Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hills Center during CMS and state inspections, most recent first.
Four residents with severe cognitive impairment and dependence on staff for care experienced unwitnessed injuries, including bruises and a fracture, that were not reported or were reported late to the State agency as required by facility policy. Investigations were incomplete, lacking interviews with relevant parties and documentation of conclusions, and the DON confirmed that reporting and documentation procedures were not followed.
Three residents with severe cognitive impairment and high dependency for ADLs experienced injuries of unknown origin, including bruising and a fracture. In each case, the facility did not complete thorough investigations, failed to interview relevant parties, and did not document conclusions in IDT progress notes. Suspected causes were not confirmed, and preventive interventions were not implemented.
A resident with severe cognitive impairment and multiple diagnoses was admitted without a signed consent for treatment by facility providers, as the legal guardian insisted on exclusive care by VA providers. Despite this, staff obtained or attempted to obtain medical orders from facility providers on several occasions, contrary to the guardian's directives and without proper authorization.
Two residents with cognitive impairments were involved in a physical altercation after one entered the other's room, resulting in injury. Despite a physician's order for a stop sign to be placed at the doorway to prevent such incidents, observations confirmed the stop sign was not consistently in place. Staff interviews indicated the sign was frequently removed, and the facility's investigation could not conclusively determine the events due to the residents' cognitive deficits.
The facility did not timely report or investigate multiple injuries of unknown origin and a resident-to-resident altercation, affecting three residents with severe cognitive impairment and histories of behavioral issues or falls. Required documentation, staff interviews, and state agency notifications were not completed, and incidents were only reported after family concerns were raised.
The facility did not conduct or document required investigations into injuries of unknown origin for two residents with severe cognitive impairment, nor into a physical altercation between two residents that resulted in injury. In each case, there was a lack of incident reporting, staff interviews, and formal investigation, despite facility policy requiring these actions.
The facility did not ensure the presence of a registered nurse (RN) for the required hours on multiple days, with several instances of no RN coverage or less than eight hours of RN coverage. This lapse was confirmed by the DON and had the potential to impact all 70 residents.
Staff failed to keep the kitchen clean, with significant buildup of debris and substances under a grate and around equipment, and did not use proper sanitary technique when checking food temperatures, sometimes reusing alcohol swabs between different foods. These actions had the potential to affect all residents who consumed food from the kitchen.
Surveyors found that the laundry room was not kept clean or sanitary, with lint buildup on pipes, wet and discolored puddles on the floor, cracked and peeling flooring, and accumulated dirt and debris. The Maintenance Director confirmed these conditions and acknowledged the need for cleaning, while the facility's policy did not address the issue.
Several residents were prescribed psychotropic medications, including escitalopram and Depakote, for conditions such as agitation, mood, and behaviors without appropriate or documented clinical diagnoses. Care plans did not consistently address the use of these medications, and the DON confirmed that the documented reasons for prescribing were not appropriate indications. This resulted in a deficiency related to the facility's failure to ensure proper medication management and documentation.
A resident with severe cognitive impairment had conflicting code status information in their medical record, with the electronic record indicating Full Code while the care plan and a signed DNRCC-A form indicated DNRCC-A status. Nursing staff and the DON confirmed the inconsistency, which was linked to issues during a recent electronic medical record system change.
A resident with severe cognitive impairment and behavioral disturbances was placed in her room with the door held closed by staff during episodes of aggression, without a documented assessment, physician order, or care plan intervention for physical restraint. Facility policy requiring documentation and evaluation of restraint use was not followed.
The facility failed to properly monitor and document a bruise for a resident with cognitive impairment, as ongoing assessments of the bruise's characteristics were not completed and the care plan was delayed. Additionally, wound care orders for another resident with a burn wound were not implemented in a timely manner due to a system change, and there was no evidence the correct treatment was provided as ordered.
A resident with severe cognitive impairment and a history of falls was left unsupervised in a common area despite care plan interventions requiring supervision. The resident was later found on the floor with a skin tear, and staff confirmed that the supervision intervention was not in place as required by the care plan and facility policy.
