Forest Hill Health & Rehabilitation

Inspectors wroteBased on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on three of three units (Unit 2, 3 and 4 only operational units, Unit 1 under renovation) and in the main entryway, which resulted in Substandard Quality of Care.

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the rooms of Resident # 3 and #130 and throughout the entire facility.

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 4 Residents (# 123, #2, # 76 and # 113) in a survey sample of 63 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to ensure residents on three of three living units were free from misappropriation of resident property, to include specifics for one Resident #441 in a sample of 63 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation review the facility staff failed to review and revise the care plans for 5 Residents (#42, 106, 124, 130, and #132) in a survey sample of 63 Residents.

Inspectors wroteBased on observations, staff interviews, resident record review, and a review of facility documents, the facility staff failed to apply a Occupational Therapy (OT) recommended splitting/orthotic device for one (1) of 63 residents (Resident #50), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, resident record review, the facility staff failed to obtain dental services for two (2) of 63 residents (Resident #27 and 96), in the survey sample.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the required in-service training for nurses' aides be sufficient and no less than 12 hours per year for 4 of 6 Certified Nursing Assistant's (CNA's) reviewed during the survey.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are cared for in a manner that promotes maintenance or enhancement of his or her quality of life for one (1) Resident (#24) in a survey sample of 63 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one (1) resident (Resident # 83) in survey sample of 64 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to allow resident to manage financial affairs for 1 of 38 residents (Resident #135), in the survey sample.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure two (2) of 63 residents (Resident #39 and Resident #46) in the survey sample were given the opportunity to formulate an advance directive.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete an Advanced Beneficiary Notice (ABN) for two (2) Residents, (Residents #192 and #37) in the four (4) sampled residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure personal privacy was afforded to three (3) residents (Residents # 123, #2, and # 46) in a survey sample of 63 residents. 1. For Resident # 123, the facility staff failed to provide a curtain to pull around the bed while providing ADL (Activities of Daily Living) Care. Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. [...]

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff discouraged one Resident from communication with external local entities/police during an abuse allegation, and did not allow evidence from a police report of the abuse situation for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to protect one Resident from abuse by a room mate with known illicit drug and alcohol abuse in their shared room for 1 Resident (Residents #131) in a survey sample size of 63 residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to protect Residents, report abuse timely, investigate fully, and allow a police report of the abuse for 4 Residents (Residents #130, #131, #7, and #39) in a survey sample size of 63 residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to report an allegation of abuse to the state agency, police, and other stake holders timely for 4 Residents (Residents #131, #130, #7, and #39) in a survey sample size of 63 residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate an allegation of abuse fully for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents.

Inspectors wroteBased on the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 63 residents (Resident #50), in the survey sample.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 63 residents in the survey sample (Resident # 139), a closed record resident.

Inspectors wroteBased on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 4 Residents (Residents #3, #32, #59, and #132) in a sample of 63 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow the professional standards of quality regarding treatments for one (1) resident (Resident # 24) in survey sample of 63 residents.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure proper Activities of Daily Living services were provided for three (3) residents (Residents #123, #83 and #24) in a survey sample of 63 residents.

Inspectors wroteBased on observation, interview clinical record review and facility documentation the facility staff failed to ensure Residents receive treatment and assistive devices to maintain vision for 1 Resident in a survey sample of 38 Residents.

