Forest Creek Village

In the surveyor’s words

From the most serious findings on record at Forest Creek Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 24, 2025

  Based on observation, interview, and record review the facility failed to ensure food was served in a sanitary environment for 1 of 2 kitchen observations. The kitchen floors were dirty. Findings include: During the initial tour of the kitchen on 6/23/25 from 8:26 a.m. until 8:32 a.m., observed buildup of an unknown dark substance, dust, debris, a screwdriver, and several plastic lids under a freezer of the main kitchen area. A buildup of dust and debris under the shelves in the dry storage room was observed. At that time, the dietary supervisor indicated the floors under the freezer and in the dry storage room should have been cleaned. […]

• No harm, potential for more than minimal, patternF759Mar 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were free of a medication error rate greater than 5 percent for 4 of 25 opportunities, resulting in a medication error rate of 16 percent. Resident B , Resident C) Findings include: 1. On 3/14/25 at 7:23 a.m., observed RN 1 administer Wixela 250/50 micrograms (mcg) (prescription metered dose inhaler used to treat asthma and chronic obstructive pulmonary disease) and Incruse Ellipta 62.5 mcg (prescription metered dose inhaler used to treat chronic obstructive pulmonary disease) to Resident B. RN 1 did not ask Resident B to rinse her mouth with water and spit the water out before RN 1 left Resident B's room. At that time, RN 1 indicated he had finished administering Resident B's medications. […]

• No harm, potential for more than minimal, patternF812Feb 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 3 of 4 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Cook 5, Dietary Staff 6) Findings include: 1. During the initial kitchen observation on 2/11/24 from 9:35 a.m. to 9:45 a.m., observed Cook 5 walking throughout the kitchen area. Cook 5 had hair pulled from the front to the back of the head and hair in front of and behind the ears. The hair was observed to not be covered. 2. During a follow up kitchen observation on 2/11/24 from 12:20 p.m. to 12:30 p.m., the following was observed: - Cook 5 was working at the steam table where the noon meal was being held. […]

• No harm, potential for more than minimal, patternF760Apr 29, 2022

  Based on record review and interview, the facility failed to ensure medications were dispensed or dispensed on time as ordered by the physician for 10 of 16 residents reviewed for medication error's, causing a significant medication error. (Resident 11, Resident 1, Resident 61, Resident 215, Resident 60, Resident 7, Resident 163, Resident 16, Resident 19, Resident 28) Findings include: On 4/25/22 at 11:13 a.m., the Director of Nursing (DON) provided a copy of Facility Reported Incident #622, dated 4/23/22 at 12:01 p.m. The incident report, indicated on 4/25/22 a resident alleges that nurse [Licensed Practical Nurse 1] posted her cell [phone] number at the nurses station and left the building, thereby missing passing mediations for multiple residents on her assignment. […]

• No harm, potential for more than minimal, isolatedF657Mar 12, 2026

  Based on interview and record review, the facility failed to ensure resident care plans were revised to reflect only the accurate code status for 2 of 24 residents reviewed for care plan accuracy. (Resident 4, Resident 62)Findings include:1. The clinical record for Resident 4 was reviewed on 3/8/26 at 12:50 p.m. The diagnoses included, but were not limited to, dementia and type 2 diabetes.An active physician's order, with a start date of 7/1/25 and with no stop date, indicated that Resident 4's code status was DNR (Do Not Resuscitate).An Indiana Physician Orders for Scope of Treatment (POST) form, signed and dated by the resident's representative and the physician on 3/13/25, indicated Resident 4 had elected a DNR code status.A care plan, dated 6/25/25, regarding Resident 4 as a new… […]