Forrest Manor Nursing Center

Based on observation and interview, the facility failed to: a. follow standards of practice in meal service; b. serve meals in a sanitary manner; and c. utilize professional grade equipment in the kitchen. The BOM identified 61 residents who ate meals prepared and served in the kitchen. Findings: 1. On 09/08/24 at 8:20 a.m., observations were made in the kitchen. The hand washing sink was located in the corner of the kitchen and was blocked by a mop, bucket, and a covered trash can. Above the hand washing sink was a rack with cooking utensils hanging downward from the edge of a rack, blocking access to the hand washing sink. On 09/08/24 at 8:25 a.m., [NAME] #1 was observed to plate food for multiple residents with their gloved hands including grabbing and splitting biscuits before placing the biscuit on the plate, reaching into the steam table pans and grabbing bacon, fried eggs, toast, and pancakes with their gloved hands. The cook did not change gloves between food items or residents. The cook was observed to touch the pre-printed resident diet cards, the plates, trays, counter…

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 record review and interview, the facility failed to ensure code status was clearly identified in residents' medical records for two (#9 and #18) of twenty four sampled residents whose medical records were reviewed. A facility census list, dated [DATE], documented 61 residents resided in the facility. Findings: 1. Resident #9 had diagnoses which included chronic kidney disease and chest pain. Resident #9's medical record was reviewed. A sticker attached to the outside of the hard chart read, DNR [do not resuscitate]. A second sticker attached to the outside of the hard chart read, Full Code [which means to provide life saving measures]. An Oklahoma Do-Not -Rescucitate (DNR) Consent Form, dated [DATE], was found inside the resident's medical record and documented they wanted to a DNR code status. On [DATE] at 8:10 a.m., the ADON stated the sticker which identified the resident as a full code should have been removed once the DNR form had been signed. They stated they did have a policy and procedure that…

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.

Based on record review and interview, the facility failed to consistently monitor for trends related to infectious disease. The ADON identified the census was 61. Findings: A policy titled Forrest Manor Nursing Facility Infection Control Policy and Procedure, updated 05/23/22, read in part, .Facility has established an infection control program under which it .Investigates, controls and prevents infections in the facility . A review of the facilities infection surveillance documentation for 2024 did not document the facility had been tracking infectious disease or looking for trends related to infectious diseases for 01/24, 02/24 or 03/24. On 09/11/24 at 12:34 p.m., the ADON stated there were was no documentation infection surveillance could be located for 01/24, 02/24, or 03/24.

Based on record review and interview, the facility failed to ensure a resident was safe to self-administer medication for one (#204) of one sampled resident reviewed for self-administering medications. The ADON identified one resident that self-administered medications. Findings: An undated policy titled Right to Self-Administer Medications read in part, .Each resident has the right to self-administration of drugs unless the interdisciplinary team has determined that the practice would be a danger to the resident or others .The attached form will be completed and kept in the resident's medical record .the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to carry out the responsibility . Physician orders, dated 08/09/24, documented Resident #204 was to receive albuterol 3 mg/ipratropium 0.5 mg (bronchodilator medication) via nebulizer four times a day and it could be kept at bedside; and tiotropium bromide (anticholinergic medication) 2.5 mcg two inhalations once a day and it could be kept at bedside. On 09/11/24 at 12:34 p.m., the ADON stated…

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.

Based on record review and interview, the facility failed to provide a CMS-10123 form to a resident who discharged from part Medicare Part A services for one (#50) of three sampled residents reviewed for required paperwork related to discharging from Medicare Part A services. The BOM stated six resident had discharged from Medicare Part A services in the previous six months to the survey. Findings: An undated CMS-10123 form, documented Resident #50's coverage for Medicare Part A services would end on 06/14/24. The form was not signed. On 09/09/24 at 1:31 p.m., the BOM stated they had forgot to provide Resident #50 a CMS-10123 form for Medicare Part A services which Resident #50 discharged from on 06/14/24.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for one (#203) of five sampled residents reviewed for care plans. The ADON identifed 61 residents resided in the facility. Findings: Resident #203 had diagnoses which included diabetes mellitus and hypertension. There was no documentation a baseline care plan had been completed. On 09/12/24 at 10:21 a.m., RN #1 stated they did not complete Resident #203's admission. They stated they did not know if a baseline care plan was completed. On 09/11/24 at 12:34 pm, the ADON stated a baseline care plan for resident #203 was not located.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#203) of five sampled residents reviewed for care plans. The ADON identified 61 residents resided in the facility. Findings: Resident #203 had diagnoses which included diabetes mellitus and hypertension. There was no documentation a comprehensive care plan was completed for the resident. On 09/11/24 at 12:34 p.m., the ADON stated a care plan for resident #203 was not completed.

