Continuing Healthcare at Forest Hill

Inspectors wroteBased on record review, observations, interviews, and policy review, the facility failed to ensure food was served in form to meet residents' needs. This affected one resident (#2) of three residents reviewed for specialized diets. The facility census was 69.

Inspectors wroteBased on observations, record review, policy review, and interview, the facility failed to implement infection control protocols for residents with orders for Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). This had the potential to affect ten (Residents #8, #20, #44, #45, #54, #59, #61, #67, #73 and #78) of 15 residents observed during meal service and one (Resident #9) of one residents observed during administration of medication through a feeding tube. Findings Include: Based on observations, record review, policy review, and interview, the facility failed to implement infection control protocols for residents with orders for Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). [...]

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed to ensure resident personal belongings were moved after a room change. This affected one resident (Resident #64) of two residents reviewed for personal property. The facility census was 69. Findings Include: Record review revealed Resident #64 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, obstructive and reflux uropathy, anxiety, urinary tract infections, and stage 4 chronic kidney disease. Review of Resident #64's admission minimum data set (MDS) completed on 11/13/25 revealed a brief interview for mental status (BIMS) score of 15. Interview on 01/14/26 at 1:36 P.M. with family representative of Resident #64 revealed during Christmas (December of 2025) Resident #64's family purchased a new leather recliner chair for the resident and a new blanket. [...]

Inspectors wroteBased on record review, interview, and observation the facility failed to ensure urologist follow-up appointments were scheduled for residents with an indwelling urinary catheter. This affected one resident (Resident #64) of one residents reviewed for incontinence. The facility census was 69.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure residents did not receive unnecessary medications. This affected one resident (Resident #61) of 20 residents reviewed for medical record accuracy and one resident (Resident #69) of six residents reviewed for antibiotic use. The facility census was 69.

Inspectors wroteBased on resident interview, medical record review and staff interview with facility failed to ensure documentation of toileting was completed every shift in the medical record. This affected two (Residents #28 and #29) of two residents reviewed for toileting assistance. The facility census was 69.

Inspectors wroteBased on medical record review, emergency medical service and hospital record review, interview, policy review and review of nursing standards of practice, the facility failed to ensure Resident #58 was free of unnecessary medication without adequate monitoring. This affected one (#58) of three residents reviewed for medication errors. The facility census was 61. Actual Harm occurred on 10/26/25 when Resident #58, a resident with a known low heart rate requiring cardiovascular medications to be held due (due to low heart rate) was administered four cardiovascular medications resulting in the resident becoming unresponsive one hour after medication administration. Resident #58 was transported to the emergency room by ambulance, where she was treated with intravenous fluids for hypotension (low blood pressure) a result of the medication administration. [...]

Inspectors wroteBased on medical record review, policy review, review of medication error reports and interview, the facility failed to ensure medications were administered without significant error. Actual harm occurred on 06/06/25 when Resident #10, who had moderately impaired cognition and was dependent of staff to prepare and administer medications, received medications prescribed for another resident that included cardiac medications that lower the heart rate and blood pressure, medication to prevent platelets from clumping together, medication to treat gout and antianxiety medications. This resulted in the resident experiencing a change in condition requiring transport to the emergency room. [...]

Inspectors wroteBased on observation, record review, medication information review, policy review and interview, the facility failed to administer medication as ordered and/or in accordance with acceptable standards of practice. Three errors out of 28 opportunities were identified resulting in a 10.7% medication error rate. This affected one (Resident #5) of five residents observed for medication administration.

Inspectors wroteBased on review of the facility Payroll Based Journal information, facility assessment, staffing schedule information and staff interviews the facility failed to ensure sufficient staffing levels were maintained to provide resident care and services. This had the potential to affect all 75 residents within the facility.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected four (Resident #11, #30, #52, and #53) of 27 records reviewed.

Inspectors wrote3. Review of Resident #35's medical record revealed diagnoses including cognitive communication deficit, type two diabetes mellitus, chronic respiratory failure, cerebral infarction, anxiety disorder, depression, and atrial fibrillation. On 09/04/24 Resident #35 had a weight of 225.9 pounds recorded. Review of a nursing note dated 09/30/24 at 11:49 A.M. indicated Resident #35 was seen by a nurse practitioner related to cough and chest discomfort. New orders were obtained for a chest x-ray and cardiology consult. An interdisciplinary team note dated 10/03/24 at 1:50 P.M. indicated Resident #35 was reviewed and had a cardiology appointment pending. On 10/10/24, a weight of 256.2 pounds was recorded. There was no further record of a cardiology appointment being made. Review of a dietary note dated 10/10/24 at 11:33 A.M. revealed Resident #35 was having an annual review completed. [...]

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to provide care and services to restore bladder function and treat urinary tract infections (UTI) timely. This affected four (#3, #11, #44 and #52) of four residents reviewed for UTI's, and one (#57) resident reviewed for an indwelling urinary catheter. The census was 75.

Inspectors wroteBased on medical review, review of infection control log, interviews, observations, and policy review the facility failed to ensure appropriate use of antibiotics and/or assessment were completed accurately. This affected five (Resident #12, #41, #48, #52, and #57) of nine reviewed for urinary tract infection and unnecessary medication review.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure residents call lights were readily assessable. This affected five residents (#47 Resident #3, #43, #48, #54) observed during the initial tour.

Inspectors wroteBased on medical record review, review of shower schedules, and interview, the facility failed to ensure bathing preferences were honored. This affected one (Resident #178) of 14 residents interviewed related to choices.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure advanced directives were accurate. This affected one (#59) of 24 residents reviewed for advanced directives. The census was 75.

