Forest Manor Nursing and Rehabilitation Center

Based on record review, observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff transported linens in a manner to prevent the spread of communicable diseases and infection. This had the potential to effect 168 residents living in the facility.Findings: Review of the facility's policy titled, Infection Control Linen Handling dated 06/14 revealed the following:Soiled Linen can be a source of infection and should be handled carefully. Soiled linen.Deposit soiled linen.into hamper. cover. On 02/09/2026 at 8:45 a.m., an observation was made of a CNA transporting an uncovered laundry basket to the soiled linen room. The uncovered linen basket was handed to S3LDY. On 02/09/2026 at 8:46 a.m., an interview was conducted with S3LDY. She confirmed the uncovered laundry basket contained soiled linen. She further confirmed soiled linens should always be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#5) resident reviewed for intravenous antibiotic therapy. The facility failed to administer antibiotic therapy at the prescribed rate for Resident #5.Review of the facility's policy dated 10/2016, titled Administration of Fluids/Medications via a Central Line Catheter revealed in part, the following:11. Start the infusion at the prescribed rate. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #5's current Physician Orders revealed an order for Cefepime Intravenous Solution 2 grams per 100 milliliters. Use 2 grams intravenously three times a day.An observation was made on 02/10/2026 at 11:55 a.m. of S7LPN initiating Resident #5's Cefepime intravenous infusion. S7LPN initiated the infusion at 150 mL an hour. The Cefepime intravenous bag label read infuse at 100 mL an hour.An interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure each resident received necessary respiratory care consistent with professional standards of practice. The facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 1 (#119) resident reviewed for oxygen therapy.Review of the facility's policy dated 08/2021, titled, Infection Control Oxygen Equipment Cleaning revealed the following, in part:7. Tubing should be replaced every 7 days. Review of Resident #119's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease. Review of Resident #119's MDS with an ARD of 12/31/2025 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #119's current Physician Orders revealed the following, in part:Start Date: 06/03/2024, oxygen at 2 L nasal cannula every 1 hour as needed. An observation was made on 02/09/2026 at 9:19 a.m. of Resident #119's oxygen tubing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure accuchecks were completed timely and insulin was administered before meals as ordered for 2 (#81, #93) of 4 (#8, #76, #81, and #93) residents reviewed for insulin administration. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. Administration of any drug requires a physician's order. Resident #81 Review of Resident #81's Clinical Record revealed he was re-admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #81's current Physician Orders revealed the following, in part: Novolog Flex Pen U-100 Insulin Apart 100 units/mL subcutaneous Pen-injector: administer 4 units subcutaneously before each meal as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for 3 (#88, #81 and #93) of 7 (#7, #8, #13, #76, #88, #81, and #93) residents observed during medication administration. A total of 26 opportunities were observed with 3 medication errors, which resulted in a medication error rate of 11.54%. The facility failed to ensure: 1. Resident #88's Eliquis was given as ordered; and 2. Resident #81's Insulin was administered before meals as ordered. 3. Resident #93's Insulin was administered before meals as ordered. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. Administration of any drug requires a physician's order. 3. Drugs and biologicals are administered nor more than one hour before and no more than one hour after dosage time on order. Resident #88 Review of Resident #88's Clinical Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors for 3 (#88, #81 and #93) of 7 (#7, #8, #13, #76, #88, #81, and #93) residents reviewed for medications. The deficient practice had the potential to effect the 158 residents residing in the facility who received medications. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. Administration of any drug requires a physician's order. 3. Drugs and biologicals are administered no more than one hour before and no more than one hour after dosage time on order. Resident #88 Review of Resident #88's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Chronic Systolic Congestive Heart Failure. Review of Resident #88's January 2025 Physician Orders revealed the following, in part: Eliquis 5mg one tablet by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. A resident's catheter remained off of the floor for 1(#91) of 3 (#24, #91, and #407) residents observed with an indwelling catheter; and 2. Staff properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during care for 4 of 4 (#24, #91, #407, and #409) residents whom required EBP. Findings: 1. Review of Resident #91's Clinical Record revealed she was readmitted to the facility on [DATE] with diagnoses, which included the following, in part: Personal History of Urinary Tract Infections, Retention of Urine, and Urgency of Urination. Review of Resident #91's current Physician Orders revealed Catheter-Foley 18F with an onset date of 05/31/2024. