Forest Park Nursing & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 7, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and received adequate supervision and assistance for one (Resident #1) of five residents reviewed for Incident and accidents. 1.The facility failed to provide adequate supervision for Resident #1 to prevent her from having injuries and falls from 02/02/25 to 02/08/25; subsequently Resident #1 sustained a left wrist fracture of unknown origin on 02/02/25, fell on [DATE] sustained a lip bleed, found on the floor next to her bed on 02/07/25 and on 02/08/25 she had left sided facial bruising, a swollen chin, and dark reddish gums. […]

• Immediate jeopardy, patternF580Jan 2, 2024

  Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #1) of 3 residents reviewed for parameters to notify Physician of critical blood pressure levels. 1. The facility failed to notify Resident #'1's physician and administer PRN Clonidine, when Resident #1's systolic blood pressure was over 170, as ordered, on at least four days; on 10/17/23 when the systolic blood pressure was 200, 10/27/23 when the systolic blood pressure was 196, 11/08/23 when the systolic blood pressure was 185, and 11/09/23 when the systolic blood pressure was 181, all when Resident#1's systolic blood pressure was over 170. […]

• Immediate jeopardy, patternF684Jan 2, 2024

  Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of three residents reviewed for change in physical, mental, or psychosocial status. The facility failed to give Resident #1 her PRN anti-hypertensive medication as ordered and noted on the care plan. The facility failed monitor and document signs and symptoms of malignant hypertension as noted on the care plan for Resident #1. […]

• Immediate jeopardy, patternF760Jan 2, 2024

  Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of three residents reviewed for medications. Nurse C failed to give the PRN Clonidine as ordered by the physician for Resident #1 on 10/17/23, 10/27/23, 11/08/23, and 11/09/23, when Resident #'s systolic blood pressure was over 170. Resident #1 was sent to the hospital on 11/16/23 after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on 11/18/23. An immediate Jeopardy was identified on 12/29/23. […]

• Immediate jeopardy, patternF689Jul 15, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Residents #1) of six residents reviewed for elopements. 1. The facility failed to ensure Resident #1 was not adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had severe cognitive impairment, wandering behavior and lacked safety awareness. Resident #1 eloped from the facility on 11/27/20 and was found by facility staff, that was coming into work, in the back-parking lot without his wander guard bracelet on. Resident #1 sustained bruising to his left eye, a laceration to his left eyebrow, and left subacute subdural hematoma, resulting in a hospital visit. 2. […]