Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Forsyth Care Center during CMS and state inspections, most recent first.
Food storage and sanitation practices were not followed when dented cans were kept with other inventory, multiple refrigerated and frozen foods were left open, unlabeled, or improperly dated, fans in the walk-in cooler and freezer had dirt and dust on them while blowing over food, and dishes and plate covers were stacked while still wet. Staff interviews confirmed that dented cans should be separated, opened foods should be sealed and labeled, fans should not have dirt or debris, and dishes should be air-dried before stacking.
Failure to Provide Showers and Grooming Consistent with Resident Preferences: Multiple cognitively intact residents with ADL assistance needs reported feeling dirty, neglected, or frustrated because they were not receiving showers as often as preferred. Shower records and progress notes showed missed or inconsistent bathing documentation, while staff said showers were limited by short staffing, the shower aide being pulled to the floor, and residents sometimes only accepting showers from certain staff. One resident’s hair was observed greasy, and several residents stated they wanted more frequent showers than they were receiving.
The facility failed to document alternatives, risk-benefit review, informed consent, care planning, and ongoing assessments before and during side rail use for multiple residents. Several residents had side rails observed in the raised position, including one with a loose rail, while records lacked orders, safety assessments, measurements, and consent. Staff interviews showed inconsistent processes for evaluating and monitoring side rails, and the DON, ADON, MDS staff, and maintenance all described gaps in responsibility and documentation.
Infection prevention and control failed when staff were not consistently educated on EBP, EBP was not included in care plans for residents with indwelling devices, and precaution signage was missing outside some rooms. Staff provided catheter care and PICC line care with gloves only and no gown for residents with urinary catheters or a PICC, while other staff gave conflicting answers about which residents were on EBP and what PPE was required.
Failure to Provide Required Medicare Non-Coverage Notices: The facility did not provide the required SNFABN or NOMNC to two residents when Medicare Part A skilled services ended. Staff did not document the notices for either resident, and the BOM and Administrator confirmed the forms were not given and did not know why they were missing.
Missed physician orders and fluid restriction monitoring. A resident with DM, HTN, and CHF had progress notes ordering a 1.5-liter fluid restriction, daily weights, and later discontinuation of Tradjenta due to CHF, but the POS still listed Tradjenta and did not include the fluid restriction or intake monitoring. The care plan was not updated, and interviews showed nursing and dietary staff were not consistently receiving or checking progress-note orders.
Failure to order, care plan, and clean CPAP use: A resident admitted with a right humerus fracture and anemia had a CPAP at the bedside and reported staff were applying it and adding water most nights, but the resident had no CPAP order on the POS and no CPAP care plan entry. Staff interviews confirmed CNAs were responsible for CPAP care, CPAPs were cleaned weekly on night shift, and an LPN stated the resident needed orders for CPAP use.
A facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping ketoconazole cream and shampoo at their bedside without proper documentation or physician orders. The resident, with a history of COPD, bipolar disorder, and diabetes, used these medications for a skin condition but was unaware if staff knew about them. Facility staff were not informed of these medications, and the resident's care plan did not reflect any assessment or orders for self-administration, contrary to facility policy.
A resident with moderate cognitive impairment and self-care deficits related to weakness and shortness of breath did not receive showers as preferred, despite requesting them. The resident's care plan required assistance with bathing twice a week, but documentation showed only one instance of independent showering. Staff interviews revealed inconsistencies in understanding and documenting the resident's shower schedule, leading to a failure in supporting the resident's right to self-determination.
