Forest Hills of Dc

Inspectors wroteBased on record review and interview, the facility staff failed to inform residents when changes are made to Medicare covered items and services as soon as reasonably possible as evidenced by the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was not given by the facility at least two days before the end of Medicare covered services for two (2) Medicare beneficiary residents in 33 sampled residents. (Resident #61, #68)

Inspectors wroteBased on observation, record reviews, and staff interviews, for two (2) of 33 sampled residents, the facility staff failed to ensure the licensed pharmacist conducted a monthly drug regimen review for one resident and the attending physician, or designee failed to respond to pharmacists' recommendations for one resident.

Inspectors wroteBased on observations, record reviews and staff interviews, facility staff failed to prepare and distribute food under sanitary conditions as evidenced by the following observations.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 33 sampled residents, it was determined that facility staff failed to show documented evidence that they provided nursing care and treatment for a resident on aspiration precautions; and for a resident on fall precautions and at risk for pressure injury. Residents' #10, #1.

Inspectors wroteBased on observations and staff interviews, facility staff failed to maintain essential kitchen equipment (walk-in freezer) in good order.

Inspectors wroteBased on observations, record reviews and staff interviews, facility staff failed to maintain an effective pest control program so that the facility is free of pests (flies).

Inspectors wroteBased on record review and staff interview, for one (1) of three (3) sampled residents, the facility's staff failed to ensure a resident's assessment reflected the type of facility where she was previously admitted . (Resident #1)

Inspectors wroteBased on record review and staff interviews, for one (1) of three (3) sampled residents, the facility failed to: administer Eliquis(anticoagulant)at the currently prescribed dose [5mg by mouth two-times a day]. And, Metoprolol (beta blocker) in the currently prescribed formulary [Succinate Extended Release].(Resident #1)

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #1 was not administered unnecessary medications. This was evident for one (1) of three (3) sampled residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility staff failed to ensure a medication cart was locked and secure from residents, visitor, and other personnel for one (1) of two medications observed on Unit 2.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's Medication Administration Record included the correct formulary for a medication used to treat elevated blood pressure for one (1) of three (3) sampled residents. (Resident #1)

Inspectors wroteBased on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions. These findings have the potential to affect all residents.

Inspectors wroteBased on record reviews and staff interviews, for two (2) out of 19 sampled residents, facility staff failed to accurately code their Minimum Data Set (MDS) assessments. (Residents #11 and #57)

Inspectors wroteBased on record review and staff interview, for one (1) out of 19 sampled residents, facility staff failed to develop a care plan with goals and interventions to address Resident #11's use of antibiotics.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 19 sampled residents, the facility staff failed to update and revise the care plan with resident-centered goals for Resident #55 following a fall that occurred on 07/13/24.

Inspectors wroteBased on record review and staff interview, for one (1) out of 19 sampled residents, facility staff failed to implement their antibiotic stewardship system for monitoring antibiotic use and adverse reactions for one (1) resident since 03/14/24, approximately nine (9) months. (Resident #1)

Inspectors wroteBased on record review and staff interviews, for one (1) of 32 sampled residents (#7), the facility staff failed to implement adequate supervision and assistance to prevent falls with injury for a cognitively impaired resident identified as a high risk for falls. These failures resulted in actual harm to Resident #7 on 1/2/23.

Inspectors wroteBased on record review and staff interview, for four (4) of 32 sampled residents, facility staff failed to provide written notice of the bed hold policy to include the number of bed hold days to the resident or their responsible party upon transfer to the emergency room. Residents' #197, #253, #27 and #98.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to revise and update person-centered care plans for 4 (four) of 32 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to ensure that three (3 ) of 32 sampled residents had hospice care plans that included: a description of the care, services, and frequency of visits to be provided by the contracted hospice provider.

Inspectors wroteBased on observation and staff interviews, the facility failed to visibly post signage of the accurate contact information for the State Survey Agency to ensure residents and resident representatives were able to file a complaint. The facility census was 43 on the first day of the survey.

Inspectors wroteBased on record review and staff interviews, for one (1) of 32 sampled residents, the facility staff failed to notify a resident, their representative, or the Ombudsman of the reason for the resident's transfer to the hospital in writing. Resident #253.

Inspectors wroteBased on record reviews and staff interviews, for three (3) of 32 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS) for one who had a fall, one resident's Drug Regimen Review, and one resident's hospice services. Residents' #7, #35 and #252. 1. Facility staff failed to accurately code Resident #7's MDS for Drug Regimen Review. Resident #7 was admitted on [DATE] with multiple diagnoses including Alzheimer's Disease, Anxiety Disorder, Dementia and Generalized Muscle Weakness. Pharmacy drug regimen review dated 01/02/23 documented, Recommend a psych consult for continued use of Sertraline, donepezil, and melatonin in context of fall on 01/02/23[doctors name] the psychiatrist. Physician response: Disagree continue for anxiety. [...]

Inspectors wroteBased on record review and staff interview, for two (2) of 32 sampled residents, facility staff failed to develop and implement a comprehensive resident centered care plan to address: Resident #199's right toe wound and Resident #7's use of antianxiety medications. Residents' #199 and #7.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of 32 sampled residents, facility staff failed to ensure that the resident received proper treatment and assistive devices to maintain hearing abilities. Resident #299.

Inspectors wroteBased on two (2) observations, record reviews and staff interviews, for one (1) of 32 sampled residents, facility staff failed to ensure that the system to account for the reconciliation, dispensing, and administration of controlled medications was followed. Resident #41.

