Forest Hills Care Center

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to maintain the residents' rights to a safe, comfortable, and homelike environment. This was evident in 3 (Units 1, 2, and 3) of 3 units observed. Specifically, 1.) The cover for the clean linen carts in Units 1 and 2 were soiled and heavily worn. 2.) The high back of Resident #41's wheelchair was in disrepair.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility did not ensure that services provided or arranged by the facility meet professional standards of quality. This was evident in 1 (Resident #46) of 1 resident reviewed for pain. Specifically, Resident #46 had physician orders for Lidocaine patch to be applied daily at 9:00 AM to bilateral shoulders for pain. Licensed Practical Nurse #2 had signed off Resident #46's lidocaine patch order on the medication administration record as having administered it, although they did not apply the pain patch on Resident #46's shoulders. Cross Reference:

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that pain management was provided to a resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident in 1 (Resident #46) of 1 resident reviewed for pain. Specifically, Resident #46 had physician orders for Lidocaine patch to be applied daily at 9:00 AM to bilateral shoulders for pain. During observation at 11:18 AM, there were no pain patches observed on Resident #46's shoulders. However, the Medication Administration Record for 06/05/2025 at 9:00 AM documented that the Lidocaine patch had been administered.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey from 06/04/2025 to 06/11/2025, the facility failed to maintain infection prevention and control practices. This was evident in 1 (Resident #12) of 5 residents investigated for Pressure Ulcer out of 38 total sampled residents. Specifically, Licensed Practical Nurse #3 did not perform hand hygiene and glove changes during wound care observation.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that the survey results were posted in a place readily accessible to residents, family members, and legal representatives in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located in a corner with no signage in the area, and was not readily accessible to residents. The finding is: The facility policy and procedure titled Resident Right effective 11/2/2021and revised 10/4/2023 documented the facility will post reports with respect to any survey, certification and complaint investigation made respecting the facility during the 3 preceding years. It should be available for any individual to review upon request. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 2 of 3 resident units. (Unit 2, and Unit 3) during review of the Environment. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 12/21/2023, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for two (Resident #18 and #67) of four residents reviewed. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #18 's and Resident #67 's wishes. The finding is: The policy and procedure titled Bath and Shower revised 01/2023 documented all residents receive a daily bed bath. All residents receive a shower twice a week and per resident's choice it always can be adjusted. Shower schedule is kept on each floor (updated daily as residents are discharged and admitted . CNA will provide showers in accordance with a shower list. 1. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey conducted from 12/18/2023 to 12/21/2023, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to address the resident's needs. This was evident for 1 (Resident #9) of 22 total sampled residents. Specifically, a Comprehensive Care Plan related to Resident #9's discharge plan was not developed and implemented.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure that drugs and biologicals were safe and secure to protect from unauthorized access. Specifically, 1) authorized and unauthorized staff were noted entering the medication room with and without using the keypad on the door, and 2) medication was left unattended in resident areas. This is evident for the Medication Storage Task on Unit 3.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification survey 12/18/2023-12/21/2023, the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner or clinical specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies, and procedures for notification of a practitioner. This was evident for 1 of 4 residents reviewed for Pressure Ulcer/Injury out of 21 sampled residents. (Resident #4) Specifically, there was no evidence the facility promptly notified the Medical Director of a contaminated urine culture report received on 12/15/2023 that required resubmission due to contamination.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey of 12/18/2023 through 12/21/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, staff was observed not washing hands or wearing gloves before handling food for the resident. This was evident during the Dining observation. The facility's policy titled Infection Control: Meal services in Dining Room revised 01/2023 documented to never touch any prepared food items i.e. muffins bread with bare hands. On 12/18/23 at 12:11 PM, Certified Nursing Assistant #12 was observed during lunch time in the 2nd floor dining room assisting Resident #21 with their meal. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (2nd Floor) of 3 Units observed for dining. Specifically, a Certified Nursing Assistant did not perform hand hygiene between assisting residents with hand hygiene.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, functional, and comfortable environment was provided for residents, staff, and the public. Specifically, staff bathrooms in the nursing station was observed in disrepair. This was observed on the 3rd floor and basement level of the facility. The finding is: On 12/20/2023 at 11:34 AM, 12/21/2023 at 11:01 AM, the staff bathroom located in the 3rd Floor nursing station area was observed with a discolored radiator with a rusty brown colored stain on it, and peeling paint. In addition, an opening was observed in the corner between the wall and the floor. On 12/20/23 at 01:15 PM, the the basement bathroom by physical therapy the bathroom noted with dirty corners with black colored residue on left and right edges of the 2-inch tiles in entry way. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification and Complaint survey, the facility did not ensure food was prepared in accordance with professional standards of food safety. Specifically, staff were observed not washing hands prior to and during food preparation, not washing hands after disposing of trash, refrigerator temperatures were not maintained, dishwasher temperatures were not in accordance with manufacturer guidelines, food was not labeled and dated in the kitchen storeroom.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure infection control practices were maintained. Specifically, 1- oxygen tubing was observed touching the floor; and, 2- recreation staff were observed not wearing Personal Protective Equipment (PPE) before entering a resident's room on contact/droplet precautions. This was evident for 2 of 2 residents reviewed in the area of Respiratory Care. (Resident # 236 and # 389)

Inspectors wroteBased on observation, record review, and interview during the Re-certification survey, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, Resident # 35 was observed on 2 occasions wearing inappropriate clothing, one occasion wearing a pajama pant and a different pajama top, then on another occasion, wearing a cotton like short pant and a t-shirt, and a blanket on the wheelchair, in the dining room, This was evident for 1 of 2 residents reviewed for Dignity (Resident #35)