Average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hill Manor Health Center during CMS and state inspections, most recent first.
The facility did not meet professional standards of quality when licensed nurses failed to complete and document full assessments of stage 2 sacral pressure ulcers for two residents with conditions including DM, PVD, PCM, and CKD. Initial body checks recorded basic measurements, but subsequent weekly evaluations lacked updated measurements and detailed descriptions such as color, drainage, odor, surrounding skin condition, and pain level. The DON and an LVN acknowledged that such elements should be included in pressure ulcer assessments, and facility policy required comprehensive documentation of pressure sores, including location, stage, dimensions, and exudate or necrotic tissue.
A resident with severe cognitive impairment and a history of wandering was assessed as being at risk for elopement and falls, but no care plan was developed to address these risks. After the discontinuation of a sitter, the resident eloped from the facility through an unalarmed exit and was found the next day with hypothermia, injuries, and altered mental status. Monitoring logs were inconsistently completed, and the facility lacked effective elopement prevention systems.
Surveyors found that food items in the kitchen were stored without proper labeling or dating, including opened containers of milk, eggs, sour cream, dressings, and various unlabeled liquids. Dry goods in plastic bins were also unlabeled and undated. Additionally, metal pans used for food preparation and service were stacked while still wet, rather than being air-dried as required. These actions were confirmed by the RD and did not follow professional standards or facility policy.
Nursing staff failed to accurately document the administration of controlled medications for two residents, with doses signed out on the CDR but not recorded on the MAR, and a third resident did not receive a scheduled dose of carbidopa-levodopa due to the medication not being available. The DON confirmed these lapses were not in accordance with facility policy, which requires timely administration and proper documentation of all medications.
Surveyors found that the medication refrigerator was repeatedly maintained below the required temperature range, with thick ice buildup and temperatures as low as 28°F. Multiple medications, including insulin, Daptomycin, latanoprost, tuberculin, and vaccines, were stored in this refrigerator despite manufacturer instructions for proper storage. The DON confirmed the findings and acknowledged that the low temperatures and lack of staff reporting did not meet facility policy.
A resident with a Foley catheter for urinary retention was observed with an uncovered drainage bag containing visible urine, contrary to facility policy requiring privacy covers. The DON confirmed the expectation for catheter bags to be covered to maintain resident dignity.
A resident with heart failure received Lasix for foot swelling without nursing staff monitoring the swelling to assess the medication's effectiveness. The DON confirmed that no monitoring was documented, which did not align with facility policy requiring assessment of medication outcomes.
Surveyors identified infection control deficiencies involving two residents. One resident's IV tubing was not dated as required by policy, despite ongoing medication administration. A CNA provided direct care, including changing briefs and emptying a Foley catheter bag, to another resident under Enhanced Barrier Precautions without wearing required PPE. Additionally, the same resident's Foley catheter drainage bag was found on the floor and uncovered, contrary to facility policy.
Incomplete Assessment and Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that services met professional standards of quality by not completing required assessments and documentation of pressure ulcers for two residents. One resident was admitted with multiple diagnoses including diabetes mellitus, peripheral vascular disease, protein caloric malnutrition, and chronic kidney disease, and had a documented stage 2 sacral pressure ulcer on the initial body check with measurements of 0.3 cm by 0.3 cm by 0.1 cm. However, there was no description of the ulcer recorded at that time. In addition, the weekly summary evaluation completed one week later did not include any measurements or descriptive assessment of the same sacral pressure ulcer. Another resident, admitted with diagnoses including diabetes mellitus, protein caloric malnutrition, and peripheral vascular disease, was documented on initial body check as having a stage 2 sacral pressure ulcer measuring 0.75 cm by 0.5 cm by 0 cm in depth, with redness and no drainage. The subsequent weekly summary evaluation contained no measurements or descriptive documentation of this pressure ulcer. During interviews, the DON confirmed the absence of required documentation for both residents and acknowledged that licensed nurses should have assessed and documented wound characteristics such as color, drainage, odor, surrounding skin, and pain level. An LVN also stated that pressure ulcer assessments should include measurements and descriptive details. The facility’s written policy required full assessment and documentation of pressure sores, including location, stage, width, depth, and presence of exudates or necrotic tissue, which was not followed in these cases.
Failure to Prevent Elopement and Ensure Adequate Supervision
Penalty
Summary
A resident with severe cognitive impairment and a history of wandering was admitted to the facility and assessed as being at moderate risk for elopement and high risk for falls. Despite these assessments, no care plan was developed to address the resident's risk for elopement. The resident initially had a sitter provided by the family, but this service was discontinued after a few days, and there was no documented evidence that alternative supervision or safety interventions were implemented. On the day of the incident, the resident was observed walking in the hallway and entering another resident's room. Shortly after, staff discovered the resident was missing, initiated a search, and notified the police. The facility had multiple exits leading to public streets, none of which were alarmed, and did not have a wander guard or alarm system in place. Review of monitoring logs revealed inconsistent documentation, with several missing entries and at least one instance where a CNA documented monitoring the resident during a period when the resident was actually missing. The resident was found the following day in the neighborhood by a citizen, exhibiting altered mental status and physical injuries, including hypothermia, multiple abrasions, a forehead laceration requiring sutures, and rhabdomyolysis. The facility's policies on care planning and wandering/elopement did not adequately address preventative measures, and staff interviews confirmed that required care planning and monitoring were not consistently performed.