A resident with a history of COPD, bipolar disorder, and diabetes developed a skin condition requiring prescription treatment, but the facility failed to assess, document, and notify the physician. Despite having prescribed antifungal cream and shampoo, the resident's condition was not recorded in medical records, and the physician was unaware. Staff interviews revealed a lack of communication and documentation, contrary to the facility's wound prevention policy.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when dented cans were found on the canned food rack with other cans. On 08/25/25, the rack contained a seven pound and five ounce can of baked beans with a large dent near the rim, a six pound and 10 ounce can of pineapple tidbits with a large dent on one side, a six pound and six ounce can of sliced pears with a medium dent, and a six pound and six ounce can of peaches with dents near the bottom and rim. On 08/28/25, the same dented cans remained on the rack, and two additional dented cans of cream of potato soup and cream of mushroom soup were also observed there. Staff interviews reflected that dented cans should not be used and should be removed from the rack and stored in a separate designated area, but the dented cans were still present with the other inventory during the observations. Food labeling and storage practices were also not followed. During kitchen observations, multiple seasonings were left open to air, two squeeze bottles and a jar of white liquid in the refrigerator had no labels, and several items in the walk-in refrigerator and freezer were unsealed, open to air, or lacked labels. These included a container of applesauce with an unsealed lid, a bag of sausage patties with no label, a bag of hot dogs labeled 08/06/25, a bag of lunch meat labeled 08/18/25, a bag of sliced cheese unsealed and open to air, a bag of cooked chicken labeled 8/23-8/26, a bag of hot dogs labeled 8/26, a bag of salad labeled 8/27, and multiple freezer items including crusts, bread sticks, rolls, green beans, beef patties, and leftover meat that were open to air and unlabeled. Staff interviews stated that opened food should be sealed, labeled, and dated with the open date and use-by date, and that leftovers should be used within three days, but the observations showed items that were not sealed, labeled, or properly dated. The facility also had dirty fans in the walk-in refrigerator and freezer, and dishes were stacked while still wet. Observations showed dust and dirt on fans inside both the refrigerator and freezer, with the fans blowing directly over food. The facility did not provide a policy or cleaning schedule for the fans, and staff interviews showed uncertainty about who was responsible for cleaning them. In addition, plastic bowls were stacked on a shelf under a table while still wet, and plate covers were stacked on the steam table while still wet. Staff interviews stated that dishes and plate covers should be air-dried before stacking, but the observed practice was to stack them without drying.
Failure to Provide Showers and Grooming Consistent with Resident Preferences
Penalty
Summary
The facility failed to promote resident self-determination by not providing showers and grooming care in accordance with resident preferences for five residents. The report states that the facility did not provide a policy related to showers, and multiple staff members acknowledged that shower schedules were affected by staffing shortages and the shower aide being pulled to the floor. Several residents reported feeling dirty, neglected, or frustrated because they were not receiving showers as often as they wanted or as often as they believed they should receive them. Resident #86 was cognitively intact, used a wheelchair, and was dependent for showers, dressing, and toileting. The resident’s care plan did not address the resident’s cares or need for assistance. Shower documentation showed only one shower in June and three showers in July, and no shower sheets were provided for August. During observation, the resident’s hair appeared greasy, and the resident stated feeling dirty with greasy hair when a shower was missed. Resident #77 was cognitively intact, used a wheelchair, and needed supervision to partial assistance with showers, toileting, and mobility. The resident’s care plan identified a self-care deficit and need for one staff assist with ADLs. Shower sheets showed two showers in June, four in July, and one in August. The resident stated the facility had been pulling the shower aide to the floor and that he or she usually got one shower a week but wanted more. Resident #84 had COPD, chronic pain, a communication deficit, muscle weakness, and shortness of breath, and the care plan directed staff to assist with shampoo and shower at least once a week. Shower sheets showed two showers in June, two in July, and two in August. The resident stated the facility was frequently short staffed, that shower aides were pulled to the floor, and that he or she wanted at least two showers a week but felt lucky to get one. Resident #82 was cognitively intact, required partial to moderate assistance for bathing, and had a care plan stating the resident should be shampooed and showered at least one time weekly. Progress notes did not document showers or bathing in July and August, and shower sheets showed showers on several dates in July and one in August, with some refusals documented but no further attempts noted. The resident repeatedly stated it had been at least two weeks since the last shower, that he or she wanted two showers per week, and that he or she felt dirty with greasy hair before receiving a shower. Resident #64 was cognitively intact, required maximum assistance for showers, and had a care plan identifying ADL self-care deficits. Progress notes did not document showers or bathing in July and August, and shower sheets showed one shower in July, one refusal in August, and one shower the next day. The resident stated he or she had gone at least a couple of weeks without a shower, wanted more showers, and felt dirty and neglected before the shower. Staff interviews confirmed that residents were not consistently receiving the expected number of showers because of short staffing, shower aides being pulled to the floor, and residents sometimes only accepting showers from certain staff.
