Forest Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Forest Health & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF825Jun 29, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide specialized rehabilitative services as required in the plan of care for one of five residents in the survey sample (Resident #1). The findings include: For five weeks, Resident #1 was not provided occupational and physical therapy as ordered by the physician and as required in her rehabilitation plan of treatment. Resident #1 was admitted to the facility with diagnoses that included left foot abscess, lower limb cellulitis, lymphedema, cerebral palsy, pressure ulcer and morbid obesity. […]

• No harm, potential for more than minimal, patternF684Jun 15, 2022

  Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to implement a physician's order for one of eighteen residents in the survey sample, Resdient #29. Resident #29's physician ordered eye drops were not administered for three weeks. The findings include: Resident #29 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), diabetes, congestive heart failure, chronic kidney disease, bipolar disorder, anxiety, atrial fibrillation, insomnia, hypertension, and osteoporosis. The minimum data set (MDS) dated [DATE] assessed Resident #29 as cognitively intact. On 6/14/22 at 11:58 a.m., Resident #29 was interviewed about quality of care in the facility. […]

• No harm, potential for more than minimal, patternF803Jun 15, 2022

  Based on observation, resident interview, staff interview, facility policy review and clinical record review, the facility staff failed to provide food items per the menu and/or meal ticket for two of eighteen residents in the survey sample, Resident #29 and #32. Resident #29 and 32 were not routinely provided food per their meal ticket or as listed on the menu. The findings include: 1. Resident #29 was admitted to the facility with diagnoses that included [CONDITION(S)] ([CONDITION(S)]), diabetes, [CONDITION(S)], chronic kidney disease, [CONDITION(S)], anxiety, [CONDITION(S)], [CONDITION(S)], hypertension, and [CONDITION(S)]. The minimum data set (MDS) dated [DATE] assessed Resident #29 as cognitively intact. […]

• No harm, potential for more than minimal, patternF656Feb 25, 2021

  Based on staff interview and clinical record review, the facility staff failed to develop comprehensive care plans for eleven of 22 residents in the survey sample, Resident #'s 10, 17, 33, 39, 5, 12, 31, 18, 8, 301, and 11. Resident #10 had no care plan developed for activities of daily living, incontinence, falls, nutrition, pressure ulcer prevention, psychoactive medication use, pain management, [CONDITION(S)], fluid intake restrictions or [CONDITION(S)]. Resident #17 had no care plan developed for activities of daily living, incontinence, falls, dehydration, dental problems, pressure ulcer prevention or [CONDITION(S)] medication use. […]

• No harm, potential for more than minimal, isolatedF602Sep 13, 2025

  Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident property for 1 (Resident #98) of 4 sampled residents reviewed for abuse. Specifically, Licensed Practical Nurse (LPN) #18 misappropriated Resident #98's oxycodone pain medication without the resident's permission on 04/11/2025.Findings included: A facility policy titled, Virginia Resident Abuse Policy revised 07/11/2024, indicated, POLICY: The facility will not tolerate the abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. […]