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Complaint Investigation

Forrest Oakes Healthcare

May 29, 2026 · Albemarle, NC · 620 Heathwood Drive
Citations 5
CMS Rating 3/5
Beds 60
Provider ID 345442
Healthcare Facility
Forrest Oakes Healthcare
Albemarle, NC  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Forrest Oakes Healthcare in Albemarle, NC — inspection on May 29, 2026.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0602
Freedom from Abuse, Neglect, and Exploitation Deficiencies

not want to hurt Resident #60's feelings by refusing his money.

The DON indicated the Medical

Records Manager informed her she had planned to return the money to Resident #60 when she

the money to the facility on 4/22/26 and met the Medical Records Manager in the parking lot on the afternoon of 4/23/26 where she received $280.00 from her.

The DON stated she and the Business Office Manager met with Resident #60 immediately afterwards and counted his $280.00 back to him and obtained a signed receipt from him.

The DON stated she educated the resident he should never pay any staff for services.A review was completed of a receipt for the return of $280.00 to Resident #60 dated 4/23/26 and was signed by Resident #60 and the DON.Multiple attempts were made to contact Resident #60 by phone calls and text messages but were unsuccessful.The facility submitted a plan of correction that was not accepted for past non-compliance as it did not address measures to prevent misappropriation from recurring.

345442 05/29/2026

Forrest Oakes Healthcare 620 Heathwood Drive Albemarle, NC 28001

Federal health inspectors cited Forrest Oakes Healthcare in Albemarle, NC for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2026-05-29.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Forrest Oakes Healthcare.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-06-16.

Review of Resident #48's physician orders included the following orders:- An order dated 6/26/25 for Skin Prep to the left great toe twice a day.

This order was created by the Wound Nurse.- An order dated 6/26/25 for Skin Prep to the right lateral foot twice a day.

This order was created by the Wound Nurse.

Review of the June 2025 Treatment Administration Record (TAR) revealed:- Skin Prep to the left great toe daily starting on 6/26/25.

The TAR was initialed by a nurse as being completed once a day.- Skin Prep to the right lateral foot daily starting on 6/26/25.

The TAR was initialed by a nurse as being completed once a day. A review of Resident #48's medical record indicated that as of 5/26/26, she was without any skin breakdown. An interview occurred with the Wound Nurse on 5/28/26 at 10:52 AM.

She reviewed the orders for skin prep to the left great toe and right lateral foot dated 6/26/25 to be applied twice a day.

She verified she had transcribed the order incorrectly to the TAR as daily instead of twice a day.

The Wound Nurse stated Resident #48 had discoloration to those areas and the Skin Prep was used to toughen up the skin to prevent breakdown.

The Wound Nurse confirmed that Resident #48 was without any skin breakdown.

The Nurse Practitioner (NP) was interviewed on 5/28/26 at 9:52 AM and stated she would have expected the order to be transcribed and carried out correctly. An interview was completed with the Director of Nursing (DON) on 5/29/26 at 9:50 AM and stated it was her expectation for the skin protective orders to be transcribed and carried out correctly to prevent any further breakdown.

Federal health inspectors cited Forrest Oakes Healthcare in Albemarle, NC for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2026-05-29.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Forrest Oakes Healthcare.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-06-16.

Federal health inspectors cited Forrest Oakes Healthcare in Albemarle, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-05-29.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Forrest Oakes Healthcare.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-06-16.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Albemarle, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Forrest Oakes Healthcare or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.