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The document reports survey findings related to §483.21(b)(3) Comprehensive Care Plans and indicates the facility failed to administer medications and treatments according to physician orders for residents #1 and #4. It includes facility identification details, summary deficiency tags, survey timeline references, and corrective actions such as nurse re-education and weekly medication administration record audits, with QAPI submission schedules.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/forest-manor-hcc-statement-of-deficiencies-and-plan-of-correction-cms-2567/260866/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/forest-manor-hcc-statement-of-deficiencies-and-plan-of-correction-cms-2567/260866.png","ImageObject",442,249,{"name":88,"@type":89},"Melati","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-14",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What deficiency is reported in the document?","Question",{"text":109,"@type":110},"The document states that the facility failed to administer medications and treatments according to physician orders for residents #1 and #4.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which regulation is referenced for the care plan requirement?",{"text":114,"@type":110},"The summary references §483.21(b)(3) Comprehensive Care Plans and the professional-standards requirement for services outlined by the care plan.",{"name":116,"@type":107,"acceptedAnswer":117},"What corrective actions are planned to address medication administration documentation?",{"text":118,"@type":110},"Planned actions include re-educating nurses on medication pass responsibilities, conducting weekly audits of MAR and treatment administration records, and completing progressive disciplinary actions for staff who fail to document per policy.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},260866,1790084301,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":45,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},962085570644,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 03/31/2020  \nFORM APPROVED OMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES\u003Cbr>AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA\u003Cbr>IDENTIFICATION NUMBER:\u003Cbr>315224 | (X2) MULTIPLE CONSTRUCTION\u003Cbr>A. BUILDING  \u003Cbr>B. WING   |  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>C\u003Cbr>03/04/2020 |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| NAME OF PROVIDER OR SUPPLIER\u003Cbr>FOREST MANOR HCC |  |  |  | STREET ADDRESS, CITY, STATE, ZIP CODE\u003Cbr>145 STATE PARK ROAD\u003Cbr>HOPE, NJ 07844 |  |  |  |\n| (X4) ID\u003Cbr>PREFIX\u003Cbr>TAG | SUMMARY STATEMENT OF DEFICIENCIES\u003Cbr>(EACH DEFICIENCY MUST BE PRECEDED BY FULL\u003Cbr>REGULATORY OR LSC IDENTIFYING INFORMATION) |  | ID\u003Cbr>PREFIX\u003Cbr>TAG |  | PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE\u003Cbr>DEFICIENCY) |  | (X5)\u003Cbr>COMPLETION\u003Cbr>DATE |\n| F 000\u003Cbr>F 658\u003Cbr>SS=E | INITIAL COMMENTS\u003Cbr>C \\#: NJ: 111064, 115261, 117486, 117619 124933, 120714, 128828, 130505 131376\u003Cbr>Census: 100\u003Cbr>Sample Size: 15\u003Cbr>Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)\u003Cbr>§483 .21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-\u003Cbr>(i) Meet professional standards of quality.\u003Cbr>This REQUIREMENT is not met as evidenced by:\u003Cbr>C\\#: NJ\\# 00130505, NJ00120714\u003Cbr>Based on interviews, and record review, as well as review of pertinent facility documents on 2/27/20, 2/28/20, 3/2/20, 3/3/20, and 3/4/20 it was determined that the facility failed toadminister medications and  treatments according to physician's order for 2 of 3 Residents (Residents \\#1 and \\#4) reviewed for medication administration and treatment. This deficient practice is evidenced by the following:\u003Cbr>1. According to the \"Admission Record (AR)\"form, Resident \\#4 was admitted to the facility with diagnoses that included but were not limited\u003Cbr>to:\u003Cbr>|  | F 000\u003Cbr>F 658 |  | 1)Resident \\#4 was discharged from the facility on  , prior to this survey. Resident \\#1 care orders were reviewed and clarified on 3/24/2020 .\u003Cbr>2)All Residents Medication Administration Records and Treatment Administration Records were\u003Cbr>reviewed to ensure that no other residents were affected by the deficient practice.\u003Cbr>3)The facility policies on Medication Administration have been reviewed and updated.\u003Cbr>The DON or designee will re-educate all nurses on med pass responsibilities and the Medication\u003Cbr>Administration policy. Weekly audits will be conducted by the unit managers to ensure that\u003Cbr>Medication Administration Records (MAR) and the Treatment Administration |  | 3/27/20 |\n\nLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed  \nTITLE  \n(X6) DATE 03/24/2020  \nAny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions. ) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.  \nFORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZXRZ11 Facility ID: NJ62103 If continuation sheet Page 1 of 18  \nDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nPRINTED: 03/31/2020  \nFORM APPROVED OMB NO. 0938-0391  \n\n| STATEMENT OF DEFICIENCIES\u003Cbr>AND PLAN OF CORRECTION |  | (X1) PROVIDER/SUPPLIER/CLIA\u003Cbr>IDENTIFICATION NUMBER:\u003Cbr>315224 | (X2) MULTIPLE CONSTRUCTION\u003Cbr>A. BUILDING  \u003Cbr>B. WING   |  |  |  | (X3) DATE SURVEY\u003Cbr>COMPLETED\u003Cbr>C\u003Cbr>03/04","cbCaijhPbvPLBIy9","https://ap.wps.com/l/cbCaijhPbvPLBIy9","pdf",205276,"English","# Statement of Deficiencies and Plan of Correction\n## Provider/Supplier Identification\n## Summary Statement of Deficiencies\n## Provider's Plan of Correction\n## Signatures and Completion Information","[{\"question\":\"What deficiency is reported in the document?\",\"answer\":\"The document states that the facility failed to administer medications and treatments according to physician orders for residents #1 and #4.\"},{\"question\":\"Which regulation is referenced for the care plan requirement?\",\"answer\":\"The summary references §483.21(b)(3) Comprehensive Care Plans and the professional-standards requirement for services outlined by the care plan.\"},{\"question\":\"What corrective actions are planned to address medication administration documentation?\",\"answer\":\"Planned actions include re-educating nurses on medication pass responsibilities, conducting weekly audits of MAR and treatment administration records, and completing progressive disciplinary actions for staff who fail to document per policy.\"}]","Forest Manor HCC - Statement of Deficiencies and Plan of Correction (CMS-2567) | PDF",1789346824,7]