Forest City Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Forest City Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 6, 2022

  Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff and police interviews, it was determined the facility failed to provide adequate staff supervision of a resident identified at risk for elopement to prevent the resident's elopement from the facility and failed to monitor the activities and whereabouts of a resident with known exit seeking behaviors to timely identify the resident's absence from the facility, which placed the resident in immediate jeopardy to his health and safety for one resident out of six residents identified at risk for elopement (Resident CR1). […]

• Actual harm, isolatedF689Mar 22, 2024

  Based on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls and known unsafe behaviors that increased the resident's risk for falls, to prevent a fall with serious injury, a fractured wrist, for one resident out of 18 sampled (Resident 49). Findings include: Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to include dementia, chronic kidney disease, and history of urinary tract infections. […]

• No harm, potential for more than minimal, widespreadF812Feb 7, 2025

  Based on observation and staff interview, the facility failed to maintain proper storage and service practices for food in the dietary department and second-floor resident pantry/nourishment room. This failure created the potential for contamination, microbial growth, and an increased risk of foodborne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812Apr 28, 2023

  Based on observation, a review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF880Apr 28, 2023

  Based on observations, review of the facility's infection control tracking logs and policy and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly, failed to store resident care equipment in a manner to deter the spread of infection and failed to appropriately dispose of PPE after use. Findings include: A review of the current facility policy Infection Control Program Overview, dated as reviewed by the facility April 21, 2023, revealed that the purpose of the facility Infection Control Program is to provide a safe, sanitary and comfortable environment, to help prevent the development and transmission of communicable infections and… […]