A resident with severe cognitive impairment and chronic pain did not receive a prescribed Butrans patch on two occasions due to unavailability, and the physician was not notified of the missed doses. The DON confirmed that neither she nor the physician was informed, and the pharmacy did not receive the prescription until weeks later.
A resident with dementia and behavioral disturbances repeatedly engaged in sexually inappropriate behaviors that were inconsistently documented and inadequately monitored by staff. Despite care plans and staff awareness, detailed reporting and intervention were lacking, resulting in a deficiency in behavioral health care and services.
Required postings with contact information for State agencies and advocacy groups, as well as complaint filing instructions, were placed in an area inaccessible to residents. Two residents confirmed they had never seen this information and would like access to it. The Activities Recreation Director verified that the postings were not in resident living areas and that residents did not have routine access to the posted information.
The facility failed to maintain comfortable temperatures in certain areas, affecting residents' comfort. Observations showed that the Third Street Unit and a room on the First Street Unit were warmer than other areas, with temperatures exceeding the facility's policy range. Malfunctioning PTAC units contributed to the issue, and temporary measures like box fans were not consistently used. Resident interviews confirmed discomfort due to the heat.
The facility failed to follow its abuse policies when two residents with severe cognitive impairments were left alone after a potential observation of abuse. A staff member found a male resident in a female resident's room in a compromising situation but did not immediately call for a nurse, delaying the separation of the residents. The facility's policy required immediate protection of residents, which was not adhered to, leading to a deficiency finding.
The facility failed to implement comprehensive care plans that included activities and preferences for two residents. One resident with severely impaired cognition and multiple diagnoses did not have an activity care plan or preferences documented. Another resident with moderately impaired cognition and various diagnoses also lacked an activity care plan or preferences. The facility's policy required routine assessment of each resident's interests and needs, which was not followed.
A resident with severe cognitive impairment eloped from the facility after a receptionist mistakenly allowed him to exit, thinking he was a visitor. The resident was found by police and returned without injuries. The incident revealed gaps in the facility's supervision and security measures.
Failure to Timely Report Injuries of Unknown Source to State Agency
Penalty
Summary
The facility failed to timely report injuries of unknown source to the State agency for four residents with severe cognitive impairment. Each of these residents was dependent on staff for activities of daily living and had significant communication deficits, making them unable to explain the cause of their injuries. The injuries included significant bruising and, in one case, a fracture, all of which were unwitnessed and lacked a clear explanation. Despite facility policy requiring immediate or timely reporting of such incidents, these injuries were either not reported or reported late to the State agency. For one resident, a large bruise was discovered on the left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) confirmed that the injury was not reported to the State agency and that the investigation's conclusion was not documented. Another resident was found with a bruise on the forehead, and although it was suspected to be caused by a broda chair, no interventions were implemented to prevent recurrence, and the injury was not reported to the State agency. The DON again confirmed the lack of reporting and documentation of the investigation's conclusion. A third resident was observed with a forehead bruise and was sent to the hospital for evaluation. The self-reported incident was not submitted to the State agency until two days after the injury was discovered. The fourth resident had swelling and discoloration of the left hand and wrist, later diagnosed as a fracture, with no known cause. The DON suspected the injury might have occurred due to the resident's hand getting caught in a wheelchair wheel, but this was not documented, and the injury was not reported to the State agency. In all cases, the facility's own policy defined injuries of unknown source as possible indicators of abuse and required timely reporting, which was not followed.
Failure to Thoroughly Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown sources for three residents with severe cognitive impairment and high dependency for activities of daily living. In one case, a resident was found with significant bruising on her left lower arm, but the internal investigation did not include interviews with outpatient therapy staff or the resident's daughter, both of whom were present during therapy sessions. The Director of Nursing (DON) suspected the injury occurred during therapy but did not document a conclusion in the interdisciplinary team (IDT) progress notes. Another resident was discovered with a bruise on her forehead, and although the physician and family were notified and a new treatment was initiated to monitor the bruise, the investigation did not determine the cause of the injury. The resident was unable to describe the incident due to cognitive impairment, and the IDT note lacked documentation of the cause. The Administrator suspected the injury was related to the resident's broda chair, but no interventions were implemented to prevent recurrence, and the investigation's conclusion was not documented. A third resident was noted with swelling and discoloration of the left hand and wrist, later diagnosed as a fracture. The cause of the injury was unknown, and no staff or witnesses could provide an explanation. The DON suspected the injury might have occurred when the resident's hand became caught in a wheelchair wheel, but again, no conclusion was documented in the IDT progress notes. The Administrator acknowledged that investigations had not been fully completed in the past and indicated that this issue would be addressed in future quality assurance meetings.
