Health inspection·August 15, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, investigative reports and information submitted by the facility, and staff and resident interviews it was determined that the facility failed to provide necessary set-up assistance with activities of daily living to prevent an accident resulting in minor injury to one resident out of three sampled (Resident 133). Findings include: A review of facility policy entitled Safety of Hot Liquids, revised October 2014, revealed that the potential for burns from hot liquids is considered a ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents identified with risk factors for injury from hot liquids will have appropriate interventions implemented to minimize the risk from burns. Such interventions may include, staff assistance with hot beverages as needed. A review of Resident 133's clinical record revealed that the resident was admitted to the facility July 20, 2023, with diagnoses of depression, gastro-esophageal reflux disease (GERD), transient ischemic attack (TIA) and cerebral infarction (stroke) without residual deficits, mild vascular dementia, muscle weakness, abnormal posture, and lack of coordination. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated July 27, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8 - 12 represents moderate cognitive impairment) and required extensive assist of 2 staff members for bed mobility, transfers, dressing, toileting, personal hygiene (combing hair, brushing teeth), and was independent for eating after set up help. A review of the resident's baseline care plan initially dated, July 21, 2023, revealed that the resident has an activities of daily living (ADL) self-care performance deficit related to cerebral vascular accident/transient ischemic attack (CVA/TIA. The care plan noted the planned intervention/task to assist the resident with eating. The care plan indicated that the resident was independent with eating, but staff were to offer assistance with meal set-up, especially hot liquids, date initiated July 21, 2023, to provide a Kennedy cup (a lightweight spill proof drinking cup), with lid at meals to be utilized with hot liquids, initiated July 24, 2023. A nurses' note dated July 24, 2023, at 10:38 AM, indicated that the resident spilled tea on self and was complaining of burning on her legs. Nurse checked residents' legs for red areas from tea and (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 3 Event ID: 395464 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 395464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255 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)