Pennsylvania Department of Health
FOREST HILLS REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOREST HILLS REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

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FOREST HILLS REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an abbreviated complaint survey completed on August 13, 2025, it was determined that Forest Hills Rehabilitation and Healthcare Center was cited for a deficiency of past non-compliance under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of clinical records, the facility's abuse prohibition policy, and select facility investigative documentation and staff interview, it was determined the facility failed to ensure that one resident (Resident 1) was free from physical abuse perpetrated by another resident (Resident 2) out of 6 residents sampled for abuse prevention, which resulted in serious harm and injury, a fractured humerus (arm) and femur (leg). This deficiency is cited as past non-compliance.

Findings include:

A review of a facility policy entitled "Abuse Policy" last reviewed by the facility on April 22, 2025, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

A review of Resident 2's clinical record revealed admission to the facility on March 29, 2022, with diagnoses to include dementia with behavioral disturbance (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]).

A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 10, 2025, indicated that the resident was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment).

Review of Resident 2s care plan, initiated on January 20, 2022, indicated the resident exhibits verbal and physical agitation and aggression (combative with cares such as striking out at staff, loud verbal outbursts, disruptive to self and others, spits on others, screams at others, and makes accusatory statements). The planned interventions were to administer mediations as ordered, allow time to respond, approach slowly and slightly to the side, be aware of residents personal space, gain residents attention before speaking, give clear and concise explanations, leave resident if behavioral interventions are not working, provide diversional activities, remove from public area when behavior is disruptive, speak in a low-pitch, calm and reassuring tone, and use consistent routines and caregivers.
A review of Resident 1's clinical record revealed admission to the facility on June 11, 2019, with diagnoses to include dementia, mood disorder, and chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe).

A quarterly Minimum Data Set assessment dated July 2, 2025, indicated that the resident was severely cognitively impaired with a BIMS score of 4, severe cognitive impairment.

A review of the care plan, initially dated December 26, 2023, indicated that Resident 1 was at risk for alterations in psychosocial well-being. The risk was related to unsettled relationships and conflicts, verbal and physical agitation, and aggression toward other residents and roommates. The care plan documented that Resident 1 had a history of making rude or hostile comments directed toward staff and others, being verbally abusive to roommates, and having previously struck a roommate. These behaviors were identified as being associated with the residents cognitive impairment and history of substance abuse.

A review of a nursing progress note dated August 7, 2025, at 10:35 PM revealed documentation that a fall code had been announced. The note indicated that nursing staff entered Resident 1s room and observed Resident 1 lying on her left side on the floor while yelling out. Resident 2 was documented as ambulating near the doorway of the room. The note further indicated that Resident 1 stated Resident 2 had been in her bathroom, and when she stood from her wheelchair and approached the bathroom, Resident 2 exited and pushed her, causing her to fall. The documentation indicated Resident 1 complained of pain in her left shoulder and hip, with vital signs noted to be stable. Staff separated the residents, initiated neurological checks (series of assessments performed at regular intervals to monitor a residents nervous system) along with every 15-minute observation checks, notified the physician and guardian, and ordered diagnostic x-rays.

A review of facility investigative documentation dated August 8, 2025, at 10:30 AM revealed that the facility classified the incident as physical abuse. The documentation indicated that Resident 1, identified as the victim of the aggression, was in her room when Resident 2, identified as the aggressor, exited the bathroom, pushed Resident 1, and caused her to fall to the floor. Resident 1 was noted to have called for help, and staff responded to find her sitting on the floor. Resident 1 was assessed, assisted to bed, and complained of pain in her left shoulder and left hip. The documentation further indicated that the residents were separated. Both residents placed on every 15 minute observation checks. The physician and resident representatives were notified, and x-rays were ordered. The documentation reflected that the incident was reported to appropriate protective authorities, and an abuse investigation was initiated by the facility.

Resident 1 was transferred to the emergency department on August 8, 2025, where she was diagnosed with an acute (sudden) fracture of the left humeral neck (upper arm bone, near the shoulder joint) and an acute fracture of the left femoral neck (upper portion of the thigh bone).

Review of the x-ray report dated August 8, 2025, revealed Resident 1 sustained an acute, displaced (bone moves out of normal alignment),transverse (type of bone break where the fracture line runs horizontally across the bone) fracture through the neck of the proximal femur and an acute, displaced, comminuted (bone breaks into three or more pieces) fracture through the neck of the proximal humerus as a result of the fall.

On August 10, 2025, Resident 1 underwent a left hip hemiarthroplasty (surgical procedure where only the femoral head [the ball portion of the hip joint] is replaced with a prosthetic implant).

At the time of the survey ending August 13, 2025, Resident 1 remained hospitalized. The above findings regarding the incident and the facilitys classification of the event as physical abuse were reviewed with the Nursing Home Administrator on August 13, 2025, at 10:45 AM.

This deficiency was cited as past non-compliance.
The facility's corrective action plan included the following:
1. Resident obtained a fracture from a resident-to resident altercation over the bathroom.

2. Director of Nursing (DON)/designee to conduct an audit to identify residents with wandering behaviors. Those identified will have individualized interventions implemented with care plans updated. Residents will be discussed at weekly IDT (Interdisciplinary Team) meetings.

3. DON/designee to educate the nursing staff on the Abuse Policy and behavioral intervention suggestions to assist staff with re-directing behavioral residents.

4. DON/designee to conduct random weekly audits on residents with wandering behaviors to implement individualized interventions weekly x 4 weeks then monthly x 2 months. Results will be reviewed at monthly QAPI.

The facility's compliance date was August 11, 2025, and completion of the corrective action plan noted above was confirmed during the survey ending August 13, 2025.

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 201.29 (a)(c) Resident Rights

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Plan of Correction - To be completed: 08/18/2025

Past noncompliance: no plan of correction required.

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