Failure to Ensure Resident Received Care Only from Approved Physicians
Penalty
Summary
This facility failed to ensure that a resident received care and services only from approved physicians, as required. The resident in question was admitted with diagnoses including Alzheimer's disease, heart disease, and obstructive sleep apnea, and had a severely impaired cognitive status as indicated by a BIMS score of 3 out of 15. The resident's legal guardian, who was also the daughter, refused to sign the facility's consent for treatment and insisted that all medical care be provided exclusively by VA providers. The guardian also took responsibility for scheduling and notifying the VA for all appointments, declining involvement from the facility's medical director or related providers. Despite the lack of consent for treatment by facility providers, there were multiple instances where facility staff either attempted to obtain or did obtain medical orders for the resident. These included a new order for Depakote from a CNP for increased agitation, notification of a provider regarding leg swelling, and a treatment order for a skin injury after the medical director's group was contacted. Interviews with the Administrator and DON confirmed that the facility did not have a signed consent on file and that staff actions were taken without the required authorization from the resident's legal guardian.
Failure to Prevent Resident-to-Resident Altercation and Maintain Ordered Safety Interventions
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not preventing a resident-to-resident altercation that resulted in injury, and by not ensuring that a physician-ordered stop sign was in place at a resident's doorway. Two residents with cognitive impairments were involved in an incident where one resident entered another's room, leading to a physical altercation. The resident who entered the room sustained injuries including a cut to the nose and upper lip, and the loss of a tooth. Both residents were unable to provide reliable accounts of the incident due to their cognitive status. Medical record reviews showed that one resident had diagnoses of Alzheimer's disease, psychosis, and mood disorder, with a moderately impaired cognition, and was receiving daily antidepressants and opioid medication. The other resident had Alzheimer's disease, dementia, and heart failure, with severely impaired cognition and a history of wandering and entering other residents' rooms. The care plan for the first resident included a stop sign at the doorway to provide privacy and prevent such incidents, and staff were ordered to ensure the stop sign was in place. However, observations on multiple dates confirmed that the stop sign was not present as ordered, and staff interviews revealed it was often removed by the resident and their roommate. The facility's self-reported incident investigation was inconclusive due to lack of witnesses and the cognitive deficits of both residents, making it impossible to verify the exact sequence of events. Documentation confirmed that the required stop sign was not in place at the time of the incident, and the facility's policy defined abuse as the willful infliction of injury or unreasonable confinement. The failure to maintain the ordered intervention and prevent the altercation constituted non-compliance with regulations protecting residents from abuse and neglect.
Failure to Timely Report and Investigate Injuries and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to timely report injuries of unknown origin and a resident-to-resident altercation to the state agency, as required by regulation and facility policy. In the case of one resident with severe cognitive impairment and a history of aggressive behaviors, two separate injuries of unknown origin were identified: a hand injury with a possible fracture and a significant hematoma to the forehead. In both instances, there was no documentation of a formal investigation, no staff interviews were conducted, and the incidents were not reported to the state agency within the required timeframe. The facility only filed a self-reported incident after the family raised concerns, and there was no evidence of staff education or training on abuse or injuries of unknown origin. Another resident, also with severe cognitive impairment and a history of falls, was found to have extensive bruising on the right shoulder, chest, and arm, as well as acute rib fractures and a clavicle fracture. Despite the presence of multiple injuries and the resident's inability to explain their origin, there was no documented investigation or timely reporting to the state agency. The facility's leadership was unaware of the incidents, and no self-reported incidents were filed for these events. Staff interviews and documentation required by facility policy were not completed. Additionally, a physical altercation occurred between two residents, resulting in a skin tear injury. The incident was documented in the medical record, but no self-reported incident was filed, and no investigation was conducted as required. Facility policy mandates that all alleged violations, including injuries of unknown origin and resident-to-resident altercations, be reported to the administrator and state agency within 24 hours and that thorough investigations with staff interviews and documentation be completed. These requirements were not met in the cases reviewed.
