Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as an annual survey of Forest Manor Health and Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Capacity: 162
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with policies related to maintenance service and cleaning and disinfection of environmental surfaces, specifically focusing on the condition of shower rooms in the long term care building.
Findings
The facility failed to ensure that 3 of 4 shower rooms were in good repair and free of grime build-up, with issues including water pooling under linoleum tiles, missing and damaged ceramic floor and wall tiles, rusted metal door frames and ceiling frameworks, and torn shower bed pads. These conditions were deemed unsanitary, not homelike, and posed potential safety and infection control risks affecting up to 134 of 162 residents.
Deficiencies (1)
Failed to ensure 3 of 4 shower rooms were in good repair and free of grime build-up, including water pooling under linoleum tiles, missing and damaged floor and wall tiles, rusted metal door frames and ceiling frameworks, and torn shower bed pads.
Report Facts
Residents potentially affected: 134
Total licensed capacity: 162
Linoleum floor tiles affected: 17
Missing ceramic floor tiles: 29
Missing ceramic floor tiles: 5
Cuts in shower bed pad: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (EI #4) | Reported residents on Station #1 use Station #1 and Station #3 Shower Rooms | |
| Housekeeping Supervisor and Maintenance Director (EI #3) | Conducted tour of shower rooms and commented on conditions | |
| Administrator (EI #1) | Acknowledged awareness of water under linoleum tile | |
| Housekeeper (EI #8) | Reported Station #1 Shower Room floor tiles needed replacement | |
| Licensed Practical Nurse (EI #10) | Reported knowledge of linoleum tile issue and reported it to Maintenance Director | |
| Director of Nursing (EI #2) | Reported torn shower bed pad as infection control and safety issue |
Inspection Report
Routine
Deficiencies: 2
Date: May 13, 2021
Visit Reason
The inspection was conducted to assess compliance with respiratory care procedures and food labeling and storage standards at Forest Manor Health and Rehab.
Findings
The facility failed to ensure proper storage of a resident's nebulizer mask according to policy, posing an infection risk, and failed to label food items in the cooler, freezer, and dry storage areas, potentially affecting all residents receiving meals.
Deficiencies (2)
Nebulizer mask was not stored in a plastic bag as per facility policy, risking infection.
Food items in the cooler, freezer, and dry storage area were not labeled as required by facility policy.
Report Facts
Residents affected: 1
Residents affected: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Interviewed regarding nebulizer mask storage | |
| Director of Nursing | Interviewed regarding nebulizer mask storage and infection risk | |
| Dietary Manager | Interviewed regarding food labeling practices |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 11, 2019
Visit Reason
The inspection was conducted as a result of multiple complaints alleging inadequate care including failure to provide baths as scheduled, failure to follow physician's orders for wound care, medication errors upon discharge, insufficient staffing, and poor food quality.
Complaint Details
This inspection was triggered by complaints AL00036092, AL00036202, AL00036204, AL00036205, and AL00034206 regarding inadequate bathing, medication errors, staffing shortages, and poor food quality. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure residents received scheduled baths and proper ADL care due to staffing shortages, failed to follow physician's orders for compression dressings, and discharged a resident with another resident's medication. Additionally, the food served was reported as bland and unpalatable. These deficiencies affected multiple residents and were substantiated by interviews, observations, and record reviews.
Deficiencies (6)
Failure to provide scheduled baths for residents #86 and #140 according to individualized care plans.
Failure to apply physician-ordered three-layer compression dressings for resident #197 on specified dates.
Incomplete physician's order missing route and frequency for resident #61.
Resident #198 discharged with another resident's medication, resulting in medication error.
Insufficient nursing and CNA staffing leading to unmet resident care needs including missed baths and inadequate assistance.
Food served was bland, tough, and unpalatable as reported by residents and observed by surveyors.
Report Facts
Residents affected by bathing deficiency: 2
Residents affected by compression dressing deficiency: 1
Residents affected by medication error: 1
Residents affected by staffing shortages: 4
Number of CNAs reduced: 14
Number of residents assigned to one CNA: 48
Residents affected by food quality complaint: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) EI #6 | Observed providing inadequate bathing care to resident #140 | |
| Registered Nurse/Care Plan Coordinator EI #23 | Interviewed about person-centered care plan utilization | |
| Licensed Practical Nurse/Wound Nurse EI #8 | Interviewed regarding wound care and staffing issues | |
| Registered Nurse EI #4 | Interviewed about incomplete medication order for resident #61 and staffing issues | |
| Director of Nursing EI #3 | Interviewed about medication error and staffing concerns | |
| Certified Nursing Assistant EI #7 | Interviewed about staffing shortages and missed baths | |
| Licensed Practical Nurse EI #5 | Interviewed about CNA workload and staffing inadequacy | |
| Unit Manager/RN EI #4 | Interviewed about staffing shortages and missed ADL care | |
| Cook EI #20 | Interviewed about food quality and taste |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 21, 2018
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards based on observations, review of the 2017 Food Code, chemical sanitizer data, temperature logs, and staff interviews.
Findings
The facility failed to maintain proper food temperatures, document milk temperatures, properly thaw frozen pork, follow manual dishwashing procedures, ensure hair restraints were worn, prevent cross-contamination from eyeglasses on preparation counters, maintain ice cream frozen, and keep dumpster lids closed. These deficiencies had the potential to affect many residents.
Deficiencies (8)
Chicken salad was not maintained at safe temperatures on the tray line and in the refrigerator.
Milk temperature was not monitored or documented when served from the tray line.
Thawing of frozen diced pork was not done per standards of practice (water faucet turned off).
Manual dishwashing procedures were not followed correctly, including incorrect water temperature in the sanitizing sink.
A male employee with a mustache working in the dishroom did not wear a beard cover.
Eyeglasses were placed on the cook preparation counter, risking cross-contamination.
Ice cream was not maintained frozen; it was soft with finger indentations.
Dumpster door was left open and half of a lid cover was missing on one of three dumpster units.
Report Facts
Residents affected: 147
Residents affected: 156
Chicken salad temperature: 49
Chicken salad temperature: 52
Ice cream temperature: 7
Water temperature in sanitizing sink: 89.4
Water temperature from faucet: 84
Number of dumpster units: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager (CDM) | Employee Identifier #1, involved in temperature monitoring and dishwashing observations | |
| Cook | Employee Identifier #2, involved in thawing observation and ice cream temperature interview | |
| Consultant Dietitian | Employee Identifier #4, interviewed about dumpster lid requirements |
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