Forest Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Forest Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Feb 8, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Feb 11, 2026

  Based 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.Findings: Review of the facility's policy titled, Infection Control Linen Handling dated 06/14 revealed the following:Soiled Linen can be a source of infection and should be handled carefully. Soiled linen.Deposit soiled linen.into hamper. cover. […]

• No harm, potential for more than minimal, patternF658Jan 30, 2025

  Based 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. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. […]

• No harm, potential for more than minimal, patternF759Jan 30, 2025

  Based 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. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. […]

• No harm, potential for more than minimal, patternF760Jan 30, 2025

  Based 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. Findings: Review of the facility's policy titled, Administration of Medications revealed the following, in part: Purpose: To administer medications in accordance with best practice. Procedure: 2. Administration of any drug requires a physician's order. 3. […]