Forest Hills Center

Inspectors wroteBased on personnel file review, facility record review, staff interviews, and facility policy review, the facility failed to ensure the activities program was directed by a qualified activities professional. This had the potential to affect all 74 residents residing in the facility. The facility census was 74.

Inspectors wroteBased on observations, staff and resident interviews and policy review, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affected 72 out of 72 residents who receive their meals from the kitchen, the facility identified two (#9 and #55) residents who do not eat food from the kitchen. The facility census was 74.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. In addition, the facility failed to ensure hand hygiene was completed during meal service. This affected 72 residents who received meals from the facility kitchen. The facility identified two Residents (#9 and #55) who do not eat food from the kitchen. The facility census was 74.1. Observation on 06/01/26 from 9:33 A.M. to 9:50 A.M. revealed in the refrigerator a tub of applesauce and a tub of fruit was undated, shredded cheese was open and undated and four orange juice containers had no dates. In the freezer biscuits were uncovered and open to air. [...]

Inspectors wroteBased on observation, interview, record review, resident council review, personnel file review, and Quality Assurance and Performance Improvement (QAPI) review, the facility failed to effectively administer the facility by failing to ensure the activities program was directed by qualified personnel and failing to ensure residents received an activity program that addressed their assessed interests, preferences, and psychosocial well-being. In addition, the facility failed to implement effective corrective actions to achieve compliance after the facility's QAPI program identified concerns related to activity programming and staffing. This had the potential to affect all 74 residents residing in the facility. The facility census was 74. [...]

Inspectors wroteBased on record review, interview, personnel file review, observation, and review of Quality Assurance and Performance Improvement (QAPI) documentation, the facility failed to implement and maintain an effective QAPI program by failing to identify, monitor, and implement effective corrective actions regarding deficiencies in the facility's activity program. The facility identified concerns related to activity programming and staffing through its QAPI process; however, residents continued to experience limited activity programming and the facility failed to ensure the individual directing the activity program met required qualifications. This had the potential to affect all 74 residents residing in the facility. Findings Included:Interview with the Administrator on 06/08/26 at 2:23 P.M. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure a dignified dining experience for all residents except those who eat in the dining room. Facility identified 27 Residents (#1, #4, #5, #6, #7, #8, #12, #27, #34, #37, #43, #44, #50, #54, #56, #58, #60, #61, #62, #64, #65, #66, #67, #71, #73, and #74) who eat in the dining room. Facility census was 74.

Inspectors wroteBased on observations, interview and facility policy review, the facility failed to maintain a home like environment by ensuring residents had maintained personal property/personal items This affected one resident (#26) of five reviewed for environment, the facility also failed to ensure the linen provided did not have holes in it this affected one resident (#50) of five reviewed for environment. Facility census was 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests, preferences, and psychosocial needs of residents. This affected four residents (#5, #28, #35, and #54) of four residents reviewed for activities. The facility census was 74. 1. Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, weakness, difficulty walking, unsteadiness on feet, and right hip fracture. Review of the quarterly Care Conference Summary dated 01/22/26 revealed Resident #35 enjoyed socializing within the unit, watching television, and attending movie and popcorn activities. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to perform hand hygiene prior to exiting a residents room and touching a hallway door. This had the potential to affect all residents residing on the second hall (rooms 201 to 214). In addition, the facility failed to follow enhanced barrier precautions (EBP) during tube feeding care. This affected one (Resident #09) out of three residents reviewed for EBP. The facility census was 74. Findings Included: 1. Observation on 06/02/26 at 6:35 A.M. revealed the Certified Nursing Assistant (CNA) #223 exiting room [ROOM NUMBER] carrying soiled linens while wearing gloves. CNA #223 proceeded directly to the soiled linen room located on the 200 Hall. [...]

Inspectors wroteBased on observations, staff interviews and policy review, facility failed to ensure furniture was maintained in a safe manner. This affected 25 Residents (#4, #7, #9, #12, #16, #18, #19, #23, #26, #30, #31, #36, #42, #45, #47, #49, #61, #62, #64, #66, #68, #69, #70, #72, and #75) living in the third hall. Facility census was 74.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure choice was offered for hospice services provider. This affected one resident, (#2) of one residents reviewed for hospice. The facility census was 74.

