Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident and staff interviews, review of temperature logs, review of a Packaged Terminal Air
Conditioner (PTAC) facility audit, and facility policy review, the facility failed to ensure the Third Street Unit
and one room on the First Street Unit (room [ROOM NUMBER]) were maintained at a comfortable
temperature for the residents who resided in those areas. The deficient practice affected one resident
(Resident #40) who resided in room [ROOM NUMBER] and had the potential to affect one additional
resident (Resident #2) who also resided in room [ROOM NUMBER] and all 28 residents who resided on the
Third Street Unit (Residents #10,#15, #35, #43, #44, #45, #46, #47, #48, #49, #51, #52, #54, #56, #58,
#61, #62, #64, #66, #68, #71, #73, #75, #77, #79, #85, #87, and #89). The facility census was 74.
Findings Include:
Review of the facility PTAC unit audit completed on 07/22/24 and 07/25/24 revealed there were three PTAC
units which needed to be replaced. The units in room [ROOM NUMBER] and 311 were not working at all
and the unit in room [ROOM NUMBER] was only blowing faint air. Four units were ordered and would be
installed immediately once received. A new PTAC unit was borrowed from the facility's beauty salon and
installed in room [ROOM NUMBER] on 08/05/24.
Review of the air temperature logs dated July and August 2024 revealed there were no temperatures of
specific resident rooms indicated on the logs.
Observation on 08/07/24 from 11:20 A.M. to 11:30 A.M. during the initial tour of the facility revealed Third
Street Unit felt significantly warmer than the other two units of the facility. There was one portable air
conditioning (A/C) unit in place on the Third Street unit. The A/C unit was located off the dining room area of
the unit near the entrance doors to the unit. The portable A/C unit displayed an air temperature of 77
degrees Fahrenheit (F).
Interview on 08/07/24 at 3:31 P.M. with Maintenance Director (MD) #125 confirmed a whole house facility
audit of PTAC units in resident rooms was completed on 07/22/24 (half of the facility was audited) and
07/25/24 (the rest of the facility was audited). MD #125 confirmed there were three PTAC units identified
that needed to be replaced in rooms [ROOM NUMBER]. MD #125 confirmed a new PTAC unit was installed
in room [ROOM NUMBER] on 08/05/24, however, the other two rooms (101 and 301) still needed to be
replaced. MD #125 stated both rooms should have box fans in place to help keep the rooms cool. MD #125
stated four new PTAC units had been ordered but still had not been received. MD #125 confirmed he had
not been monitoring the air temperatures in rooms [ROOM NUMBERS] to ensure they remained at a
comfortable temperature as both rooms remained occupied by residents.
(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 5
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
08/07/2024
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation and temperature reading completed on 08/07/24 from 3:52 P.M. with MD #125 revealed on
First Street Unit, room [ROOM NUMBER], was 76.3 degrees F. There was a PTAC unit observed in the
room that was not working optimally. The PTAC unit was set at 66 degrees F. There was not a box fan
observed in the resident's room. Resident #40 was observed in the room, sitting in a recliner chair, next to
the PTAC unit. The resident was using her t-shirt to fan herself by waving it back and forth while sitting in
the recliner. An interview with Resident #40 revealed when she was asked if she was comfortable, the
resident responded, I'm hot. Resident #40 confirmed there was not a box fan in her room to help keep her
cool. Resident #40's roommate, Resident #2, was not in the room at the time of the observation. A fan was
offered to Resident #40 and the resident accepted. The findings were confirmed by Maintenance Director
(MD) #125.
