Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health & Rehab Center during CMS and state inspections, most recent first.
An LPN diverted a resident's prescribed oxycodone by removing the medication from the narcotic log without administering it, instead providing other medications and falsely stating the pain medication was unavailable. The resident, who had moderate cognitive impairment and a history of chronic pain, did not receive the ordered medication, and the misappropriation was confirmed through investigation and interviews.
Facility staff did not ensure that IV antibiotics were available and administered as ordered for two residents recently admitted after hospitalization for severe infections. Multiple doses of Cefazolin were missed due to unavailability, and there was no documentation that the physician was notified or consulted about using available emergency supply. Nursing staff and the DON confirmed the process for handling unavailable medications, but it was not followed, resulting in missed doses without timely physician input.
Two residents did not receive scheduled doses of IV Cefazolin as ordered by their physicians because the medication was not available at the facility when needed. Nursing staff documented the unavailability, notified the provider and pharmacy, and explained that pharmacy deliveries occur twice daily with a process for STAT orders. Facility policies required prompt transmission of orders and use of emergency supplies, but these measures did not prevent missed doses for the affected residents.
Facility staff failed to prevent significant medication errors when two residents missed multiple doses of IV antibiotics due to medication unavailability. One resident, treated for MSSA bacteremia, missed three consecutive doses of Cefazolin because the medication was not on hand, despite pharmacy delivery and provider notification. Nursing staff and the infection preventionist indicated that missed doses were typically added to the end of the treatment course, a practice not aligned with the facility's antibiotic stewardship policy. The emergency medication supply was found to be inadequate, and no review or adjustment had been made following a change in pharmacy providers.
Misappropriation of Resident Pain Medication by LPN
Penalty
Summary
A deficiency occurred when an LPN misappropriated a resident's prescribed oxycodone pain medication without the resident's consent. The resident, who had a history of pain, osteoarthritis, and low back pain, was admitted with a care plan that included scheduled and as-needed pain medications. The resident had moderate cognitive impairment, as indicated by a BIMS score of 10, and was dependent on staff for medication administration. On the date of the incident, the LPN removed three tablets of oxycodone from the narcotic control count log, but the resident declined the medication, and the medication was not administered as prescribed. The incident came to light when the resident's family reported that the resident had not received the as-needed pain medication as requested. Upon investigation, it was found that the LPN had signed out the medication as given, but the resident denied receiving it. The LPN informed the resident that the oxycodone was not available and instead provided other medications, specifically hydroxyzine and Tylenol, while falsely stating that the controlled pain medication was unavailable. The resident documented this by sending a picture of the pills to a family member, prompting further inquiry. Further review of the narcotic count log and interviews with the resident and staff confirmed that the LPN had diverted the medication. The LPN was unable to provide a valid explanation for the missing medication and failed to comply with a request for a valid urine drug screen. The facility substantiated the misappropriation of the resident's property based on resident statements and the narcotic count review. No negative outcomes were identified for the resident as a result of the diversion.
Failure to Notify Physician and Administer Ordered IV Antibiotics Due to Medication Unavailability
Penalty
Summary
Facility staff failed to ensure that prescribed IV antibiotics were available and administered according to physician orders for two residents who were recently admitted following hospitalizations for severe infections. In both cases, the residents were ordered to receive Cefazolin 2g IV every 8 hours to complete a course of treatment for MSSA bacteremia and severe sepsis. However, multiple doses were missed due to the medication not being available at the facility, and there was no documentation that the attending physicians were notified of the missed doses or given the opportunity to provide alternate orders. For one resident, the clinical record showed that three doses of IV Cefazolin were missed, and although the pharmacy and provider were noted as being made aware of the medication's unavailability for one dose, there was no documentation regarding the other missed doses or any consideration of using available 1-gram vials from the emergency kit. The facility's own timeline indicated that additional doses were later added to the schedule to compensate, but this was not based on timely physician input at the time of the missed doses. For the second resident, several consecutive doses of IV Cefazolin were not administered due to the medication not arriving from the pharmacy. Nursing staff interviews confirmed that the process when a medication is unavailable is to notify the physician and pharmacy, and to check the emergency supply, which included 1-gram vials of Cefazolin. Despite this, there was no evidence that the physician was informed of the missed doses or consulted about using the available emergency supply. Facility policy required staff to notify the physician if an emergency delivery was unavailable, but this was not followed in these cases.