Inspectors wroteBased on observation, staff interview, facility documentation review and clinical record review, the facility failed to prevent, assess, identify and treat an avoidable pressure ulcer for one Resident (Resident #63) in a survey sample of 63 Residents.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review and facility documentation review, the facility staff failed to ensure proper foot care was provided to one (1) resident (Resident # 83) in a survey sample of 63 residents. For Resident # 83, the facility staff failed to ensure proper nail care was provided. Resident # 83 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Diabetes, Acute Respiratory Failure and Congestive Heart Failure. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 83's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and resident record review, the facility staff failed to provide incontinence care for one (1) of 63 residents (Resident #21), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents did not sustain significant unplanned weight loss for one (1) Resident (# 109) in a survey sample of 63 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide routine medications to two (2) Residents (Residents #24, and #2) in a survey sample of 63 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure Residents were free from significant medication errors for two (2) Residents (Residents #24, and #139) in a survey sample of 63 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to reflect resident's cultural and ethnic needs of the resident by not providing meal preferences for one (1) of 63 residents (Resident #36), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure that a resident's lunch was palatable and attractive for one (1) of 63 residents (Resident #129), in the survey sample.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for the facility in general, and for two (2) residents (Residents #3, and #130) in a survey sample of 63 residents

Inspectors wroteBased on observation, resident interview, staff interview, the facility staff failed to ensure rooms had visual privacy for five (5) Residents (Residents # 123, # 2, # 128, # 132 and #46 ) in a survey sample of 63 residents.

Inspectors wroteBased on Observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an environment that was free from hazards, that each Resident received supervision, and that ongoing monitoring was implemented to prevent accidents and hazards for four (4) Residents (#'s 42, 106, 124, and 130) in a survey sample of 63 Residents, which resulted in Immediate Jeopardy.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) residents (R#42, #106, #124 and #130) and each Long-Term Care Resident which resulted in Immediate Jeopardy.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to follow standards of practice affecting one resident (Resident #1) in a survey sample of 16 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility failed to ensure the Resident's right to right to choose a roommate when practicable, and the right to receive written notice, including the reason for the change, before the resident's room or roommate is changed, for 1 Residents (# 5) in a survey sample of 16 Residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to allow visitation for one resident (Resident # 1) in survey sample of 16 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to allow the Resident Representative access to the clinical record in a timely manner for two Residents ( Resident #7 & #1) in a survey sample of 16 Residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure the Residents right to a safe clean comfortable and homelike environment for residents on three of four units inhabited by facility residents.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe and orderly discharge for one resident (Resident # 1) in a survey sample of 16 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive care plan for pressure ulcers for three Residents (Residents #10, #12 & #1) in a survey sample of 16 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for 1 Resident (#5) in a survey sample of 16 Residents.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to implement an effective discharge plan for one resident in a survey sample of 16 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure that each resident receives care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident in a survey sample of 16 Residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure incontinence hygiene care was provided timely for 2 residents (Resident #10 & # 3) of 16 residents in the survey sample.

Inspectors wroteBased on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and services for pressure sores for three Residents (Residents #10, 12, & #8) in a survey sample of 16 Residents.

Inspectors wroteBased on staff interview, Ombudsman interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary dialysis services and transportation for 1 Resident (Resident's #12) in a survey sample of 16 residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure that food is palatable and served at an appetizing temperature for all Residents receiving meals from the kitchen.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to maintain clinical records that were accurate for 1 Resident (#7) in a survey sample of 16 Residents.

Inspectors wroteBased on interview, clinical record review, and facility documentation the facility staff failed to ensure a safe and functional environment for all residents who reside in room [ROOM NUMBER], reside on Wing 2, utilize the Sunroom, or receive meals from the dietary staff.

Inspectors wroteBased on observation, interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed for one of 48 sampled residents (#75) to ensure the Resident received ordered wound physician visits, care, and failed to identify a pressure wound to the heel before it reached an advanced stage. This is harm. The Findings Include: Resident # 75 was admitted to the facility on [DATE], her diagnoses included, quadriplegia, diabetes type 2, and pressure ulcers. Resident # 75's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/29/22, coded the Resident as follows: Section G - Resident #75 was coded as requiring #3- Extensive Assistance of #3 - 2 Person Physical Assistance for bed mobility and dressing. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility was not administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This has the potential to affect all residents. The Directors and Officers of the facility's parent company knew of the absence of leadership in the facility, as the Regional Administrator had been tasked with assisting in the capacity of Administrator for 2 buildings and they did not act to allocate effective full time leadership to the facility.

