Forrest Oakes Healthcare Center

F-F550: Based on record review, observations, resident, resident family, and staff interviews, the facility failed to provide incontinence care in a manner to maintain the residents' dignity for 3 of 5 residents reviewed for dignity (Residents #1, #206 ,and #9).

2.

F-F677: Based on record reviews, observations, and family, resident, and staff interviews, the facility failed to provide nail care and/or incontinence care for 8 of 13 residents dependent on staff for activities of daily living (ADL) (Residents #9, #32, #35, #51, #205, #1, #206, and #33).

Review of staff posting, assignment sheets, and the time cards revealed:

On 01/12/25 there was 1 Nursing Assistant (NA) providing resident care from 3:40 PM until 7:00 PM for a census of 50 residents.

On 01/27/25 there was 1 NA providing resident care from 4:00 PM until 7:00 PM for a census of 52 residents.

On 01/30/25 there was no NA working the floor from 4:00 PM until 7:00 PM and 1 NA providing resident care from 7:00 PM until 11:00 PM for a census of 54 residents.

On 01/31/25 there was 1 NA providing resident care from 4:00 PM until 11:00 PM and from 11:00 PM until 7:00 AM for a census of 54 residents.

On 02/01/25 there was 1 NA providing resident care from 3:00 PM until 7:00 PM for a census of 54 residents.

On 02/02/25 there was 1 NA providing resident care from 3:00 PM until 7:00 PM for a census of 54 residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 345442 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345442 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Forrest Oakes Healthcare Center 620 Heathwood Drive Albemarle, NC 28001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 A phone interview was conducted on 02/05/25 at 10:40am with Nurse #2. She stated she hadn't been at the facility working for about a month. She explained when she started working at the facility it was on day shift Level of Harm - Minimal harm or however, about a month later she went to night shift because she was overwhelmed on day shift due to not potential for actual harm having enough Nursing Assistants (NA) working. She further explained she was no longer a full-time employee, she only worked as needed because of her concerns with staffing. She went on to say when she Residents Affected - Some worked 7:00 PM-7:00 AM there were nights, and could not recall how many, she would come in and there wouldn't be an NA until 11:00 PM. She indicated she would be over a medication aide, have her own medication cart to pass out medications, do blood sugars, and there were times the residents received incontinent care and/or were assisted to bed later than they should have. She went on to say she felt like there needed to be a plan in place when an NA wasn't coming to work, but the facility didn't have a plan when an NA was not going to come to work. She then stated the nurses assisted as much as they could, but

they were trying to pass out medications.

A phone interview was conducted on 02/05/25 at 06:09 PM Nursing Assistant (NA) #8. She stated she normally worked 7:00 PM-7:00 AM and she had to work the whole building by herself two to three times a week. She also stated it was not possible to keep every person dry when working by herself or conduct routine rounds and provide incontinent care at least every two hours. She further explained some nurses would assist, and some wouldn't. She concluded the interview by stating, you just can't operate a building like that.

An interview was conducted on 02/06/25 at 9:01 AM with Nursing Assistant (NA) #6. She stated she had worked at the facility for 9 years and she had never seen staffing as bad as it was over the past three to four months. She explained she worked all shifts but at times when she would come in at 11:00 PM there would not be any NAs in the building, and she would normally have to work by herself on the night shift. She indicated there was one nurse, a med aide and herself on night shift. She further explained there was no way to keep all of the residents dry and do all of the required tasks when there were only 2 NAs on first shift or 1 NA at any time. She went on to say the census was normally above 50 residents.

An interview was conducted on 02/06/25 at 9:33 AM with the Director of Nursing (DON). She stated staffing was hard, she had requested to use an agency, and to give bonuses to the staff that did come in and work extra. However, she explained both requests had to be approved by corporate and they had not approved

the facility to use agency. She explained qualified department heads would assist the NAs when they were short staffed to ensure the residents were fed and provided with incontinent care. She also stated she expected all residents to be fed and provided incontinent care timely. She explained on the day shifts when there were 2 NAs scheduled it was not possible to complete all showers and tasks. She verified the staffing numbers on 01/12/25, 01/27/25, 01/30/25, 01/31/25, 02/01/25, and 02/02/25 were correct.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 345442 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345442 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Forrest Oakes Healthcare Center 620 Heathwood Drive Albemarle, NC 28001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50415 Residents Affected - Some Based on observation, and staff, and family interviews and record review, the facility failed to serve the lunch meal at the posted time on 2/2/25 as well as failed to serve the breakfast meal at the posted time on 2/3/25 for 2 of 5 meal observations. This practice had the potential to affect other residents for meal delivery.

The findings included:

An observation was completed on 2/2/25 at 11:30 AM of the area outside of the main dining room. A meal schedule was posted as follows:

-Breakfast 7:15 AM to 8:10 AM

-Lunch 12:00 PM to 12:45 PM

-Dinner 5:15 PM to 6:10 PM

1. On 2/2/25 at 12:30 PM four residents were observed waiting in the dining room for their lunch to be served. The Administrator was noted to be walking around the area assuring the residents their meals were due out soon. Lunch trays were served to the residents in the dining room beginning at 1:28 PM.

On 2/2/25 at 12:45 PM the Regional Dietary Manager provided a copy of the facility's meal delivery log. The meal delivery log indicated that lunch was scheduled to be served in the dining room at 12:00 PM.

a. Resident #206 was admitted to the facility on [DATE REDACTED].

The quarterly Minimum Data Set was in progress.

