Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper Handling of Soiled Linens: Staff failed to transport soiled linens in a covered manner and were observed moving uncovered laundry baskets in the hallway and exiting a resident room with un-bagged soiled linen. A CNA and other staff confirmed the linens were soiled and acknowledged that soiled linens should be covered in the hallways or bagged before leaving the room.
A resident receiving IV Cefepime had the infusion started at 150 mL/hr even though the bag label directed 100 mL/hr. An LPN confirmed the rate was incorrect, and the DON stated IV antibiotics were expected to infuse at the prescribed rate.
A resident with COPD and intact cognition was observed using oxygen with tubing dated beyond the facility’s 7-day replacement schedule. An LPN confirmed the tubing date and stated oxygen tubing should be changed every 7 days, and the DON also confirmed that schedule.
The facility failed to administer insulin before meals for two residents with Type 2 Diabetes, as per physician orders. An LPN administered insulin after meals, acknowledging the error. The DON confirmed the untimely administration was unacceptable, highlighting systemic issues with meal and medication timing.
A facility failed to maintain a medication error rate below 5%, resulting in an 11.54% error rate. A resident missed a dose of Eliquis due to unavailability, and two residents with diabetes received insulin after meals instead of before, as ordered. The LPN and DON confirmed these errors.
A facility failed to prevent significant medication errors for three residents. A resident with heart failure received Eliquis outside the prescribed time, while two residents with diabetes received Novolog insulin after meals instead of before, as ordered. The LPN confirmed the errors, and the DON acknowledged the deviations from physician orders.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in catheter management and PPE utilization. A resident's catheter bag was found on the floor, increasing infection risk. Additionally, staff did not properly use Enhanced Barrier Precaution PPE during high-contact care for residents requiring such precautions, despite clear signage. Staff acknowledged the oversight, confirming the need for proper PPE use to prevent infection transmission.
A resident with a history of UTIs was inaccurately coded in the MDS assessment as not having a UTI in the last 30 days, despite clear documentation of a UTI diagnosis and treatment. The error was due to staff using personal discretion in coding, which was later confirmed as incorrect by the DON.
A resident with Parkinson's Disease and Dysphagia required supervision during meals, but the facility failed to include this in the care plan. Despite therapy recommendations for meal supervision, the resident was observed eating without assistance. Staff were inconsistent in understanding the resident's needs, relying on verbal reports and an ineffective kiosk system. The Care Manager acknowledged that eating interventions were not typically care planned, and the DON could not provide documentation of nutritional assistance planning.
Improper Handling of Soiled Linens
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The deficiency was based on record review, observations, and interviews showing that staff failed to transport soiled linens in a manner that prevented spread of infection. The facility policy titled, Infection Control Linen Handling dated 06/14 stated that soiled linen can be a source of infection and should be handled carefully, with soiled linen deposited into a hamper and covered. During observations, a CNA was seen transporting an uncovered laundry basket to the soiled linen room, and S3LDY confirmed the basket contained soiled linen and that soiled linens should always be covered in the hallways. Later, S5WC was observed exiting a resident's room with gloved hands and holding un-bagged soiled linen, and she confirmed the cloth pad was soiled and should have been bagged before leaving the room. Another CNA was observed transporting two uncovered laundry baskets in the hallway, confirmed to contain soiled linens, and stated she was unaware soiled linens needed to be covered in the hallways. S4HSK and S2DON also confirmed soiled linens should always be covered in the hallways.
IV antibiotic infused at incorrect rate
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met when the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 resident reviewed for IV antibiotic therapy. Resident #5, who was admitted to the facility on [DATE], had a physician order for Cefepime IV solution 2 grams per 100 milliliters, to be given intravenously three times a day. During an observation on 02/10/2026 at 11:55 a.m., S7LPN initiated the Cefepime infusion at 150 mL per hour even though the bag label directed that it be infused at 100 mL per hour. During an interview at 12:10 p.m., S7LPN confirmed the infusion should have been run at 100 mL per hour and not 150 mL per hour. S2DON later stated that IV antibiotics were expected to infuse at the prescribed rate.
Oxygen Tubing Not Changed on Schedule
Penalty
Summary
The facility failed to ensure necessary respiratory care was provided consistent with professional standards of practice when it did not change Resident #119’s oxygen tubing in a timely manner. The facility policy titled, Infection Control Oxygen Equipment Cleaning, stated that tubing should be replaced every 7 days. Resident #119 was admitted with chronic obstructive pulmonary disease and had a BIMS score of 15, indicating she was cognitively intact. Her physician orders included oxygen at 2 L nasal cannula every 1 hour as needed. During observation, Resident #119 was using oxygen and the tubing was dated 01/26/2026. The resident stated she wore oxygen throughout the day and most of the night. An LPN observed the tubing in use and confirmed it was dated 01/26/2026 and that oxygen tubing should be changed every 7 days. The DON also confirmed that oxygen tubing should be changed every 7 days.