Inspectors wroteBased on interview and record review, the facility failed to provide spend down notices when resident's personal funds account reached $200 less than the Social Security Insurance resource limit. This affected two residents, (Resident #26 and Resident #47) of five residents reviewed for personal funds. The facility census was 74.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the Physician and family were notified of a change in condition. This affected oneresident, (#36) of one reviewed for change in condition. The facility census was 74.

Inspectors wroteBased on record review and staff interview, the facility failed to provide accurate Notices of Medicare Non-Coverage (NOMNC) for two residents, (#20 and #36) of four reviewed for Medicare beneficiary notices. The facility census was 74.

Inspectors wroteBased on staff interview and medical record review the facility failed to ensure indications for use were appropriate for psychotropic medications for two residents, (#49 and #75) and the facility failed to ensure two residents (#2 and #49) were monitored for psychotropic medication side effects. This affected three out of five residents sampled for unnecessary medications. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure an injury of unknown origin was reported timely to the state agency. This affected one resident (#83) of two reviewed for abuse investigations. The facility census was 74.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to complete a thorough investigation of injuries of unknown origin. This affected two residents (#20 and #83) of two reviewed for abuse investigations. Facility census was 74.

Inspectors wroteBased on record review and interview, the facility failed to establish and implement an admission policy. This affected one resident (# 81) of one resident investigated for admission policy. This had the potential to affect all facility residents. The facility census was 74.

Inspectors wroteBased on medical record review, review of hospital records, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman regarding a hospitalization and transfer for one resident (Resident #35) and failed to assist one resident (Resident #8) with discharge planning services. This affected two residents (#35 and #8) of three residents reviewed for discharge planning. The facility census was 74. Findings Include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/24 with diagnoses including Alzheimer's dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), essential hypertension, and right hip fracture. Review of hospital records revealed Resident #35 was transferred to the hospital on [DATE] following a fall on 05/12/26 which resulted in right hip pain. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure assessments were accurately completed. This affected one (Resident #55) of one resident reviewed for range of motion. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed timely and accurately upon admission. This affected one Resident (#4) of one reviewed for PASARR. The facility census was 74.

Inspectors wroteBased on record review, staff and resident representative interviews and policy review, the facility failed to ensure a care plan was created for communication and language services for Resident #36, contractures for Resident #55, and physical therapy services for Resident #84. This affected three (#36, #55 and #84) of 20 residents in the sample reviewed for care planning. The facility census was 74.

Inspectors wroteBased on record review, staff and resident representative interviews and policy review, facility failed to ensure care conferences were completed as required and completed as scheduled. This affected two (#36 and #35) of two residents reviewed for care conferences. The facility census was 74.

Inspectors wroteBased on record review, observations, staff and family interviews and policy review, the facility failed to ensure communication and language services were provided to a resident who did not understand or speak English. This affected one (#36) of one residents reviewed for language/communication. The facility census was 74.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure timely completion of an ordered diagnostic test following a fall for one resident (Resident #35) reviewed for quality of care. This affected one (#35) of one residents reviewed for quality of care. The facility census was 74.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to accurately assess newly identified pressure ulcers. This affected one (#64) out of four residents reviewed for pressure ulcers. The facility census was 74.

Inspectors wroteBased on record review and interview, the facility failed to provide care and services for a resident with contractures. This affected one (#55) of one resident reviewed for contractures. The facility census was 74.

Inspectors wroteBased on record review, observations, staff interviews and policy review, facility failed to ensure a resident was assessed timely by qualified staff after a fall, and before being moved by staff. This affected two (#4 and #47) of four residents reviewed for falls. The facility census was 74.

Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to ensure an indwelling (foley) urinary catheter was maintained in proper positioning (i.e. off the floor). This affected one (#75) of one residents reviewed for catheter. Facility identified six residents with catheters. The facility census was 75.

Inspectors wroteBased on record review, observations, staff interviews, and facility policy review, the facility failed to properly administer and care for a resident's tube feeding. This affected one (#9) of one residents reviewed for tube feeding care. The facility census was 74.

Inspectors wroteBased on record review, observations, staff and resident interviews and policy review, the facility failed to ensure drinks were provided regularly and upon resident request. This affected one (#26) of one residents reviewed for hydration. The facility census was 74.