Family member #1 was interviewed on 2/2/25 at 12:50 PM, and he stated that one of Resident #206's family members was always at the facility for mealtimes. He stated supper was served 1.5 hours late on 1/31/25 and lunch was served late on 2/2/25. He stated it was hard to encourage Resident #206 to eat without knowing when meals would be delivered.

On 2/2/25 at 1:00 PM Resident #206's Family Member #1 was heard in the hallway asking staff why the resident's lunch tray had not been delivered yet. He stated Resident #206 had waited a long time for her meal, and she was hungry. Staff stated that trays were due to come out soon.

The first cart to leave the kitchen for lunch service on 2/2/25 was 1:28 PM. The meal cart was observed to be delivered to the F hall where Resident #206 resided at 2:00 PM. Lunch was scheduled to be delivered to the F hall by 12:45 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 345442 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345442 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Forrest Oakes Healthcare Center 620 Heathwood Drive Albemarle, NC 28001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 The Regional Dietary Manager was interviewed on 2/2/25 at 2:35 PM. He indicated that a staff member called out that day without letting the manager know. He further stated that one of the meals got dropped Level of Harm - Minimal harm or during lunch service and had to be redone causing a delay. potential for actual harm According to Dietary Aide #1 who was interviewed on 2/2/25 at 2:43 PM, the dietary staff was not usually Residents Affected - Some behind with meal delivery. She indicated that lunch trays were typically out by 11:30 AM. She stated that the State surveyors being in the kitchen delayed them that day. Dietary Aide #1 stated the kitchen was short staffed due to a call out that morning. She stated that they typically have three staff members in the mornings to help with meal service. She further stated that a tray had been dropped causing the staff to prepare a new entree for lunch.

On 2/2/25 at 2:47 PM the new Dietary Manager was interviewed. She stated that the dietary staff called her that morning to let her know she needed to buy bread. She stated that when she arrived at the facility, she then had to redo the meal tickets, and that threw the kitchen off on meal delivery.

2. An observation of the breakfast meal service on 2/3/25 beginning at 7:15 AM revealed the Dietary Manager (DM) was recording the temperature of food items. The pureed eggs and ground sausage were below the holding temperature, and the DM had to place the food back in the oven to bring to up to serving temperature. The plating of food by dietary staff did not begin until 7:40 AM. The first meal cart left the kitchen at 7:50 AM. Breakfast trays were scheduled to be delivered beginning at 7:15 AM.

An interview was completed on 2/3/25 at 8:35 AM with the Dietary Manager. She stated that breakfast service was late that morning in part because of training a new cook as well as having one staff member call out. She indicated that due to some foods not being at the proper temperature for serving, the ground sausage and pureed eggs, she had to put them back in the warming oven to get the food to the correct temperature causing a further delay in serving breakfast. The Dietary Manager stated staff will say they will work then fail to show up for work.

An interview was completed on 2/3/25 at 2:46 PM with the District Dietary Manager. He stated that due to the former Dietary Manager walking out on 1/31/25 and staff calling out that mealtimes were delayed on 2/2/25 and 2/3/25. He stated that the new Dietary Manager began working on 2/3/25 as well as a new dietary staff member, and he felt the service would improve with additional staff on board.

The Director of Nursing was interviewed on 2/6/25 at 10:01 AM. She stated that dietary had hired new staff, and she expected mealtimes to get better.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 345442 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345442 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Forrest Oakes Healthcare Center 620 Heathwood Drive Albemarle, NC 28001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50415

Residents Affected - Some Based on observations and staff interviews, the facility failed to label, date and remove expired food items stored for use and remove food with signs of spoilage from 1 of 1 walk-in refrigerator and failed to ensure frozen food items were dated and not stored open to air with signs of freezer burn in 1 of 1 walk-in freezer.

These practices had the potential to affect food served to residents.

The findings included:

Accompanied by Dietary Aide #1, an observation was made of the walk-in refrigerator on [DATE REDACTED] at 10:46 AM. The following items were stored in the refrigerator:

-One undated box of butter that was open and partially used

-One undated bag of mozzarella cheese that was open and partially used

-One undated box of mozzarella cheese that was open and partially used

-One open and partially used container of sour cream dated [DATE REDACTED]

-One box of parmesan cheese opened and dated [DATE REDACTED]

-One undated metal baking pan of gelatin dessert covered with aluminum foil with a frozen white substance

on top of the foil

-One box of 12 cucumbers with white fuzzy spots

-One plastic container of honey opened and undated

-One bottle of lemon juice opened and undated

An observation of the walk-in freezer revealed the following stored items:

-One box of frozen carrots opened and undated

-One bag of shrimp undated

-One bag of toast undated

-One box western style beef patties unwrapped and open to air with ice crystals on them

On [DATE REDACTED] at 10:46 AM Dietary Aide #1 was interviewed. She stated that the former Dietary Manager (DM) walked out without notice this past Friday, [DATE REDACTED]. She indicated that the DM was the one responsible for dating food and disposing of outdated food kept in storage. Dietary Aide #1 stated a new DM would begin working on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 345442 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345442 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Forrest Oakes Healthcare Center 620 Heathwood Drive Albemarle, NC 28001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Cook #1 was also interviewed on [DATE REDACTED] at 11:15 AM. He stated that the dietary department was short staffed that day due to a call out. He stated that the Dietary Manager usually made sure the food was dated Level of Harm - Minimal harm or and stored correctly. potential for actual harm

The District Dietary Manager was interviewed on [DATE REDACTED] at 12:45 PM. He stated that the former Dietary Residents Affected - Some Manager had walked out this past Friday, [DATE REDACTED]. He indicated that he had spoken with the dietary staff this past Friday, [DATE REDACTED], regarding the need to date food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 345442