Based on observation, record review, and interview, the facility failed to care plan the use of bedrails for one (#42) of three sampled resident reviewed for accidents. The ADON identified 10 residents had some form of bed rail attached to their beds. Findings: A care plan, dated 05/23/24, did not include a problem, goal, or intervention regarding the safe use of bedrails. On 09/11/24 at 12:38 p.m., Resident #42's assigned bed was observed to have a full side rail attached to each side. On 09/11/24 at 12:46 p.m., CNA #2 stated Resident #42 had used a bed with bedrails for about six months. On 09/11/24 at 1:39 p.m., the ADON stated they had reviewed Resident #42's current care plan. They stated the resident's use of bedrails was not care planned. They stated the bedrails should have been care planned.

Based on observation, interview, and record review, the facility failed to provide showers as scheduled for one (#50) of two sampled residents whose clinical records were reviewed for ADL care for dependent residents. A facility census list, dated 09/08/24, documented 61 residents resided in the facility. Findings: On 09/08/24 at 11:45 a.m., Resident #50 was observed in bed. The resident's hair was long and appeared tangled and greasy. On 09/08/24 at 11:45 a.m., Resident #50 stated they were scheduled for two showers per week, but only received one a week. The resident stated they usually did not receive their shower scheduled for the weekend. The resident's clinical record was reviewed and documented they were scheduled to receive showers on Wednesdays and Saturdays. There was no documentation the resident was offered/received showers on 08/10/24, 08/17/24, 08/24/24, or 08/31/24 (all Saturdays). On 09/11/24 at 9:00 a.m., the ADON stated there should be a shower sheet filled out even if the resident refused. The ADON stated they needed to educate the weekend staff on ADL care and…

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.

Based on observation, record review, and interview, the facility failed to provide a care plan intervention for contracted hands of one (#6) of 24 sampled residents reviewed for the presence of contractures. The ADON identified five residents had contractures. Findings: A care plan problem for bilateral contracted hands, updated 06/04/24, documented the resident was to have contracture cushions or rolled rags in their hand if possible. On 09/08/24 at 12:32 p.m., Resident #6 was observed sitting in the dining room. Both of their hands appeared to be contracted. Neither hand had a device or material to protect and support their contracted hands. On 09/10/24 at 7:33 a.m., Resident #6 was observed in their room watching television. Both hands of the resident appeared contracted. There was nothing in either hand to protect or support the hands. On 09/10/24 at 1:56 p.m., RN #1 stated Resident #6 did have two contracted hands. On 09/11/24 at 11:12 a.m., CNA #1 stated the staff sometimes put rags in Resident #6's hands. They stated the resident did not have anything in their hand at that…

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.

Based on observation, record review, and interview, the facility failed to attempt alternatives to the use of bed rails and obtain informed consent for the use of bed rails prior to their use for one (#42) of three sampled residents reviewed for accident hazards. The ADON identified 10 residents at the facility had some form of bed rail attached to their beds. Findings: A facility Bed Safety policy, dated 12/2007, read in part, If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation of the Attending Physician, and input from the resident and/or legal representative. The policy further reads, The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Resident #42 had diagnoses which included Alzheimer's disease and atherosclerosis. A quarterly assessment, dated 05/16/24, documented Resident #42's cognition was severely impaired. On 09/11/24 at 12:38 p.m., Resident #42 was observed to have bedrails attached to both sides of their bed. At 12:46 p.m., CNA #2 stated the…

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.

Based on record review and interview, the facility failed to culture a urine sample prior to prescribing and administering an antibiotic for one (#9) of 24 sampled residents reviewed for the use of antibiotics. The ADON identified 17 residents who had been prescribed antibiotics in the past 90 days. Findings: A laboratory report documentated a sample of Resident #9's urine was collected on 07/10/24. The report documented an abnormal finding including high nitrate and white blood cell levels. The report also documented a note that stated a culture of the urine was indicated, but had not been ordered. On the bottom of the first page of the laboratory report was a hand written note which documented, Macrobid [antibiotic medication] 100 mg BID X 7 days. The hand written entry was noted by RN #1 on 07/16/24. A July 2024 MAR documented the resident had been administered Macrobid 100 mg orally for seven days starting on 07/16/24. On 09/09/24 at 7:36 a.m., Resident #9 stated they were taking an antibiotic medication. On 09/10/24 at 8:27 a.m., the ADON stated the resident was no longer being…

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.

