Every finding on record at Forest Hill Manor

Based on observations and interviews the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 lunch dining services observed (3/9/26).Findings: On 3/9/26 at 11:35 a.m., a surveyor observed a Registered Nurse (RN1) standing while assisting R23 to eat. The surveyor confirmed this finding with RN1 at the time of the observation. RN1 stated she knew she should be sitting but was only assisting for a couple minutes to cover for another staff member who had to step away. On 3/9/26 at 11:37 a.m., a surveyor observed the Director of Nursing (DON) assisting R23 to eat while standing. At 11:40 a.m a surveyor observed the DON pull up chair to assist R23 to eat. On 3/11/26 at 8:00 a.m., during an interview a surveyor and the DON, the above findings were confirmed.

Based on observation, record review, and interviews, the facility failed to obtain a provider order, complete an assessment, and monitor for the use of a seatbelt while in a motorized wheelchair for 1 of 1 residents reviewed for restraints (Resident #40 [R40]).Findings:On 3/9/26 at 3:36 p.m., a surveyor observed R40 wearing a seatbelt while sitting in a wheelchair.On 3/10/26, R40's clinical record was reviewed. R40's diagnoses included Cerebral Palsy (a group of conditions that affect movement and posture). The care plan indicated, I use a seatbelt on my new motorized wheelchair to prevent falls (slipping out of my wheelchair) due to my body habitus [the general shape, build, and physical constitution of a person's body, significantly influencing organ placement, size, and weight distribution]. The clinical record lacked evidence of a provider's order for the use of the seatbelt, an assessment for use of the seatbelt, and monitoring of the resident while using the seatbelt.On 3/11/26 at 9:34 a.m., during an interview with a surveyor, the Licensed Social Worker stated R40 received his/her new wheelchair on 2/23/26.On 3/11/26 at 8:00 a.m., during an interview with 3 surveyors, the Director of Nursing stated that R40 is able to release the seatbelt while in use, and that R40 was assessed for the use of the wheelchair and seatbelt, but the assessment was not documented. At this time, a surveyor confirmed that R40's clinical record lacked evidence of a provider order, assessment, and monitoring for the use of a seatbelt while in the wheelchair.

Based on observation and interviews, the facility failed to prepare food under sanitary conditions for 1 of 3 days of survey. (3/9/26) Finding: On 3/9/26 at approximately 11:45 a.m., a surveyor observed the cook take a small skillet off a shelf, the small skillet was observed to have been encrusted with a baked/fried on substance. On the shelf there were 2 additional small frying pans and a medium frying pan that were encrusted with a baked/fried on substance. In addition, the cooking surface of the frying pans were observed to have Teflon (a nonstick coating) on the outer borders of the cooking surface but bare metal (silver) on the bottom/middle of the cooking surface.On 3/9/26 at the time of the observation and during an interview with the cook and the dietary aide it was stated that the pans were non-stick at one time, but the Teflon wore off from cooking and cleaning the pans. This finding was confirmed by the surveyor at this time with the cook and dietary aide and later at 12:15 p.m. with the Food Service Director.

