Forest Hills Center for Rehabilitation and Healing

In the surveyor’s words

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

• Immediate jeopardy, patternF689Dec 12, 2023

  Based on observation, interview, record review, and review of other pertinent facility documents on 12/4/2023, it was determined that the facility failed to provide four of ten residents with a prescribed pureed diet, which should have been smooth, soft, and homogenous in consistency. The pureed mashed potatoes served to the residents from the kitchen on 12/4/23, were served with several chunks of potato mixed into the mashed potatoes. The facility's failure to prepare and provide the proper pureed food consistency and, failure of the nursing staff to report the improper food consistency, placed Resident #61, #28, #31 and #69, as well as all other residents, at risk of aspiration and choking which could cause serious harm, impairment or death. […]

• No harm, potential for more than minimal, widespreadF804Aug 5, 2025

  Based on observations and interviews and review of pertinent facility documents, it was determined that the facility failed to provide food at a safe and appetizing temperature. The deficient practice was identified for 6 of 6 residents (Residents #1, #19, #20, #29, #69 and #78) that participated in the Resident Council Meeting and was evidenced by the following:On 7/31/25 at 10:30 AM, while participating in Resident council meeting 6 of 6 residents verbalized, they receive food that is cold at meals. On 8/5/25 at 10:15 AM, the surveyor interviewed Unit Manager (UM) for 5th floor. The UM confirmed occasionally residents ask for their food to be heated because it arrived cold. The UM further stated cold food gets heated up on the unit in a microwave. […]

• No harm, potential for more than minimal, widespreadF806Aug 5, 2025

  Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 6 of 6 residents (Resident #2, #8, #25, #69, #94, and #116) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 7/30/25 at 12:17 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #69's tray, per the tray ticket, Resident #69 was supposed to receive coffee, strawberry short cake and health shake supplement, all three items were missing from the tray. 2. On 7/30/25 at 12:23 PM, the surveyor was observing the lunch meal on 4th floor unit. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2025

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and observed the following: 1. In the bread storage area, the surveyor observed one loaf of sliced white bread, one loaf of sliced whole wheat bread, one bag of 12 hotdog buns, and one loaf of rye bread all opened and without open/use by labels. The FSD stated they use the manufacturers use by dates.2. […]

• No harm, potential for more than minimal, widespreadF814Aug 5, 2025

  Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area; and found the following. There was garbage debris that included food wrappers, food containers, cups, gloves, paper products, and plastic utensil around the dumpster and surrounding areas. […]