Based on observation, record review, and interview, the facility failed to inspect the bed and bedrails of a resident prior to the use of bedrails for one (#42) of three sampled resident reviewed for accident hazards. The ADON identified 10 residents at the facility had some form of bed rail attached to their beds. Findings: A facility Bed Safety policy, dated 12/2007, read in part, To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories) the facility shall promote the following : a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. On 09/11/24 at 12:38 p.m., Resident #42's assigned bed was observed to have a full side rail attached to each side. On 09/11/24 at 12:41 p.m., CNA #2 stated Resident #42 did have full bedrails on their bed. They stated the resident was moved to their currently assigned room about six months prior to the survey. They stated the bed…

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.

Based on record review and interview, the facility failed to ensure advance directives were offered, with education provided, to three (#22, 24, and #38) of four residents sampled for advance directives. The Resident Census and Conditions of Residents report, dated 06/28/23, identified 66 residents resided at the facility. Findings: 1. Resident #22 was admitted with diagnoses which included diabetes type two. Review of the clinical record for Resident #22, revealed an advance directive acknowledgement form was not in the clinical record. On 06/29/23 at 10:03 a.m., the DON and the BOM were asked where the advance directive acknowledgement was for Resident #22. They stated Resident #22 did not have one if it was not in the clinical record. The BOM stated the acknowledgement was in the admission packet and was offered and explained to the resident and resident representative on admission, however, the representative did not sign the acknowledgement. 2. Resident #24 was admitted with diagnoses which included dementia. Review of the clinical record for Resident #24, revealed an advance…

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.

Based on record review and interview, the facility failed to provide advance notice of discharge from Medicare skilled services for three (#23, 27, and #38) of three residents who were reviewed for beneficiary notification. The BOM identified five residents who receive Medicare Part A services. Findings: 1. Resident #23 was admitted to Medicare Part A skilled services on 01/08/23. Resident #23 was discharged from skilled services on 05/24/23. Review of the SNF Beneficiary Protection Notification Review form, revealed the facility/provider had initiated the discharge from Medicare Part A services when benefit days were not exhausted. The form documented a SNF ABN was not completed and provided to Resident #23. The form documented the facility was not using the SNF ABN form. The form documented Resident #23 received a NOMNC. Resident #23 remained at the facility and received long term care. 2. Resident #27 was admitted to Medicare Part A skilled services on 12/8/22. Resident #27 was discharged from skilled services on 01/11/23. Review of the SNF Beneficiary Protection Notification…

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.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing and humidification bottles were changed for one (#30) of one resident sampled for oxygen services. The DON identified 14 residents who received oxygen services resided at the facility. Findings: Resident #30 was admitted with diagnoses which included emphysema. On 06/27/23 at 4:00 p.m., Resident #30 was observed in the east dining room. Resident #30 was observed to be using oxygen at one liter per minute via a nasal cannula. The tubing and humidification bottle were observed to be undated. On 06/29/23 at 08:45 a.m., Resident #30 was observed to have an oxygen concentrator in their room. The humidification bottle was observed to have one third of a cup of water and was undated. The oxygen tubing was observed to be undated. On 06/29/23 at 1:51 p.m., LPN #1 was asked what the policy and procedure was for oxygen and humidification bottles. They stated it was the responsibility of the night nurse to change and date them every other week. LPN #1 was asked where the task of changing the 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.

Based on observation, record review, and interview, the facility failed to ensure a psychotropic medication was not prescribed on an as needed basis for greater than 14 days without a physician's documented rationale, for one (#38) of five sampled residents reviewed for unnecessary medications. The, Resident Census and Conditions of Residents report, dated 07/05/23, documented 70 residents received psychotropic medications. Findings: Resident #38 had a diagnosis of anxiety disorder, unspecified. A Consultant Pharmacist Communication to Physician form, dated 04/18/23, documented the physician should document a rationale for the PRN use of Valium 5 mg if it was to be used beyond 14 days. The form documented the physician's response as, 90 days. A Consultant Pharmacist Communication to Physician form, dated 05/17/23, documented the resident's current PRN Valium order must have a rationale and duration for continued use beyond 14 days. The physician's documented response on the form was, 90 days. There was no documentation of a rationale for the extended PRN use of the Valium. A…

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.

Based on observation, record review, and interview, the facility failed to ensure unpasturized eggs were not served in a manner to prevent foodborne illness and to maintain a clean and sanitary ice machine. The DON identified 65 residents who received medications and meals from the kitchen. Findings: On 06/27/23 at 11:45a.m., observation of refrigerator #3 revealed a box of unpasturized eggs. The dietary manager was asked if they prepare eggs with runny yolks for residents. They stated, yes when a resident request it. The manager was asked if the eggs used for the residents were pasturized. They looked at the box of eggs and stated No. On 06/29/23 at 3:30p.m., the ice machine was observed with the maintenance supervisor. When the plastic deflector sheild was wiped with a white paper towel it revealed a a black and brown substance. The maintenance superviors was asked what the substance was. They stated it was dirt and mold. When asked how often the ice machine was cleaned they stated, it was cleaned by maintenance staff monthly and a service company quarterly. Review of the cleaning…

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.

