Forest Hill Manor Health Center

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided that meet professional standards of quality when assessments of pressure sores were incomplete for 2 of 3 residents (Residents 1 & 2). This failure had the potential to compromise Residents' health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received adequate monitoring to prevent an elopement (leaving the facility without authorization) for one of two sampled residents (Resident 1). Resident 1's elopement assessment indicated she was at risk for elopement, and a care plan was not developed upon admission. On 6/27/25, Resident 1 eloped, was found the next day on 6/28/25 in the neighborhood, transferred to a hospital, was noted to have hypothermia (significant and potentially dangerous drop in body temperature with most common cause from exposure to cold weather) and sustained injuries of forehead laceration (cut) requiring suturing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened, undated, and unlabeled food items in the reach-in refrigerator; 2. There were undated and unlabeled food items in the food preparation area; 3. Pans used for food preparation and food service were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 24 of 24 residents who received their food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) to document medication administration as in accordance with the facility policy and procedures (P&P) and the availability of medication for three out of 13 sampled residents (Resident 10, Resident 9, and Resident 15). These failures had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally) and had the potential for untreated or worsening of patient's medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage when the medication refrigerator temperature is below the acceptable range of 36 Fahrenheit (F) to 46 (F). These failures had the potential for residents to receive medications with reduced efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and privacy was upheld for one of two sampled residents (Resident 179) when Resident 179's Foley catheter drainage bag, (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 179.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 13 sampled residents (Residents 19) were free from unnecessary medication when Resident 19 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring. This deficient practice resulted in unmonitored medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for two of seven residents (Resident 83 and 179) when: 1. Resident 83's intravenous (IV, within or into a vein) tubing was undated; 2. A Certified Nursing Assistant not wearing wearing Personal Protective Equipment (PPE, its equipment worn to minimize exposure to hazards in the workplace) during patient care and; 3. Resident 179's Foley catheter drainage bag (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) was on the floor and uncovered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for 12 of 12 sampled residents (Residents 8,178, 179, 184, 181, 12, 132, 4, 20, 7, 13, and 6). The survey team expanded the sample and identified that a total of 25 resident had the bed rails. The facility failed to follow their bed rails policy when: 1. There was no documentation that alternatives for bed rails were attempted prior to installing bed rails for 25 of 25 residents; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. The convection oven (a cooking device that heats food) located in the skilled nursing facility (SNF) pantry area was not kept in a sanitary condition; 2. No thermometer inside the freezer designated for the SNF residents; 3. The freezer temperature log was not completed, and multiple times, the temperature was 1-2 degrees above 0 Fahrenheit (F, a scale of temperature) degree; 4. The freezer designated for the SNF residents had multiple items unlabeled; 5. An opened bag of pasta was not labeled in the dry storage area; 6. The ice machine was not kept in a sanitary condition; 7. One faucet of the main kitchen was not well maintained; [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.53 percent (%, unit of measurement) medication error rate, when 4 medication errors occurred out of 38 opportunities during the medication administration, for three out of nine residents (Residents 12, 4 and 185). These failures resulted in the medications, not given in accordance with the prescriber's orders, manufacturer's specifications and medication administration's instructions, which resulted in residents, not receiving the full therapeutic effect of the medications or the proper administration of the medication and may cause preventable side effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed vocational nurse C (LVN C) did not sanitize the blood pressure cuff and pulse oximeter, before she used them on Resident 12; 2. There was a personal food, placed on top of the medication cart 2; and 3. Resident 4's oxygen tubing had no label and was found on the floor. These failures could result in the spread of infection and cross-contamination that could affect the 25 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for five of seven sampled residents (Residents 8, 178, 179, 181, and 184). This failure could lead to the delivery of unnecessary or inappropriate medical services against Residents 8, 178, 179, 181, and 184 goals and wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with a mental disorder [MD, a wide range of conditions that affect mood, thinking, and behavior] and residents with intellectual disability [ID, when there are limits to a resident's ability to learn at an expected level and function in daily life] or related disorders [RD]) screening was completed for one out of two residents. This failure had the potential for Resident 8 not to receive the required care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for two out of 12 sampled residents (Residents 4 and 20) within 48 hours of the resident's admission when: 1. For Resident 4, there was no care plan to address oxygen use; 2. For Resident 20, there was no care plan for bowel and bladder incontinence; 3. For Resident 20, there was no care plan to manage blood sugar to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). These deficient practices had the potential for delayed administration of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow physician's order for oxygen (colorless, odorless, and tasteless gas supports life) rate administration for one of three sampled residents (Resident 181). This failure had the potential to compromise Resident 181's health, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use and failed to obtain an informed consent for one of 12 sampled residents (Resident 4). These failures had could lead to the administration of unnecessary medication to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, discontinued medications were properly discarded and not kept in the medication cart when: 1. For Resident 2, discontinued 30 tablets of montelukast sodium (medication used to prevent breathing difficulties) 10 milligram (mg, unit of measurement), and 53 tablets of hydrocodone-acetaminophen 5-325 (controlled medication for pain) mg, were kept in medication cart 2; and 2. For Resident 78, discontinued 26 tablets of oxycodone hydrochloride (controlled medication for pain) 5 mg, and 23 capsules of pregabalin (controlled medication that can treat nerve and muscle pain), 25 mg, were still in medication cart 2. These failures had the potential for residents to receive discontinued medications and controlled medication diversion.

