Crestpark Forrest City, LLC

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that the facility failed to report suspicion of sexual abuse within the two-hour allotted time frame per Center for Medicare and Medicaid Services (CMS) guidelines, for one (Resident #2) of one resident reviewed for allegations of sexual abuse discovered on 04/27/2026 at 10:15 AM and was reported on 04/28/2026 at 11:45 AM.

Inspectors wroteBased on record review, interview and facility policy review, it was determined the facility failed to report alleged violations involving abuse and misappropriation to the proper state agency within the allotted time frame for three (Resident #18, Resident #39, and Resident #43) of three residents reviewed.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to ensure immediate protective measures were implemented and maintained until a thorough investigation was initiated. The facility also failed to immediately report to the Office of Long-Term Care (OLTC) to enable the state agency to provide the necessary oversight of the facility's efforts to investigate and protect residents from potential harm for one (Resident #43) of one resident reviewed.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure the Five Rights of Medication was performed by nursing staff before giving a resident's family/representative the incorrect medications upon discharge from the facility and failed to ensure the discharge instructions were confirmed with resident's family/representative upon discharge effecting two (Resident #42 and Resident #12 ) of two residents reviewed.

Inspectors wroteBased on record review, interview, and facility policy review, it was determined the facility failed to ensure residents were free from misappropriation of resident property for three (Resident #19, #18, and #39) of three residents reviewed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 2 of 2 ice machines in the facility, one in the kitchen and one on the 400 Hall were maintained in clean and sanitary condition to prevent food and beverage contamination; dairy products stored in the refrigerator were sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; kitchen ceiling tiles were cleaned to provide a sanitary environment for food preparation. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to prevent misappropriation of resident medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to 3 affect residents who received regular diets from 1 of 1 kitchen according to a list provided by Dietary Manager #11 on 08/06/24 at 9:33 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of hot products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 24 residents who received their meal trays in the dining room, 12 residents who received their meal trays in their rooms on the 100 Hall and 200 Halls, and 8 residents who received their meal trays in their room on the 700 Hall, as documented on a list provided by Dietary Manager #11 on 08/05/24 at 9:33 AM.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets.

Inspectors wroteBased on observations, interviews, and review of the facility's policies and state requirements, the facility failed to ensure a safe and secure environment as evidenced by not adhering to the facility's policies and procedures after an accident/fall for 2 (Resident #48 and Resident #251) of 2 residents reviewed for a fall with serious injury.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow enhanced barrier precautions when flushing a feeding tube for 1 (Resident #3) of 1 sampled resident reviewed feeding tube care and on enhanced barrier precautions (EBP).

Inspectors wroteBased on interviews, record review, facility document review, it was determined the facility failed to ensure the care plan was revised to accurately indicate wandering behaviors with interventions to prevent the potential for elopement for 2 (Resident #1 and Resident #3) of 3 residents reviewed for wandering behaviors.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit seeking behaviors from exiting the facility unsupervised for 1 (Resident #1) of 3 residents reviewed for elopement.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure incontinent care was provided in a timely manner for 1(Resident #1) of 3 (Resident #1, #2 and #3) sampled residents who depended on staff for incontinent care.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were maintained in good repair, clean, and free of odors in 5 (Resident Rooms 113, 119, 120, 121 and 209) of 5 rooms on the 100 and 200 Halls.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed; Physician Orders for a pimento cheese sandwich was provided on a supper tray for 1 (Resident #20) of 1 sampled resident. The failed practices had the potential to affect 2 residents who received pureed diets, 2 residents who received pureed meat only and 9 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 08/15/23 at 2:37 PM and 3 residents who had Physician Orders for sandwiches at supper according to a list provided by the Director of Nursing (DON) on 08/18/23 at 9:35 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets and 2 residents who received pureed meat only, as documented on the list provided by the Dietary Supervisor on 08/15/23

Inspectors wroteBased on observation and interview, the facility failed to ensure foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and 2 of 2 ice machines were maintained in clean and sanitary condition to prevent contamination of airborne particles. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an effective pest control program to ensure the kitchen service areas and 7 (Rooms 113, 116, 119, 121, 209, 214 and 215) resident rooms and the 400 Hall to ensure the facility was free of insect and spiders. This failed practice had the potential to affect all 43 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident, or their responsible parties were provided with the opportunity to formulate an Advance Directive if desired, to allow resident to make decisions regarding their care in the event of their incapacitation for 1 Resident (Resident #20) of 1 sampled resident and establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive, refuse medical or surgical treatment. This failed practice had the potential to affect all 42 residents as documented on the Resident Matrix provided by the Administrator on 08/15/23 at 9:24 AM.