Based on clinical record reviews, and interviews, the facility failed to provide physician ordered respiratory services requiring specific types of respiratory care and services including supplemental oxygen and continuous positive airway pressure (CPAP) and/or bilevel positive airway pressure (BIPAP) treatments for 1 of 3 residents reviewed for respiratory care (Resident # 1 [R1]).1.R1's clinical record has a provider written order dated 6/30/25 at 1305 [1:05 p.m.] 1. Please check pulse ox (oxygen saturation rate) 4x [times]/shift. Call covering provider if SpO2 (peripheral capillary oxygen saturation rate) < [less than] 90% while awake or < [less than] 88% when sleeping. R1's clinical record Nursing Narrative Note: dated 7/3/25 at 3:30 p.m. states, SpO2 88%, 89%, 93%, 94%. The clinical record lacks evidence that the covering provider was called when SpO2 was less than 90% while awake or less than 88% when sleeping. R1's clinical record Nursing Narrative Note dated 7/12/25 at 21:21 (9:21 p.m.) states, Writer went in to see resident at 0745 [7:45 a.m.] R1 resting in bed in less than 45-degree position. CPAP on with oxygen set at 4L/min. NP ([nasal prong] nasal canula). From 0747 [7:47 a.m.] to 750 [7:50 a.m.] O2 Sat via pulse oximetry read 79%, 80%, 83%, 84%, 85%, 86%, 87%, 88%, 90%, 92%, and 1112 [11:12 a.m.] to 1114 [11:14 a.m.] O2 Sat 56%, 57%, 59%, 60%, 73%, 75%, 79%, 80%, 83%, 88%, 89%, 92%. It took 2 minutes for oxygen sat to go from 56% to 92%. The clinical record lacks evidence that the covering provider was called when SpO2 was less than 90% while awake or less than 88% when sleeping. R1's clinical record Nursing Narrative Note dated 7/13/25 at 8:17 a.m. states, [R1] is wearing the NP oxygen set at 4L/min. Pulse oximeter form 0800 to 0801 readings are 80%, 84%, 85%, 87%, 89%, 86%, 88%, 90%, 91%. The clinical record lacks evidence that the covering provider was called when SpO2 was less than 90% while awake or less than 88% when sleeping. R1's clinical record Nursing Narrative Note dated 7/13/25 at 22:03 (10:03 p.m.) 1501 (3:01 p.m.) P65. O2 Sat 88%, 87%, 89%, 90%, wearing CPAP at 4 L/Min. It took 3 minutes to reach 90%. 1843 (6:43 p.m.) to 1844 (6:44 p.m.): P64, O2 Sat 79%, 80%, 81%, 84%, 88%, *7%, 90%. [R1] is wearing the CPAP at 4L/min. The clinical record lacks evidence that the covering provider was called when SpO2 was less than 90% while awake or less than 88% when sleeping. 2. R1's clinical record contains written orders dated 7/10/25 Continuous Positive Airway Pressure (CPAP) 06/14/23 10:00:00 EDT [eastern daylight time], every day at bedtime. On 7/15/25 at 10:13 a.m. during an observation and interview with a surveyor, R1 was observed using a CPAP (or BIPAP) machine with a mask that covered the nose and mouth with tubing attached to a CPAP (or BIPAP) machine that had supplemental oxygen via an oxygen concentrator unit set at 3L [liters]/min. [minute]. The surveyor observed R1 remove the mask, unattached the oxygen tubing from the CPAP (or BIPAP) machine and reattach the oxygen tubing to a nasal canula, which he/she then used for supplemental oxygen. There was no evidence in the clinical record whether R1 is supposed to use a CPAP (or BIPAP) machine other than at bedtime, and there is no evidence in the clinical record that supplemental oxygen is supposed to be attached to the CPAP (or BIPAP) machine during use. On 7/15/25 at 2:18 p.m. in an interview with the Director of Nursing (DON), a surveyor confirmed that R1's clinical record lacks evidence that the covering provider was called when R1's SpO2 was less than 90% while awake or less than 88% when sleeping on 7/3/25, 7/12/25, and 7/13/25, and confirmed that the order for CPAP (or BIPAP) is not clear. The DON stated that the provider orders were not clear as to when R1 needs to use the CPAP and/or BIPAP, and if supplemental oxygen is supposed to be used with the CPAP and/or BIPAP.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 2/20/25 at 9:58 a.m., during an interview with a surveyor and the Administrator, the staffing schedules were reviewed for the fourth quarter of 2024. The Administrator confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends.

Based on observations, record reviews and interviews, the facility failed to update/revise care plans for the use of Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #26 [R26] and [R27]) Findings: 1. On 2/19/25 at 7:55 a.m., a surveyor observed an EBP sign on the outside of the door of R26's room. Record review showed that R26 has wounds on both heels with daily dressing changes. The care plan was reviewed and lacked evidence of addressing the need for the EBP while providing care to R26. On 2/20/25 at 1:30 p.m., during an interview with a surveyor and the Residential Care Coordinator, the surveyor confirmed that R26's care plan had not been updated to include the required EBP. 33242 2. On 2/18/25 at 1:01 p.m., a surveyor observed an EBP sign displayed outside the door of R27's room. On 2/20/25, the Director of Nursing provided orders, dated 8/8/24, for R27 that indicated that the resident was on precautions due to Vancomycin-resistant Enterococci (VRE) in the urine. The care plan was reviewed but lacked evidence of the resident needing EBP continuously, with no end date, for this diagnosis. At 1:45 p.m., during an interview with a surveyor, the Resident Care Coordinator stated that this had not been added to R27's care plan.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain resident equipment and the building in good repair, homelike, and in a sanitary condition on 2 of 2 units (Skilled Nursing Unit [SNF] and Long Term Care Unit [LTC]). Findings: 1. On 2/19/25 at 10:30 a.m., the Administrator, Housekeeping/laundry Manager (HLM) and a surveyor observed multiple areas of the building that included floors in resident rooms, the Skilled Unit dining room, common areas, and hallways on both units. The flooring was observed to have discolored areas that created a soiled and/or worn appearance and cracked floor coverings, which created uncleanable surfaces. The HLM stated that the floors are down to the last layers, they are so worn and that is why the floors look the way they do; the surveyor also noted that some of the thresholds between the hallway and resident rooms on the LTC Unit had dirt buildup along the cracks. On 2/19/25 at 3:30 p.m., during the end of day conference with the Administrator, the surveyors reviewed other areas of concern with the environment to include chipped paint along a door frame and the trim that was broken on the edge of a sink in room [ROOM NUMBER] and a soiled floor mat in room [ROOM NUMBER]. 35904 2. On 2/20/25 at 1:54 p.m., in an observation and interview with Registered Nurse #2, a surveyor confirmed that R15's wheelchair had dirt and dried debris on both arms, and wheels of his/her wheelchair.

Based on observations and interviews, the facility failed to ensure that hot water temperatures in resident rooms did not exceed 120 degrees Fahrenheit and that blue floor tiles in the Skilled Unit hallway were completely glued to the floor creating a possible trip hazard, on 2 of 3 days of survey (2/18-2/19/25). Findings: 1. On 2/18/25 between 11:25 a.m. - 11:46 a.m., two surveyors observed the following hot water temperatures: room [ROOM NUMBER], the hot water temperature was 124.8; room [ROOM NUMBER], the hot water temperature was 122.1; room [ROOM NUMBER], the hot water temperature was 124.5; room [ROOM NUMBER], the hot water temperature was 124.8; room [ROOM NUMBER], the hot water temperature was 122.5; room [ROOM NUMBER], the hot water temperature was 120.9; and room [ROOM NUMBER], the hot water temperature was 120.8. At 11:48 a.m., two surveyors discussed with the Administrator that there were hot water temperatures above 120 degrees in some of the rooms. room [ROOM NUMBER] was rechecked at this time and was not above 120 degrees. On 2/18/25 between 1:38 p.m.- 1:46 p.m., surveyors observed the following hot water temperatures: room [ROOM NUMBER], the hot water temperature was 121.2; room [ROOM NUMBER], the hot water temperature was 122.1; room [ROOM NUMBER], the hot water temperature was 121.5; and room [ROOM NUMBER], the hot water temperature was 120.4. At 2:02 p.m., during an interview with a surveyor, the Administrator stated that the water temperatures were adjusted this morning after the first report, but they will make another one. They will continue to check rooms today and continue to make adjustments. On 2/19/25 at 11:32 a.m., in room [ROOM NUMBER], the hot water temperature was 120.3. On 2/19/25 at 12:20 p.m., the Administrator stated that the mixing valve was found to be faulty was changed this morning and they are continuing to make adjustments. 2. On 2/19/25 at 9:09 a.m., two surveyors observed areas of blue floor tiles in the Skilled Unit hallway that were starting to lift because they were becoming unglued in areas, presenting a possible trip hazard. On 2/19/25 at 10:30 a.m., during an interview with a surveyor, the Administrator stated that the blue tiles are downstairs, and they had plans to replace them.

Based on observations and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 5 residents reviewed for respiratory care (Resident #11 [R11], [R27] and [R33]). Findings: 1. On 2/18/25 at 11:35 a.m., a surveyor observed R11's oxygen tubing, dated 1/20/25, resting on the floor. The oxygen concentrator filters were observed to be heavily soiled with dust / debris. On 2/19/25 at 8:07 a.m., a surveyor observed R11's oxygen concentrator filters to be heavily soiled with dust / debris. On 2/19/25 at 12:28 p.m., during an interview, a surveyor and the Director of Nursing (DON), observed R11's oxygen concentrator filters to be heavily soiled with dust/debris. The DON stated the tubing should be changed every 2 weeks unless otherwise directed by the provider. At this time the surveyor confirmed the tubing had not been changed per protocol and the concentrator was not maintained in a manner to prevent the development and/or transmission of disease. 33242 2. On 2/18/25 at 1:01 p.m., a surveyor observed R27's oxygen tubing, dated 1/7/25, and the INVACARE oxygen concentrator was missing both side filters. On 2/19/25 at 8:45 a.m., a surveyor observed the oxygen tubing, dated 1/7/25, and the oxygen concentrator still was missing both side filters. On 2/19/25 at 12:20 p.m., during an interview with a surveyor, R27 stated that he/she uses oxygen every night. Review of the manual of the INVACARE Platinum Series XL, 5, 10 indicated that the concentrator was not to be operated without the filter. On 2/19/25 at 12:24 p.m., the DON and surveyor observed R27's oxygen concentrator was missing the filters, and the tubing that was dated 1/7/25. The DON stated that all respiratory tubing and respiratory masks were to be changed every 2 weeks. 35904 3. On 2/18/25 at 11:37 a.m., a surveyor observed R33's oxygen tubing with nasal cannula, dated 1/20/25, resting on the floor. On 2/19/25 at 12:28 p.m., during an interview with the DON, a surveyor confirmed the tubing had not been changed timely per protocol.

