Forest Hill Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Forest Hill Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 5, 2025

  Based on Observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an environment that was free from hazards, that each Resident received supervision, and that ongoing monitoring was implemented to prevent accidents and hazards for four (4) Residents (#'s 42, 106, 124, and 130) in a survey sample of 63 Residents, which resulted in Immediate Jeopardy. The findings included: The facility staff admitted Resident #42, #106, #124, and #130 with known substance abuse histories. They continued to use illicit drugs and alcohol, returning to the facility after a leave of absence under the influence of illegal drugs and or/alcohol. […]

• Immediate jeopardy, patternF835Feb 5, 2025

  Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) residents (R#42, #106, #124 and #130) and each Long-Term Care Resident which resulted in Immediate Jeopardy. The findings included: For all facility residents, the Administration failed to act on the residents found to be using illicit drugs and alcohol in the building, failed to ensure all residents were protected from those substances being brought into the building, and failed to act on one (1) Resident creating sharp stabbing-like weapons from dining room… […]

• Actual harm, isolatedF686Jul 14, 2022

  Based on observation, interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed for one of 48 sampled residents (#75) to ensure the Resident received ordered wound physician visits, care, and failed to identify a pressure wound to the heel before it reached an advanced stage. This is harm. The Findings Include: Resident # 75 was admitted to the facility on [DATE], her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 75's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/29/22, coded the Resident as follows: Section G - Resident #75 was coded as requiring #3- Extensive Assistance of #3 - 2 Person Physical Assistance for bed mobility and dressing. […]

• No harm, potential for more than minimal, widespreadF584Feb 5, 2025

  3. Unit two: For Resident #3, the facility staff failed to maintain a clean, comfortable, homelike living environment. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. […]

• No harm, potential for more than minimal, widespreadF925Feb 5, 2025

  Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the rooms of Resident # 3 and #130 and throughout the entire facility. The findings include: 1. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. […]