Park Forest Care Center LLC

In the surveyor’s words

From the most serious findings on record at Park Forest Care Center LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Dec 31, 2024

  Based on record review, observation, and interviews, the facility failed to create an environment that protected the right of eight (#1, #2 #3, #4, #5, #6, #7, #8) of eight residents reviewed for abuse out of eight sample residents to be free from abuse. The facility's failure contributed to repeated incidents of abuse and actual harm. Record review and interview revealed Resident #1, under age 35, was blind, nonverbal, non-interviewable, severely cognitively impaired, and dependent on care. On 10/14/24 at 9:39 a.m., a housekeeper observed Resident #2 sexually abusing Resident #1 in her bed. Resident #1 had blood in her incontinence brief and was actively bleeding. […]

• Immediate jeopardy, patternF600Jun 10, 2021

  Based on observations, interviews and record review, the facility failed to protect six residents (#63, #26, #30, #37, #18, and #6) of nine residents reviewed, from neglect and abuse out of 48 sample residents. NEGLECT The facility failed to provide services - implementation and monitoring of its plan to address a known rodent infestation, resulting in resident fear, disgust and actual injury. Specifically: According to the Department's records, the facility recognized rodents were entering the facility through the crawl space in late April and indicated it had a plan to address this concern. […]

• Immediate jeopardy, isolatedF693Jun 10, 2021

  Based on observations, interviews and record review, the facility failed to have an effective system in place to ensure two or four residents reviewed (#45 and #35) out of seven residents, received the appropriate treatment and services to prevent complications of enteral feeding, such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically: Record review and observations on 6/2/21 at 9:20 a.m., 6/3/21 at 9:30 a.m., and 6/7/21 at 10:12 a.m., revealed the facility failed to follow facility policy, standards of practice, care plan directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #45 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Feb 9, 2026

  Based on record review and interviews, the facility failed to ensure one (#11) of three residents reviewed for feeding tube out of 22 sample residents received necessary care and services to remain free from neglect. Resident #11 was nonverbal and dependent on staff for nutrition and hydration through a gastrostomy tube (G-tube). The resident was unable to communicate needs, discomfort, or hunger and relied entirely on staff to provide ordered tube feeding. The physician's orders revealed the resident required continuous enteral feeding with scheduled water flushes to meet the resident's nutritional and hydration needs.On 1/28/26, the resident's tube feeding was not administered beginning at 4:00 p.m. until 6:00 a.m. on 1/29/26. […]

• Actual harm, isolatedF689Feb 9, 2026

  Based on observations, record review and interviews, the facility failed to ensure two (#5 and #2) of seven residents reviewed for accidents out of 22 sample residents received adequate supervision to prevent accidents. Resident #5 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness.Resident #5 was identified as a high fall risk. On 12/25/25, Resident #5 sustained an unwitnessed fall. On 12/29/25, the resident sustained an additional unwitnessed fall. The facility recommended implementing a communication board due to the resident's difficult communication. […]