Forest Manor Health and Rehab

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observations, interviews and a review of a facility policy titled, Labeling and Dating Foods (Date Marking), the facility failed to ensure food items in the cooler, freezer and dry storage area were labeled. This had the potential to affect 121 of 121 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Labeling and Dating Foods (Date Marking) with no effective date, revealed: Guideline: . 1. Date marking for dry storage food items . dry food items will be dated with the date the case was received into the facility and will be using, first in-first out .3. Frozen food packages removed from the case will be dated with the date, the item was received into the facility and will be stored using the first in-first out .4. […]

• No harm, potential for more than minimal, patternF584Jun 29, 2023

  Based on observation, interview, the facility's policies for Maintenance Service and Cleaning and Disinfection of Environmental Surfaces, and the facility's Housekeeper job description; the facility failed to ensure 3 of 4 shower rooms in the long term care building were in good repair and free of grime build-up. In addition, the hallway at the entrance to the Station #2 Shower Room had water pooling under the linoleum tile, which was stained and peeling. This affected the shower rooms on Station #1, Station #2, and Station #3 and had the potential to affect 134 of 162 residents in the facility. […]

• No harm, potential for more than minimal, patternF880Aug 19, 2021

  Based on observations, interviews, record review and review of POTTER and PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #4, the Licensed Practical Nurse (LPN)/Treatment Nurse, removed her gloves, sanitized her hands, and put on clean gloves after cleaning Resident Identifier (RI) #9 and #11's pressure ulcers, and before applying clean dressings to resident's pressure ulcers on 08/18/2021. This deficient practice affected RI #9 and #11, two of three residents sampled for pressure ulcers. Findings Include: Page 1225 of Chapter 48 titled Skin Integrity and Wound Care of POTTER and PERRY's FUNDAMENTALS OF NURSING with a copyright date of 2017, revealed the following: . IMPLEMENTATION . 3. Clean ulcer thoroughly with normal saline or cleaning agent . […]

• No harm, potential for more than minimal, patternF658Feb 25, 2021

  Based on interviews, medical record review, and a review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, the facility failed to ensure RI (Resident Identifier) #1, a resident admitted to the facility on [DATE] and discharged on [DATE], then readmitted on [DATE] and discharged again on 01/31/21, received the ordered medication Clonazapam (Klonopin) on 01/14/21, 01/15/21, 01/16/21, 01/22/21, 01/23/21, 01/24/21, and 01/25/21, as ordered by the physician. RI #1 did not receive the Klonopin on 7 of 15 total days the resident was in the facility. This deficient practice affected RI #1, one of five sampled residents whose physician's orders [REDACTED]. […]

• No harm, potential for more than minimal, isolatedF656Jul 7, 2022

  Based on interviews, record review and a facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to ensure a comprehensive care plan was developed and implemented for RI (Resident Identifier) #1 a resident who resided in the facility from [DATE] through 11/04/21. This deficient practice affected RI #1, one of seven residents whose care plans were reviewed. Findings Include: A review of a facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016 revealed, . Policy Interpretation and Implementation 1. […]