Based on observations and interviews, the facility failed to implement infection prevention measures for 2 of 3 days of survey (2/18/25 and 2/19/25) and failed to fully develop/implement a water management program to prevent the growth and spread of Legionella and other water-borne pathogens in the area of monitoring for control measures for 1 of 1 review of water management program. Findings: The facility's Enhanced Barrier Precautions signage directed staff and providers to wear gloves and a gown for the following High-Contact Resident Care Activities: -dressing -bathing/showering -transferring -changing linens -providing hygiene -changing briefs or assisting with toileting -device care or use: central line, urinary catheter, feeding tube, tracheostomy -wound care: any skin opening requiring a dressing 1. On 2/18/25 at 11:28 a.m., a surveyor observed personal protective equipment signage to indicate necessary precautions, to include a gown, needed before entering room. The surveyor observed the Unit Caretaker changing linen and making Resident 33's (R33's) bed and did not wear a protective gown when handling used linen and bedspread for a resident on enhanced barrier precautions (EBP). On 2/20/25 at 11:28 a.m., in an interview with the Director of Nursing (DON), a surveyor confirmed that the Unit Caretaker did not wear a gown when handling linen and bedspread for R33, on EBP's. 2. On 2/19/25 at 8:20 a.m., a surveyor observed a Certified Nursing Assistant - Medications (CNA-M) administer eye drops in both eyes for R11 without wearing gloves. In an interview with the CNA-M, she stated she probably should have worn gloves. On 2/20/25 at 11:28 a.m., in an interview with the DON, a surveyor confirmed that the CNA-M did not wear gloves when administering eye drops for R33. The DON stated that Lippincott Nursing Procedures are used as guidance for appropriate medication administration, and the CNA-M should have been wearing gloves. On 2/20/25 a surveyor reviewed Lippincott Nursing Procedures, ninth education, copyright 2023, page 338 stated perform hand hygiene and then put on gloves, when administering eye drops. 32540 3. On 2/19/25 at 7:55 a.m., a surveyor observed an Enhanced Barrier Precaution sign to indicate necessary precautions be used when assisting R26, to include a gown, and gloves that were needed when providing care. The surveyor observed two certified Nursing Assistants (CNA) assisting R26 to reposition in bed, both CNAs did not wear a protective gown and one CNA did not wear gloves when assisting R26 with repositioning, they failed to follow the enhanced barrier precautions (EBP) for R26. On 2/19/25 at 9:00 a.m., a surveyor confirmed the above finding with the charge nurse. 33242 4. On 2/19/25 at 8:13 a.m., a surveyor observed CNA take R28 into the bathroom by wheelchair. The surveyor observed an Enhanced Barrier Precaution sign on the doorframe area. CNA was not wearing a gown when entering or exiting the bathroom. At 8:21 a.m., the surveyor observed Registered Nurse (RN) go into R28's bathroom and then observed her transporting R28 in a wheelchair out of the bathroom. At 8:25 a.m., during an interview with a surveyor, RN stated that she assisted R28 with toileting hygiene and transferred R28 to the wheelchair and did not know that R28 was on enhanced barrier precautions, but would check why. On 2/19/25 at 8:50 a.m., during an interview with a surveyor, and with a CNA present, RN stated that R28 tested positive for Vancomycin-Resistant Enterococcus (VRE) and that they should be wearing gowns when providing care to R28. On 2/19/25 at 9:21 a.m., during an interview with a surveyor, Infection Preventionist confirmed that R28 was on EBP for VRE in the urine and that is why the sign is posted outside the door. 5. The facility's Water Management Program indicated the individual or team responsible for the Water Management Program manages the following: Documented results of all monitoring activities; Corrective actions and procedures to follow if a test result outside of acceptable limits is obtained; and Documented corrective actions taken when the control limits are not maintained. The Control Locations Management Log identified areas to monitor (action item), control ranges, and minimum frequency of checks. Further review included multiple action items that included: check hot water temperatures of faucets to ensure proper heating (monthly), clean showerheads and run hoses weekly, ensuring all active outlets are flushed weekly, and cleaning the ice machine at least twice a year, with more items listed. On 2/19/25 at 10:18 a.m., during an interview with a surveyor, the Forest Hill Maintenance Specialist stated that he only checks the water temperatures that comes into the boiler room that is generated by the hospital. He does not check hot water temperatures at faucets to ensure proper heating or any other monitoring that was identified on the Control Locations Management Log. On 2/19/25 at 10:30 a.m., during an interview with a surveyor, the Administrator stated that he would check for further information regarding action items that were to be monitored. On 2/19/25 at 12:20 p.m., during an interview with a surveyor, the Administrator confirmed that the facility is not monitoring the action items identified per Water Management Policy except for the ice machine and boiler room checks.

Based on record review and interview, the facility failed to recognize a potential significant weight loss for 1 of 5 sampled residents reviewed for nutrition (Resident #30 [R30]). Finding: On 2/19/25, R30's clinical record was reviewed. R30's care plan, revised on 11/29/24, indicated R30 lost weight and will now get a nutritional supplement once a day. R30's care plan indicated a goal to maintain a body weight within 3 lbs of 179 lbs. R30's weights were as follows: On 9/5/24, R30 weighed 184 lbs. On 10/18/24, R30 weighed 175 lbs. On 11/19/24, R30 weighed 168 lbs. On 1/7/25, R30 weighed 160 lbs. On 2/13/25, R30 weighed 155 lbs. On 2/20/25 at 9:40 a.m., during an interview with a surveyor, the Director of Nursing stated the dietician had ordered a supplement, but the order had dropped off. At this time, the surveyor confirmed R30's clinical record lacked evidence that nursing staff had not notified the medical provider or the registered dietitian, and had not initiated nutritional interventions, such as requesting additional supplements to address the weight loss.

