Forrest Oakes Healthcare: Skin Care Order Errors - NC
The resident, identified in inspection records only as Resident 48, is a woman living under hospice care for terminal vascular dementia. She has severely impaired cognition and cannot move her legs freely, the result of contractures in both knees. She came to the facility already carrying a diagnosis of protein calorie malnutrition. By the time inspectors arrived in late May 2026, her medical record showed she had developed a deep tissue injury to her right hip, blisters on her right inner ankle, and blisters on her left posterior thigh.
In June 2025, the facility's wound nurse wrote two orders to protect what remained of the resident's skin. One called for Skin Prep applied to the left great toe twice a day. The other called for Skin Prep applied to the right lateral foot twice a day. The wound nurse created both orders herself on June 26, 2025.
Then she transcribed both of them incorrectly onto the Treatment Administration Record, the document nurses initial each time they complete a treatment. Instead of twice daily, both orders were recorded as once daily. For the next eleven months, nurses initialed the record once a day and moved on. Nobody flagged it.
When inspectors reviewed the June 2025 Treatment Administration Record during a complaint inspection on May 28 and 29, 2026, the discrepancy was plain. The orders said twice a day. The record showed once a day, starting the same date the orders were written.
The wound nurse acknowledged the mistake in an interview on May 28. She said she had intended the Skin Prep to toughen the skin in those areas because of discoloration she had observed, and that her goal was to prevent breakdown. She confirmed she had written the order incorrectly and that it had been carried out at half the intended frequency as a result. She also confirmed that as of the inspection, the resident had no skin breakdown in those specific areas.
The Nurse Practitioner, interviewed the same morning, said she would have expected the order to be transcribed and carried out correctly. The Director of Nursing, interviewed the following day, said the same: her expectation was that skin protective orders be transcribed and followed accurately to prevent further breakdown.
Neither offered an explanation for how the error persisted undetected for nearly a year.
The inspection was triggered by a complaint and covered three residents with pressure ulcers. The transcription error was found in one of those three charts. Inspectors rated the violation at the level of minimal harm or potential for actual harm, the lower end of the federal scale, citing the absence of visible skin breakdown in the affected areas at the time of the visit.
That finding offers some relief. It does not answer why a wound nurse's own order, for a patient she was actively monitoring for skin deterioration, was entered incorrectly from the start and never reconciled against the original physician order during any of the months that followed.
Resident 48's care plan, last reviewed in June 2025, noted her thin and fragile skin, her poor oral intake, and her actual wounds: the deep tissue injury at the right hip, the blisters. The plan called for treatments to be administered as ordered and monitored for effectiveness. For nearly a year, one of those treatments was administered at half the ordered frequency, and the monitoring did not catch it.
She is, by the facility's own documentation, terminally ill. The skin she has left is the skin she will die in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forrest Oakes Healthcare from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Forrest Oakes Healthcare in Albemarle, NC was cited for violations during a health inspection on May 29, 2026.
The resident, identified in inspection records only as Resident 48, is a woman living under hospice care for terminal vascular dementia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.