Forestville Rehabilitation and Wellness Center

In the surveyor’s words

From the most serious findings on record at Forestville Rehabilitation and Wellness Center, in the surveyor’s own words.

• Actual harm, isolatedF697Jun 3, 2024

  Based on resident interviews, record review, review of other pertinent documentation, and staff interviews, it was determined that the facility failed to treat a resident who complained of severe pain resulting in harm to the resident. This was evident for 1 of 8 (Resident #91) residents reviewed for pain management. The findings include: During observation rounds on 5/20/24 at 10 am, Resident #91 stated while s/he was being transferred from his/her bed to the chair by the Physical Therapist (PT) #49, s/he heard a popping sound and I told her you broke my leg. S/he stated prior to the transfer s/he told staff #49; You cannot pick me up by yourself, it takes 2 people. […]

• No harm, potential for more than minimal, widespreadF850Jan 12, 2026

  Based on the facility bed licensure, staff interviews, and a review of the facility staff roster, it was determined that there were no qualified or licensed social worker or qualified social services designee employed on a full-time basis for this 162 licensed bed facility. This was observed during the recertification/complaint survey and has the potential to affect all residents.The findings include:Facilities licensed for more than 120 bed capacity must employ a qualified social worker on a full time basis. A qualified social worker is defined as an individual with a licensed in social work or a bachelor's degree in a related human services field and at least one year of supervised social work experience in a health care setting. […]

• No harm, potential for more than minimal, widespreadF919Sep 20, 2021

  Based on observation and interview it was determined that the facility failed to have a call system in place that was audible at the nursing station. This was evident for 2 out of 2 nursing stations The findings include. On 9/14/21 at 10:30 AM the surveyor was in the nursing station on the 2nd floor, the surveyor failed to hear any resident's call bell from the nursing station, when the surveyor stepped out of the nursing station she observed several rooms with the call light lit above the resident's room but there was no sound at the nursing station. […]

• No harm, potential for more than minimal, widespreadF908Apr 23, 2021

  Based on the review of administrative and employee records and interview with staff, it was determined that the facility failed to ensure that the gas stove in the kitchen was inspected and certified by a licensed Gasfitter. The facility's failure to maintain the kitchen stove in a safe operation condition has potential to impact all residents in the facility. The findings include: On 04/13/21 at 12:18 PM in an interview, the Maintenance Director reported that in May 2019 two of the six burners on the facility's gas stove were not working properly. The Maintenance Director explained that the burners were collecting water, which drained down into the burner plate. Every couple of days the water would build up and prevent the pilot from lighting. […]

• No harm, potential for more than minimal, patternF567Jun 4, 2026

  Based on record review and staff interview, the facility failed to provide residents, who gave permission to allow the facility to manage their SSI/SSA funds, access to surplus SSI/SSA fund on demand for the month of April 2026. This was evident for 3 of 14 residents (Resident #3, #11, & #13) reviewed during a complaint survey. The findings include: Surveyor review of a complaint 2981750 on 5/29/26 at 9:40am that was sent to OHCQ on 4/13/26 and updated on 5/5/26 alleged the facility failed to provide resident surplus SSI/SSA funds when requested. Interview with Resident #3 on 5/29/26 at 10:40am reveal Resident #3 alleged that he/she was denied his/her surplus SSI/SSA funds when requested for the month of April 2026. […]