Inspectors wroteBased on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time personnel to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food-borne illness for 25 residents eating facility-prepared foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate food preferences, and food allergies for two out of seven sampled residents (Resident 7, and 4), when: 1. For Resident 7, milk was not provided in her lunch tray, and; 2. For Resident 4, she was allergic to egg whites and had eggs in her breakfast tray. This failure had the potential for decreased meal intake, adverse effects from food allergies, and negative effect on health and well-being for sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the chosen foods indicated on resident's lunch meal ticket for three of 8 residents (Residents 3, 216, and 217) and the facility staff did not puree (very smooth, crushed or blended food) foods with fluids which provided flavor and/or nutritional value for one of 8 residents (Resident 2). These failures had the potential to affect the physical health and well-being of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Store bought salad dressings, pickle relish and yogurt were opened and not labeled; 2. Refrigerator in the skilled nursing facilities (SNF) prep kitchen had drinks unlabeled. 3. An ice machine was not kept in a sanitary condition. 4. Frying station had some black, brown, and white sticky build up on its sides and kitchen flooring was not well maintained; 5. The microwave oven located in the skilled nursing facility (SNF) prep kitchen was not kept in a sanitary condition; 6. SNF waitstaff did not practice proper hand hygiene; 7. Canned food and oatmeal containers were dented and stored in a ready to use storage; 8. Food containers were stacked up wet; 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when: 1. The licensed vocational nurse A (LVN A) did not perform hand hygiene before preparation of medications and before donning (putting on) and after removal of gloves during medication administration for residents 167, 67, and 217. 2. The licensed vocational nurse B (LVN B) did not perform hand hygiene during wound and supra pubic catheter (SPC- a device that is inserted into bladder to drain urine) care for Resident 15. These failures had the potential for residents, staff, and visitors at risk of possible spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure Depakote (drugs that affect brain activities associated with mental processes and behaviors, example is antipsychotics) was administered with informed consent (form indicating who and when the risks and benefits of a medication were explained to the resident or the family member) for one of the five residents (Resident 167). This failure had the potential of not honoring resident's rights to be informed about her treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 9 and 67) received the appropriate care and services when: 1. For Resident 9, facility staff did not perform resident's HgbA1c test (hemoglobin (protein in red blood cells that carries oxygen) A1C test, a simple blood test that measures your average blood sugar levels over the past 3 months) as ordered; and 2. For Resident 67, nursing staff did not remove resident's lidocaine patch (used to help relieve pain) as ordered. These failures had the potential to affect the health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet resident's needs when: 1) License vocational nurse A (LVN A) provided an expired protein supplement to Resident 67; 2) Medications were not given to Resident 15 and Resident 9 due to unavailability; 3) The emergency kit (e-kit, a box containing the emergency supplies and medications needed to provide treatment) were not replaced in a timely manner. These failures had the potential to result in not being able to meet resident's needs especially in times of emergency.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.41 percent (%, unit of measurement) medication error rate when two medication errors out of 37 opportunities were identified during medication pass for two of six residents (Resident 15 and 9). These failures had the potential to result in an ineffective drug therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Improper storage of an emergency kit (e-kit, a box containing medication needed for immediate administration) containing C-II medications (Classification by the Drug Enforcement Agency: C-II or Schedule II substance is considered to have a high potential for abuse); 2. Controlled medication for one discharge resident was found inside the medication refrigerator. These failures had the potential for drug diversion.