Inspectors wroteBased on record review and interviews, the facility failed to have a complete and accurate medical record related to skin monitoring. This affected one (Resident #71) of one resident reviewed for pressure ulcer. The facility census was 74.

Inspectors wroteBased on observation, medical record review, staff interviews, review of facility investigations, review of facility Self Reported Incidents (SRI) and review of facility policy, the facility failed to report injuries of unknown sources in a timely manner to the State agency. This affected four of four residents (Residents #7, #11, #14, and #18) reviewed for injuries of unknown sources. The facility census was 72 residents.

Inspectors wroteBased on observation, medical record review, staff interviews, review of facility investigations and review of facility policy, the facility failed to thoroughly investigate injuries of unknown sources. This affected three (Residents #7, #11, and #14) of four residents reviewed for injuries of unknown sources. The facility census was 72 residents.

Inspectors wroteBased on medical record review and staff interview, this facility failed to ensure residents were able to receive care and services from approved physicians only. This effected one (Resident #161) of the four residents reviewed for the right to choose their own care provider. The facility census was 70.

Inspectors wroteBased on medical record review, facility Self-Reported incident review, hospital record review, staff interview, observation, and review of facility policies, the facility failed to ensure residents were free from resident-to-resident altercations resulting in injury as well as ensuring ordered stop signs in doorway openings were in place. This affected two (Resident #159 and #63) of the seven residents reviewed for abuse. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, review of Emergency Medical System (EMS) run report, review of the Certification and Licensure System (CALS), and facility policy review, the facility failed to timely report injuries of unknown origin to the state agency for Residents #153 and #155 and failed to report a resident to resident incident involving Resident #63. This affected three residents (#63, #153, and #155) of seven residents reviewed for abuse. The facility census was 70.

Inspectors wroteBased on record review, facility investigation report review, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed for injuries of unknown origin for residents #153 and #155, and failed to complete an investigation into a resident to resident altercation involving Resident #63. This affected three residents (#63, #153 and #155) of seven residents reviewed for abuse. The facility census was 70.

Inspectors wroteBased on facility staff schedule review and staff interviews, the facility failed to provide registered nurse (RN) coverage as required. This had the potential to affect all 70 residents residing in the facility. Findings Include: Review of facility staff schedule, dated 07/14/24 to 08/31/24, revealed the following days did not have the proper RN coverage: 07/14/24 (no RN), 07/16/24 (no RN), 07/17/24 (no RN), 07/20/24 (no RN), 07/21/24 (no RN), 07/22/24 (no RN), 07/23/24 (no RN), 07/24/24 (no RN), 07/27/24 (only seven hours of RN coverage), 07/28/24 (no RN), 07/30/24 (no RN), 07/31/24 (no RN), 08/05/24 (only 5.25 hours of RN coverage), 08/07/24 (no RN), 08/10/24 (no RN), 08/14/24 (no RN), 08/19/24 (no RN), 08/20/24 (no RN), 08/21/24 (no RN), 08/24/24 (no RN), 08/25/24 (no RN), 08/27/24 (no RN), and 08/28/24 (no RN). Interview with Director of Nursing (DON) on 05/01/25 at 11:00 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to obtain food temperatures in a sanitary manner. This had the potential to affect all 69 residents who consumed food from the kitchen. Resident #3 consumed nothing by mouth. The facility census was 70.

Inspectors wroteBased on observation and interview, the facility failed to maintain the laundry room in a clean and sanitary manner. This had the potential to affect all 70 residents residing in the facility.

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to ensure residents had appropriate diagnoses for psychological medications. This affected five residents (#35, #48, #50, #53, and #63) of nine residents reviewed for unnecessary medications or behavioral-emotional health services. The facility census was 70.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure accurate advanced directive information was present throughout the medical record for Resident #3. This affected one resident (#3) out of three residents reviewed for advanced directives. The facility census was 70.

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to assess Resident #53 prior to utilizing a physical restraint. This affected one resident (#53) out of one resident reviewed for physical restraints. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to properly monitor resident bruises. This affected one (Resident #37) of three residents reviewed for skin conditions. Also, the facility failed to implement wound orders in a timely manner. This affected one (Resident #70) of three residents reviewed for skin conditions. The facility census was 70.

Inspectors wroteBased on record review, observation, interview, and review of the facility policy, the facility failed to ensure fall interventions were in place for Resident #13. This affected one resident (#13) of six residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication as ordered for Resident #70 and notify the physician when the medication was unavailable. This affected one resident (#70) of two residents reviewed for pain management. The facility census was 70.