Side Rail Use Lacked Required Assessment, Consent, and Care Planning
Penalty
Summary
The facility failed to document identification and use of possible alternatives before using side rails, failed to document assessment of the risks and benefits of side rail use, failed to obtain informed consent before installation, failed to care plan side rail use, and failed to complete ongoing assessments to determine whether side rails remained appropriate for eight residents. The report states the facility census was 93 and cites the facility policy requiring alternatives to be attempted first, followed by assessment for bed rail use, entrapment risk review, and informed consent. Resident #1 had vascular dementia, generalized anxiety disorder, and type 2 diabetes mellitus, and the MDS showed severe cognitive impairment and substantial to maximum assistance with ADLs. Observations on multiple dates showed a metal quarter side rail on the right side of the bed in the raised position and extremely loose, at an angle rather than straight up. The resident’s care plan did not address side rail use, and the record did not show a side rail assessment, entrapment measurements, review of risks and benefits with the representative, or signed consent. Staff interviews indicated the resident used the rail for positioning, the rail was not checked daily, and maintenance had not previously checked it. Resident #2 had dementia and muscle weakness, with significant memory loss and severe cognitive decline on the quarterly MDS. Observations showed quarter side rails on both sides of the bed in the up position, along with a fall mat. The care plan did not address side rail use, the POS did not include an order for side rails, and the record did not show a side rail assessment, regular inspection documentation, or informed consent. Similar documentation gaps were identified for Resident #12, Resident #19, Resident #47, Resident #86, Resident #77, and Resident #100, including absent side rail care planning, absent safety assessments or measurements, absent consent, and absent documentation of alternatives or risk-benefit review. Interviews with nursing, maintenance, MDS, DON, ADON, and administration showed staff described side rails as used for mobility or positioning, but also acknowledged missing assessments, missing consents, inconsistent responsibility for measurements, and lack of routine documented safety checks.
Infection Prevention and Control Program Failed to Ensure EBP Education, Care Planning, PPE Use, and Signage
Penalty
Summary
The facility failed to maintain a complete and effective infection prevention and control program by not ensuring staff were educated on enhanced barrier precautions (EBP), not ensuring EBP was care planned for residents with indwelling devices, and not ensuring clear precaution signage was posted outside resident rooms. The report states that EBP are infection control interventions designed to reduce transmission of resistant organisms and involve targeted gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, including urinary catheters and PICC lines. One resident was admitted with pneumonia due to klebsiella pneumoniae and acute kidney failure with tubular necrosis, had severe cognitive impairment, required substantial to maximum assistance with ADLs, and had an indwelling Foley catheter. The resident’s record did not include EBP on the facility’s current list of residents on EBP, and the care plan did not address EBP or the catheter. Observations showed no EBP sign on the room door on multiple occasions. During one observation, CNA D and CNA E provided catheter care while wearing gloves only and no gown. Staff interviews reflected inconsistent understanding of EBP, with some staff stating the resident was not on EBP because there was no sign on the door, while others stated residents with catheters should be on EBP and that EBP should be included in the care plan. A second resident had an indwelling urinary catheter and a care plan that addressed catheter care and monitoring for UTI, but did not address EBP. During observation, CNA B entered the room, sanitized hands, applied gloves, adjusted and cleaned the catheter tubing, and left without wearing a gown, even though an EBP sign was posted on the door. A third resident had a PICC line for IV antibiotics related to endocarditis and sepsis, but the care plan did not address EBP. During observation, an LPN entered the room to administer IV antibiotics through the PICC line wearing gloves only and no gown, and there was no sign indicating the resident was on EBP outside the room. Another resident with a history of MRSA was listed as being on EBP in the facility’s current list and care plan, but observations repeatedly showed no EBP sign on the room door, and staff gave conflicting statements about whether the resident was on EBP and what PPE was required.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices at the initiation, reduction, or termination of Medicare Part A skilled services for two residents who remained in the facility after discharge from Medicare Part A coverage. The report states that the facility did not provide either the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) or the Notice of Medicare Provider Non-Coverage (NOMNC, CMS-10123) for Resident #16 and Resident #107, and the facility also did not have a policy related to giving residents or resident representatives these notices. For Resident #16, Medicare Part A skilled services began on 05/01/25 and the last covered day was documented as 06/20/25, but staff did not document providing the required SNFABN or NOMNC. For Resident #107, Medicare Part A skilled services began on 04/07/25 and the last covered day was documented as 05/14/25, but staff likewise did not document providing either required notice. During interviews on 09/02/25, the Business Office Manager confirmed the notices were not provided and said she did not know why, and the Administrator said he did not know the facility failed to provide the forms and was not sure which staff were responsible.
