Forsyth Rehabilitation & Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility failed to keep dented cans separated from other cans, when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, when the facility staff failed to ensure fans in food areas were free from dirt and debris, and when staff stacked dishes while still wet. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 93 residents.1. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed promote each resident's right to self-determination when the facility failed to provide services to maintain good grooming and personal hygiene in accordance with resident preferences for five residents (Resident #86, #77, #84, #82, and #64). The facility census was 93. Review showed the facility did not provide a policy related to showers. 1. Review of Resident #86's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 06/12/25;-Diagnoses included diabetes (a chronic condition in which the body cannot regulate blood sugar levels properly), chronic pain, high blood pressure, and chronic osteomyelitis (an autoimmune disease that causes bone inflammation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rails; and failed to complete ongoing assessments to ensure the side rails are appropriate for use for eight residents (Resident #1, Resident #2, Resident #12, Resident #19, Resident #47, Resident #86, Resident #77, and Resident #100). The facility census was 93. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and effective infection prevention and control program when the facility failed to ensure staff were educated on enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities); failed to ensure staff wore appropriate protective personal equipment (PPE) when providing catheter care for two residents (Resident #1 and #66) with a catheter (flexible tubing that is used to drain urine from the bladder) and when accessing a peripherally inserted venous catheter (PICC - a tube inserted into a large vein near the heart got long term IV access) for one resident (Resident #101); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or the Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) at the initiation, reduction, or termination of Medicare Part A benefits for two sampled residents (Resident #16 and Resident #107) who remained in the facility upon discharge from Medicare Part A services. The facility census was 93. [...]

Inspectors wroteBased on interview and record review, the facility failed to carry out and document a physician order timely for a discontinued medication and failed to implement monitoring of fluid intake for one resident (Resident #77). The facility census was 93. Review showed the facility did not provide a policy regarding physician orders.1. Review of Resident #77's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 10/08/24;-Diagnoses included diabetes (metabolic disorder characterized by high blood sugar levels), high blood pressure, and congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 04/18/25, showed the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided respiratory care per standards of practice when staff failed to have a process in place to ensure routine cleaning of a continuous positive airway pressure (CPAP - a mask that uses air pressure to keep the airway open during sleep) device, failed to obtain orders for the use of the CPAP, and failed to include the use of a CPAP on the care plan for one resident (Resident #100). The facility census was 93.1. Review of Resident #100's face showed the following information:-admission date of 08/14/25;-Diagnoses included fracture of the humerus (upper arm bone) on right arm and anemia (deficiency of red blood cells). Review of the resident's discharge instructions from the hospital, dated 08/14/25, showed the resident used a CPAP at bedtime. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to support each resident's right to self-administer medication when the facility did not explore one resident's (Resident #1) ability to self-administer medications and creams the resident had in his/her room. The facility's census was 71. Review of the facility's policy titled, Medication Storage in the Facility, dated April 2017, showed the following: -Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate per facility policy; -A written order for the bedside storage of medications to be present in the resident's medical record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed ensure each resident's right to self-determination was supported when facility staff failed to offer and provide showers as preferred for one resident (Resident #1). The facility census was 71. Review of the facility's policy titled, Activities of Daily Living (ADLs), undated, showed the following: -This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating and communication. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide care per standards of practice to all residents when staff failed to to assess, identify, and provide appropriate treatment for a skin condition and failed to notify the physician of the change in condition for one resident (Resident #1) who developed a skin condition on the resident's face and head that required prescription shampoo and cream to treat. The facility census was 71 residents. Review of the facility's policy titled Wound Prevention, revised 8/2023, showed the following: -Conduct a comprehensive assessment upon move in to identify any existing wounds, skin conditions, or risk factors for wound development; -Perform routine skin assessments on all residents during regular monthly assessments; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection and control program, per standards of practice and facility policy, when the facility failed to ensure two employees (Housekeeper A and Licensed Practical Nurse (LPN) B), of six sampled residents, received tuberculosis (TB-a communicable disease that affects the lungs) screening tests as needed. The facility census was 75. General requirements for Tuberculosis Testing in Long-Term Care Facilities per 19 CSR 20-20.100: -Long-term care facilities shall screen staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -All skin test results are to be documented in millimeters (mm) of induration; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed free from possible contamination and in sound condition in accordance with professional standards when staff failed to dispose of food after expiration, ready-to-eat foods were touched with bare hands, a thermometer was not properly cleaned, and frozen meat was not stored properly. The failed practice had the potential to affect 76 census residents consuming food in the kitchen. Review of the facility's procedure titled, Basics for Handling Food Safety, undated, showed the following: -Do not buy food past sell by, use-by, or other expiration dates; -Don't cross contaminate; -Keep raw meat, poultry, fish, and their juices away from other food; -Make sure thawing meat and poultry juices do not drip onto other food. