6/2025 at 9:19 AM revealed Nursing Assistant (NA), Staff A, and NA, Staff B, in Resident ID #1's room providing morning care.
Additionally, Staff A and Staff B did not have gowns on, as required.During a surveyor observation on 10/15/2025 at approximately 8:00 AM, of the video surveillance footage provided by Resident ID #1's family, dated 10/8/2025 at 8:59 AM revealed Staff A in the resident's room providing care.
Additionally, Staff A did not have a gown on, as required.During a surveyor interview on 10/15/2025 at 11:22 AM with the Infection Preventionist he acknowledged that Resident ID #1 has been on EBP due to his/her gastrostomy since his/her admission and all staff providing care should be wearing a gown and gloves.During a surveyor interview on 10/15/2025 at 11:39 AM with Staff A, she acknowledged that she was not wearing a gown while providing care to Resident ID #1 on 10/6 and 10/8/2025.During a surveyor interview on 10/15/2025 at 12:41 PM with Staff B, she acknowledged that she was not wearing a gown while providing care to Resident ID #1 on 10/8/2025.During a surveyor interview on 10/15/2025 at approximately 1:00 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection relative to use of EBP for Resident ID #1.
Facility ID: