Continuing Healthcare at Forest Hill

In the surveyor’s words

From the most serious findings on record at Continuing Healthcare at Forest Hill, in the surveyor’s own words.

• Actual harm, isolatedF757Nov 20, 2025

  Based on medical record review, emergency medical service and hospital record review, interview, policy review and review of nursing standards of practice, the facility failed to ensure Resident #58 was free of unnecessary medication without adequate monitoring. This affected one (#58) of three residents reviewed for medication errors. The facility census was 61. Actual Harm occurred on 10/26/25 when Resident #58, a resident with a known low heart rate requiring cardiovascular medications to be held due (due to low heart rate) was administered four cardiovascular medications resulting in the resident becoming unresponsive one hour after medication administration. […]

• Actual harm, isolatedF760Jun 26, 2025

  Based on medical record review, policy review, review of medication error reports and interview, the facility failed to ensure medications were administered without significant error. Actual harm occurred on 06/06/25 when Resident #10, who had moderately impaired cognition and was dependent of staff to prepare and administer medications, received medications prescribed for another resident that included cardiac medications that lower the heart rate and blood pressure, medication to prevent platelets from clumping together, medication to treat gout and antianxiety medications. This resulted in the resident experiencing a change in condition requiring transport to the emergency room. […]

• Actual harm, isolatedF688Jun 14, 2021

  Based on observation, staff interview, and medical record review the facility failed to ensure one resident (Resident #4) did not develop contractures to the fingers. Actual Harm occurred to Resident #4 when the resident did not receive the needed range of motion to prevent the development of avoidable finger contractures. This affected one of three sampled residents reviewed for limited range of motion. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF697Jun 14, 2021

  Based on observation, staff interview, and medical record review the facility failed to develop a pain management program to address pain during dressing changes and pain associated with finger contractures. Harm occurred to Resident #4 when facility staff moved the resident's hand extending his fingers and removed a dressing from the resident's right ear causing the resident extreme pain as evidenced by facial grimacing, groaning, wincing, clenching his fists, and crying. This affected one of one resident (Resident #4) reviewed for pain. […]

• No harm, potential for more than minimal, widespreadF725Oct 29, 2024

  Based on review of the facility Payroll Based Journal information, facility assessment, staffing schedule information and staff interviews the facility failed to ensure sufficient staffing levels were maintained to provide resident care and services. This had the potential to affect all 75 residents within the facility. Findings include: Review of the facility Payroll Based Journal (PBJ) data report for the third quarter (April 1 to June 30, 2024) revealed the facility had a one star staffing rating and low weekend staffing levels. The facility assessment with a reviewed date of 08/28/24 indicated a minimum staffing level plan of five to ten direct care nurses per day and seven to 14 State tested Nurse Aides (STNA) per day. […]