Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Forum Parkway Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to implement a dietitian’s recommendation for nutritional supplements led to significant weight loss in a resident with severe cognitive impairment, malnutrition, and depression. The resident had poor PO intake, ate only part of meals, and reported that the food did not taste good. Staff and leadership described a breakdown in communication between the dietitian, ADON, and MD, and the resident’s weight dropped from 104.6 pounds to 97.2 pounds over the review period.
An LVN crushed a potassium chloride ER tablet instead of dissolving it as ordered before giving it via G-tube to a resident with a feeding tube. In a separate event, an RN prepared sodium chloride for a resident with heart failure and hyponatremia, left it on the med cart when the resident was in therapy, and later forgot to give it after the resident returned; the RN had already signed the MAR before administration.
A resident with multiple chronic conditions and moderate cognitive impairment was served a meal containing rice, despite documented dislikes for all types of rice on her meal ticket. Staff interviews confirmed that the meal ticket was not properly checked, and no substitute was provided, resulting in the resident eating less than half of her meal.
The facility did not consistently provide meals that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing food options, resulting in a deficiency related to dietary services.
A resident with COPD and other health issues did not receive appropriate oxygen therapy due to the facility's failure to document updated physician orders and monitor oxygen levels. The resident's oxygen was increased to 8-10 liters per minute based on verbal orders, but this was not recorded in the medical records, leading to inconsistent oxygen delivery.
A facility failed to ensure proper dialysis care and communication for a resident with chronic kidney disease. The resident's care plan required monitoring for dialysis complications and documenting vital signs, but necessary communication forms were not completed. Staff interviews revealed a lack of adherence to protocols for managing these forms, leading to potential missed orders from the dialysis center.
A facility failed to verify feeding tube placement before administering medications to a resident with a feeding tube, risking aspiration. Additionally, expired medications were found in medication rooms and refrigerators, indicating lapses in medication management. Staff interviews revealed responsibilities for checking expired medications were not consistently met, and no training records were provided to confirm adherence to storage protocols.
A resident with multiple diagnoses was prescribed Ingrezza, Zolpidem, and Buspirone, but the facility failed to monitor for side effects as required by their policy. Despite the care plan indicating a need for monitoring, there were no documented orders or evidence of such monitoring. Interviews revealed that staff were unaware of the need for specific monitoring orders, and the DON confirmed that monitoring should have been in place to prevent adverse outcomes.
The facility failed to ensure proper use of PPE during care for two residents on enhanced barrier precautions. A resident with a feeding tube did not receive appropriate care when an RN neglected to wear a gown during medication pass and tube feeding site care. Similarly, another resident with a Foley catheter was at risk when a CNA performed incontinence care without a gown. Staff interviews confirmed the facility's policy required PPE use, but non-compliance led to infection control deficiencies.
A resident with severe cognitive impairment and physical limitations did not receive necessary grooming assistance to remove unwanted facial hair, despite requiring substantial assistance for personal hygiene. Facility staff interviews revealed that CNAs were responsible for shaving residents on shower days, but the resident's refusals were not documented or addressed. The facility's policy required documentation of refusals and notification of supervisors, but it lacked specific guidelines on shaving frequency.
A resident with an indwelling urinary catheter did not receive appropriate catheter care, leading to a deficiency in care. The resident, who required substantial assistance and had a care plan to prevent urinary tract infections, reported feeling unclean and irritated. Observations and interviews revealed that a CNA failed to provide proper catheter care, which was acknowledged as an oversight. Staff confirmed that CNAs were responsible for catheter care, and the facility's policy emphasized the importance of cleaning the catheter to prevent infections.
A facility failed to date and initial the dressing on a resident's peripheral IV line, which is necessary for monitoring and changing the dressing to prevent infection. The charge nurse admitted to not checking the date, and the DON acknowledged the facility's responsibility in monitoring the IV line. The resident was receiving prophylactic fluids, and the oversight was noted despite previous staff training on dressing changes.
The facility failed to accurately dispense medications upon discharge for two residents. One resident was sent home with another's medications, and the error was reported by a family member. Another resident was transferred with incorrect medications, which were returned and corrected. These incidents indicate a failure in the facility's medication verification and reconciliation process.