Missed Physician Orders and Fluid Restriction Monitoring
Penalty
Summary
The facility failed to carry out and document physician orders timely for a discontinued medication and failed to implement monitoring of fluid intake for Resident #77. The resident was admitted on 10/08/24 and had diagnoses including diabetes, high blood pressure, and CHF. The quarterly MDS dated 04/18/25 showed the resident was cognitively intact, and the care plan dated 04/28/25 identified a self-care deficit requiring one staff assist with ADLs and noted diuretic therapy related to edema. A physician progress note dated 07/10/25 ordered a 1.5-liter fluid restriction, daily weights, and reporting of sudden weight changes greater than two pounds daily. Subsequent physician progress notes dated 07/17/25 and 08/15/25 continued the 1.5-liter fluid restriction and daily weight monitoring, and the 08/24/25 note stated Lasix had been adjusted and Tradjenta 5 mg daily was discontinued due to being inappropriate with heart failure. However, the resident's current POS dated 08/28/25 still listed Tradjenta 5 mg daily from 01/31/25 and did not include the 1.5-liter fluid restriction or fluid intake monitoring order. The care plan dated 04/28/25 was not updated with the new orders for routine weights and fluid intake limits. During interviews, an LPN stated new orders are entered from faxed or verbal orders and that progress notes are not checked for new orders, while another LPN said some physicians place orders in progress notes and that orders are sometimes missed. The DM said dietary was notified of fluid restriction orders by dietary slip and that the resident had only received a new fluid restriction order the day before the interview. The DON stated the new physicians were writing orders in progress notes and not notifying nursing, and the resident's order for Tradjenta was discontinued in the physician note but was not communicated to the nurses. The physician stated the nurse should carry out the orders listed in the progress note.
Failure to Order, Care Plan, and Clean CPAP Use
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who was admitted with diagnoses including a right humerus fracture and anemia. The resident's hospital discharge instructions dated 08/14/25 indicated the resident used a CPAP at bedtime. During observation on 08/26/25, a CPAP was seen sitting on the resident's bedside table, and the resident stated he or she could not use it without assistance because of a broken arm, but staff were putting it on the resident. During interview on 08/27/25, the resident stated staff put water in the CPAP and applied it most nights, that the resident wore it every night, and that someone helped care for it at home. The resident also stated staff told him or her they knew how to use the CPAP when the resident was admitted. Record review showed the resident's care plan dated 08/25/25 did not address CPAP use, and the current Physician Order Sheet had no order for CPAP cleaning or use. Staff interviews confirmed the gap in orders and care planning: a CNA stated CNAs were responsible for applying, removing, and cleaning CPAPs but had never observed a CPAP for the resident; an LPN stated residents using CPAP should have physician orders, CPAPs were cleaned weekly on night shift, the resident had a CPAP, and the resident had no orders for CPAP use; another LPN stated a resident with a CPAP needed orders and that staff would not know a resident needed CPAP use without orders.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to support a resident's right to self-administer medication by not assessing the resident's ability to self-administer medications and creams found in their room. The facility's policy allows for bedside medication storage if a prescriber provides a written order and the resident's self-administration skills are assessed. However, the resident's care plan and medical records did not reflect any assessment or orders for the medications found at the bedside, including ketoconazole cream and shampoo prescribed by an external dermatologist. The resident, who has a history of chronic obstructive pulmonary disease, bipolar disorder, and diabetes, was found with a partially used tube of ketoconazole cream and a bottle of medicated shampoo in their room. The resident reported using these for a skin condition but was unaware if the facility staff knew about these medications. Interviews with facility staff, including CNAs and a CMT, revealed that they were not aware of the resident having these medications at the bedside, and no orders were documented for them. The resident's physician confirmed that there were no orders for the medicated shampoo or cream in the resident's Medication Administration Record (MAR) but believed the resident could manage these medications at the bedside if there was an order. The Director of Nursing and the Administrator reiterated that medications should not be kept at a resident's bedside without a physician's order, highlighting a lapse in communication and adherence to facility policy regarding medication management.
