Health inspection·December 20, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review, staff interview, Nurse Practitioner (NP) interview, and policy review, the facility failed to ensure neurological (neuro) checks were completed when resident's had unwitnessed falls and falls involving the head. This affected two (#63 and #85) of three residents reviewed for falls. This had the potential to affect all 108 residents in the facility. Findings include: 1) Review of the medical record of Resident #63 revealed an admission date of 09/09/24. Diagnoses included metabolic encephalopathy, dementia, type two diabetes mellitus, and obstructive sleep apnea (OSA). Review of the quarterly Minimum Data Set (MDS) assessment for Resident #63 dated 09/20/24; revealed the resident had severely impaired cognition. Review of a fall investigation for Resident #63 dated 11/15/24, revealed, at approximately 4:30 A.M., Resident #63 was found sitting on the floor close to his geriatric (geri) chair. The resident was assessed with no injuries. The on-call physician was notified of the fall at 7:30 A.M. and the resident's son was notified of the fall at 8:11 A.M. Review of neuro-checks for Resident #63 dated 11/15/24; revealed the first four 15-minute checks and first hour check was not signed off as complete until 11/22/24, by the Director of Nursing (DON). Interview with the DON on 12/17/24 at 4:14 P.M., verified the first four 15-minute checks and first hour check was not signed off until 11/22/24. The DON stated he had no doubt the checks were being done; however, he found staff were not signing them off as complete at the time they were due, so he had to go back and ensure they were completed. 2) Review of the medical record of Resident #85 revealed an admission date of 10/07/24. Diagnoses included right ulnar fracture, resistant hypertension, dysphagia, and a history of falling. Review of the comprehensive MDS assessment for Resident #85 dated 10/15/24, revealed the resident had moderately impaired cognition. The resident required partial/moderate assistance with bed mobility, substantial/maximal assistance with bathing and was dependent on staff for toileting, dressing, and transfers. Review of a nursing progress note for Resident #85 dated 10/21/24, revealed the nurse witnessed Resident #85 attempting to pick something up off the floor in the hallway and fell on her face. The (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: 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 12/20/2024 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)