Forrest Oakes Healthcare

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of personal funds when the Medical Records Manager accepted money from the resident for cleaning his personal apartment. The Medical Records Manager was alleged to have accepted $280.00 from Resident #60 on 4/17/26. This deficient practice occurred for 1 of 1 resident reviewed for misappropriation of resident property (Resident #60).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed prior to admission for 1 of 2 residents reviewed for PASRR (Resident #7).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner and staff, the facility failed to accurately transcribe and carry out physician orders for protective skin care for 1 of 3 residents reviewed with pressure ulcers (Resident #48).

Inspectors wroteBased on observations, record reviews, staff, and Nurse Practitioner interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #46).

Inspectors wroteBased on manufacturer recommendations, observations, record reviews, and staff interviews, the facility failed to date multi use medications upon opening and failed to refrigerate unopened medication per manufacturer instructions on 1 of 3 medication carts reviewed (D Hall Cart).

Inspectors wroteBased on record review, observations, and staff and Nurse Practitioner interviews, the facility failed to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #33) reviewed.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a safe environment as evidenced by exposed wires to the bed control cord (room [ROOM NUMBER]) and to clean the vents of the Packaged Terminal Air Conditioner (PTAC-room [ROOM NUMBER]). The facility also failed to ensure resident rooms were clean and in good repair (Rooms #112, 128, 144, 120, 122, 126, and 129). This was for 8 of 18 resident rooms reviewed for comfortable, clean and homelike environment.

Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to review and revise a care plan following the most recent Minimum Data Set (MDS) assessment in the area of falls (Resident #6) and failed to revise the care plan in the area of side rails (Resident #31). In addition, the facility failed to develop an individualized and comprehensive care plan in the area of Activities of Daily Living (Residents #51 and #205) This was for 4 of 18 resident records reviewed.

Inspectors wroteBased on record reviews, observations, and family, resident, and staff interviews, the facility failed to provide nail care and/or incontinence care for 8 of 13 residents dependent on staff for activities of daily living (ADL) (Residents #9, #32, #35, #51, #205, #1, #206, and #33).

Inspectors wroteBased on observations, record reviews, staff interviews, resident interviews, and resident family interviews, the facility failed to provide sufficient nursing staff to provide incontinence care in a manner to maintain the residents' dignity (Resident #1, #206, and #9) and failed to provide assistance with Activities of Daily Living (ADL) to residents who required extensive to total care with nail care and incontinence care (Residents #9, #32, #35, #51, #205, #1, #206, and #33). This affected 8 of 18 sampled residents reviewed for sufficient staffing.

Inspectors wroteBased on observation, and staff, and family interviews and record review, the facility failed to serve the lunch meal at the posted time on 2/2/25 as well as failed to serve the breakfast meal at the posted time on 2/3/25 for 2 of 5 meal observations. This practice had the potential to affect other residents for meal delivery.

Inspectors wroteBased on observations and staff interviews, the facility failed to label, date and remove expired food items stored for use and remove food with signs of spoilage from 1 of 1 walk-in refrigerator and failed to ensure frozen food items were dated and not stored open to air with signs of freezer burn in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations, resident, resident family, and staff interviews, the facility failed to provide incontinence care in a manner to maintain the residents' dignity for 3 of 5 residents reviewed for dignity (Residents #1, #206 ,and #9).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to place a resident's call light within reach for 2 of 2 residents reviewed for accommodation of needs (Residents #6 and #14).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop an individualized and comprehensive care plan in the areas of pain and opioid medications (Resident #21), and the facility failed to implement a care plan area for safety (Resident #25). This was for 2 of 18 residents whose care plans were reviewed. 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included unspecified abnormalities of gait, osteoarthritis, and chronic pain syndrome. A review of the medication orders for Resident #21 for December 2024 revealed an order for oxycodone 5 milligrams, give 2 capsules by mouth every 4 hours as needed for pain that was active from 11/7/24 until 12/16/24. The order was changed to oxycodone 5 milligrams, give 1 capsule by mouth every 4 hours as needed for pain with a start date of 12/19/24 and end date of 12/31/24. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain a safe environment as evidenced by a housekeeping staff member mopping the entire width of the F hallway (Rooms 135-146) which would have required residents, staff, and visitors to walk on the wet floor. This was for 1 out of 5 resident hallways.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #33).

Inspectors wroteBased on record review, resident council members and staff interviews, the facility failed to resolve repeated grievances regarding cold food for 2 of the last 4 months, not answering call bells timely for 3 of the last 4 months and late medications for 4 of the last 4 resident council meetings.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure residents over the bed lights were in working order. This was for 2 (Resident #30 and Resident #40) of 5 residents reviewed for pressure ulcers. The facility also failed to ensure the walls in resident rooms were in good repair. This was for 4 (room #'s 117, #118, #123 and #127) of 19 rooms reviewed for homelike environment.

Inspectors wroteBased on observation, resident, and staff interviews the facility failed to provide the residents with meals served at regularly scheduled times for 1 of 1 meal observation of the F-Hall. This practice had the potential to affect meals served to other residents.

Inspectors wroteBased on observations, and staff interviews the facility failed to discard opened food items ready for use by the labeled discard date and failed to label, and date opened foods in 1 of 1 reach-in refrigerator and failed to label, and date opened foods in 1 of 1 reach-in freezer. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate medical records in the areas of medication and PICC (a peripherally inserted central catheter inserted into the vein of the arm) line dressing change (Resident #62) for 1 of 7 residents whose medications were reviewed.

Inspectors wroteBased on record reviews, observations, Hospice, Physician, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey completed 5/20/21. This was for two deficiencies that were cited in the areas of Activities of Daily Living Care Provided for Dependent Residents, and Resident Records-Identifiable Information. [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to promote dignity by the resident having no control of her over the bed light resulting in being awakened and disturbed when her over the bed light was turned at the light switch by the room door to assist her roommate. This resulted in the resident feeling angry and frustrated. This was for 1 (Resident #29) of 3 residents reviewed for dignity.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to complete a self-administration of medication assessment, obtain a physician's order, and care plan self- administration of medication before leaving medication at the resident's bedside. This was for 1 of 7 residents (Resident #27) reviewed for unnecessary medication.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to provide showers as scheduled or as needed for 1 (Resident #29) 3 residents reviewed for choices.

Inspectors wroteBased on record reviews and interviews with staff, the facility failed to document correct route of medication administration for 1 of 5 resident's (Resident #40) reviewed for unnecessary medication.

Inspectors wroteBased on record reviews, observations, and interviews with staff, the facility failed to set an alternating pressure mattress according to a resident's weight in 1 of 5 (Resident #40) residents reviewed for pressure injuries.

Inspectors wroteBased on record review, resident, staff and Physician interviews, the facility failed to obtain blood glucose checks as ordered for an insulin dependent resident. This was for 1 (Resident #25) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and facility staff interviews, the facility failed to complete a comprehensive discharge summary for 1 of 1 resident reviewed for discharge. (Resident #63).