Health inspection·June 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, interview, and facility policy review the facility failed to implement comprehensive care plans to include activities and preferences. This affected two residents (Resident #17 and #66) of four residents reviewed for comprehensive care plans. The facility census was 73. Findings Include: 1. Review of Resident #17's medical record revealed an admission date of 05/17/24 with diagnoses including diabetes mellitus type two, dementia, chronic kidney failure, and paranoid personality disorder. Resident #17 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 and required assistance from staff for activities of daily living (ADL) tasks, including transfers and mobility. Review of Resident #17's comprehensive care plan dated 05/17/24 revealed there was not an activity care plan or activity preferences completed for Resident #17. Interview on 06/25/24 at 11:53 A.M. with the Administrator confirmed Resident #17 did not have an activity care plan or activity preferences completed as part of the comprehensive care plan dated 05/17/24. 2. Review of Resident #66's medical record revealed an admission date of 05/30/24 with diagnoses including diabetes mellitus type two, senile degeneration of the brain, alcohol dependence, dementia, and delusional disorders. Resident #66 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 11 out of 15. Resident #66 required limited assistance from staff for activities of daily living (ADL) tasks. Resident #66 was independent with ambulation and mobility. Review of Resident #66's comprehensive care plan with initiated date of 06/03/24 revealed Resident #66 did not have an activity care plan or activity preferences completed upon admission. Interview on 06/25/24 at 11:53 A.M. with the Administrator confirmed Resident #66 did not have an activity care plan or activity preferences completed for the comprehensive care plan dated 05/30/24. Review of the facility's policy titled, Activities dated 06/01/24 revealed Each resident's interest and needs will be assessed on a routine basis. The assessment shall include but is not limited to: Resident Assessment Instrument Process: MDS/Care Area Assessment/Care Plan, Activity assessment to include resident's interests, preferences and needed adaptations, social history, and discharge information, when applicable. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365980 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)