Forest Hills Center

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

aware. Medical Director's physician group on-call called and notified. A treatment order was put in place.Interview on 10/16/25 at 2:00 P.M. with the Administrator and DON revealed when Resident #161 admitted to the facility they did not have a signed consent on file for the resident to receive care from the facility's Medical Director or any related providers. The Administrator claimed the facility had been going back and forth with the daughter asking her to sign the consent for medical treatment to be provided by the facility Medical Director and she continued to refuse claiming she wanted only the VA physicians to look at her father. The Administrator and DON acknowledged the examples on 08/06/25, 08/09/25, and 08/18/25 when the facility staff attempted to obtain or did obtain orders to treat Resident #161.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assessment dated [DATE REDACTED] revealed the resident experienced long and short-term memory impairment and had a severely impaired cognition for daily decision-making abilities. This resident was noted to wander the unit and display disorganized thinking and inattention. Review of the plan of care dated 08/04/25 and revised 10/13/25 revealed Resident #159 was at a high risk for elopement as evidenced by attempting to get out of the unit doors. Resident #159 also noted to wander into other resident's rooms and would collect some of their things and would lay in other resident's bed. Interventions included to redirect her to a safer area if she wandering to a potentially unsafe area or situation.Review of Resident #159's hospital documentation dated 08/10/25 at 4:23 A.M. revealed this resident was an [AGE] year-old Spanish speaking female with severe dementia who presented to the emergency room as a level 2 trauma fall. Apparently,

she was at a memory care unit and was assaulted by one of the other dementia patients. The physical assessment revealed there was an abrasion to the top lip, right bridge of the nose, a laceration to the top gum and top lip as well as missing a tooth. Review of the Health Status Note dated 08/10/25 at 12:50 P.M. by an unknown author revealed Resident #159 returned back to facility from emergency room at 12:45 P.M. via a stretcher accompanied by two transportation staff. Resident #159 was awake and was transferred into bed. The after-visit summary was received with no new orders.Interview on 10/16/25 at 3:00 P.M. with Senior Administrator #412 confirmed the facility's SRI investigation lacked evidence to support the ordered stop sign was in place when the incident between Resident #63 and #159. Senior Administrator #412 also claimed that this incident was unsubstantiated due to no one actually witnessing Resident #63 push Resident #159 causing her to fall and due to both residents cognitive deficient, they could not rely only on Resident #63 statement that he tried to get Resident #159 out of his room, and she wouldn't leave so he pushed her. Review of the facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/24 revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse was defined as including but not limited to hitting, slapping, punching, biting, and kicking. This deficiency represents non-compliance investigated under Master Complaint Number 2599554 and Complaint Number 1392707.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

cognition for daily decision-making abilities. Resident #63 was noted to display physical and verbal behaviors directed towards others as well as rejection of care. Resident #63 was noted to be free of upper or lower extremity impairments and required a walker for ambulation. He required setup or clean up assistance for eating, oral hygiene, toileting hygiene, and personal hygiene as well as substantial to maximal assistance for bathing and bed mobility. Resident #63 was noted to receive antidepressants and opioids daily.

Review of this facility's Self-Reported Incidents (SRI) revealed, an SRI had not been implemented or an investigation completed for the physical altercation incident that occurred between Resident #63 and another unknown resident.

Interview on 10/15/2024 at 2:45 P.M. with Senior Administrator #412 confirmed when there was an incident between two residents resulting in an injury, the facility was to implement an SRI and conduct an investigation into that incident. Senior Administrator #412 confirmed the facility did not open an SRI or complete an investigation for an incident that occurred between two residents on 08/06/25.

Review of facility policy titled, Abuse, Neglect and Exploitation, dated 01/01/24 revealed that possible indicators of abuse are physical injury of resident, of unknown source. The policy further states that the written procedures for investigations include identifying and interviewing all involved persons including potential witnesses and providing complete and thorough documentation of the investigation. The policy further states that all alleged violations are to be reported to the Administrator and state agency no later than 24 hours after.

This deficiency represents non-compliance investigated under Master Complaint Number 2599554 and Complaint Number 1392707.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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 Residents Affected - Few

cognition for daily decision-making abilities. Resident #63 was noted to display physical and verbal behaviors directed towards others as well as rejection of care. Resident #63 was noted to be free of upper or lower extremity impairments and required a walker for ambulation. He required setup or clean up assistance for eating, oral hygiene, toileting hygiene, and personal hygiene as well as substantial to maximal assistance for bathing and bed mobility. Resident #63 was noted to receive antidepressants and opioids daily.

Review of this facility's Self-Reported Incidents (SRI) revealed, an SRI had not been implemented or an investigation completed for the physical altercation incident that occurred between Resident #63 and another unknown resident.

Interview on 10/15/2024 at 2:45 P.M. with Senior Administrator #412 confirmed when there was an incident between two residents resulting in an injury, the facility was to implement an SRI and conduct an investigation into that incident. Senior Administrator #412 confirmed the facility did not open an SRI or complete an investigation for an incident that occurred between two residents on 08/06/25.

Review of facility policy titled, Abuse, Neglect and Exploitation, dated 01/01/24 revealed that possible indicators of abuse are physical injury of resident, of unknown source. The policy further states that the written procedures for investigations include identifying and interviewing all involved persons including potential witnesses and providing complete and thorough documentation of the investigation.

Review of the facility policy titled, Fall Prevention and Management Policy, dated 01/08/25 revealed all falls would be reviewed and investigated.

This deficiency represents non-compliance investigated under Master Complaint Number 2599554 and Complaint Number 1392707.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet