Health inspection·March 21, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to ensure advance directive orders were appropriately included in both the physical chart and the electronic medical record. This affected one (#95) of one resident reviewed for Advanced Directives. The facility census was 76. Findings include: Review of Resident #76's closed medical record revealed an admission date of [DATE], with a re-admission date of [DATE], with diagnoses including gastrointestinal hemorrhage, duodenal ulcer, muscle weakness, ischemic cardiomyopathy, congestive heart failure, non-rheumatic aortic stenosis, atrial fibrillation, myasthenia gravis, chronic pulmonary edema, hypertension, hyperlipidemia, hypothyroidism, anemia, and depression. Resident #72 passed away in the facility on [DATE]. Review of Resident #72's electronic medical record listed the resident as a full code. Review of physician order dated [DATE] revealed Resident #72 to be full code. Review of physician progress note assessment dated [DATE] revealed that Resident #72 disposition was now Do Not Resuscitate Comfort Care, Resident #76 and family considering hospice care. Review of progress note dated [DATE] revealed Resident #72 expired on this date surrounded by loved ones at 3:46 P.M., determined by two Registered Nurses listening for heart beat apically. Family made the resident's representative aware of expiration. Nurse received order to release body to funeral home. Family currently with resident saying last goodbyes. Interview on [DATE] at 3:30 P.M. with the Director of Nursing (DON) verified that the electronic health record states full code, and the hard chart had a Do Not Resuscitate Comfort Care document. Review of the policy titled Do Not Resuscitate Order, dated 04/2017 revealed the Do Not Resuscitate order must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. 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: 366389 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 366389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244 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)