Forest Hills of DC

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 9, 2023

  Based on record review and staff interviews, for one (1) of 32 sampled residents (#7), the facility staff failed to implement adequate supervision and assistance to prevent falls with injury for a cognitively impaired resident identified as a high risk for falls. These failures resulted in actual harm to Resident #7 on 1/2/23. The findings included: Resident #7 was admitted on [DATE] with multiple diagnoses including Generalized Muscle Weakness, Dementia, and Alzheimer's Disease. A review of Resident #7's medical record revealed a physician's order dated 06/25/22 that directed, Maintain fall risk precaution at all times every shift. […]

• No harm, potential for more than minimal, widespreadF568Feb 25, 2022

  Based on record review and staff interview, facility staff failed to ensure resident funds were not commingled with the funds of any other person other than another resident. The facility census was 45. (Identifiers for Non-Residents'- TF1, TF2 and TF3) The findings included: Review of the facility's trial balance report dated 2/18/22 showed a total of 18 resident accounts. When the writer reconciled the trial balance report with the facility census report dated 2/17/22, it was revealed that three (3) of 18 (TF1, TF2, and TF3) accounts listed on the trail balance report did not belong to residents that reside in the skilled nursing facility. […]

• No harm, potential for more than minimal, patternF812Dec 6, 2024

  Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions. These findings have the potential to affect all residents. The findings included: 1. An open pack of provolone cheese and a pan with chunks of grapefruit were stored in a refrigerator undated, in the kitchen on unit Healthcare 1. 2. Two (2) of 14 white cutting boards, and two (2) of 14 green cutting boards in the main kitchen were soiled and discolored. 3. Food temperature logs from the main kitchen, and the kitchen on healthcare 1 and 2, were missing several entries throughout the month of October 2024. 4. One (1) of two (2) convection ovens in the main kitchen (bottom), was soiled. 5. […]

• No harm, potential for more than minimal, patternF625Aug 9, 2023

  Based on record review and staff interview, for four (4) of 32 sampled residents, facility staff failed to provide written notice of the bed hold policy to include the number of bed hold days to the resident or their responsible party upon transfer to the emergency room . Residents' #197, #253, #27 and #98. The findings included: The facility policy Bed Hold documented, . At the time of transfer or leave of absence, the social worker will notify the resident/responsible party of the transfer and the number of bed-hold days remaining . 1. […]

• No harm, potential for more than minimal, patternF657Aug 9, 2023

  Based on record review and staff interviews, the facility staff failed to revise and update person-centered care plans for 4 (four) of 32 sampled residents. Residents #12, #41, #17, and #23 The findings included: The facility policy Care Plans, Comprehensive Person-Centered documented, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . The Interdisciplinary Team (IDT) must review and update care plan . when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay . 1. Facility staff failed to update Resident #12's care plan to show that the resident had sustained a fall with injuries. […]