Forest Manor Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure a resident's medical records accurately reflected the residents' wishes for emergency basic life support for 1 (#9) of 34 reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE], when Resident #9 was admitted to Hospice care and her code status changed from receiving CPR (Cardiopulmonary Resuscitation) to DNR (Do Not Resuscitate). Resident #9 had a physician's order in the Electronic Medical Record revealing end of life wishes were DNR, which did not match the Advanced Directive wishes in the Physical Medical Chart, to receive CPR. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.