Forest Manor HCC

Inspectors wroteCompliant #: NJ168954, NJ169014 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was dependent on staff for transfers was safely and properly transferred to bed with two staff members via a Hoyer lift (a mechanical lift) who was transferred by one staff member on 11/2/23, and fell sustaining a laceration to their head and a skin tear to their left hand. This deficient practice was identified for 1 of 3 residents (Resident #301) reviewed for accidents and was evidenced by the following: On 3/19/25 at 10:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LHNA) to provide a copy of the Facility Reportable Event (FRE) that was reported to the New Jersey Department of Health (NJDOH) for Resident #301. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. On 3/19/25 at 10:14 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. The 5 bay steam table was observed dirty with broccoli, potatoes white/greyish colored murky water in all 5 bays. The FSD stated the steam table bays should be cleaned nightly at end of day and acknowledged that they were not drained and cleaned according to facility policy. They should be drained and cleaned to prevent cross contamination and bacteria. 2. In the walk-in freezer, the surveyor observed multiple open bags of French toast, tilapia, mixed vegetables and cookie dough; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of 20 residents (Resident #14) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: On 3/19/25 at 10:20 AM and 3/24/25 at 10:10 AM, the surveyor observed Resident #14 lying in bed, awake and alert. The surveyor observed that the call light was hanging on the left side of the resident's bed. Resident #14 stated they would shout for help if they could not find the call light. On 3/19/25 at 10:22 AM, the surveyor interviewed the Unit Manager/ Licensed Practical Nurse (UM/LPN), who stated that the call bell should be within the residents' reach. The UM/LPN placed the call light on the resident's sheets. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included refusal of care. This deficient practice was identified for one (1) of 20 residents (Resident #49) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 3/19/25 at 10:05 AM, the surveyor observed Resident #49's right hand closed tightly, with nails dug into the palm. The surveyor interviewed the residents and stated they could not open their hands but did not bother them. On 3/19/25 at 10:15 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that the resident was refusing any device for the hand. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure signing the reconciliation form Individual Patient Controlled Substance Administration Record - 30 dose (IPCSAR; declining inventory log) form after the dispensed and administered a controlled dangerous substance (narcotic with high potential for drug diversion) medication for one (1) of 20 residents (Resident #250) medication carts reviewed for medication storage. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, it was determined that the facility failed: a.) to have readily accessible an initial physician assessment (IPA) and b.) legible physician's progress notes (PPN). This deficient practice was identified for 3 of 6 residents reviewed (Resident #83, #49, and #72) and was evidenced by the following: 1. On 3/19/25 at 10:42 AM, the surveyor observed Resident #83 awake in their bed. Resident #83 stated they have only been in the facility for two months but might be staying long-term. Resident #83 stated they had seen the Nurse Practitioner (NP) but did not remember seeing the Primary Physician (PP #1). A review of Resident #83 Face sheet (FS) (an admission summary), was admitted to the facility with diagnoses that included but were not limited to depression, anxiety disorder, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, review of medical records, and pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for handling soiled linens observed in the hallway of the floor unit. This deficient practice was evidenced by the following: On 3/24/25 at 10:14 AM, the surveyor observed a Certified Nurse Assistant (CNA) dragging the plastic bag with soiled linens inside from the shower room to the soiled utility room. The CNA said she was rushing to remove the dirty linens from the bathroom. The CNA stated she should use the bin in the hallway to put the soiled linens, but she did not want to use it because it would be full. On 3/24/25 at 10:16 AM, the surveyor called the attention of the Unit Manager/Licensed Practical Nurse (UM/LPN), who witnessed the CNA dragging the plastic bag full of soiled linens. [...]

Inspectors wroteBased on observations and interviews from 03/19/2025 to 03/21/2025 in the presence of the Administrator and Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning. This deficient practice had the potential to affect 2 of 120 resident and was evidenced by the following: An observation on 3/19/2025 at 10:55 AM revealed that 2 of 2 call bells for resident room [ROOM NUMBER] did not function when tested by the DM. Neither audible nor visual notification of activation was given at the nurse's station. In an interview at the time, the DM confirmed the observation and stated that he would have someone repair it right away. The facility's Administrator was informed of the deficient practices at the Life Safety Code exit conference on 03/21/2025 at 2:00 PM. N.J.A.C 8:39-31.2 (e)