Failure to Investigate Injuries of Unknown Origin and Resident Altercations
Penalty
Summary
The facility failed to conduct thorough investigations into injuries of unknown origin and a resident-to-resident altercation, affecting three residents. For one resident with severe cognitive impairment and a history of aggressive behaviors, there were two separate incidents involving significant injuries—a hand injury with a possible fracture and a head injury with hematomas and bruising. In both cases, there was no documented evidence of a formal investigation, no staff interviews, and no incident reports were submitted at the time of the injuries. The Director of Nursing and Administrator confirmed that they did not complete or document investigations, often assuming the injuries were self-inflicted due to the resident's behaviors. Another resident, also with severe cognitive impairment and a history of falls, was found with extensive bruising on the shoulder, chest, and arm, and later diagnosed with acute rib and clavicle fractures. Despite the severity and unexplained nature of these injuries, there was no documented investigation or self-reported incident filed. Staff interviews revealed that no one witnessed the events leading to the injuries, and the Director of Nursing attributed the bruising to a fall without supporting evidence or documentation of staff interviews. A third resident was involved in a physical altercation with another resident, resulting in a skin tear. The incident was documented in the medical record, but no self-reported incident was filed and no investigation was conducted. Facility policy required that all injuries of unknown origin and resident-to-resident altercations be investigated, including staff interviews and thorough documentation, but these procedures were not followed in any of the cases reviewed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage, as evidenced by a review of staff schedules from 07/14/24 to 08/31/24, which showed multiple days with either no RN coverage or less than the mandated eight hours of RN coverage. Specific dates were identified where no RN was present, and on some days, RN coverage was less than the required duration. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the lack of proper RN coverage on the listed dates. The absence of adequate RN staffing had the potential to affect all 70 residents residing in the facility.
Unsanitary Kitchen Conditions and Improper Food Temperature Practices
Penalty
Summary
Facility staff failed to maintain the kitchen in a clean and sanitary condition and did not follow proper procedures for obtaining food temperatures. Observations on two separate occasions revealed a large grate in front of the oven with a thick layer of black and brown substances, appearing moist, covering the area underneath. The floor under kitchen equipment and around the edges was found to have a buildup of dirt, food debris, and miscellaneous items, including a plastic cup under the reach-in refrigerator. Staff interviews confirmed that the area under the grate sometimes emitted a smell and that both the floor and the area under the grate required cleaning. The grate area was identified as a drain for the dishwasher and was subject to both backflow and cleaning activities by kitchen and maintenance staff. Additionally, a staff member was observed taking food temperatures in a manner that did not meet sanitary standards. The staff member used the same alcohol swab to clean the thermometer between different food items on multiple occasions, rather than using a new swab for each item. This practice was confirmed by the staff member during an interview at the end of the observation.
Laundry Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain the laundry room in a clean and sanitary condition, as observed during a walkthrough with the Maintenance Director. The washers were positioned approximately one and a half to two feet from the back wall, where PVC pipes and water lines were present, and the area between the wall and pipes was covered in lint. The floor had multiple wet spots, including two green puddles, and was blackened in appearance. On the dirty side of the laundry room, a sink was found with a buildup of dust, lint, and debris, and the floor had several cracked and peeling areas with accumulated dirt and leaves along the wall. The Maintenance Director confirmed these observations and acknowledged the need for cleaning. The facility's provided policy did not address these concerns.