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature in accordance with professional standards for eight residents (Resident #18, #20, #25, #51, #8, #12, #7, and #73) of 20 sampled residents. Review of the facility's policy titled, Food Temperatures, dated 05/2015, revealed Hot food should be at least 120 degrees F [Fahrenheit] when served to the resident. 1. Review of Resident #18's Face Sheet, undated, in the electronic medical record (EMR) showed the following: -admission date of 02/19/20; -readmission date of 03/21/23; -Diagnoses included vitamin deficiency. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pureed food was prepared properly with appropriate texture in accordance with professional standards for seven residents receiving pureed texture. Review of the facility's procedure titled, Pureed, undated showed pureed food should have a smooth texture with no lumps. During an interview on 01/10/24, at 9:37 A.M., the Dietary [NAME] (DC) said they had seven residents who received the pureed texture. Review of the recipe for the pureed brown sugar glazed ham showed the following: -Prepare according to regular recipe with food thickener and water or stock and process until smooth. During an observation on 01/10/24, at 11:56 A.M., the DC prepared pureed ham. He/she placed plain boiled diced ham into the Robot Coupe (mechanical blender) and turned the machine on for processing. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a PASSAR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #14) of six residents reviewed for PASSAR. 1. During an interview on 01/10/24, at 10:46 A.M., the Administrator said they did not have any specific policy related to PASSAR. Review of Resident #14's Face Sheet, undated, located in the electronic medical record (EMR) under the profile tab, showed the following: -admission date of 09/28/12; -readmission date of 12/26/16; -Diagnoses included anxiety disorder, major depressive disorder, and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (Resident # 41), of three residents reviewed for activities of daily living/restorative services, received services to maintain or improve walking ability when staff failed to offer to walk with the resident. This failure created a potential for further decline of the resident's lower body strength and walking ability. 1. Review of Resident #41's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 03/20/22; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two residents (Resident #41 and #65), of five residents reviewed for immunizations, received the pneumococcal vaccination series or had documented refusals. These failures had the potential to increase the spread of pneumonia among the unvaccinated residents. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 01/24/22 and accessed on 01/11/24 at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html showed the following: -For adults 65 years or older, who have not previously received any pneumococcal vaccine, the CDC recommends to give 1 dose of PCV [pneumococcal conjugate vaccine] 15 or PCV20; -If PCV15 is used, this should be followed by a dose of PPSV [pneumococcal polysccahride vaccine] 23 at least one year later; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a clean manner when staff failed to keep the handsink clean, failed to keep walls in the dishwashing area clean, failed to keep shelves in the walk-in cooler clean, failed to keep an air vent clean, and failed to keep flies to a minimum. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice when multiple staff did not properly wear face coverings while assisting/conversing with seven residents (Resident #2, #3, #9, #16, #28, #48 and #70) during a coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) pandemic. The facility census was 83. Review of the updated guidance for healthcare workers from Centers for Disease Control and Prevention (CDC) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/23/21, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the floors throughout the kitchen were kept clean and free from debris. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; -Post the schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in resident rooms on the 300 hall including rooms of six residents (Resident #11, #20, #40, #55, #56, and #57). The facility census was 83. Record review of the facility's policy Pest Control, undated, showed the following: -Purpose to provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Record review of the facility's completed maintenance work orders for April 2021 to July 23, 2021, showed no mention of flies in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to report an allegation of abuse to the state survey agency (Department of Health and Senior Services - DHSS) when one resident (Resident #71) stated that Nurse Aide (NA H) and one resident (Resident #49) were having an affair. The facility census was 83. Record review of the facility's Abuse Prevention Policy, dated 11/28/16, showed the following information: -Immediately educate all staff to report to the administrator and/or designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the cleanliness of resident oxygen nasal cannula tubing and failed to ensure the oxygen humidification bottle contained water for one resident (Resident #1). The facility census was 83. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; -Oxygen therapy is usually combined with a humidification device, to prevent mucosal dryness; -Because oxygen concentrator tanks deliver absolutely dry oxygen, humidification is recommended by some; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physicians' orders for bed rails and failed to complete bed rail assessments and measurements to check for risk of entrapment for two residents (Resident #180 and Resident #181). The facility census was 83. Record review of the facility's policy titled, Physical Restraints, undated, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body; -Determine the type of side rails to be used; -Determine the medical symptoms to be treated with side rails; -Involve the resident and the resident's representative in planning for side rail use. [...]