Inspectors wroteBased on record review and interview the facility failed to ensure comprehensive information was conveyed to the receiving health care provider and documented as such in the medical record. This affected one (Resident #52) of two residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a discharge summary of a resident stay was completed following discharge from the facility. This affected one (Resident #75) of one residents reviewed for discharge. The facility census was 75.

Inspectors wroteBased on observations, medical record review, review of shower schedules and interview, the facility failed to provide hygiene and/or grooming for three (Residents #29, #54, and #73) of 24 residents screened for hygiene/grooming.

Inspectors wroteBased on medical record review, observations, interviews, and policy review the facility failed to ensure a decline in pressure ulcer was timely identified and adequately treated. This affected one (Resident #15) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, observation, and interviews the facility failed to implement interventions to prevent foot drop/contractures/limited range of motion. This affected two (Resident #30 and #59) of two residents reviewed for mobility/positioning.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure fall prevention interventions were in place as ordered and fall investigations were completed after a fall. This affected two (#3 and #54) of four residents reviewed for accidents. The census was 75.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure weekly weights were monitored for a resident who had significant weight loss. This affected one (Resident #73) of two residents reviewed for nutrition.

Inspectors wroteBased on medical record review, observation, interview, policy review and manufacturer guideline review the facility failed to ensure oxygen was administered per orders and respiratory equipment was stored properly. This affected two (Resident #15 and #229) residents of four residents reviewed for respiratory care.

Inspectors wroteBased on medical record review and interview, the facility failed to provide pain medication as ordered, obtain clarification regarding medication administration, and offer non-pharmacological interventions prior to the administration of pain medication ordered on an as needed basis. This affected two (Residents #29 and #178) of four residents reviewed for pain management.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to develop individualized comprehensive dementia care plans and policies related to dementia care. This affected one (#48) of one resident reviewed for dementia care. The census was 75.

Inspectors wroteBased on medical record review, policy review and interview, the pharmacist failed to identify irregularities in the medical record. This affected two (#3 and #48) of five residents reviewed for unnecessary medications. The census was 75.

Inspectors wroteBased on medical record review, National Library of Medicine review and interview, the facility failed to address abnormal laboratory results. This affected one (Resident #48) of five residents reviewed for unnecessary medications. The census was 75.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure residents receiving antipsychotic medications had adequate indications of use and behavioral interventions. This affected one (#48) of five residents reviewed for unnecessary medications. The census was 75.

Inspectors wroteBased on closed record review and interview the facility failed to ensure residents were placed in contact isolation precautions as indicated. This affected one (Resident #78) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, observation, interview and policy review the facility failed to provide comprehensive, resident centered care related to edema and congestive heart failure. This affected one (Resident #24) of three records reviewed.

Inspectors wroteBased on closed record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer for Resident #78 within 30 days of admission. The facility failed to ensure adequate interventions and treatment were in place to promote healing and prevent deterioration of the ulcer. This affected one resident (#78) of two residents reviewed for pressure ulcers. The facility census was 74.

Inspectors wroteBased on closed record review, interview, and policy review the facility failed to ensure antibiotic use was appropriate and criteria was met for the treatment of infections. This affected one resident (Resident #78) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident received treatment to a non-pressure related skin issue as ordered by the advanced level provider. This affected one resident (#5) of three residents reviewed for wounds.

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain adequate staffing levels to provide bathing for residents. This affected five residents (Residents #2, #16, #52, #56 and #278) of five residents reviewed for bathing with the potential to affect all 69 residents. The facility census was 69.

Inspectors wroteBased on resident interview, observation, staff interview and policy review, the facility failed to ensure food was served at appropriate temperatures. This had the potential to affect all but one resident (Resident #4) identified as not receiving nutritional services from the dietary department. The facility census was 69.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure garbage was properly secured inside the dumpster and not lying on the ground outside the dumpster. This had the potential to affect all residents within the facility. The facility census was 69.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to wear appropriate personal protective equipment (PPE) when the COVID-19 county transmission level was high, failed to maintain Resident #21's urine bag off the floor, failed to ensure ice scoops during ice pass on the North Hall (100 hall) were placed in a sanitary location when not in use, failed to ensure a nurse did not handle medications with her bare hands, and failed to ensure residents who were on enhanced barrier precautions had appropriate PPE for staff to wear when providing care. This affected four residents (Resident #21, #62, #66 and #224) observed for infection control procedures and had the potential to affect all 69 residents residing in the facility

Inspectors wroteBased on interview, record review and policy review the facility failed to ensure showers were provided as scheduled and per resident preference. This affected five Residents (#2, #16, #52, #56, and #278) of five residents reviewed for activities of daily living. The facility census was 69.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure resident wishes for life saving procedures were clearly designated in the medical record. This affected one resident (Resident #31) of 31 residents reviewed for advance directives. The census was 69.

Inspectors wroteBased on medical record review, and interview, the facility failed to ensure Resident #59 was invited to participate in care plan conferences and failed to ensure the resident's activity interests had not changed since admission and the activity program provided was meeting the resident's individual needs. This affected one resident (Resident #59) of two residents reviewed for involvement in care planning. The census was 69.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure activities were provided on the weekends to meet the resident needs. This affected one resident (Resident #9) of two residents reviewed for activities. The facility census was 69.

Inspectors wroteBased on medical record review, policy review and interview the facility failed to ensure antipsychotic medication use was appropriate. This affected three residents (Resident #19, #21 and #67) out of five residents reviewed for unnecessary medications. The facility census was 69.

Inspectors wroteBased on observation, medical record review, medication information review, interview, and policy review the facility failed to ensure the medication administration error rate was not greater than five percent. Two medication errors out of 25 opportunities were observed resulting in an eight percent medication error rate. This affected two (Residents #4 and #16) of seven residents observed for medication administration.