Failure to Support Resident's Right to Self-Determination in Showering
Penalty
Summary
The facility staff failed to ensure a resident's right to self-determination was supported by not offering and providing showers as preferred. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, including showering, had not received a shower in three weeks despite requesting one. The resident expressed frustration at being ignored by staff when asking for a shower and stated a preference for showering at least once a week. The resident's care plan indicated a need for assistance with bathing due to self-care deficits related to weakness and shortness of breath. The care plan specified that the resident should shampoo and shower twice a week. However, documentation showed only one instance of the resident showering independently, with no other records of showers during the specified timeframe. Observations revealed the resident had scaly patches on the skin and unopened medicated shampoo, indicating a lack of adherence to prescribed hygiene routines. Interviews with facility staff, including CNAs, a CMT, an RN, and the Director of Nursing, revealed inconsistencies in the understanding and documentation of the resident's shower schedule. Staff members provided conflicting information about the frequency of showers and the resident's compliance with showering. The resident's physician emphasized the need for showers at least twice a week, but staff interviews indicated a lack of awareness and documentation of the resident's showering needs and preferences.
Failure to Assess and Treat Resident's Skin Condition
Penalty
Summary
The facility failed to provide care per standards of practice when staff did not assess, identify, and provide appropriate treatment for a skin condition in a resident. The resident, who had a history of chronic obstructive pulmonary disease, bipolar disorder, and diabetes mellitus, developed a skin condition on the face and head that required prescription shampoo and cream. Despite the presence of scaly patches and a prescribed antifungal cream and shampoo, the facility staff did not document notifying the resident's physician about the skin condition. The resident's medical records showed no documentation of the skin condition or notification to the physician, and the resident's physician confirmed being unaware of the condition. Interviews with facility staff revealed that the nurse was responsible for completing weekly skin assessments and providing treatments, but there was a lack of communication and documentation regarding the resident's skin condition. The resident's care plan indicated a risk for skin breakdown, but the weekly skin assessments did not reflect the presence of the skin condition. The facility's policy on wound prevention required comprehensive assessments and prompt reporting of changes in skin condition, but these procedures were not followed. The Assistant Director of Nursing and the Administrator acknowledged that changes in a resident's skin should be documented and reported to the physician, but this was not done in this case. The deficiency highlights a failure in the facility's processes for assessing and managing skin conditions, leading to inadequate care for the resident.
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What surveyors actually found near you
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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 Forsyth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shepherd Of The Hills Living Center | 6.7 mi | ★★★★★ | 13 | 0 |
| Point Lookout Nursing & Rehab | 6.9 mi | ★★★★★ | 1 | 0 |
| Ozark Riverview Manor | 23.4 mi | ★★★★★ | 11 | 0 |
| Ozark Care & Rehab Center | 23.7 mi | ★★★★★ | 5 | 0 |
| Nixa Nursing & Rehab | 27.2 mi | ★★★★★ | 0 | 0 |
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