Inappropriate Use of Psychotropic Medications Without Proper Diagnoses
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses to justify their use. Medical record reviews revealed that several residents were prescribed medications such as escitalopram and Depakote for conditions like depression, agitation, mood, and behaviors, without corresponding or appropriate clinical diagnoses documented in their records. For example, one resident was prescribed escitalopram for depression despite not having a diagnosis of depression, and Depakote was ordered for several residents with indications such as agitation, mood, and behaviors, which are not approved indications for the medication. Care plans for these residents did not consistently address the use of these psychotropic medications or specify the behaviors or symptoms being treated. In some cases, the care plans mentioned potential side effects and monitoring interventions but failed to link these to specific, clinically justified diagnoses. Interviews with the DON confirmed that terms like "behaviors," "agitation," and "mood" were not appropriate diagnoses for the use of Depakote, and that some residents were receiving medications without a proper diagnosis to support their use. Review of prescribing information for Depakote indicated that its approved uses are for the treatment of seizures, prophylaxis of migraine headaches, and treatment of manic episodes associated with bipolar disorder. The facility's own policy on psychotropic medication use requires that such medications be prescribed with a documented clinical indication consistent with accepted clinical standards of practice. The lack of appropriate diagnoses and documentation for the use of these medications constituted a deficiency in the facility's medication management practices.
Inconsistent Advanced Directive Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that accurate advanced directive information was consistently present throughout the medical record for one resident. The resident in question had multiple complex diagnoses, including severe cognitive impairment, and was unable to make decisions independently. A review of the resident's records revealed discrepancies: the electronic medical record and its banner indicated the resident was a Full Code, while the care plan and a signed physician DNRCC-A (Do Not Resuscitate Comfort Care Arrest) form indicated a DNRCC-A status. The care plan detailed specific interventions consistent with DNRCC-A, and the DNR form was filed in the electronic medical record. Interviews with nursing staff and the DON confirmed the inconsistency between the electronic medical record's code status and the care plan documentation. Staff reported that the electronic medical record banner is the primary source for verifying code status, which could lead to confusion in an emergency. The DON and Senior Administrator acknowledged the discrepancy and attributed it to issues with data transfer during a recent change in the electronic medical record platform.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to assess a resident prior to the use of a physical restraint. The resident, who had diagnoses including dementia, pseudobulbar affect, anxiety, frontotemporal cognitive disorder, psychosis, major depressive disorder, and mood disorder, exhibited behaviors such as running and screaming in the hallway, physical and verbal aggression, wandering, and rejection of care. According to the physician's consult, staff would place the resident in her room and hold the door closed for approximately 30 minutes during episodes of violent behavior to prevent her from harming herself or others. A review of the resident's medical record, facility assessments, and care plan revealed no documentation of a physical restraint assessment, no physician orders for restraint use, and no care plan interventions related to restraints. The facility's policy required documentation of medical symptoms warranting restraint use, attempts at less restrictive alternatives, ongoing re-evaluation, and care plan updates, none of which were present in this case. Interviews with the Medical Director and DON confirmed the absence of incident reports, documentation, or restraint assessments for the resident.
Failure to Monitor Bruises and Timely Implement Wound Orders
Penalty
Summary
The facility failed to properly monitor and document the progression of a bruise for a resident with significant cognitive impairment and multiple complex diagnoses, including dementia, hemiplegia, and malignant neoplasm. After a bruise was noted on the resident's right eye, an order was given to monitor the area every shift until resolved. However, from the time the bruise was first documented until it was considered healed, there was no ongoing documentation describing the size, condition, color, or other relevant characteristics of the bruise, aside from the initial assessment. The care plan addressing the bruise was not implemented until several weeks after the injury had resolved, and the facility was unable to provide requested documentation supporting that the bruise was properly monitored during the specified period. Additionally, the facility did not implement wound care orders in a timely manner for another resident with severe cognitive impairment and multiple medical conditions, including hemiplegia, diabetes, and a burn wound. Although a physician's order was in place to provide specific wound care, there was a delay in updating and carrying out the correct treatment due to a system changeover. The unit manager confirmed that the correct order was not timely implemented and was unable to provide evidence that the prescribed wound care was administered as ordered. These deficiencies demonstrate lapses in both the monitoring and documentation of skin conditions and the timely implementation of physician-ordered treatments for residents with complex medical needs. The lack of proper documentation and timely care interventions directly affected the residents reviewed for skin conditions during the survey.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall prevention interventions were in place for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, peripheral vascular disease, and psychosis. The resident had a documented history of falls and was assessed as being at risk for further falls due to cognitive and physical limitations. The care plan included specific interventions such as keeping the resident in supervised areas, particularly by the nurse's station or in activities when in a wheelchair, and staff education to maintain supervision. Despite these interventions being documented in the care plan and progress notes, the resident was observed in the dining area without supervision on multiple occasions. On one occasion, the resident was found on the floor in the lounge area with a skin tear on his right elbow, and staff confirmed that the required supervision intervention was not in place at the time of the fall. Interviews with facility staff, including a CNA and the DON, verified that the resident had been left unsupervised in the dining area, contrary to the care plan and facility policy. The facility's fall prevention policy required individualized interventions based on assessment and risk factors, which were not consistently implemented for this resident.