Based on record review and interview, the facility failed to submit data to the PBJ staffing information for the third quarter of 2022. The Resident Census and Conditions of Residents report, dated 06/28/23, identified 66 residents resided at the facility. Findings: The PBJ Staffing Data Report [NAME] Report 1705D FY Quarter 3 2022 (April 1 - June 30) document, run dated 06/26/23, documented the facility had not submitted PBJ staffing data for that quarter. On 06/30/23 at 9:22 a.m., the CBOM #1 was asked if it was their responsibility to submit PBJ data. They stated it was. CBOM #1 was asked if the data had been submitted for the second quarter of 2022. CP #1 stated they were unsure but would go into the system and check. CBOM #1 then stated they were unable to access the system with their current password and they were working with someone to gain access.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure hand hygiene was conducted: a. when passing meal trays during the noon meal, and b. when administering medications to two (#25 and #51) of three residents observed during medication administration. The DON identified 65 residents who received medications and meals from the kitchen. Findings: 1. On 06/28/23 at 12:25 p.m., the meal cart was taken to hall 100. CNA #1 was not observed to wash/sanitize their hands. CNA #1 was observed to obtain a meal tray from the cart and enter room [ROOM NUMBER]. CNA #1 was observed to assist the resident to a sitting position on the side of the bed, unwrap the silverware from the napkin, and cut food on the plate. On 06/28/23 at 12:27 p.m., CNA #1 was observed to obtain another meal tray and enter room [ROOM NUMBER]. CNA #1 was not observed to wash/sanitize their hands. On 06/28/23 at 12:28 p.m., CNA #1 was observed to obtain another meal tray and enter room [ROOM NUMBER]. CNA #1 was not observed to wash/sanitize…

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.

Based on observation, interview, and record review, it was determined, the facility failed to ensure an assessment was completed to ensure the resident's bed/chair alarms were not a restraint and/or did not cause agitation for two (#9 and #52 ) of two residents reviewed for bed/chair alarms. The director of nursing documented there were four residents in the facility with bed/chair alarms. Findings: 1. Resident #9 had diagnoses which included Alzheimer's disease. A telephone order, dated 08/15/19, documented an order for a clip alarm due to the increased risk for falls. An admission assessment, dated 08/23/19, documented the resident was moderately impaired in cognitive skills for daily decision making, required extensive assistance with most activities of daily living, had no falls, and used a bed/chair alarm daily. A care plan, dated 09/02/19, documented: Problem The resident was at risk for falls/injury related to weakness, cognitive impairment, behaviors, and anxiety. Goal The resident's dignity would be maintained and no un-addressed falls/injury would occur over the next 90…

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's care plan was fully developed for one (#52) of 16 sampled residents whose care plans were reviewed. The administrator identified there were 58 residents in the facility. Findings: Resident #52 was admitted with diagnoses which included non-Alzheimer's dementia and history of falling. An annual assessment, dated 10/31/19, documented the resident was severely cognitively impaired, required the extensive assistance of one staff for most activities of daily living, used a wheelchair for mobility, had one fall with a major injury, had two falls with no injury, and had a bed and chair alarm. A care plan, dated 11/27/19, was reviewed and there was no care plan in place for bed and chair alarms. On 12/09/19 at 8:20 a.m., the resident was observed in her wheelchair being wheeled by a staff member to the dining room. On 12/12/19 at 1:28 p.m., the director of nursing was asked if the pressure alarms had been care planned. She stated she did not know.

Based on observation, interview, and record review, it was determined the facility failed to ensure cross contamination did not occur during incontinent care for one (#109) of one sampled resident reviewed for incontinent care. The director of nursing identified four residents in the facility who were incontinent of both bowel and bladder. Findings: Resident #109 had diagnoses which included dementia. A quarterly assessment, dated 10/23/19, documented the resident was severely impaired cognitively, required total assistance with activities of daily living, and was always incontinent of bowel and bladder. On 12/09/19 at 2:19 p.m., the resident was observed in bed with her eyes closed. On 12/12/19 at 9:55 a.m., certified nurse assistant #3 was observed providing peri-care for the resident. The certified nurse assistant washed her hands and put gloves on and then cleaned the resident's buttocks, which contained feces. The certified nurse assistant cleaned the area and did not remove her gloves or wash her hands. She used her soiled gloves to open a small individual container of…

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.