Failure to Provide Timely IV Antibiotics Due to Medication Unavailability
Penalty
Summary
Facility staff failed to provide timely pharmaceutical services by not having intravenous (IV) Cefazolin available for administration as ordered by physicians for two residents. In the first case, a resident admitted with severe sepsis and MSSA bacteremia was prescribed Cefazolin 2g IV every 8 hours to complete a 14-day course. The facility's medication administration record showed that the resident missed two doses on one day and one dose the following day due to the medication not being available. Nursing documentation indicated that both the provider and pharmacy were notified, and the pharmacy confirmed the order was received and filled, with delivery occurring early in the morning. However, there was no documentation reflecting the missed doses on the first day, and the medication was not administered as scheduled. In the second case, another resident admitted after hospitalization for acute metabolic encephalopathy and Staphylococcus aureus bacteremia was also prescribed Cefazolin 2g IV every 8 hours. The medication administration record indicated that two scheduled doses were not given because the drug had not arrived from the pharmacy. The pharmacy reported receiving and processing the order, with the medication picked up for delivery in the early morning hours. Nursing staff explained that their process involves entering orders into the electronic health record to transmit to the pharmacy and contacting the provider and pharmacy if medications are unavailable at the scheduled time. The director of nursing confirmed that if orders are received by a certain time, delivery may not occur until the next morning, and outlined steps staff could take if medications are not available, such as checking emergency supplies or requesting STAT delivery. Facility policies reviewed indicated that staff should promptly transmit medication orders to the pharmacy and obtain medications from emergency supplies if necessary. If a delay or missed dose is anticipated, staff are to notify the pharmacy and arrange for STAT delivery, and if that is not possible, contact the attending physician for alternate orders. Despite these policies, the facility did not have the required medications available for administration as ordered, resulting in missed doses for both residents.
Missed IV Antibiotic Doses Due to Medication Unavailability
Penalty
Summary
Facility staff failed to ensure that residents were free from significant medication errors, specifically resulting in multiple missed doses of intravenous (IV) antibiotics for two residents. One resident, who was admitted following hospitalization for severe sepsis and diagnosed with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, was ordered to receive IV Cefazolin every eight hours to complete a 14-day course. Upon review, it was found that this resident missed three consecutive doses of Cefazolin—two on one day and one on the following day—due to the medication not being available at the facility. Documentation in the medical administration record (MAR) and nursing notes confirmed that the missed doses were attributed to the unavailability of the medication, with both the provider and pharmacy being notified. The contracted pharmacy reported that the order for Cefazolin was received and filled, with delivery occurring as scheduled. However, the facility staff did not have the medication available for administration at the required times, and the emergency supply in the backup box was insufficient to meet the prescribed dosage. Interviews with nursing staff, the infection preventionist, and facility leadership revealed an understanding that missed antibiotic doses would be added to the end of the treatment course, although this practice was acknowledged as not being in accordance with the facility's antibiotic stewardship program. The infection preventionist also noted that missed doses had become more frequent since a change in pharmacy providers, and that discussions regarding the adequacy of the emergency medication supply had not yet occurred. The facility's antimicrobial stewardship policy did not address the management of missed antibiotic doses.
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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 Lynchburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tate Springs Health & Rehab | 0.3 mi | ★★★★★ | 0 | 0 |
| Seven Hills Rehabilitation And Nursing | 0.5 mi | ★★★★★ | 8 | 1 |
| Guggenheimer Health And Rehab Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Lynchburg Health & Rehabilitation Center | 3 mi | ★★★★★ | 5 | 0 |
| Westminster-canterbury Of Lynchburg Inc | 3 mi | ★★★★★ | 3 | 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.