Inspectors wroteBased on observation, staff interview, facility document review, and in the course of a complaint investigation, the facility failed to ensure employment of a qualified Social worker on a full time basis. This has the potential to affect all residents. This is Substandard Quality of Care. The Facility failed to provide a full time Social worker for the second week of survey, and planned to use another facility's Social worker to help out 2-3 days per week.

Inspectors wroteBased on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to maintain an infection prevention and control program for the prevention, identifying, reporting, and investigating infections.

Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to have a designated individual to serve as the Infection Preventionist (IP) which has the potential to affect all 143 Residents residing in the facility.

Inspectors wroteBased on staff interview, and facility documentation review, the facility staff failed to notify Residents and families when new cases of COVID-19 were identified in the facility, affecting all 143 Residents residing in the facility.

Inspectors wroteBased on observation, Resident interview, and staff interview, the facility staff failed to provide a clean, comfortable, and homelike environment for Residents on one unit (the 400 unit) out of 4 units. Specifically, observations of the 400 unit shower room and Resident rooms included the following: 1) The shower room had no hot water from 2 out of 3 shower heads 2) One shower head was detached from the hose and inoperable so the water temperature could not even be tested. 3) The shower room sink had a leaky faucet and there were rust stains in the sink basin. 4) There were rust spots on the floor in various places in the shower room and black spots on the floor in one of the shower stalls. 5) There was a dry, white, crusty substance covering the entire base plate of the shower handle in one of the three shower stalls. [...]

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise care plans for 6 Residents (Resident #127, 93, 4, 49, 75, and 34) in a survey sample of 48 Residents.

Inspectors wroteBased on staff interviews, facility documentation review and clinical record review, the facility staff failed to follow the nursing standards of practice, for two Residents (Resident #106 & #127) in a survey sample of 48 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the resident's needs safely, timely, and in a manner that promotes each residents rights, physical, mental, and psychosocial well being.

Inspectors wroteBased on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure a Registered Nurse (RN) Director of Nursing (DON) was present and overseeing resident care, and staff competencies on a full time basis.

Inspectors wroteBased on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure competent nursing staff to provide nursing and related services to meet the resident's needs for 4 of five record reviews. The Facility failed to provide performance competency reviews to ensuring skilled and competently trained staff, able to provide for Resident care needs.

Inspectors wroteBased on observation, and interview the facility failed to properly store drugs on two medication carts in a sample of four medication carts.

Inspectors wroteBased on observation, interview, facility record review and in the course of a complaint investigation, the facility staff failed to employ sufficient staff to carry out the functions of the food and nutrition services for the facility as a whole.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units.

Inspectors wroteBased on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Resident (Resident #121, 23, 140), in a sample of 5 Residents reviewed for immunizations.

Inspectors wroteBased on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 4 Residents (Residents #46, #23, #92, and #83) in a sample of 5 Residents reviewed for testing and for 9 staff (Employee K, CNA J, RN C, LPN C, Employee C, Employee L, CNA K, LPN E, and Employee M) in a sample of 9 employees reviewed for COVID testing.

Inspectors wroteBased on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to offer COVID vaccination(s) to four Residents (Resident #121, 23, 140 and 92), in a sample of 5 Residents reviewed for immunizations.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to complete exemption documents for 10 of 10 exemptions requested by staff (Employee K, Employee Y, Employee G, CNA J, CNA F, CNA H, CNA G, LPN C, LPN J, and RN C)

Inspectors wroteBased on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure completion of staff abuse training for 3 of 5 sampled records

Inspectors wroteBased on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to maintain dignity for one Resident (Resident #142) in a sample size of 48 Residents. Specifically, the facility staff did not assist Resident #142 to obtain clothes/get dressed for approximately 2 months.