Based on record review and interviews, the facility failed to notify timely the Medical Provider of abnormal laboratory results that required further tests to determine cause and the Resident Representative (RR) with results of abnormal labs when results were requested, for 1 of 1 residents reviewed for hospitalization (Resident # [R42]). Findings: 1. On 2/20/25, R42's clinical record was reviewed and indicated that on 1/21/25, R42 had blood work, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), that were sent to the hospital for analysis and were resulted at 9:06 a.m. (CBC) and 9:23 a.m. (CMP) on 1/21/25. R42's abnormal lab results were as follows: White blood cell count was high at 14.6 with a normal reference range of 4.0-10.0; Sodium level was high at 158, with a normal reference range of 136-145; and Potassium level was high at 5.3, with a normal reference range of 3.5-5.1. On 1/22/25 at 1:44 p.m., the facility's documentation indicated that the (abnormal) blood work was reviewed by Nurse Practitioner (NP), 28 hours after resulted. The NP ordered a STAT (to be completed immediately) urinalysis. On 2/20/25 at 1:24 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated that the Medical Provider should have been made aware of the abnormal lab results by telephone when they were resulted. 2. Review of R42's clinical record indicated on 1/21/25 at 5:30 p.m., documentation indicated that R42's RR requested an update on the blood work results. The RR was told that the results were in the chart and would be reviewed by the doctor tomorrow and that RR would be called tomorrow after that review. On 2/20/25 at 1:24 p.m., during an interview with multiple surveyors present, the DON stated that he saw the note that was written about not giving the RR the information regarding the lab results and making the RR wait until the following day and that the RR should have been given the information (as the RR could have requested transfer to the hospital for further workup).

Based on clinical record review and interview, the facility failed to ensure physician orders were followed for 1 of 5 sampled residents for unnecessary medications (Resident #13 [R13]). Finding: On 2/19/25 at 3:05 p.m., during a clinical record review for R13, the electronic Medication Administration Record (MAR) showed that R13's blood sugars (BS) were checked 4 times a day and the sliding scale insulin would provide coverage as indicted per the sliding scale. Review of the physician order indicated the use of Novolin R insulin for sliding scale insulin coverage. Sliding scale coverage was ordered for BS starting at 150, coverage would be provided using the following sliding scale: 150-200 = 2 units of Novolin R 201-250 = 4 units of Novolin R 251-300 = 6 units of Novolin R 301-350 = 8 units of Novolin R 351-400 = 10 units of Novolin R On 2/6/25 at 7:47 p.m., R13's BS was 175, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/9/25 at 10:44 a.m., R13's BS was 153, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/10/25 at 3:35 p.m., R13's BS was 228, R13's sliding scale indicates that he/she should have received 4 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/11/25 at 5:21 a.m., R13's BS was 151, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/11/25 at 10:50 a.m., R13's BS was 162, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/13/25 at 5:09 a.m., R13's BS was 161, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/13/25 at 10:48 a.m., R13's BS was 205, R13's sliding scale indicates that he/she should have received 4 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/13/25 at 3:38 p.m., R13's BS was 240, R13's sliding scale indicates that he/she should have received 4 units. Documentation on the MAR shows that R13 received 1 unit of Novolin R insulin. On 2/13/25 at 7:59 p.m., R13's BS was 157, R13's sliding scale indicates that he/she should have received 2 units. Documentation on the MAR does not show how much insulin coverage he/she received. On 2/20/25 at 8:15 a.m., during an interview with the Resident Care Coordinator, R13's MAR was reviewed The surveyor confirmed that on several days R13 had BS that would have required coverage from sliding scale and he/she did not receive the correct dose.

Based on record review, facility policy review, and interview, the facility failed to ensure residents were offered pneumococcal immunizations for 1 of 5 residents reviewed for immunizations (Resident #34 [R34]). Finding: The facility's policy, Pneumococcal/Influenza Immunization Policy, last revised 2/12, indicated that all patients will be offered the vaccine unless contraindicated due to health history. Administration of the vaccine will be in accordance with the Pneumococcal Immunization/Influenza Standing Order. On 2/19/25, R34's clinical record was reviewed. The surveyor could not find evidence that R34 was offered, declined, or had received a Pneumococcal Immunization. On 2/20/25 at 9:31 a.m., during an interview with a surveyor, the Infection Preventionist stated that there was no offering, history of receiving, or declination of a Pneumococcal Immunization in R34's clinical record and that R34's Resident Representative consented yesterday, after the surveyor asked for further information on R34's vaccination status.