Failure to Provide Ordered Pain Medication and Notify Physician
Penalty
Summary
The facility failed to provide pain medication as ordered for a resident with multiple complex medical conditions, including hemiplegia, aphasia, diabetes, COPD, vascular dementia, and chronic pain syndrome. The resident had a physician's order for a Butrans transdermal patch to be applied weekly for pain management. Review of the Medication Administration Record showed that the patch was not applied on two scheduled dates, and progress notes indicated the medication was unavailable at those times. Despite the unavailability of the ordered pain medication, there was no documentation that the physician was notified of this issue. The Director of Nursing confirmed that neither she nor the physician had been informed that the Butrans patch was not available. The pharmacy did not receive the prescription until several weeks after the initial order, as the physician was unaware of the situation. The resident's pain was managed by switching as-needed medication to a scheduled regimen during this period.
Failure to Monitor and Document Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to adequately monitor, document, and prevent a resident's inappropriate sexual behaviors, despite clear evidence of ongoing incidents. The resident, who had a history of dementia with behavioral disturbances, agitation, and other psychiatric diagnoses, exhibited sexually inappropriate behaviors on multiple occasions as documented by CNAs. However, these behaviors were not thoroughly documented in the resident's progress notes, and there was a lack of detailed reporting regarding the nature of the incidents. The care plan included interventions for these behaviors, but physician orders did not specifically address monitoring for sexual behaviors, and staff documentation was inconsistent and incomplete. Observations revealed the resident engaging in inappropriate physical contact with another resident in a common area, with staff present but not intervening until prompted. Interviews with staff confirmed awareness of the resident's behaviors and the expectation for detailed documentation and reporting, which was not consistently followed. The DON acknowledged that aides' documentation of sexual behaviors was vague and that more detailed notes and reporting to responsible parties were necessary. The failure to monitor, document, and prevent these behaviors constituted a deficiency in providing necessary behavioral health care and services.
Required Resident Rights Postings Not Accessible
Penalty
Summary
The facility failed to ensure that required postings, including the list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, as well as the statement that residents may file a complaint with the State Survey Agency, were readily accessible to all residents. Observations during the annual survey revealed that these postings were located in a hallway outside of the building's interior locked doors, an area inaccessible to residents. Further observations confirmed that the postings were not present within the three locked hallways where residents were confined. Interviews with two residents during a resident council meeting confirmed they had never seen the postings or documents with information on how to contact the ombudsman or state department of health and expressed a desire to have this information. The Activities Recreation Director also confirmed that the postings were not in resident living areas and that residents did not have routine access to the area where the postings were located.
Failure to Maintain Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain a comfortable temperature in specific areas, affecting residents' comfort and potentially their health. Observations and interviews revealed that the Third Street Unit and a room on the First Street Unit were significantly warmer than other areas of the facility. The temperature in these areas exceeded the facility's policy range of 71 to 81 degrees Fahrenheit, with readings as high as 83 degrees Fahrenheit in some locations. The deficiency was identified during a survey following a complaint investigation. The issue was exacerbated by malfunctioning Packaged Terminal Air Conditioner (PTAC) units in several rooms, including one that was not working at all and another that was only blowing faint air. Despite a facility audit identifying the need for replacement units, the new PTAC units had not yet been received, and temporary measures such as box fans were not consistently implemented. Resident interviews confirmed discomfort due to the heat, with one resident using her t-shirt to fan herself. The facility's failure to monitor and maintain appropriate room temperatures contributed to the deficiency.