Inspectors wroteBased on observation, interview, facility documentation and clinical record review the facility staff failed to promote self determination through support of resident choice, for Resident # 84 in a survey sample of 48 Residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to allow a Resident to have visitors at the time of their choosing, for one Resident (#127) in a survey sample of 48 Residents.

Inspectors wroteBased on interview, facility record review and clinical record review the facility staff failed to report allegations of abuse to the State Agency (VDH Office of Licensure and Certification) for 1 Resident (# 64) in a survey sample of 48 Residents.

Inspectors wroteBased on electronic health record (EHR) review the facility failed ensure the preadmission screening (PASARR) evaluation for an individual with a mental disorder was conducted for one resident (Resident #45) in a sample of 48.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a resident-centered baseline care plan that met professional standards of quality care for one resident (Resident #127) in a sample of 48 Residents.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to supervise one Resident during meal time to ensure safety (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 was observed eating her lunch in an unsafe position presenting a potential choking hazard on 07/11/2022.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to identify, monitor, and treat significant weight loss for one Resident (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 experienced an 18.91% weight loss over a 3 month time period (January 2022 through April 2022).

Inspectors wroteBased on observation, interview, facility record review and clinical record review the facility staff failed to provide medically related social services to maintain highest practicable well-being for 1 Resident (#34) in a survey sample of 48 Residents.

Inspectors wroteBased on observation, interview, facility documentation and during the course of a complaint investigation the facility staff failed to follow the menus for the facility in general and for Resident #34.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to maintain accurate clinical records for 2 Residents (#'s 75) in a survey sample of 48 Residents.

Inspectors wroteBased in observation, interview, facility documentation and clinical record review the facility staff failed to maintain patient care equipment for 1 Resident #34 in a survey sample of 48 Residents.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to ensure the bed frame and the mattress are compatible, for 1 Resident # 34 in a survey sample of 48 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to ensure a working call light for one Resident (Resident #91) in a sample size of 48 Residents. Resident #91's call light was not working for a number of days in June and July 2022.

Inspectors wroteBased on observations, staff interviews and facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment on 3 of 4 units, unit's 200, 300 and 400.

Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regard to employee screening for 9 Employees (CNA C, CNA D, CNA E, CNA F, CNA G, LPN D, LPN E, LPN F, LPN G) in a survey sample of 25 employee records.

Inspectors wroteBased on observation, staff interview, and facility documentation, the facility staff failed to maintain infection control practices in accordance with the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 for 2 Residents (Resident #555 and #102) and 2 of 5 areas of the facility. 1. The facility staff failed to implement transmission based precautions (TBP) for Resident #555, who was a new admission to the facility. 2. The facility staff failed to implement transmission based precautions (TBP) for Resident #102, who was a new admission to the facility. 3. The facility staff failed to provide proper screening for visitor/vendor entry into the facility. 4. The facility staff failed to ensure personal protective equipment was properly worn.

Inspectors wroteBased on clinical record reviews, staff interviews and review of facility documentation, the facility staff failed to ensure misappropriation of resident property to include the diversion of 2 of 40 resident's (#254 and #304) physician ordered controlled substances for staff use or personal gain.

Inspectors wroteBased on facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications and provide safekeeping of hard scripts for controlled drugs, for 3 Residents (Resident #28, #32, and #102) in a survey sample of 40 Residents. 1. For Resident #28, the facility staff failed to maintain an accurate inventory of controlled medications. 2. For Resident #32, the facility staff failed to maintain an accurate inventory of controlled medications. 3. For Resident #102, the facility staff failed to provide safekeeping of hard scripts for controlled drugs, to prevent drug diversion.

Inspectors wroteBased on resident interview, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to obtain routine dental services for 1 of 40 residents (Resident #52), in the survey sample.

Inspectors wroteBased on observations, staff interviews and facility document review, it was determined that facility staff failed to provide a safe environment in 1 bathroom on 1 of the facility's 4 units.