Deficiency Records for Forest Hill Health and Rehabilitation
Updated as of October 01, 2019
This is not the most recent data for Forest Hill Health and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Forest Hill Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-07-25 | 2019-09-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-07-25 | 2019-09-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-19 | 2019-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-04-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-21 | 2019-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-31 | 2019-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-31 | 2019-04-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Establish methods for sharing information. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-31 | 2019-03-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-31 | 2019-03-17 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-01-31 | 2019-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-31 | 2019-03-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-01-31 | 2019-03-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-31 | 2019-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-31 | 2019-03-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-01-31 | 2019-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-31 | 2019-03-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-31 | 2019-03-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2019-01-31 | 2019-03-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-31 | 2019-03-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-08 | 2018-12-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-08 | 2018-12-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-08 | 2018-12-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-08 | 2018-12-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-31 | 2018-10-30 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-09-19 | 2018-10-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-19 | 2018-10-30 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-09-19 | 2018-10-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-09-19 | 2018-10-30 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-09-19 | 2018-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-19 | 2018-10-30 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-19 | 2018-10-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-19 | 2018-10-30 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-19 | 2018-10-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-19 | 2018-10-30 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-09-19 | 2018-10-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-19 | 2018-10-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-19 | 2018-10-30 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-07-23 | 2018-10-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-07-23 | 2018-10-30 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-07-23 | 2018-10-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-07-23 | 2018-10-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-23 | 2018-10-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-23 | 2018-10-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-23 | 2018-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-23 | 2018-10-30 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-07-23 | 2018-10-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-23 | 2018-10-30 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-07-23 | 2018-10-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-23 | 2018-10-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-07-23 | 2018-10-30 | Y |
| Install proper backup exit lighting. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Have an externally vented heating system. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-06 | 2018-09-26 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-07-23 | 2018-09-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-23 | 2018-09-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-23 | 2018-09-05 | N |
| Provide appropriate foot care. | Health | 2018-07-23 | 2018-09-05 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-07-23 | 2018-09-05 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-07-23 | 2018-09-05 | N |
| Provide or obtain dental services for each resident. | Health | 2018-07-23 | 2018-09-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-23 | 2018-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-23 | 2018-09-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-23 | 2018-09-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-07-23 | 2018-09-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-07-23 | 2018-09-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-07-23 | 2018-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-23 | 2018-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-23 | 2018-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-23 | 2018-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-23 | 2018-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-23 | 2018-09-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-07-23 | 2018-09-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-23 | 2018-05-21 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-05-19 | 2017-08-19 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-05-19 | 2017-08-19 | Y |
| Meet other general requirements. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Use approved construction type or materials. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-01 | 2017-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-12 | 2017-07-24 | Y |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-05-19 | 2017-07-24 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-05-19 | 2017-07-24 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-05-19 | 2017-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-19 | 2017-07-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-05-19 | 2017-07-03 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-05-19 | 2017-07-03 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-05-19 | 2017-07-03 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-19 | 2017-07-03 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-19 | 2017-07-03 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-05-19 | 2017-07-03 | N |
| Hire a qualified dietician. | Health | 2017-05-19 | 2017-07-03 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-05-19 | 2017-07-03 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-05-19 | 2017-07-03 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-19 | 2017-07-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-19 | 2017-07-03 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-05-19 | 2017-07-03 | N |
| Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. | Health | 2017-05-19 | 2017-07-03 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-05-19 | 2017-07-03 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-05-19 | 2017-07-03 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-19 | 2017-07-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-05-19 | 2017-07-03 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-19 | 2017-07-03 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-19 | 2017-07-03 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-19 | 2017-07-03 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-05-19 | 2017-07-03 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-05-19 | 2017-07-03 | Y |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-05-19 | 2017-07-03 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-19 | 2017-07-03 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2017-05-19 | 2017-07-03 | Y |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-05-19 | 2017-07-03 | Y |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-05-19 | 2017-07-03 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-19 | 2017-07-03 | Y |
| Keep clinical records for an appropriate amount of time. | Health | 2017-05-19 | 2017-07-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-05-19 | 2017-07-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-01-05 | 2017-02-07 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-05 | 2017-02-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-01-05 | 2017-02-07 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-05 | 2017-02-07 | Y |