A resident with severe cognitive impairment and limited mobility developed a Stage IV pressure ulcer on the right calf due to the facility's failure to follow physician orders and provide adequate care. The resident's knee immobilizer was not removed as required, and staff did not document any refusal of care, leading to the ulcer's development.
Failure to Implement Dietitian Recommendation for Nutritional Supplement
Penalty
Summary
The facility failed to maintain acceptable nutritional status for one resident who had severe cognitive impairment, non-alzheimer's disease, malnutrition, and depression. The resident was admitted with a weight of 105 pounds, and the dietitian’s nutritional assessment noted poor oral intake since admission and recommended starting a nutritional supplement twice daily to increase calorie and protein intake. The resident’s care plan identified a nutritional risk related to protein-calorie malnutrition and significant weight loss thresholds, but the record did not show the dietitian’s recommendation was entered as an intervention. The resident’s weight declined over time from 104.6 pounds on 12/24/25 to 103.2 pounds on 01/06/26, 98.4 pounds on 02/05/26, and 97.2 pounds on 03/01/26, representing a 7.07% loss, or 7.4 pounds, from 12/24/25 to 03/01/26. Staff interviews showed the resident often ate about 50% to 70% of meals, and if she ate less than 50%, a supplement shake would be offered. The resident stated the food did not taste good and she did not eat much of it. The resident’s RP reported being told recently about the weight loss and said the resident had complained about the food. Interviews with facility staff and the dietitian showed the recommendation for nutritional supplements was not timely communicated and implemented. The ADON stated the facility did not have a process in place at the time to communicate dietitian recommendations, and the dietitian said she assumed staff would review her assessments and see the recommendations. The physician stated she normally received a form with the dietitian’s recommendations for review and approval, but could not specify further regarding this resident’s weight loss. The DON stated the dietitian recommendations were supposed to be given to the ADON and then to the doctor, and acknowledged that if recommendations were not followed a resident could lose weight.
Medication Administration Errors With Enteral Tube Potassium and Missed Sodium Chloride Dose
Penalty
Summary
Pharmaceutical services were not provided in a way that met resident needs when an LVN administered potassium chloride extended-release through a gastrostomy tube to a resident with a feeding tube and intact cognition. The resident had diagnoses including gastrostomy status and cognitive communication deficit, and the physician order directed that potassium chloride ER 20 mEq be given via G-tube every 6 hours and dissolved in 8 oz of water for 2 minutes before being poured into the tube. During observation, the LVN crushed the potassium tablet along with other medications instead of dissolving it as ordered, then flushed the tube and administered the medications through the tube. The LVN stated she knew the order said to dissolve the potassium in water but did not know it was not supposed to be crushed. A second medication administration error occurred when an RN prepared sodium chloride 1 gram for a resident with heart failure and hyponatremia but left the medication on the medication cart after the resident was not in the room. The resident’s order was for sodium chloride 1 gram by mouth three times daily, and the MAR showed the morning dose had been last administered at 6:00 AM. During observation, the medication was found in an unlabeled cup on the cart, and the RN identified it as the resident’s sodium chloride. The RN stated she had popped the medication, went to give it to the resident, found him in therapy, and then forgot to administer it when he returned. The RN also stated she had signed the MAR before the resident received the medication and acknowledged she was not supposed to do that. She further stated she should have discarded the medication or taken it to the therapy area to administer it, and that she was not supposed to keep the medication in the cart or document it as given before administration. The DON stated nurses were expected to administer medications once popped and not leave them on the cart, and that the RN had no reason for signing off on the MAR before giving the medication.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's documented food preferences. Specifically, a female resident with multiple medical conditions, including chronic heart failure, stroke history, neurocognitive disorder, and other chronic illnesses, was served white rice for lunch despite her meal ticket clearly listing a dislike for all types of rice. Observation showed that she ate less than half of her meal, and she reported not eating much because she did not like rice. The meal ticket on her tray indicated her dislike for rice, but no substitute item was provided. Interviews with staff revealed that dietary, nursing, and CNA staff were responsible for checking meal tickets and trays to ensure accuracy with resident preferences, allergies, and dietary needs. Despite these procedures, the error was not caught, and the resident received a meal inconsistent with her preferences. Staff acknowledged the oversight and explained that the kitchen was responsible for matching trays to tickets, and that the resident should have received mashed potatoes as a substitute. The facility's policy required staff to inspect trays for accuracy and report discrepancies, but this process failed in this instance.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options as required. This deficiency was identified based on observations and findings that the facility did not consistently provide meals tailored to individual dietary needs and preferences, potentially exposing residents to foods they could not tolerate or did not prefer.
