Forest City Rehab & NRSG CTR

In the surveyor’s words

From the most serious findings on record at Forest City Rehab & NRSG CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Oct 24, 2024

  Based on interview, and record review the facility failed to ensure a resident with a history of embolic strokes (R167) received physician ordered anticoagulants. This failure resulted in R167 requiring emergency transport to the hospital for an acute embolic stroke. R167 was hospitalized until [DATE], when he passed away. The facility also failed to ensure an anticoagulant medication was administered as ordered for R116 for 2 of 8 residents (R167 & R116) reviewed for significant medication error in the sample of 33. The Immediate Jeopardy began on [DATE] when R167 was readmitted to the facility and the facility failed to ensure the physician prescribed anticoagulant medication was obtained from pharmacy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:02 PM. […]

• Immediate jeopardy, isolatedF600May 7, 2024

  Based on observation, interview and record review the facility failed to ensure residents were free from physical and sexual abuse from R1 who has a history of physical and sexual behaviors that escalated to staff then to residents. This failure resulted in R1 punching R2 in the face, pushing R3's chair over and causing him to fall to the floor and exposing himself to R4. The facility failed to ensure residents were free from physical abuse. This applies to 6 of 10 residents (R2, R3,R4, R6, R8, R10) reviewed for abuse in the sample of 10. The findings include: The Immediate Jeopardy began on 4/13/24 when R1's behaviors escalated. R1 punched R2 in the face. On 4/16/24, R1 flipped R3 out of the chair causing him to fall to the floor. On 4/18/24 R1 exposed himself to R4. […]

• Immediate jeopardy, isolatedF689May 7, 2024

  Based on interview and record review the facility failed to supervise a resident with escalating behaviors of physical and sexual aggressions with known behaviors. This failure resulted in R1 not being supervised after exhibiting physical behaviors towards residents (R2, R3) and sexually assaulting R4. This applies to 1of 10 residents (R1) reviewed for safety in the sample of 10. The findings include: The Immediate Jeopardy began on 4/13/24 when R1's behaviors escalated, R1 punched R2 in the face. On 4/16/24, R1 flipped R3 out of the chair causing him to fall to the floor, he was sent out to the local hospital for his behaviors and returned to the facility on [DATE]. On 4/18/24, R1 was found unsupervised in the hallway and exposed himself to R4. […]

• Actual harm, isolatedF689Aug 14, 2026

  Based on interview and record review the facility failed to ensure a resident's safety while providing cares which applies to 1 of 3 residents (R1) reviewed for falls in a sample of 7. This failure resulted in R1 falling out of bed, while receiving care, and sustaining a leg fracture.The findings include:R1's Facility assessment dated [DATE] showed R1 was a cognitively impaired resident with admitting diagnoses which included dementia, bipolar disorder, and obesity. This assessment showed R1 was dependent on staff with functional abilities (activities of daily living-ADLs) which included toileting hygiene, lower body dressing, personal hygiene, rolling in bed, sitting up in bed, and bed to chair transfers.R1's Fall assessment dated [DATE] showed R1 was a high fall risk.R1's Care plan dated… […]

• Actual harm, isolatedF692Feb 6, 2026

  Based on interview and record review the facility failed to identify, document, and update dietary interventions for a resident with a history of weight loss and a recent change in food intake for 1 of 3 residents (R1) reviewed for weight loss in the sample of 5. These failures resulted in a severe weight loss of 29% for R1 from 1/6/26 until 1/16/26.The findings include:R1's Face sheet dated 2/5/26 showed diagnoses to include, but not limited to diabetes, atherosclerosis (hardening and narrowing) of the aorta, asthma, hypothyroidism, gastro-esophageal reflux disease (GERD), cataracts, dysphagia (difficulty swallowing), lack of coordination, and abnormalities of gait/mobility. R1's facility assessment dated [DATE] showed she had moderate cognitive impairment and required supervision to eat. […]