Forest Hills Healthcare Center.

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 14, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, medical record review, review of the incident log, review of facility in-service records, review of a personnel file, review of the safety inspection bus checklist, review of witness statements and the facility's internal investigation, review of policies, review of the emergency medical services (EMS) report, review of emergency room (ER) notes, interview with the Medical Director, and resident and staff interviews, the facility failed to ensure a resident dependent on staff, was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility van to a physician's visit. […]

• Immediate jeopardy, isolatedF689May 5, 2022

  Based on medical record review, observations, interviews with staff and residents, review of hospital records, review of a facility investigation/staff statements, review of a weather report, and review of facility policy, the facility failed to assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors, and level of supervision for Resident #06, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy with the potential for serious life-threatening harm, injuries, and/or death on [DATE] at approximately 7:15 P.M. […]

• Immediate jeopardy, isolatedF684Mar 21, 2022

  Based on closed medical record review, interviews with facility staff, review of the facility neurological checks post fall, review of hospital records, and review of facility policies, the facility failed to ensure necessary care and services were provided to a resident who had an unwitnessed fall and staff had not performed neurological assessments according to the facility policy. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries, when Resident #115 suffered an unwitnessed fall on 01/04/22 at 4:45 A.M. and subsequently experienced a change in condition requiring hospitalization . Neurological checks were started, but were not completed after 01/05/22 at 10:00 A.M. […]

• Immediate jeopardy, isolatedF689Mar 21, 2022

  Based on medical record review, interviews with staff, observation of residents and meals, interview with the Nurse Practitioner, review of hospital documentation and reports, review of meal tickets, and review of the facility document titled Eating, the facility failed to ensure staff provided adequate supervision during meals for one resident (#08) with a diagnosis of dysphagia oropharyngeal phase, and who was identified to be at risk for aspiration and choking. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #08 choked, requiring staff to perform the [MEDICATION(S)] maneuver, after being served a meal tray without supervision, subsequently went into cardiopulmonary arrest, and passed away at the hospital on [DATE] at 2:46 A.M. […]

• Actual harm, isolatedF760Sep 1, 2022

  Based on medical record review, review of the hospital records, staff interview, review of the facility investigation, review of the incident log, review of the witness statement, and policy review, the facility failed to ensure residents were free from significant medication errors. This resulted in Actual Harm when Licensed Practical Nurse (LPN) #30 administered Resident #02 another resident's medication and subsequently Resident #02 was admitted to the hospital with an acute kidney injury and [CONDITION(S)]. The facility census was 84. Finding include: Review of the medical record revealed Resident #02 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]