Based on record review and interviews, the facility failed to notify the provider of abnormal laboratory results timely for 1 of 1 residents reviewed for hospitalization (Resident #42 [R42]). Finding: On 2/20/25, R42's clinical record was reviewed and indicated that on 1/21/25, R42 had blood work and a chest x-ray ordered by the doctor (MD). The bloodwork, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), were obtained by the facility and sent to the hospital for analysis and were resulted at 9:06 a.m. (CBC) and 9:23 a.m. (CMP) on 1/21/25. R42's abnormal lab results were as follows: White blood cell count was high at 14.6 with a normal reference range of 4.0-10.0; Sodium level was high at 158, with a normal reference range of 136-145; and Potassium level was high at 5.3, with a normal reference range of 3.5-5.1. On 1/21/25 at 5:30 p.m., the facility's documentation indicated that the results were in the chart and would be reviewed by MD tomorrow. On 1/22/25 at 1:44 p.m., the facility's documentation indicated that the (abnormal) blood work and chest x-ray results were reviewed by Nurse Practitioner (NP), 28 hours after resulted. On 2/20/25 at 12:21 p.m., during an interview with a surveyor, Registered Nurse stated that if a resident has labs that were completed, they have to check the computer for the results unless it is a critical value and then the laboratory would call (the facility is owned by the hospital and share the same electronic medical record). On 2/20/25 at 1:24 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated that the Medical Provider should have been made aware of the abnormal lab results by telephone when they were resulted.

Based on observation and interview, the facility failed to ensure all expired drugs and biologicals, available for resident use, had been removed from 1 of 2 medication storage units (skilled nursing unit), and 1 of 1 medication storage refrigerator (medication storage refrigerator long term care unit). Findings: 1. On 2/20/25 at 10:36 a.m., during an inspection of the medication storage room on the skilled unit, a surveyor discovered one box of Ayr Saline Nasal Gel (sinus spray), available for resident use, that had expired on 7/24. 2. On 2/20/25 at 10:55 a.m., during an inspection of the medication storage room refrigerator on the long term care unit, a surveyor discovered one bottle of GI (gastrointestinal) Cocktail (Lidocaine, Banophen, Mylanta) (medication for dyspepsia [upper abdominal pain]) give 15 milliliters (ml) by mouth twice daily as needed, with Resident #15's name on the bottle, which had a discard after 2/2/25 written on the label. R15's current physician's orders, dated 8/17/23, included an order for GI Cocktail 15 ml, solution, oral, twice a day as needed for dyspepsia. The above findings were confirmed with the Certified Nursing Assistant - Medications on 2/20/25 at the time of the observations, and the medications were immediately removed for destruction.

Based on record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Diabetes for 1 of 13 residents reviewed (Resident #13 [R13]) Findings: Review of Resident #13's clinical record revealed that he/she was admitted to the facility on [DATE]. Review of the current physician order for Novolin R insulin sliding scale. Resident #13's current care plan was reviewed, and it lacked evidence that the care plan included goals and interventions for the care area of Diabetes and use of insulin. On 2/20/25 at 8:27 a.m. During a review of R13's care plan with the Residential Care Coordinator, the surveyor confirmed that the treatment of R13's Diabetes was not addressed in his/her care plan.