Improper Food Storage, Labeling, and Equipment Handling in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. During a tour, opened and undated food items such as milk, liquid eggs, sour cream, salad dressings, and maple syrup were found in the reach-in refrigerator. Additionally, several containers and glasses with various colored liquids and a bowl with a pink substance were opened, undated, and unlabeled. The registered dietician confirmed these findings and acknowledged that all food items should be properly dated and labeled according to facility policy. The facility's policy also specifies use-by dates for refrigerated items, which were not adhered to in these instances. Further observations revealed that plastic containers above the food preparation area contained rigatoni noodles, lentils, rice, brown sugar, polenta, and panko breadcrumbs, all of which were unlabeled and undated. The registered dietician confirmed that these items should have been labeled and dated upon placement in the containers. Additionally, 13 metal pans were found stacked while still wet, contrary to FDA Food Code requirements that equipment and utensils be air-dried before storage. These deficiencies were confirmed by the registered dietician and were not in accordance with professional standards or the facility's own policies.
Failure to Accurately Document and Provide Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability and administration of controlled drugs for three residents. For one resident with anxiety, there were three occasions where nursing staff signed out diazepam on the Controlled Drug Record (CDR) but did not document administration on the Medication Administration Record (MAR), as confirmed by the Director of Nursing (DON). For another resident with type 2 diabetes mellitus, a nurse signed out oxycodone-acetaminophen on the CDR but failed to document administration on the MAR. Facility policy requires that the date, time, dosage, and signature of the person administering the medication be recorded in the resident's medical record and on the CDR for controlled substances. Additionally, a resident with Parkinson's disease did not receive a scheduled dose of carbidopa-levodopa because the medication was not available at the time of administration. The nurse indicated the medication was ordered from the pharmacy, but the dose was missed. Facility policy states that medications should be administered within one hour of their prescribed time and that medications should be available at all times. The DON confirmed that nurses are expected to order medications in advance to prevent running out.
Improper Medication Refrigerator Temperature Control
Penalty
Summary
Surveyors observed that the medication refrigerator in the medication room was not maintained within the required temperature range of 36°F to 46°F. On inspection, the refrigerator was found to have a thick buildup of ice and temperatures as low as 28°F and 32°F, with medications stored inside. The Director of Nursing (DON) confirmed these findings and acknowledged that the ice buildup and low temperatures were not acceptable. Medications stored in the refrigerator included unopened vials of insulin, compounded Daptomycin, unopened bottles of latanoprost eyedrops, vials of tuberculin, an emergency kit containing insulin and Lorazepam, and doses of influenza vaccine, all of which had manufacturer or pharmacy labels indicating specific storage temperature requirements that were not met. A review of the medication refrigerator temperature log for the month showed seven instances where the temperature was recorded at 34°F, below the acceptable range. The DON stated that these temperatures were not acceptable and should have been reported by nursing staff. Facility policy requires that all drugs and biologicals be stored under proper temperature controls in locked compartments, but this was not followed as evidenced by the repeated low temperatures and lack of reporting or corrective action by staff.
Uncovered Foley Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident's Foley catheter drainage bag was left uncovered while the resident was lying in bed. During an observation, the drainage bag was found on the floor with visible yellow urine, and it was not concealed by a privacy cover. The resident had a medical history of urinary retention and had an active physician's order for an indwelling Foley catheter. The Director of Nursing confirmed in an interview that the drainage bag should have been covered with a privacy bag, in accordance with facility policy. The facility's policy on dignity, revised in February 2021, specifically prohibits practices that compromise resident dignity and requires staff to help residents keep urinary catheter bags covered. The failure to cover the drainage bag was identified as not upholding the resident's dignity and privacy.
Failure to Monitor Effectiveness of Lasix Therapy
Penalty
Summary
A resident with a diagnosis of diastolic congestive heart failure was admitted to the facility and had a physician's order for Lasix 20 mg to be administered every 48 hours for swelling in the feet. Review of the medication administration record (MAR) showed that nursing staff administered the medication but did not monitor for swelling in the feet as required to assess the effectiveness of the treatment. During an interview and record review, the DON confirmed that there was no monitoring documented for swelling, and acknowledged that such monitoring should have been performed. The facility's policy on medication therapy requires that medication use be supported by appropriate care practices, including adequate assessment, which was not followed in this case.
Infection Control Lapses in IV Tubing, PPE Use, and Catheter Care
Penalty
Summary
The facility failed to follow infection prevention and control practices for two residents. For one resident with a peripherally inserted central catheter (PICC) line, the intravenous (IV) tubing was observed to be undated while medication was being administered. Physician orders required daily changes of the IV tubing, and facility policy specified that new tubing should be labeled with the date, time, and initials. The Director of Nursing (DON) confirmed the tubing was not dated as required by policy. In another instance, a Certified Nursing Assistant (CNA) was observed providing direct care to a resident, including changing briefs and emptying a Foley catheter bag, without wearing personal protective equipment (PPE) such as gloves and a gown. The resident had a physician order for Enhanced Barrier Precautions (EBP) due to the presence of an indwelling Foley catheter, and signage outside the room indicated that PPE was required for high-contact care activities. The CNA acknowledged not wearing PPE during these activities, and the Infection Prevention Nurse confirmed that PPE should have been used. Additionally, the same resident's Foley catheter drainage bag was observed on the floor and uncovered. Facility policy and the DON confirmed that catheter drainage bags should not be in contact with the floor to maintain infection control standards. The resident's clinical record indicated a diagnosis of urinary retention and an order for an indwelling Foley catheter.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pacific Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Woods | 0 mi | ★★★★★ | 11 | 0 |
| Oceanview Post Acute | 0.6 mi | ★★★★★ | 15 | 0 |
| Cypress Ridge Care Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Monterey Post Acute | 1.6 mi | ★★★★★ | 4 | 0 |
| Westland House | 2.9 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.