Forest Park Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Forest Park Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 14, 2025

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by failing to provide orientation and/or training to agency staff and failed to ensure agency staff responded to a medical emergency, which resulted in a delay in emergency services to a resident who went unresponsive (Resident 1). This failure placed a total of 48 residents in an immediate jeopardy situation who would require emergency intervention if found unresponsive (Residents ,d+[DATE]). […]

• Immediate jeopardy, patternF684Dec 6, 2024

  Based on clinical record review, facility document review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for two of 11 residents reviewed (Residents 4 and 5). This failure resulted in continued decline of one resident (Resident 4), which required an emergency transfer to the hospital for low blood oxygen levels and difficulty breathing which contributed to cardiac arrest and resulted in death. […]

• Immediate jeopardy, patternF689Dec 22, 2022

  Based on clinical record review, observation, facility document review, staff interview, and facility policy review, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 7). This failure placed three additional residents at the facility in an Immediate Jeopardy situation who were identified as at risk for elopement (Residents 8, 10, and 11) out of 11 residents reviewed. […]

• Immediate jeopardy, isolatedF689Dec 6, 2024

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found lying in the parking lot of the facility and was medically compromised as evidenced by a low body temperature and abrasions. […]

• Actual harm, isolatedF684May 1, 2026

  Based on facility policy reviews, clinical record reviews, facility documentation review, hospital records review, and staff interviews, it was determined that the facility failed to ensure wound care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of four residents reviewed (Resident 1), which resulted in actual harm as evidenced by the need for surgical intervention for exposed hardware from a surgically repaired fracture for Resident 1.Findings include: Review of facility policy, titled Surgery-Related (Pre- and Postoperative) Management- Clinical Protocol, revealed, in part, The staff and physician will monitor for, and address, postoperative risks and complications such as… […]