Based on the facility reported incident dated 9/17/24, review of the facility's investigation report dated 9/17/24, facility's investigation follow-up report dated 9/20/24, facility policy, record review, and interviews, the facility failed to protect a resident from being sexually harmed, and potentially being emotionally harmed and causing the resident to sustain emotional fear, sadness, and embarrassment for 1 of 1 resident sampled for abuse (Resident #1 [R1]). A reasonable person could have psychosocial harm. Finding: On 9/17/24, the facility reported to the Maine Department of Health and Human Service, Division of Licensing and Certification a facility reportable incident of staff to resident sexual abuse. Documentation in the facility's Investigation Summary Report indicates that on 9/17/24, a Certified Nursing Assistant #1 (CNA1) reported to the facility's Director of Nursing (DON) that on 9/17/24 at 10:30 a.m. CNA1 noted R1's room door was closed and noted she had not seen R1 recently. CNA1 entered the room without knocking and states she saw an employee, the Transporter, [Facility] Activities sitting in front of R1 and describes that the Transporter, [Facility] Activities appeared to be startled to see CNA1 entering the room and removed his hands from under R1's shirt. CNA1 states, I saw [the Transporter] had his hands in R1's shirt on [his/her] breast. Documentation in R1's clinical record, under a physician progress note indicates that R1 has diagnoses to include generalized anxiety disorder, major depressive disorder, PTSD [post-traumatic stress disorder], agitation, dementia, major neurocognitive disorder, Alzheimer's disease, and vascular dementia. Documentation in the resident's clinical record, showed no outward signs of emotional distress from the incident. R1 is incapable of giving his/her consent to sexual activity. It would be reasonable that R1 would be very distraught that his/her dignity was violated by a staff placing his hands on R1's breast. Documentation in the facility's current Abuse, Neglect, Exploitation and Misappropriation of Property policy indicates that residents will be free from sexual abuse. On 9/30/24 at 12:00 p.m., in an interview with a surveyor, CNA1 states that she was searching for R1, went into R1's room and observed the Transporter, Activities staff with his hands up the front of R1's shirt, under R1's clothing on his/her breasts. CNA1 states the Transporter, Activities staff removed his hands from under R1's shirt, then fixed R1's shirt when she entered the room. CNA1 took R1's hand and led him/her to the hallway where R1 continued to walk down the hallway. CNA1 states that R1 had a dazed look on his/her face, and she immediately reported the incident to the Director of Nursing (DON). On 9/30/24 at 11:36 a.m. in an interview with a surveyor, the Administrator, Chief Operating Officer confirmed that the Transporter, Activities staff admitted to him that, he [Transporter, Activities staff] had his hands between R1's breasts and touching his/her breasts. He did admit to me that [R1] was not of [his/her] normal state of mind, could not consent. R1 did not have the cognitive ability to get out of the situation of being sexually touched and was under the control of the Transporter [Facility] Activities. Potential long-lasting embarrassment and emotional distress would occur knowing that he/she was sexually touched. A reasonable person would suffer from anger and deep sadness due to lack of control over the situation and would experience fear of the Transporter [Facility] Activities. As a result of the facility's investigation the following correction actions were immediately taken on 9/17/24: -The facility immediately took action by ensuring the resident was safe and the resident was assessed and showed no signs of distress. - The Transporter [Facility] Activities was immediately terminated from employment on 9/17/24 after meeting with the Administrator, Chief Operating Officer, and the DON. The local police were notified, Licensing and Certification and the Adult Protective Agency were notified, the resident's physician and the resident representatives were notified. -The DON began to hold in-service education reviewing Abuse Reporting and Investigation, with more training to take place next week. The DON documented on an attendance record, which contained staff names, and the completion of the in-services attended. Additionally, based on the above information, Immediate Jeopardy (IJ) at past non-compliance was called on 10/15/24 for the facility's failure to ensure that a resident was free from abuse [sexual]. Please see F-0000- Initial Comments related to the IJ removal plan.

Based on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 3 unlicensed staff reviewed for in-service training completed the required training (Staff #1, and Staff #2). Findings: During a review of facility staff education records the following was identified: 1. Transporter, [Facility] Activities, staff #1 was hired on 3/28/16. The education record lacks evidence of mandatory abuse, neglect, exploitation and misappropriation of resident property education/training in within the past year. 2. Housekeeping and Engineer Services, Handyman, staff #2 was hired on 1/5/23. The education record lacks evidence of mandatory abuse, neglect, exploitation and misappropriation of resident property education/training in within the past year. On 9/30/24 at 4:44 p.m. in an interview with a surveyor, the Director of Nursing confirmed that not all of the mandatory training required was completed for Staff #1, and staff #2 within the past year.

Based on interviews, the facility's bathing schedule, and facility's bathing documentation, and electronic medical record the facility failed to ensure that resident's preferences were being followed in the area of bathing for 1 of 1 resident reviewed. (Resident's #1 [R1]). Findings: On 9/4/24 at 10:07 a.m. in an interview with a surveyor, R1 indicated that he/she should be getting whirlpools every evening, that it is care planned, and he/she did not receive whirlpools for 7 days in the past 31 days. R1 further indicated that he/she only refused a whirlpool bath 1 time due to being sick, and 1 time because he/she returned from an outing late and knew it was late for staff to give him/her a whirlpool. Review of LTC IPOC (plan of care) for R1, last evaluated on 8/27/24, indicates under ADL (activities of daily living), I request a daily whirlpool in the evening. I may decline at times, if my schedule changes or I don't feel up to it. Review of facility Whirlpool Schedule indicates under Miscellaneous, R1, WP (whirlpool) every evening before 9 pm [9:00 p.m.]. Review of CORP - Section GG (MDS 3.0) - Detail Report for R1, printed on 9/4/24, dated 8/25/24 9:30 PM (p.m.), Inpatient, indicates, please describe the resident's shower/bathe performance., Substantial/maximal assistance. The detail report does not specify what type of bathing R1 received. On 9/4/24 at 11:53 a.m. in an interview with a surveyor, Registered Nurse #1 [R1] indicated that last October things changed with the documentation and as a facility they decided to choose how they document bathing according to Section GG of the Material Data Set (MDS) 3.0. which doesn't specify the type of bath a resident receives. The surveyor confirmed that R1's documentation does not indicate if he/she received a bed bath, whirlpool bath, or shower. Review of R1's clinical record lacked evidence that he/she received any whirlpools in the past 31 days. On 9/4/24 at 1:04 p.m. in an interview with the Administrator, a surveyor confirmed that there is no evidence that R1 received any whirlpool baths in the past 31 days.

