Forest Hills Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Forest Hills Care and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656May 7, 2025

  Based on observation, record review and interview, the facility failed to ensure comprehensive care plans were developed for 2 (#80 and #108) of 20 sampled residents whose care plans were reviewed. The DON reported 140 residents resided in the facility. Findings: 1. On 04/29/25 at 2:37 p.m., Resident #80 was observed in bed. Resident #80's right hand was observed to be contracted. A facility policy titled Comprehensive Person-Centered Care Plan, reviewed 10/23/19, read in part, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the facility will provide care. An admission record, dated 06/20/24, showed Resident #80 had diagnoses which included kidney failure and dementia. […]

• No harm, potential for more than minimal, patternF688May 7, 2025

  Based on observation, record review, and interview, the facility failed to ensure: a. range of motion services were provided for 2 (#97 and #75); and b. provide contracture interventions for 1 (#80) of 3 sampled residents who were reviewed for range of motion. The DON identified 12 residents with contractures and 43 residents with limited range of motion. Findings: 1. A policy titled Establishment of an Individual Restorative Program, dated 01/02/24, read in part, To provide treatment and services to maintain and improve functional abilities per physician order. […]

• No harm, potential for more than minimal, patternF880May 7, 2025

  Based on observation, record review and interview, the facility failed to: a. follow EBP during the provision of care for 1 (#108) of 2 sampled residents reviewed for catheter care; and b. ensure clean laundry was transported appropriately. The DON reported 11 residents had urinary catheters and 110 residents' laundry was cleaned by the facility. Findings: 1. On 05/05/25 at 3:45 p.m., LPN #3 was observed providing catheter care to Resident #108. LPN #3 was not observed to wear a gown. A facility policy titled Enhanced Barrier Precautions, reviewed 05/15/24, read in part, The facility may expand the use of PPE [personal protective equipment] & refer to the use of gowns & gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to hands/clothing. […]

• No harm, potential for more than minimal, patternF883May 7, 2025

  Based on record review and interview, the facility failed to ensure residents were offered the pneumococcal immunization for 3 (#28, 83, and #330) of 5 sampled residents reviewed for immunizations. The DON identified 140 residents resided in the facility. Findings: A policy titled Pneumococcal Vaccine, dated 12/05/24, read in part, The opportunity to receive the Pneumococcal Vaccine will be extended to all Residents. The facility will provide pertinent information regarding the Risks/Benefits of receiving the Vaccine. 1. An undated face sheet showed Resident #330 had a diagnosis of diabetes. Review of the immunization tab in the electronic clinical record did not show the resident had been offered the pneumococcal immunization. 2. […]

• No harm, potential for more than minimal, patternF761Feb 9, 2024

  Based on observation and interview, the facility failed to ensure medications were labeled and not expired for three (200 hall treatment cart, 600 hall treatment cart, and 500 hall medication cart) of seven medication/treatment carts observed. The DON identified 13 medication/treatment carts in the facility. Findings: 1. On 02/05/24 at 7:38 a.m., the medication/treatment cart for 400 hall was observed to be unlocked and unattended. On 02/05/24 at 7:40 a.m., LPN #3 was observed to lock the medication/treatment cart. On 02/05/24 at 7:40 a.m., the medication/treatment cart for the 300 hall was observed to be unlocked and unattended. […]