Inspectors wroteBased on one (1) observation, record review and staff interview, a multi-dose Humalog (type of Insulin) pen was stored for use that failed to have a resident label or an expiration date.

Inspectors wroteBased on observations, record review, resident and staff interviews, for one (1) of 32 sampled residents, facility staff failed to ensure Resident #41 received the correct food consistency ordered by the physician.

Inspectors wroteBased on observations and interview, facility staff failed to store and distribute food under sanitary condition as evidenced by food items such as brown gravy, baked fish, bread chunks, a squash and zucchini dish, and two (2) liters of a white sauce, stored in various containers in one (1) of one (1) walk-in refrigerator that were not labeled, food items such as five (5) of five (5) containers with chopped and sliced carrots, one (1) of one (1) container of red onions, one (1) of one container of sliced celery, one (1) of one (1) container of chopped cabbage, one (1) of one (1) container of sliced yellow squash, one (1) of one container of sliced zucchini, one (1) of one (1) container of sliced cucumbers, and one (1) of one (1) container of sliced tomatoes, that were labeled with a use-by date of July 29, 2023, one (1) one (1) open pack of cheddar cheese that was labeled with a use-by [...]

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure resident funds were not commingled with the funds of any other person other than another resident. The facility census was 45. (Identifiers for Non-Residents'- TF1, TF2 and TF3)

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare and serve foods under sanitary conditions as evidenced by four (4) of four (4) damaged cutting boards, one (1) of one (1) soiled salamander grill, one (1) of one (1) fire extinguisher that was past due its yearly inspection date, four (4) of eight (8) soiled fire suppression nozzles, one (1) of three (3) dishwashing machines that leaked from the bottom when used, and one (1) of three (3) dishwashing machine that did not consistently reach a minimum final rinse temperature of 180 degrees Fahrenheit.

Inspectors wroteBased on observation, record review, and staff interviews, for five (5) of 32 sampled residents, the facility's staff failed to maintain Infection Control Practices to minimize or prevent the potential spread of infection as evidenced by: (1) staff not performing hand hygiene before serving a lunch tray for one (1) resident; (2) staff not performing hand hygiene between care (hygiene) for two (2) residents; (3) staff not providing a barrier during wound care for 1 resident; and (4) not wearing clean gloves when changing bed linen for one (1) resident. (Residents' #1, #2, #9, #17, and #239).

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) high temperature dishwashing machine in the main kitchen that did not reach a minimum final rinse temperature of 180 degrees Fahrenheit on two (2) of three (3) observations, and one (1) of one (1) dishwashing machine in second floor kitchen that consistently leaked from the bottom when in use.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure that one (1) resident's funds were conveyed within 30 days of their death. The facility census was 45. (Resident #289)

Inspectors wroteBased on record reviews and staff interviews for three (3) of 32 sampled residents, facility staff failed to offer residents or their representatives an opportunity to formulate an Advance Directive. (Residents' #20, #37 and #38).

Inspectors wroteBased on record review, staff and family interview, the facility's staff failed to inform a resident's family member about the resident's change in status (bruise to right brow) for one (1) of 32 sampled residents. (Resident #19)

Inspectors wroteBased on record review and staff interview, for three (3) of 32 sampled residents, facility staff failed to implement its written policy and procedure to investigate injuries of unknown source. (Residents' #4, #11 and #189)

Inspectors wroteBased on observations, record reviews, and staff interviews, for three (3) of 32 sampled residents facility staff failed to report to the State Agency: (1) a facility-reported-incident (FRI) involving a medication error for one (1) resident;(2) a FRI involving an injury of unknown origin for one resident; and (3) a FRI involving an accident(fall) within the required time frame of 24 hours for one (1) resident. (Residents' #3, #20 and #239).

Inspectors wroteBased on record review and staff interview, for one (1) of 32 sampled residents, facility staff failed to convey a resident's comprehensive care plan goals to the receiving provider during three (3) hospital transfers. (Resident #20)

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure Minimum Data Set (MDS) was accurately coded for a resident's discharge status for one (1) of 32 sampled residents. (Resident #141)

Inspectors wroteBased on observation, record review and staff interview for one (1) of 32 sampled residents, facility staff failed to develop a baseline care plan to include Residents low vision resulting from an active diagnosis of Macular degeneration within 48 hours of admission to the facility. (Resident #139)

Inspectors wroteBased on observation, record review, and staff interviews for two (2) of 32 sampled residents, the facility's staff failed to: (1) assess one (1) resident for edema to her left arm; and (2) follow physician's order to spoon feed one (1) resident at all meals. (Residents' #39 and #139)

Inspectors wroteBased on observation, record review, and responsible party and staff interview, the facility's staff failed to ensure durable medical equipment (sling of a sit-to-stand mechanical lift) was in good working condition before transferring (to the commode) Resident #19, who subsequently had an assisted fall without injuries.

Inspectors wroteBased on record review and resident and staff interview, the physician failed to review the resident's complete health record to include residents' diagnosis of Macular Degeneration for one (1) of 32 sampled residents. (Resident #139)

Inspectors wroteBased on observation and staff interview during a tour of one (1) of two (2) medication storage rooms, facility staff failed to ensure that three (3) of three (3) insulin vials were dated when first opened.

Inspectors wroteBased on record reviews and staff interview, the facility staff failed to accurately document a resident's Advance Directive directions (wish) to be a Do Not Resuscitate (DNR) in the medical record one (1) of 32 sampled residents. (Resident #36)