Inspection Reports for Provision Living of Forest Hills

The inspection was conducted in response to a complaint received from Adult Protective Services alleging that Resident A's cat was not cared for, Resident A did not receive showers and was not clean, and Resident A's room was not clean.

The investigation established a violation regarding the care of Resident A's cat, which was not properly described in the resident's service plan. The allegations that Resident A did not receive showers and was not clean, and that Resident A's room was not clean, were not substantiated despite observations of trash and litter in the room and a strong urine smell.

Complaint received from Adult Protective Services on 09/25/2025 alleging neglect of Resident A's cat, lack of showers and cleanliness for Resident A, and unclean room conditions. APS did not open the complaint for investigation.

The investigation was initiated due to complaints alleging that Resident A was not assessed for injury or had family notified after a fall, and that Resident B went 24 hours without medication.

The investigation found no violation regarding Resident A's fall and subsequent care, as the facility monitored Resident A appropriately and ensured hospital evaluation and follow-up. However, a violation was established for Resident B due to missed medication administration caused by pharmacy refill system errors and documentation discrepancies.

The complaint alleged Resident A fell on 4/18/2025 resulting in injury and the facility did not assess Resident A for injury or notify family. It also alleged Resident B went 24 hours without medication. The investigation substantiated the medication issue for Resident B but did not substantiate the injury assessment or family notification issue for Resident A.

The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and regulations for the facility.

The facility was found to be in non-compliance with three specific rules related to medication cart security, food protection in the kitchen, and safe storage of oxygen tanks. Violations were established for each of these areas.

The investigation was initiated due to a complaint alleging that Resident A had an undiagnosed urinary tract infection resulting in falls and cognitive decline.

The investigation found no violation regarding the undiagnosed urinary tract infection allegation; however, a violation was established because the facility did not take reasonable action to ensure the protection of Resident A after an increase in falls and cognitive decline were documented but not addressed or communicated to the physician.

Complaint alleged Resident A had undiagnosed urinary tract infection resulting in falls and cognitive decline. The allegation was not substantiated for the UTI claim but substantiated for failure to protect Resident A from harm related to cognitive decline and falls.

The inspection was conducted in response to a complaint alleging that the facility would not allow Resident A to return from the hospital on 9/8/23.

The investigation found that Resident A was not permitted to return to the facility due to her alcohol abuse, belligerent behavior, and threats toward staff. The facility issued a less than 30-day discharge notice but failed to locate an alternate placement for Resident A, resulting in noncompliance with the applicable admission and retention rule.

The complaint alleged that the facility refused to allow Resident A to return from the hospital on 9/8/23 despite medical clearance. The complaint was substantiated as a violation was established.

The document serves as a notification of the renewal of the Home for the Aged license following an administrative review of licensing activity for the past year.

The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license.

The inspection was conducted in response to a complaint alleging the facility failed to respond to door alarms, resulting in a resident being missing from the facility.

The investigation found that the facility failed to respond appropriately to door alarms due to inadequate staff training and failure to follow protocols. Resident A was found sleeping in another resident's room after being missing for several hours. Multiple violations related to emergency procedures, service plan updates, and staff training were established.

Complaint received on 2023-02-23 alleged the facility failed to respond to door alarms on 2023-02-22, resulting in Resident A being missing and police involvement. The complaint was substantiated with violations established.

The inspection was conducted in response to a complaint alleging multiple issues including resident falls, untimely call light responses, caregiver marijuana use, medication administration failures, and residents not being bathed.

The investigation found no violations related to falls, call light response times, caregiver marijuana use, or bathing. However, a violation was established regarding medication administration due to multiple residents missing medications because the medications were unavailable or could not be found in the medication cart.

The complaint alleged multiple residents have fallen and later passed away, call lights were not answered timely, caregivers were under the influence of marijuana, medications were not administered, and residents were not bathed. The investigation substantiated only the medication administration allegation.

The inspection was conducted in response to a complaint alleging that Resident A was issued an improper discharge without proper notice and appeal information.

The investigation found that the facility initially issued the discharge notice to the incorrect responsible party but corrected this by reissuing the notice to the correct guardian. The allegation of improper discharge was not substantiated. However, the facility failed to complete an incident report when Resident A was sent to the hospital for alcohol abuse, resulting in a violation.

Complaint alleged Resident A was issued an improper discharge without proper notice and appeal instructions. The allegation was not substantiated as the facility corrected the discharge notice. However, a violation was found for failure to complete an incident report related to Resident A's hospital send-out for alcohol abuse.

The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Provision Living at Forest Hills.

The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. A temporary license with a maximum capacity of 116 beds was recommended for issuance.