Observations and air temperature readings completed on 08/07/24 from 3:58 P.M. to 4:10 P.M. with MD
#125 revealed upon entering the Third Street Unit, the entry hallway was 77 degrees F. There were two
additional portable A/C units observed on the Third Street Unit that had been added on the day of the
survey per MD #125. One A/C unit was placed on each end of the long hallway. At 3:59 P.M., room [ROOM
NUMBER] was 78 degrees F. Resident #15 was observed in the room, laying in his bed. The air
temperature above the resident's head over the bed was 78.4 degrees F. Resident #15 was not able to be
interviewed due to cognitive impairment. There was not a box fan observed in room [ROOM NUMBER]. MD
#125 confirmed the room temperature was too warm and not comfortable for a reasonable person. At 4:09
P.M., in the hallway outside of room [ROOM NUMBER], the air temperature was 83 degrees F. The portable
A/C unit that was set up on the same end of the hallway registered an air temperature of 81 degrees F. The
findings were confirmed by MD #125.
Review of the facility policy, Quality of Life-Homelike Environment, revised 05/2017, revealed the policy
stated, the facility staff and management shall maximize, to the extent possible, the characteristics of the
facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe
temperatures between 71 and 81 degrees F.
This deficiency reveals non-compliance during the investigation of Complaint Number OH00156292.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365980
If continuation sheet
Page 2 of 5
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
08/07/2024
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of a facility-reported incident (FRI) investigation, staff interviews, and facility policy
review, the facility failed to follow abuse policies and procedures when Residents #10 and #15 were left
alone after a potential observation of abuse. The deficient practice affected two (Residents #10 and #15) of
three residents reviewed for abuse. The facility census was 74.
Residents Affected - Few
Findings Include:
Review of the medical record for Resident #10 revealed an original admission date of 11/15/21 and a
readmission date on 12/12/22. Diagnoses included unspecified psychosis, restlessness and agitation,
mood (affective) disorder, cognitive communication disorder, anxiety disorder, and Alzheimer's Disease.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10
was rarely or never understood. Per staff assessment, the resident had severely impaired cognition.
Resident #10 was totally dependent on staff to complete Activities of Daily Living (ADLs).
Review of Resident #10's care plan revealed resident will pull her clothing over her head exposing herself to
others dated 12/12/22, updated 08/07/24.
Review of the nurse's note dated 07/27/24 at 3:55 P.M. revealed the nurse (later identified as Licensed
Practical Nurse (LPN) #104) was alerted by Stated Tested Nurse Assistant (STNA) (later identified as
STNA #100) that a male resident (later identified as Resident #15) was kissing resident's chest. STNA #100
redirected the male resident from Resident #10's room. LPN #104 did a head to toe assessment on
Resident #10 and no injuries were noted. Vital signs were blood pressure (BP) 118/76, heart rate (HR) 70,
temperature 98.2, and oxygen saturation 94%. No complaints of pain or discomfort. The Assistant Director
of Nursing (ADON) was notified.
Review of the nurse's note dated 07/30/24 at 3:42 P.M. revealed the physician ordered stop sign to be
added to Resident #10's door. The resident's Power of Attorney (POA) was notified.
Review of the nurse's note dated 07/31/24 at 9:49 A.M. revealed on 07/29/24, while the Director of Social
Services (DSS) completed an assessment on Resident #10, the resident pulled the social worker closer to
her with a smile. When the SSD stepped back to create space between herself and Resident #10, the
resident held the SSD's hand. During the assessment, Resident #10 pulled on the SSD's shirt, after three
or four attempts to redirect Resident #10, the resident placed the SSD's hand on her own shirt for the SSD
to hold onto. Resident #10 was smiling and wanted to be closer to her.
Review of the medical record for Resident #15 revealed an admission date on 06/20/23. Medical diagnoses
included depression, aphasia, Bipolar Disorder, need for assistance with personal care, anxiety disorder,
unspecified psychosis, and Alzheimer's disease.
Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #15 scored 0 out of 15 on the
Brief Interview for Mental Status (BIMS) assessment. Resident #15 was totally dependent on staff to
complete ADLs.