Failure to Document and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received appropriate care consistent with professional standards. Specifically, the facility did not have accurate physician orders for the oxygen use of a resident, which could lead to inadequate or inappropriate oxygen delivery. The resident, a male with a history of stroke, cancer, pneumonia, anxiety disorder, and COPD/emphysema, was observed to have issues with breathing and required an increase in oxygen levels beyond the documented physician orders. The resident's care plan indicated the need for oxygen therapy, but the physician orders on record only specified oxygen at 2-4 liters per minute. However, due to the resident's difficulty in breathing, the nursing staff increased the oxygen to 8-10 liters per minute based on verbal communication with the physician, but this change was not documented in the resident's medical records. Observations revealed the resident was receiving 7 liters per minute, which was inconsistent with the verbal order of 8-10 liters per minute. Interviews with nursing staff, including an RN and an LVN, confirmed that the new oxygen order was not entered into the system, and the resident's oxygen levels were not consistently monitored as required. The Director of Nursing was unaware of the lack of updated orders and emphasized the importance of transcribing physician orders into the system. The facility's policies on telephone orders and oxygen administration were not followed, leading to a risk of the resident not receiving the correct level of oxygen needed for proper breathing.
Failure in Dialysis Communication and Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate care and communication between the facility and the dialysis center. The resident, a female with chronic kidney disease, was admitted to the facility and required hemodialysis. Her care plan included goals to monitor for complications from dialysis and to obtain and document vital signs before and after dialysis sessions. However, the facility did not complete the necessary dialysis communication forms for the resident, which are crucial for exchanging information between the facility and the dialysis center. Interviews with staff revealed a lack of adherence to the protocol for managing dialysis communication forms. A Licensed Vocational Nurse (LVN) acknowledged the responsibility to send the resident with a communication form to dialysis and collect it upon her return, but admitted to not following through. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) also confirmed the importance of these forms for communication and noted that they were missing. The RN admitted to not documenting communication with the dialysis center or notifying management about the missing forms. The Director of Nursing (DON) expressed expectations for staff to manage the communication forms and perform post-dialysis assessments, but these expectations were not met. The facility's policy on end-stage renal disease care emphasized the importance of agreements for information exchange between the facility and the dialysis center, which were not upheld. This deficiency in communication could lead to missed orders and recommendations from the dialysis center, potentially impacting the resident's care.
Deficiencies in Feeding Tube Management and Medication Storage
Penalty
Summary
The facility failed to ensure proper monitoring and verification of a feeding tube's placement before administering medications to a resident. The resident, a male with a history of stroke and cognitive communication deficit, required a feeding tube for nutrition. During a medication administration observation, an LVN did not check the gastronomy tube placement or gastric residual before administering medications, contrary to the facility's protocol. The LVN acknowledged the oversight and recognized the potential risk of aspiration if the resident's body was not absorbing the feeding as expected. Additionally, the facility did not adequately manage expired medications in its medication rooms and refrigerators. Observations revealed expired acetaminophen suppositories and aspirin bottles that were not removed or destroyed as required. Interviews with nursing staff indicated that it was their responsibility to check for expired medications, but lapses occurred, leading to the presence of outdated drugs in the facility. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for ensuring that expired medications were removed weekly. However, the ADON admitted to missing expired medications during checks, and no training records were provided to verify that staff had been adequately trained on medication storage procedures. The facility's policy clearly stated that outdated drugs should not be used and must be returned or destroyed, highlighting a failure in adherence to established protocols.