Forest Hills Rehabilitation & Healthcare Center
FOREST HILLS REHABILITATION & HEALTHCARE CENTER in WEATHERLY, PA — inspection on January 2, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During on-site survey conducted on January 2, 2026, at 2:15 PM, Resident C2 was observed seated in a wheelchair outside of his room, across from the nurses' station, with a lunch tray placed on a bedside table and independently eating. At the time of observation, no staff member was present providing one-to-one supervision as required by the resident's care plan and the facility's One-to-One Supervision Guidelines.
The assigned nurse aide (Employee 4) was observed seated behind the nurses' station at a computer, and Resident C2 was not maintained within the staff member's direct line of vision or within reach, as required by facility policy.
During an interview conducted on January 2, 2026, at 2:18 PM, Employee 4, nurse aide confirmed Resident C2 required one-to-one supervision and reported being assigned to provide that supervision.
Based on the facility's investigative documentation and written witness statements, Resident C2 was identified as requiring one-to-one supervision at the time of the resident-to-resident physical altercation on December 28, 2025.
However, the facility's documentation did not consistently demonstrate that one-to-one supervision was effectively maintained during the incident, as evidenced by Resident CR1's ability to approach, engage, and physically strike Resident C2 prior to staff intervention. An attempt was made by the surveyor to contact the assigned nurse aide (Employee 3) to obtain clarification regarding supervision at the time of the incident; however, the nurse aide did not respond to surveyor contact attempts.
The subsequent observation on January 2, 2026, revealed continued noncompliance with the facility's one-to-one supervision policy for Resident C2, demonstrating the facility was unable to consistently implement required supervision interventions intended to prevent unsafe resident-to-resident interactions.
During an interview with the Director of Nursing on January 2, 2026, at 3:30 PM, the surveyor reviewed the findings related to the resident-to-resident physical altercation and the observations regarding one-to-one supervision.
The Director of Nursing confirmed Resident C2 required one-to-one supervision per the care plan and facility policy.
The facility failed to demonstrate consistent implementation of required one-to-one supervision for Resident C2, limiting the facility's ability to ensure the resident was protected from physical abuse by another resident. 28 Pa.
Code 201.14 (a) Responsibility of licensee. 28 Pa.
Code 211.10 (d) Resident care policies. 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.
395464 01/02/2026
Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255
Review of Employee 2's time records showed she clocked out at 9:33 PM.
Review
alleged incident was first documented, as indicated by her statement she returned to the floor to
stated he became aware of the incident the following day and stated the facility did not report or further investigate the staff action because there was no serious bodily injury, sexual abuse, or death and therefore it was not considered reportable.
When asked whether documentation existed showing the facility ruled out physical, mental, or psychosocial abuse (harm affecting emotional or psychological well-being), the facility was unable to provide such documentation.
The facility was unable to provide documentation that the allegation involving Employee 2 throwing water on Resident 1 was reported to the State Survey Agency as required by facility policy.
The facility was also unable to provide documentation of a complete investigation into the allegation, including evidence of interviews of all involved individuals, investigative findings, or documentation demonstrating abuse was ruled out.
These findings were reviewed with the Nursing Home Administrator on February 12, 2026, at 1:10 PM. At that time, no additional documentation was provided demonstrating that a thorough investigation had been conducted or that the staff-to-resident allegation had been reported in accordance with facility policy and reporting requirements. 28 Pa.
Code 201.14(a)(c) Responsibility of licensee. 28 Pa.
Code 201.18(e)(1) Management. 28 Pa.
Code 201.29 (a)(c) Resident Rights28 Pa.
Code 211.10(a)(d) Resident care policies.28 Pa.
Code 211.12 (d)(1)(5) Nursing services.