Forest Hills Rehabilitation & Healthcare Center

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department and on three of four resident pantry areas (Area 1, Area 3, and Area 4).

Inspectors wroteBased on review of clinical records, select facility policy review, and staff interview, it was determined the facility failed to ensure a resident was free of chemical restraints that were not necessary to treat the resident's medical symptoms, were without justification, and did not demonstrate individualized, nonpharmacological approaches to care for one out of 36 residents reviewed (Resident 39).

Inspectors wroteBased on the clinical record review, select facility policy review, documentation provided by the facility, and staff interview, it was determined the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit, in accordance with professional standards of practice and facility policy, for five of 36 sampled residents (Residents 8, 68, 132, 161, and 166).

Inspectors wroteBased on clinical record review, policy review, observations, and staff interviews, it was determined the facility failed to identify the use of a physical restraint and failed to implement the facility policy regarding restraints for one of 36 sampled residents (Resident 56).

Inspectors wroteBased on the clinical record and select policy review, documentation provided by the facility and staff interview, it was determined the facility failed to timely identify and address risk factors for the development of a pressure ulcer and failed to implement and sustain effective interventions to prevent recurrence for one of 36 sampled residents (Resident 3).

Inspectors wroteBased on observation, review of clinical records, select facility policy, and staff and resident interviews, it was determined the facility failed to consistently provide timely and necessary foot care for one of 36 residents sampled (Resident 66).

Inspectors wroteBased on a review of clinical records, facility policy, and staff and resident interviews, it was determined the facility failed to ensure residents received necessary behavioral health services, including trauma-informed evaluation and follow-up psychological services, to attain or maintain their highest practicable mental and psychosocial well-being for two of 36 sampled residents (Residents 66 and 22).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift. Findings Include: Observations in the facility first floor lobby and second floor lobby on March 11, 2026, at 1:25 PM and March 12, 2026, at 8:10 AM revealed that the facility's nurse staffing information was not posted in the facility's designated area. An interview with the Assistant Director of Nursing on March 12, 2026, at 8:20 AM revealed that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, select facility-provided investigative documentation, staff interviews, and direct observation, it was determined that the facility failed to ensure that one resident (Resident C2) was free from physical abuse perpetrated by another resident (Resident CR1), for one out of eleven residents sampled for abuse prevention.

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated, corrective actions implemented, and results reported to the State Survey Agency within five working days, in accordance with regulatory requirements and facility policy, for 1 of 10 residents reviewed (Resident 1).

Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy, and select facility investigative documentation and staff interview, it was determined the facility failed to ensure that one resident (Resident 1) was free from physical abuse perpetrated by another resident (Resident 2) out of 6 residents sampled for abuse prevention, which resulted in serious harm and injury, a fractured humerus (arm) and femur (leg). This deficiency is cited as past non-compliance.

Inspectors wroteBased on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 36 residents reviewed (Resident 105).

Inspectors wroteBased on review of clinical records, select facility policy, and resident and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 141) out of 36 residents sampled.

Inspectors wroteBased on clinical record review, payor source data, and resident and staff interview, it was determined the facility failed to provide timely and necessary dental services for two residents (Resident 48 and 103) and failed to provide routine dental for one resident (Resident 55) out of 36 residents reviewed who were Medicaid recipients.

Inspectors wroteBased on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 28) out of 36 sampled were free from physical abuse perpetrated by another resident (Resident 133).

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews it was determined the facility failed to provide the necessary staff assistance with activities of daily living to maintain good personal grooming for residents dependent on staff assistance for nail care for two of five residents sampled (Residents 25 and 141).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews it was determined the facility failed to timely provide care and services, consistent with professional standards of practice, to promote healing of pressure ulcer development for one of four residents reviewed. (Resident 10)

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of four medication carts observed (Master Hall Three).

Inspectors wroteBased on observation and staff interviews it was determined the facility failed to provide a sanitary environment for residents, staff, and the public in one of out of three buildings sampled (Garage 1).

Inspectors wroteBased on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's medications as scheduled for one of 35 reviewed (Resident 129).

Inspectors wroteBased on a review of clinical records and a staff interview, it was determined that the facility failed to ensure the pharmacist identifies irregularities in drug regimens of one of 35 residents sampled (Resident 101).

Inspectors wroteBased on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that a physician evaluated the appropriateness of an as-needed anti-psychotic medication at least every 14 days for one of the five residents sampled.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for three residents out of 35 sampled (Resident 127, 149, and 178).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis for two out of 35 residents sampled (Residents 98 and 101).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to develop and implement a resident's person-centered comprehensive care plan designed to meet a resident's safety needs related to suicidal ideations and expressions of distress voiced by one out of 35 sampled (Resident 178).

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to review and revise a resident's care plan related to the resident's unsafe smoking behaviors and non-compliance with the facility smoking policy for one out of two residents sampled (Resident 43).

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to administer pain medication in accordance with physician orders for one of the 35 residents sampled (Resident 113).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care to a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one resident out of one sampled with a diagnosis of PTSD (Resident 19).

Inspectors wroteBased on review of clinical records, select facility policy and investigative reports, and observation, and resident and staff interview, it was determined that the facility failed to ensure that two residents (Residents 2 and 5) out of seven sampled were free from physical abuse.

Inspectors wroteBased on a review of clinical records, CMS guidance and facility documentation, and staff and resident interviews, it was determined the facility failed to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable practices of disenrolling residents from the Medicare Health Plans to ensure all risks of disenrolling are fully explained, both verbally and in writing, and that residents are assessed as competent at the time to make informed health care decisions for three resident of five reviewed (Resident 3, 4 and 5 ).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide maintenance services necessary to maintain a comfortable and homelike resident environment by failing to maintain comfortable water temperatures in one of two shower rooms on the area 4 resident unit and a functioning wall heating unit in resident room [ROOM NUMBER].

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain sanitary practices for managing infectious and/or hazardous waste storage on the facility grounds.

Inspectors wroteBased a review of clinical records and resident and staff interviews it was revealed that the facility failed to provide services necessary to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with bathing/showering activities of daily living for one of resident out of five reviewed (Resident 2)

Inspectors wroteBased on review clinical records, facility provided documentation, and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality and assures each resident is treated with dignity as evidenced by experiences reported by 11 residents out of 20 interviewed (Residents 8, 36, 26, 38, 34, 110, 115, 120, 128, 165, and 166).