Forest Hill Manor

Inspectors wroteBased on observations and interviews the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 lunch dining services observed (3/9/26).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to obtain a provider order, complete an assessment, and monitor for the use of a seatbelt while in a motorized wheelchair for 1 of 1 residents reviewed for restraints (Resident #40 [R40]).

Inspectors wroteBased on observation and interviews, the facility failed to prepare food under sanitary conditions for 1 of 3 days of survey. (3/9/26)

Inspectors wroteBased on clinical record reviews, and interviews, the facility failed to provide physician ordered respiratory services requiring specific types of respiratory care and services including supplemental oxygen and continuous positive airway pressure (CPAP) and/or bilevel positive airway pressure (BIPAP) treatments for 1 of 3 residents reviewed for respiratory care (Resident # 1 [R1]).1. R1's clinical record has a provider written order dated 6/30/25 at 1305 [1:05 p.m.] 1. Please check pulse ox (oxygen saturation rate) 4x [times]/shift. Call covering provider if SpO2 (peripheral capillary oxygen saturation rate) < [less than] 90% while awake or < [less than] 88% when sleeping. R1's clinical record Nursing Narrative Note: dated 7/3/25 at 3:30 p.m. states, SpO2 88%, 89%, 93%, 94%. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain resident equipment and the building in good repair, homelike, and in a sanitary condition on 2 of 2 units (Skilled Nursing Unit [SNF] and Long Term Care Unit [LTC]).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to update/revise care plans for the use of Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #26 [R26] and [R27])

Inspectors wroteBased on observations and interviews, the facility failed to ensure that hot water temperatures in resident rooms did not exceed 120 degrees Fahrenheit and that blue floor tiles in the Skilled Unit hallway were completely glued to the floor creating a possible trip hazard, on 2 of 3 days of survey (2/18-2/19/25).

Inspectors wroteBased on observations and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 5 residents reviewed for respiratory care (Resident #11 [R11], [R27] and [R33]).

Inspectors wroteBased on observations and interviews, the facility failed to implement infection prevention measures for 2 of 3 days of survey (2/18/25 and 2/19/25) and failed to fully develop/implement a water management program to prevent the growth and spread of Legionella and other water-borne pathogens in the area of monitoring for control measures for 1 of 1 review of water management program.

Inspectors wroteBased on record review and interviews, the facility failed to notify timely the Medical Provider of abnormal laboratory results that required further tests to determine cause and the Resident Representative (RR) with results of abnormal labs when results were requested, for 1 of 1 residents reviewed for hospitalization (Resident # [R42]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Diabetes for 1 of 13 residents reviewed (Resident #13 [R13])

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure physician orders were followed for 1 of 5 sampled residents for unnecessary medications (Resident #13 [R13]).

Inspectors wroteBased on record review and interview, the facility failed to recognize a potential significant weight loss for 1 of 5 sampled residents reviewed for nutrition (Resident #30 [R30]).

Inspectors wroteBased on observation and interview, the facility failed to ensure all expired drugs and biologicals, available for resident use, had been removed from 1 of 2 medication storage units (skilled nursing unit), and 1 of 1 medication storage refrigerator (medication storage refrigerator long term care unit).

Inspectors wroteBased on record review and interviews, the facility failed to notify the provider of abnormal laboratory results timely for 1 of 1 residents reviewed for hospitalization (Resident #42 [R42]).

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to ensure residents were offered pneumococcal immunizations for 1 of 5 residents reviewed for immunizations (Resident #34 [R34]).

Inspectors wroteBased on the facility reported incident dated 9/17/24, review of the facility's investigation report dated 9/17/24, facility's investigation follow-up report dated 9/20/24, facility policy, record review, and interviews, the facility failed to protect a resident from being sexually harmed, and potentially being emotionally harmed and causing the resident to sustain emotional fear, sadness, and embarrassment for 1 of 1 resident sampled for abuse (Resident #1 [R1]). A reasonable person could have psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 3 unlicensed staff reviewed for in-service training completed the required training (Staff #1, and Staff #2).

Inspectors wroteBased on interviews, the facility's bathing schedule, and facility's bathing documentation, and electronic medical record the facility failed to ensure that resident's preferences were being followed in the area of bathing for 1 of 1 resident reviewed. (Resident's #1 [R1]).

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to obtain a urine sample for 1 of 2 residents reviewed for resident to resident abuse (Resident #24 [R24]).

Inspectors wroteBased on record review, policy and procedure review and interview, the facility failed to follow their fall policy and procedure for completing neurological checks for 3 of 3 residents who had a fall and sustained a head injury. (Resident #41 [R41], R12, R34)

Inspectors wroteBased on observations and interviews, the facility failed to implement infection prevention measures for 2 of 3 days of survey (2/25/24, and 2/26/24).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the admission Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 1 of 1 sampled residents reviewed for Pre-admission Screening and Resident Review (PASRR) (Resident #40 [R40]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 1 residents reviewed (Resident #40 [R40]).

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for drawers, cabinets, oven/stove overhead vent, propane pipe, bowls, dishes, ice machine, air fryer, and food in a reach-in freezer. Additionally, the facility failed to label and date food in a reach-in freezer. This was for 1 of 1 kitchen tours on 1 of 3 days of survey (2/25/24).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure 5 of 6 residents (Residents #41 [R41], R43, R18, R17, and R28) reviewed for immunizations were reviewed and offered pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations.

Inspectors wroteBased on performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 2 of 6 sampled employees (Unit Care Taker, and Certified Nursing Assistant [CNA]).