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1(#106) of 31 sampled residents by failing to ensure Resident #106 was coded correctly for a urinary tract infection (UTI). Findings: Review of Resident #106's Clinical Record revealed admission date of 06/15/2021, with diagnoses which included History of UTI. Review of Resident #106's Annual MDS with an Assessment Reference Date (ARD) of 12/30/2024, revealed Section I: Infections, Line I2300-UTI in last 30 days coded No by S4LPN on 12/31/2024. Review of Resident #106's Physician's Orders revealed Doxycycline 100 mg by mouth twice a day for 5 days related to History of UTI with an onset date of 12/23/2024. Review of Resident #106's Nurse's Notes revealed on 12/23/2024 the writer noted new order Doxycycline 100 mg by mouth twice a day for 5 days. Review of Resident #106's Physician's Progress note dated 12/23/2024 History of Present Illness section revealed, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 1 (#134) resident out of 31 total sampled residents. The facility failed to ensure Resident #134 was care planned for nutritional assistance in which she required supervision with meals. Findings: Review of Resident #134's Clinical Record revealed she was admitted on [DATE] with diagnoses which included Parkinson's Disease and Dysphagia. Review of Resident #134's Quarterly MDS with ARD of 12/06/2024 revealed Section GG: Eating was coded as supervision or touching assistance with one person physical assistance. Review of Resident #134's most recent Care Plan failed to reveal any interventions for activities of daily living related to eating nor any interventions for nutritional assistance needed. Review of Resident #134's Speech Therapy (ST) Discharge summary dated [DATE] revealed in part ST educated Resident #134 and staff on how to implement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure services were provided to meet quality professional standards for 2 (#4 and #98) of 32 residents reviewed in the final sample. The facility failed to ensure the following: 1. Nursing staff accurately documented the administration of oxygen therapy services and application of orthopedic walking boot for Resident #4, and 2. Nursing staff accurately documented administration of oxygen therapy services for Resident #98. Findings: Review of the facility's policy titled, Oxygen Administration, Concentrator, Storage, Assemblage revealed the following, in part: Procedure: 1. Obtain appropriate physician's order. Resident #4 Review of Resident #4's clinical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included Displaced Oblique Fracture of Shaft of Right Fibula, Chronic Diastolic Congestive Heart Failure, and Atrial Fibrillation. Review of Resident #4's MDS with an ARD of 01/17/2024 revealed a BIMS of 14, which indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident received adequate supervision to prevent an accident for 1 (#125) of 6 (#9, #92, #94, #125, #128, and #137) residents reviewed for accidents. Findings: Review of Resident #125's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Urinary Tract Infection, Lack of Coordination, Abnormal Gait and Mobility, and History of Falls. Review of Resident #125's Quarterly MDS with an ARD of 01/05/2024 revealed he had a BIMS of 9, which indicated he was moderately cognitively impaired. Further review of the MDS revealed he required supervision or touching assistance with ambulation. Review of Resident #125's Care Plan revealed the following, in part: Problem Onset: 04/28/2023 Problem: Risk for falls related to history of falls. Approaches, in part: Bright sign placed in bathroom, on 09/20/2023 added bright tape to bathroom call light for visual cue. Problem Onset: 01/10/2024 Problems: At risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Narcotic medication was stored appropriately in 1 (Cart D) out of 8 (Cart A, Cart B, Cart C, Cart D, Cart E, Cart F, Cart G, and Cart H) medication carts observed, and 2. Medications were stored in a locked compartment and not available to unauthorized staff or residents to access for 1 (#159) of 8 (#81, #105, #111, #121, #129, #142, #159 and #513) residents reviewed for medication administration. Findings: 1. An observation was made of Cart D on 02/05/2024 at 3:00 p.m. with S13LPN with one loose, white, oblong pill stamped with M367 in an unlabeled medication cup. An interview was conducted on 02/05/2024 at 3:29 p.m. with S13LPN following the above observation. She confirmed the loose, white, oblong pill stamped with M367 was hydrocodone 10mg. She stated, a while ago,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure: 1. Staff practiced proper glove use and hand hygiene during meal service. This had the potential to affect all of the 163 residents residing in the facility. 2. Oxygen tubing remained off the floor and covered when not is use for 2 (#4 and #81) of 5 (#4, #24, #81, #92 and #112) residents reviewed for oxygen. Findings: 1. Review of facility's policy titled Hand Hygiene revealed, in part: Purpose - To cleanse hands to prevent transmission of infection or other conditions. - To provide clean, health environment for residents, staff and visitors. Indication for hand washing 3. Before and after procedures. 9. Wearing gloves does not replace the need to perform hand hygiene. Selecting Hand Washing Method: 2. When to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to ensure a resident had pain medication available when necessary for 1 (#63) of 32 residents reviewed in the final sample. Findings: Review of the facility's policy titled, Pain Screen and Management revealed, in part: All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. 4. Acute onset of pain: a. A pain screen is completed when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief. b. When documenting regarding pain, the following elements should be addressed: Date and time of onset, location of pain, character,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.