Forestview

In the surveyor’s words

From the most serious findings on record at Forestview, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 9, 2021

  Based on observation, review of clinical records, facility documentation and policy and procedures, and staff interviews, it was determined that the facility failed to properly assist/supervise a resident with a hot beverage that resulted in an accident and actual harm of a skin burn for one of 16 residents reviewed (Resident R45). Findings include: Review of a facility policy entitled Microwaves dated 2/04/21, indicated that beverages/liquids heated in microwaves should not exceed temperature of 155 degrees Fahrenheit to minimize the risk of [CONDITION(S)], staff will provide documentation when reheating a food or beverage item in any microwave within the facility, and that a thermometer and tracking log will be available at each microwave. […]

• Actual harm, isolatedF600Jun 4, 2021

  Based on review of facility policy, documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a three centimeter (cm) laceration to the posterior (back) of the head and fractures of vertebrae (bones of the spinal column) and right ribs. This deficiency is cited as past non-compliance. Findings include: A review of facility policy titled, Resident Abuse, dated 2/4/2021, revealed that, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. […]

• Actual harm, isolatedF689Jun 4, 2021

  Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to provide adequate assistance as indicated in facility policy and on resident's plan of care summary related to their transfer status with a mechanical lift which resulted in actual harm for one of three residents reviewed (Resident R1) which resulted in actual harm of a three centimeter (cm) laceration to the posterior (back) of the head and fractures of vertebrae (bones of the spinal column) and right ribs. This deficiency is cited as past non-compliance. […]

• No harm, potential for more than minimal, patternF655Aug 14, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 18 residents reviewed (Residents R1, R13, and R74).Findings include: A facility policy entitled Care Plans-Baseline dated 4/23/26, indicated The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:The stated goals and objectives of the resident;A summary of the resident's medications and dietary instructions;Any services and treatments to be administered by the facility and personnel acting on behalf of… […]

• No harm, potential for more than minimal, patternF565Dec 9, 2021

  Based on review of facility documents and policies, and staff and resident interviews it was determined that the facility failed to ensure that facility staff attend monthly Resident Council meetings only at the group's invitation, that the residents are able to voice their concerns at the meetings, and that the meeting concerns are recorded for timely follow-up and resolutions to resident concerns for six of six Resident Council attendants (Residents R19, R23, R28, R34, R55, and R60). […]