Forrest Oakes Healthcare

In the surveyor’s words

From the most serious findings on record at Forrest Oakes Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF697May 6, 2022

  Based on observations, record review, resident, staff, Wound Care Physician and Medical Director (MD) interviews, the facility failed to provide pain management prior to surgical debridement of Resident #1's pressure ulcers. Surgical debridement is a procedure to remove debris or infected/dead tissue from a wound. The procedure lasted forty-five minutes. Resident #1 expressed pain, cried, grimaced, cringed, became nauseated and requested cessation of the procedure. Resident #1 experienced pain at a level of 9 on a scale of 0 to 10 and was not provided pain management consistent with her comprehensive person-centered care plan or her goals and preferences. This deficient practice affected 1 of 1 resident reviewed for pressure ulcers. […]

• Immediate jeopardy, isolatedF760Mar 5, 2021

  Based on record reviews and staff interviews, the facility failed to obtain and administer an intermediate acting insulin (NPH) and a rapid-acting insulin ([MEDICATION(S)]) for 1 of 3 newly admitted insulin dependent residents (Resident #2) resulting in hospitalization for six days with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital's discharge medication list included orders which read: 1. NPH 20 units subcutaneous daily before breakfast. 2. NPH 8 units subcutaneous each night at bedtime. 3. […]

• No harm, potential for more than minimal, widespreadF812Nov 10, 2022

  Based on observation and staff interviews the facility failed to maintain the refrigerator temperature of 41 degrees ( ) Fahrenheit (F) or below, failed to store opened and cooked foods within safe temperature ranges, failed to discard expired foods stored ready for use and failed to label and date opened foods in 1 of 1 reach-in refrigerators which had the potential to affect food served to residents. The findings included: 1. An initial tour of the kitchen was conducted with the Dietary Manager (DM) on [DATE] at 10:16 AM, the thermometer in the reach-in refrigerator read 58 F. Recheck of reach-in refrigerator temperature on [DATE] at 10:45 AM, thermometer read 52 F. […]

• No harm, potential for more than minimal, patternF584Feb 6, 2025

  Based 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. The findings included: 1a. On 2/3/25 at 11:33 AM, room [ROOM NUMBER]'s bed control was observed lying on the mattress to the right of the resident's pillow. The bed control cord was noted with approximately 1 inch of yellow electrical tape below the control box. […]

• No harm, potential for more than minimal, patternF657Feb 6, 2025

  Based 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. The findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included history of a stroke and chronic obstructive pulmonary disease (COPD). The active care plan was last reviewed and revised on 10/3/24. […]