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) incidents pertaining to a.) a bruise of unknown origin and b.) four incidences of resident-to-resident physical abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #21 and #81) and was evidenced by the following: 1. On 03/22/23 at 11:14 AM, the surveyor observed Resident #21 sitting in a wheelchair in the hallway. The surveyor interviewed the resident at this time. The resident stated that they have been at the facility for several years. According to the admission Record, Resident #21 was admitted to the facility with diagnoses which included, but were not limited to, Dementia, need for assistance with personal care, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 03/22/23 at 12:03 PM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the dry storage room, an opened an undated package of chicken soup mix powder wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the container should have been dated when opened. 2. In the dry storage room, a dented can of applesauce was stored on a shelf alongside undented cans. When interviewed, the FSD stated the can should not have been on the rack and should have been placed in the designated dented can area. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to transcribe a current Physician's Order for a resident's diet for 1 of 5 residents (Resident #36) reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that a resident received supplemental oxygen as prescribed by the physician for 1 of 1 resident (Resident #3) reviewed for respiratory care. The deficient practice was evidenced by the following: On 03/22/23 at 11:35 AM, the surveyor observed Resident #3 in bed wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that they usually receive 2 LPM of oxygen. On 03/24/23 at 10:10 AM, the surveyor observed Resident #3 sitting in their wheelchair in their room. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to consistently assess and monitor the dialysis access site for any complications before and after dialysis treatments for 1 of 1 resident (Resident #26) reviewed for dialysis care This deficient practice was evidenced by the following: According to the admission Record, Resident #26 was admitted with diagnoses which included, but were not limited to, end stage renal (kidney) disease and dependence on renal dialysis. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the managment of care, dated 01/31/23, revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated that the resident had moderately impaired cognition. [...]

Inspectors wroteCOMPLAINT # NJ00160909 Based on interview, record review, and review of facility documents, it was determined that the facility failed to a.) notify the physician when a medication became unavailable and b.) maintain an accurate record of a controlled drug for 1 of 3 residents (Resident #138) reviewed for pain management. This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #138 had diagnoses that included, but were not limited to, palliative care, umbilical hernia, and altered mental status. Review of Resident #138's Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/06/23, revealed the resident was rarely/never understood, and had moderately impaired cognitive skills for daily decision making. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations for 1 of 6 residents (Resident #5) reviewed for unnecessary medications. The deficient practice was evidenced by the following: On 03/27/23 at 10:30 AM, the surveyor observed Resident #5 in bed. The resident stated that he/she slept well but was tired. Resident #5 informed the surveyor that he/she didn't want to get out of bed. According to the admission Record, Resident #5 was admitted to the facility with diagnoses that included, but were not limited, to unspecified Dementia without behavioral disturbances and Major Depressive Disorder. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure a PRN (as needed) psychotropic medication was ordered for a 14-day period for 1 of 5 residents (Resident #81) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 03/24/23 at 12:17 PM, the surveyor observed Resident #81 sitting at a table during the lunch meal service. The resident was calm and showed no signs or symptoms of distress or discomfort. According to the admission Record, Resident #81 was admitted to the facility with diagnoses which included, but were not limited to, dementia without behavioral disturbance, insomnia, restlessness, and agitation. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner, and properly store potentially hazardous foods to ensure they are used by a safe use by date to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 08/13/21 at 9:00 AM the surveyor conducted a tour of the kitchen in the presence of the Dietary Director. 1.) At 9:12 AM, the surveyor observed the ice scoop that was attached to the wall next to the ice machine and stored in a plastic holder. The bottom part of the ice scoop was in direct contact with the holder. The surveyor observed a grayish material caked to the bottom of the ice scoop holder. The Dietary Director stated that the ice scoop holder looked dusty and was usually cleaned everyday. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a.) ensure that interventions were in place and consistently implemented to prevent accidents, and b.) ensure that residents at risk for falls received adequate supervision to prevent falls. This deficient practice was identified for two of five residents, (Resident #31 and #78) reviewed for accidents and was evidenced by the following: 1.) On 08/13/21 at 10:41 AM, the surveyor observed Resident #78 seated in a wheelchair in front of the nurse's station with an overbed table placed in front of him/her. The surveyor observed that both resident's eyes were black underneath, and the bridge of the resident's nose was reddish in color and swollen. The resident stated that that he/she had fallen out of his/her wheelchair but couldn't recall when. [...]