Based upon record review, review of the facility Side rail Mangement and Entrapment Prevention policy and procedure, the Bed Safety Assessment form, and interviews, the facility failed to implement the facility policy and procedure to monitor for bed side rail safety which resulted in 1 of 1 resident's sustaining a broken right upper arm (humerus) ( Resident#1). Finding: On 11/10/16 the Division of Licensing and Certification (DLC) received a Nursing Facility Reportable Incident Form from Forest Hill Manor indicating that Resident #1 was found face down on the floor with right arm stuck in quarter rail and further indicated resident seen in E.R. (emergency room ) Resident returned with a sling + diagnosed with [REDACTED]. On 11/21/2016 an onsite investigation was conducted by DLC, the investigating surveyor was given a Side rail Management and Entrapment Prevention Policy and Procedure which includes a blank Bed Safety Assessment form by the Director of Nursing (DON). The policy and procedure indicates, under the policy section: It is the policy of NMMC (Northern Maine Medical Center) to have in place a process that requires ongoing patient evaluation, monitoring and equipment upholding, which will result in optimizing, bed safety, and further indicates under the procedure section: 1. Prior to initiating any type of side rails, an individual risk benefit assessment will take place by the treatment team ., 5. All beds, mattresses and bed rails will be inspected, evaluated and maintained every 6 months to identify and remove potential fall and entrapment hazards by the maintenance department, 6. The bed assessment records will be kept in the maintenance office for reference and Quality improvement purposes. Review of the clinical record lacked evidence that Resident #1's bed rails were inspected, evaluated, and maintained every 6 months to identify and remove fall and entrapment hazards as directed by the facility policy. In an interview with a surveyor on 11/21/2016 at 9:45 a.m., the Maintenance Supervisor indicated, when asked if the facility monitors for bed side rail safety, we don't check them regularly, only if we have a complaint about the bed. In an interview with a surveyor on 11/21/2016 at 11:52 a.m., the DON confirmed that the Side rail Management and Entrapment Prevention policy and procedure and the Bed Safety Assessment form has not been implemented/completed by Forest Hill Manor.

Based on record review and interviews, the facility's failure to provide adequate supervision consistent with the resident's safety needs, resulted in 1 of 1 residents (Resident #1) falling out of bed on two occasions. The resident suffered a fracture of the left patella during one of these falls. Finding: On June 6, 2013, a complaint investigation was completed at the facility as a result of a self-reported incident. On January 11, 2013, Resident #1 was receiving morning care. At 7:50 a.m., the CNA, who was caring for the resident, reported that the resident had fallen out of bed while the bed was in the raised position when the CNA was changing the bed linen. The resident sustained [REDACTED]. Later in the a.m., when the resident was getting up in a chair, the resident began to complain of pain in the left knee. On January 11, 2013, the resident was seen by the Family Nurse Practioner (FMP). On January 11, 2013, the nurse's notes indicated that Resident #1 had complained of pain in the left leg all shift and a bruise was now noted on the left knee area. Ice packs were applied with some relief. Percocet was given at 3:30 a.m. because Resident #1 stated, "can't sleep, my leg hurts too bad and it's keeping me awake, I hope they don't have to cut that one off too." On January 13, 2013, Resident #1 continued to complain of left knee pain and increased redness and edema was noted. Percocet was administered and apparently effectively managed the resident's pain. On January 14, 2013, Resident #1 continued to complain of left knee pain and increased redness and swelling was observed. The FMP was notified and an X-ray was obtained. The results of the X-ray of the left knee indicated evidence of a communuted fracture of the patella. On January 18, 2013, the Rehabilitation Department issued a report to be review and signed by care providers that stated the following: "Please always have 2 people when turning --- in bed. Pull resident towards opposite side of bed before turning ----. (i.e. pull --- toward R side of bed before turning towards L side; vice versa.) Thanks." On January 18, 2013, Resident #1's care plan was also updated to indicate the need for two assist when turning the resident in bed. On January 28, 2013, at 11:20 a.m., a CNA reported to the treatment nurse that Resident #1 was on floor after having rolled off the bed while a.m. care was being provided. The CNA admitted that she had been providing care to Resident #1 by herself and was unaware that a two person assist was now required to assure the resident's safety when turning him/her in bed. The resident was moved back to the bed and placed on a backboard. The nursing assessment indicated that the resident was complaining of left knee pain, had bruising and swelling to the right neck and right shoulder and a skin tear with bleeding on the right hand and stump. The Doctor was immediately notified and the resident was transferred to the hospital for evaluation at 12:45 p.m. and then returned to the facility.