Inspectors wroteBased on record review, observation and interview, the facility failed to monitor, thoroughly document, and prevent Resident #48's behaviors. This affected one resident (#48) of four residents reviewed for mood and behavior. The facility census was 70.

Inspectors wroteBased on observations, resident interview, and staff interview, the facility failed to have all required postings readily accessible to all residents in the facility. This had the potential to affect all 70 residents residing in the facility.

Inspectors wroteBased on observations, resident and staff interviews, review of temperature logs, review of a Packaged Terminal Air Conditioner (PTAC) facility audit, and facility policy review, the facility failed to ensure the Third Street Unit and one room on the First Street Unit (room [ROOM NUMBER]) were maintained at a comfortable temperature for the residents who resided in those areas. The deficient practice affected one resident (Resident #40) who resided in room [ROOM NUMBER] and had the potential to affect one additional resident (Resident #2) who also resided in room [ROOM NUMBER] and all 28 residents who resided on the Third Street Unit (Residents #10,#15, #35, #43, #44, #45, #46, #47, #48, #49, #51, #52, #54, #56, #58, #61, #62, #64, #66, #68, #71, #73, #75, #77, #79, #85, #87, and #89). The facility census was 74. Findings Include: [...]

Inspectors wroteBased on record review, review of a facility-reported incident (FRI) investigation, staff interviews, and facility policy review, the facility failed to follow abuse policies and procedures when Residents #10 and #15 were left alone after a potential observation of abuse. The deficient practice affected two (Residents #10 and #15) of three residents reviewed for abuse. The facility census was 74. Findings Include: Review of the medical record for Resident #10 revealed an original admission date of 11/15/21 and a readmission date on 12/12/22. Diagnoses included unspecified psychosis, restlessness and agitation, mood (affective) disorder, cognitive communication disorder, anxiety disorder, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was rarely or never understood. [...]

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to implement comprehensive care plans to include activities and preferences. This affected two residents (Resident #17 and #66) of four residents reviewed for comprehensive care plans. The facility census was 73. Findings Include: 1. Review of Resident #17's medical record revealed an admission date of 05/17/24 with diagnoses including diabetes mellitus type two, dementia, chronic kidney failure, and paranoid personality disorder. Resident #17 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 and required assistance from staff for activities of daily living (ADL) tasks, including transfers and mobility. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observations, staff and resident interviews, review the National Weather Forecast, and review of facility policies, the facility failed to prevent Resident #25 from eloping. This affected one (Resident #25) of three reviewed for elopement. The facility census was 74.

Inspectors wroteBased on closed medical record review, resident representative interview, staff interviews, review of the grievance log, review of a missing items concern form, and facility policy review, the facility failed to protect Resident #74's belongings from being lost. This affected one resident (#74) of three reviewed for missing items. The facility census was 72. Findings Include: Review of the former Resident #74's closed medical record revealed an admission date on 11/21/23 and a discharge date on 12/14/23. Medical diagnoses included anxiety disorder, unsteadiness on feet, chronic kidney disease Stage 3, dementia with behavioral disturbance, and metabolic encephalopathy. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had impaired cognition and scored nine out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to properly track infections to identify infectious trends or patterns to prevent transmission. This had the potential to affect all 76 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #14's skin was monitored appropriately for bruising or signs of abnormal bleeding related to anticoagulant use. This affected one resident (Resident #14) out of one resident reviewed for non-pressure skin conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #14 and Resident #48 neurological checks were properly completed to assess for injury after falls. This affected two (Resident #14 and #48) of two residents reviewed for head injuries.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #69 received medication timely to manage pain. This affected one resident (Resident #69) of one resident reviewed for pain.

Inspectors wroteBased on record review and staff interview, the facility failed to explicitly grant the resident or resident representative the right to rescind Binding Arbitration Agreements within 30 days of signing the agreement. This affected three residents (#17, #19, and #36) of three residents reviewed for Binding Arbitration Agreements.

Inspectors wroteBased on record review and interview, facility failed to ensure Resident #26 and #324 met the criteria for antibiotic use before antibiotics were administered. This affected two (Resident #26 and #324) of two residents reviewed for antibiotic stewardship.