Failure to Follow Abuse Policies in Resident Interaction
Penalty
Summary
The facility failed to adhere to its abuse policies and procedures when two residents were left alone after a potential observation of abuse. Resident #10, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was found in a compromising situation with Resident #15. Resident #15, also with severe cognitive impairment and dependent on staff, was observed by a staff member in Resident #10's room with his pants down, engaging in inappropriate behavior. The incident was reported by a State Tested Nurse Assistant (STNA) who found Resident #15 in Resident #10's room, with Resident #10's shirt lifted and Resident #15 kissing her chest while touching himself. The STNA did not immediately call for a nurse but instead went to get the Licensed Practical Nurse (LPN) to separate the residents. The facility's policy required immediate protection of residents from further abuse, which was not followed as the residents were left alone initially. The facility's policy on abuse, neglect, and exploitation mandates immediate response to protect alleged victims and increase supervision during and after an investigation. However, the actions taken by the staff did not align with these procedures, as the residents were not immediately protected from further interaction after the incident was observed. This deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention policies.
Failure to Implement Comprehensive Care Plans for Activities and Preferences
Penalty
Summary
The facility failed to implement comprehensive care plans that included activities and preferences for two residents. Resident #17, who was admitted with diagnoses such as diabetes mellitus type two, dementia, chronic kidney failure, and paranoid personality disorder, had severely impaired cognition with a BIMS score of zero out of 15. The resident required assistance for activities of daily living, including transfers and mobility. However, the comprehensive care plan dated 05/17/24 did not include an activity care plan or activity preferences for this resident, as confirmed by the Administrator during an interview. Similarly, Resident #66, admitted with diagnoses including diabetes mellitus type two, senile degeneration of the brain, alcohol dependence, dementia, and delusional disorders, had moderately impaired cognition with a BIMS score of 11 out of 15. This resident required limited assistance for activities of daily living but was independent with ambulation and mobility. The comprehensive care plan initiated on 06/03/24 also lacked an activity care plan or activity preferences, as confirmed by the Administrator. The facility's policy on activities, dated 06/01/24, required that each resident's interests and needs be assessed routinely, including an activity assessment. This deficiency was investigated under Complaint Number OH00154476.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment from eloping. The resident, who had diagnoses including encephalopathy, Alzheimer's disease, type II diabetes mellitus, and anxiety disorder, was admitted to the facility and assessed as being at high risk for elopement. Despite this, the resident was able to leave the facility unsupervised. On the day of the incident, the resident was noted to be agitated and expressed a desire to leave. The resident was last seen by staff with a personal belonging bag and was later found missing from the unit. The receptionist mistakenly allowed the resident to exit the facility, thinking he was a visitor. The resident was eventually found by police and returned to the facility without any injuries. The incident occurred when the receptionist let the resident out, mistaking him for a visitor. The resident was able to leave the facility through a door that had been propped open by a family member. Staff quickly realized the resident was missing and initiated a search, involving both facility staff and the police. The resident was found at a nearby restaurant and returned to the facility. Interviews with staff and the receptionist revealed that the receptionist was not aware of the new resident's identity and did not have a picture of him in the elopement binder. The facility's policies on elopement and wandering residents were not adequately followed, leading to the resident's unsupervised departure. The receptionist's lack of awareness about the new resident and the failure to verify the identity of individuals leaving the facility contributed to the incident. The facility's response included immediate actions to locate the resident and assess him for injuries, but the initial failure to prevent the elopement highlighted gaps in the facility's supervision and security measures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westerwood Rehabilitation | 0.5 mi | ★★★★★ | 10 | 0 |
| The Laurels Of Walden Park | 1.8 mi | ★★★★★ | 42 | 0 |
| Westerville Post Acute. | 1.8 mi | ★★★★★ | 1 | 0 |
| Inniswood Health And Rehabilitation | 2.8 mi | ★★★★★ | 1 | 0 |
| Buckeye Terrace Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 10 | 0 |
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