Failure to Administer Insulin Timely Before Meals
Penalty
Summary
The facility failed to ensure that insulin administration for two residents met professional standards of quality. Resident #81, who had Type 2 Diabetes Mellitus with Diabetic Neuropathy, was observed to have a blood sugar level of 220 at 11:38 a.m., but insulin was not administered until 12:09 p.m., after the resident had already received their meal. Similarly, Resident #93, who also had Type 2 Diabetes Mellitus, was observed to have consumed 95% of her meal before receiving her insulin, which was ordered to be administered before meals. Both instances were confirmed by the LPN responsible for administering the insulin, who acknowledged that the insulin should have been given before meals as per the physician's orders. Further interviews revealed systemic issues contributing to the deficiency. An LPN on another hall stated that it was not feasible to complete blood sugar checks and administer insulin to all residents requiring it before meals due to the timing of meal deliveries. The Director of Nursing confirmed that the insulin administration for Residents #81 and #93 did not adhere to the physician's orders and acknowledged that the untimely administration of insulin was not an acceptable practice. This indicates a failure in the facility's processes to ensure timely and appropriate insulin administration as per professional standards and physician orders.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during medication administration for three residents. Resident #88 did not receive her prescribed dose of Eliquis at the scheduled time due to the medication being unavailable. This omission was confirmed by the LPN responsible for administering the medication, who acknowledged that the dose was missed and not given within the required time frame. Additionally, two residents with diabetes, #81 and #93, did not receive their prescribed insulin before meals as ordered. Both residents had their blood glucose levels checked, and the insulin was administered after they had finished eating, contrary to the physician's orders. The LPN involved confirmed that the insulin should have been administered before meals, as per the sliding scale orders. The Director of Nursing corroborated these findings, acknowledging that the failure to administer medications as ordered constituted medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three out of seven residents reviewed for medications. Resident #88, who had a diagnosis of Chronic Systolic Congestive Heart Failure, was prescribed Eliquis 5mg to be administered twice daily at 8:00 a.m. and 8:00 p.m. However, the medication was administered at 9:57 a.m. on January 29, 2025, outside the one-hour window allowed by the facility's medication administration policy. This deviation from the prescribed schedule constitutes a significant medication error. Additionally, Residents #81 and #93, both diagnosed with Type 2 Diabetes Mellitus, were prescribed Novolog insulin to be administered subcutaneously before meals. Observations revealed that the insulin was administered after the residents had consumed their meals, contrary to the physician's orders. The LPN responsible for administering the insulin confirmed the error, acknowledging that the insulin should have been given before meals. The Director of Nursing also confirmed that these instances were medication errors, as the medications were not administered in a timely manner as ordered by the physician.
Infection Control Deficiencies in PPE Utilization and Catheter Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a resident with an indwelling catheter, where the catheter bag was observed lying on the floor. This was confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged that the catheter bag should not have been on the floor due to the increased risk of infection. Additionally, the facility did not ensure proper utilization of Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) for residents requiring such precautions. Multiple instances were observed where Certified Nursing Assistants (CNAs) failed to don gowns while providing high-contact care to residents with Enhanced Barrier Precautions. Despite signs indicating the need for gown and glove use, staff members either did not notice the signs or incorrectly assumed the precautions were no longer necessary. The facility's policy on Enhanced Barrier Precautions, which requires gown and glove use during high-contact care for residents with multidrug-resistant organisms or indwelling devices, was not adhered to. Interviews with staff confirmed the oversight, as they acknowledged the presence of EBP signs and the requirement to wear PPE, yet failed to comply during care activities. The DON confirmed the necessity of following these precautions to prevent the transmission of infections.
Inaccurate MDS Coding for UTI
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's status by incorrectly coding a urinary tract infection (UTI) for a resident. The resident, who had a history of UTIs, was admitted with a diagnosis that included a UTI. Despite being treated with Doxycycline for a UTI that was diagnosed on 12/23/2024, the Annual MDS assessment completed on 12/31/2024 incorrectly indicated that the resident did not have a UTI in the last 30 days. This error was identified during a review of the resident's clinical records, which included physician's orders, nurse's notes, and hospital discharge summaries that clearly documented the UTI diagnosis and treatment. Interviews with facility staff revealed that the MDS was completed using nurse's notes and hospital discharge paperwork, and the staff member responsible for the assessment used personal discretion to code the UTI as 'No' due to perceived insufficient documentation. The Director of Nursing (DON) confirmed that the MDS should have been coded 'Yes' for a UTI in the last 30 days, as the documentation clearly supported the diagnosis and treatment of a UTI. This discrepancy highlights a failure in accurately coding the resident's condition, which is essential for proper care planning and resource allocation.
Failure to Implement Nutritional Assistance Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required nutritional assistance. The resident, diagnosed with Parkinson's Disease and Dysphagia, was admitted with a need for supervision during meals. Despite the resident's Quarterly MDS indicating a requirement for supervision or touching assistance with eating, the care plan did not include any interventions related to eating or nutritional assistance. Observations revealed the resident feeding herself without supervision, contrary to the recommendations from Speech Therapy and Occupational Therapy discharge summaries, which indicated the need for meal supervision due to upper extremity muscle weakness and postural alignment issues. Interviews with staff, including CNAs and LPNs, highlighted inconsistencies in understanding and implementing the resident's care needs. Staff relied on verbal reports and the facility's kiosk system to determine the level of assistance required, but were unable to locate documentation confirming the resident's needs. The Care Manager admitted that interventions related to eating were not typically included in care plans at the facility, and the Director of Nursing could not provide documentation of the resident ever being care planned for nutritional assistance. This lack of documentation and communication led to the resident not receiving the necessary supervision during meals.
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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 Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christwood | 1 mi | ★★★★★ | 3 | 0 |
| Pontchartrain Health Care Center | 5.2 mi | ★★★★★ | 3 | 0 |
| Trinity Trace Community Care Center | 5.3 mi | ★★★★★ | 4 | 0 |
| Heritage Manor Of Mandeville | 7.4 mi | ★★★★★ | 5 | 0 |
| Lacombe Nursing Centre | 15.8 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.