A list of the most recent deficiencies for Forest Hill Manor Health Center. 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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-01-24 | 2024-03-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-01-23 | 2024-02-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-23 | 2024-02-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-23 | 2024-02-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-23 | 2024-02-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-23 | 2024-02-09 | 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 necessary and PRN use is limited. | Health | 2024-01-23 | 2024-02-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-23 | 2024-02-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-23 | 2024-02-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-23 | 2024-02-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-23 | 2024-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-23 | 2024-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-23 | 2024-02-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-08-05 | 2022-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-09 | 2022-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-09 | 2022-08-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Establish methods for sharing information. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-28 | 2020-02-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-18 | 2020-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-18 | 2020-01-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-18 | 2020-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-18 | 2020-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-18 | 2020-01-02 | N |