Review of the nurse's note dated 07/27/24 at 3:55 P.M. revealed LPN #104 was alerted by STNA #100
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365980
If continuation sheet
Page 3 of 5
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
08/07/2024
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)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
that Resident #15's pants were down and his depends were off and the resident was observed kissing the
chest of a female resident (Resident #10) in her room. Resident #15 stated, What do you want? Resident
#15 was removed from Resident #10's room and immediately assisted with clothing. Resident #15 refused
to be assessed. The ADON was notified and Resident #15 was placed on one on one supervision
immediately.
Residents Affected - Few
Review of the nurse's noted dated 07/27/24 at 4:00 P.M. revealed the on-call Certified Nurse Practitioner
(CNP) was notified and no new orders were given. Resident #15's spouse and the Administrator were
notified.
One on one supervision of Resident #15 with staff continued through 07/31/24 (four days) with no
additional incidents noted. Resident #15 was seen by the CNP on 07/31/24. Resident #15 was being
followed by neuro psychiatrist and was notified of escalated behavior. Resident #15 continued on Seroquel
(an antipsychotic medication, Sertraline (an antidepressant medication), and Depakote (a mood stabilizer
medication).
Review of a Facility Reported Incident (FRI) #250128 investigation dated 07/27/24 revealed Resident #15
was an alleged perpetrator of a sexual abuse allegation against another female resident (Resident #10).
Review of the witness statement written by STNA #100 revealed the aide reported a male resident was in
female resident's room when he walked in and saw the female resident on the bed with her shirt up. The
male resident was sitting on the bed with his pants down kissing the female resident's chest. STNA #100
went and got nurse. The male resident was removed from the room and placed on one on one supervision.
The female resident had socks and pants on and her shirt was lifted. The male resident had his pants
down, kissing the chest of the female resident while touching himself.
Interview on 08/07/24 at 1:27 P.M. with STNA #100 confirmed he found Resident #15 in Resident #10's
room. Resident #10 was laying on the bed with her shirt lifted. Resident #15 was sitting on the side of the
bed next to Resident #10 with his pants down and was observed kissing Resident #15's chest while
touching himself. STNA #100 stated he called for the nurse and the residents were immediately separated.
Resident #15 was placed on one on one supervision which he provided for the remainder of his shift.
Resident #10 was assessed and did not have any injuries. Both residents had severely impaired cognition
and neither recalled the incident. STNA #100 was shown his witness statement that was completed at the
time of the incident on 07/27/24. STNA #100 confirmed it was his written statement which indicated he went
and got the nurse. STNA #100 stated he thought he called for the nurse but that is not what he wrote down.
Interview on 08/07/24 at 2:41 P.M. with LPN #104 confirmed she was the assigned floor nurse on 07/27/24
when the incident occurred between Resident #10 and Resident #15. LPN #104 stated STNA #100 walked
over to her and asked her to follow him to Resident #10's room. LPN #104 confirmed STNA #100 did not
call or yell for her from inside Resident #10's room.
Interview on 08/07/24 at 6:16 P.M. with the Administrator confirmed it was the facility's policy to ensure
residents were protected from any further abuse should they witness or receive an allegation of abuse.
Resident #10 and Resident #15 should not have been left alone after STNA #100 made an observation of
sexual contact between the residents.
Review of the facility policy, Abuse, Neglect and Exploitation, dated 01/01/24, revealed the policy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365980
If continuation sheet
Page 4 of 5
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
08/07/2024
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)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
stated, the facility will implement policies and procedures to prevent and prohibit all types of abuse. The
facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well
as additional abuse during and after the investigation. Examples include responding immediately to protect
the alleged victim and increased supervision of the alleged victim and other residents.
Residents Affected - Few
This deficiency reveals non-compliance during investigation of Complaint Number OH00156340.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365980
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
FAQ · About this visit
Common questions about this visit
What happened during the August 7, 2024 survey of FOREST HILLS CENTER?
This was a inspection survey of FOREST HILLS CENTER on August 7, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOREST HILLS CENTER on August 7, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.