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by not monitoring for side effects of certain prescribed medications. The resident in question, a female with mild cognitive impairment and multiple diagnoses including anxiety disorder, bipolar disorder, and obstructive sleep apnea, was prescribed Ingrezza, Zolpidem, and Buspirone. Despite the care plan indicating a need to monitor for side effects, there were no documented orders or evidence of monitoring for these medications. The resident's medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), did not show any documentation of side effect monitoring for the prescribed medications. Interviews with the resident and nursing staff revealed that while the resident reported no side effects, the nurse responsible for her care was unaware of any specific orders for monitoring side effects. The Director of Nursing (DON) confirmed that such monitoring should have been in place to prevent adverse outcomes. The facility's policy on adverse consequences and medication errors requires monitoring for potential adverse effects of medications. However, this policy was not followed, as evidenced by the lack of monitoring orders and documentation in the resident's records. This oversight could lead to adverse consequences for the resident, as the facility did not adhere to its own policy to ensure prompt identification and reporting of any medication-related issues.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members during care activities for two residents. Resident #7, a female with a feeding tube and on enhanced barrier precautions, did not receive proper care when RN C performed medication pass and tube feeding site care without wearing a gown, despite being aware of the precautions indicated by an orange dot at the door. RN C acknowledged the oversight and admitted that not wearing a gown placed the resident at risk of infection. Similarly, Resident #9, who had an indwelling Foley catheter and was also on enhanced barrier precautions, was not provided with appropriate care when CNA M performed incontinence care without donning a gown or face shield. Although CNA M used gloves and practiced hand hygiene, she forgot to wear a gown, which was required as part of the enhanced barrier precautions. CNA M recognized her mistake and understood that her actions could lead to contamination and infection risk for the resident. Interviews with other staff members, including LVN D and the Director of Nursing (DON), confirmed that the facility's policy required the use of gloves and gowns for residents on enhanced barrier precautions. The DON emphasized that failing to adhere to these precautions could result in the transmission of infections. The facility's policy on Enhanced Barrier Precautions outlined the necessity of using PPE during high-contact care activities to prevent the spread of infectious diseases, but the staff's failure to comply with these guidelines led to the identified deficiencies.
Failure to Provide Grooming Assistance for Resident
Penalty
Summary
The facility failed to provide necessary grooming assistance to Resident #14, who was unable to perform activities of daily living due to severe cognitive impairment and physical limitations. The resident, a female with multiple diagnoses including coronary artery disease, heart failure, diabetes mellitus, aphasia, hemiplegia, unspecified dementia, and cerebrovascular accident, required substantial to maximal assistance for personal hygiene. Despite this need, the facility did not ensure that Resident #14 received grooming assistance to remove unwanted facial hair, which was observed to be 10-15 long brown and gray hairs approximately 0.5 inches in length on her chin. Interviews with facility staff, including a CNA, LVN, ADON, and DON, revealed that the responsibility for shaving residents fell on the CNAs, who were expected to offer shaving services on shower days. However, Resident #14's personal hygiene records indicated that she was not shaved on multiple occasions, and her refusals were not adequately addressed. The CNA responsible for Resident #14 stated that the resident usually refused shaving, but there was no documentation of these refusals or any follow-up actions taken by the nursing staff to address the issue. The facility's policy on shaving residents, revised in October 2010, required documentation of refusals and notification of supervisors, but it did not specify the frequency of shaving. The lack of adherence to this policy and the failure to ensure Resident #14's grooming needs were met could lead to social isolation, loss of dignity, and self-worth for residents requiring assistance. The DON acknowledged that the issue was a dignity concern, emphasizing the importance of maintaining residents' appearance and self-esteem.
Failure in Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, a cognitively intact female with a BIMS score of 13, required substantial assistance with personal hygiene and had an indwelling catheter due to neurogenic bladder and other medical conditions. The care plan for the resident included specific interventions to prevent urinary tract infections, such as changing the catheter as ordered and checking for signs of infection. However, the facility did not follow these physician orders for routine catheter care, including cleaning the catheter properly. During an interview, the resident expressed feeling unclean and irritated near the catheter insertion site, indicating a lack of proper care. Observations revealed that a CNA failed to provide catheter care during incontinence care, which was acknowledged by the CNA as an oversight. Interviews with staff, including an LVN and the DON, confirmed that CNAs were responsible for catheter care and that failing to perform this care placed residents at risk of infection. The facility's policy on catheter care emphasized the importance of cleaning the catheter to prevent infections, but this was not adhered to in the case of the resident.
Failure to Date IV Dressing Leads to Deficiency
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically by not dating and initialing the dressing on the resident's peripheral IV line. This oversight was observed in a resident who was receiving prophylactic fluids through a peripheral IV line. The resident, a female with moderate cognition and a history of urinary tract infection, had an IV line inserted for fluid administration. During an observation, it was noted that the dressing on the IV line was intact but lacked a date, which is crucial for monitoring and changing the dressing to prevent infection. The charge nurse responsible for the resident admitted to not checking the date on the dressing, acknowledging that this omission could lead to infection due to the inability to track when the dressing should be changed. The Director of Nursing (DON) confirmed that the facility was responsible for monitoring the IV line, despite it being inserted by an external service provider. The facility's policy required that the dressing be labeled with the date, time, and other details, which was not adhered to in this instance. Training records indicated that the charge nurse had previously attended training on dressing changes, yet the deficiency occurred.
Medication Dispensing Errors Upon Resident Discharge
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for two residents upon discharge. Resident #1 was discharged with medications that were not hers, as confirmed by her family member who reported the issue to the facility. The medications sent home with Resident #1 were labeled with Resident #2's name. This error was identified when the family member of Resident #1 provided photos of the incorrect medication labels to the facility. Similarly, Resident #2 was transferred to an assisted living facility with medications that belonged to another resident. The family member of Resident #2 returned the incorrect medications to the facility and received the correct ones. The facility documented the return of the medications the following day. Both incidents highlight a failure in the facility's process for verifying and reconciling medications before discharge, as outlined in their policy.
Failure to Prevent Stage IV Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a Stage IV pressure ulcer on the right calf of a resident. The resident, who was admitted with a fracture of the right tibia and other medical conditions including severe cognitive impairment and limited mobility, was at risk for pressure ulcers. Despite this, the facility did not ensure proper care and monitoring of the resident's skin integrity, particularly under a knee immobilizer that was supposed to be removed at rest according to physician orders. The resident's care plan indicated a risk for pressure ulcers, but there was no specific documentation regarding the care of the right calf or the knee immobilizer. Interviews with staff revealed that the knee immobilizer was not removed as required, and the resident was not repositioned adequately due to her non-compliance and pain. The facility's staff failed to follow physician orders and did not document any refusal of care by the resident, leading to the development of a severe pressure ulcer. The deficiency was identified when a family member noticed swelling and a foul odor from the resident's leg, prompting a hospital visit where the Stage IV pressure ulcer was diagnosed. The facility's lack of adherence to care protocols and inadequate documentation contributed to the resident's condition worsening, highlighting a significant lapse in the standard of care provided.
Removal Plan
- Audit by DON and/or designee on all residents who have orders for splints, casts, or boots to ensure that there is no unidentified skin breakdown.
- Inservice by DON/Designee with Licensed nurses on circulation checks.
- Inservice on following physician orders by DON/Designee with Licensed nurses.
- Licensed nurses, CNA and CMA were educated on the process of accurate documentation of refusal.
- New admissions will be reviewed in morning clinical meeting to ensure that all physician orders are being followed.
- New Hires will be in-serviced on following physician orders and accurate documentation during the orientation process.
- DON/Designee will audit all patients with soft cast/brace/sling for skin alterations.
- Random skin Audit by DON/Designee on residents that have a soft cast/brace.
- DON/Designee will review new physician orders related to soft cast/brace/sling during the morning clinical meeting.
- DON/Designee will review MARS for resident with soft cast/brace/sling to ensure accurate documentation is completed.
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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 Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkwood Village | 1.1 mi | ★★★★★ | 1 | 0 |
| Westpark Rehabilitation And Living | 1.3 mi | ★★★★★ | 27 | 0 |
| La Dora Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Bedford Wellness & Rehabilitation | 1.7 mi | ★★★★★ | 16 | 0 |
| Hurst Plaza Nursing & Rehab | 3.2 mi | ★★★★★ | 6 | 0 |
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