Forest City Rehab & Nrsg Ctr

Inspectors wroteBased on interview and record review the facility failed to protect a resident's dignity during an activity. This applies to one of four residents (R1) reviewed for dignity in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to schedule a urology appointment for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from misappropriation of property by staff. This failure resulted in money being removed from a residents bank account after the resident expired and staff having a resident's cell phone at home. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to identify, document, and update dietary interventions for a resident with a history of weight loss and a recent change in food intake for 1 of 3 residents (R1) reviewed for weight loss in the sample of 5. These failures resulted in a severe weight loss of 29% for R1 from 1/6/26 until 1/16/26.

Inspectors wroteBased on interview and record review the facility failed complete a thorough, initial skin assessment and ongoing skin assessments for a resident at risk for skin breakdown with redness to her buttocks and peri-area for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the menus for residents on regular, mechanical and pureed diets. This failure has the potential to affect all 166 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure beard coverings were worn when preparing resident meals. This failure has the potential to affect all 166 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have pressure treatments and pressure reducing interventions in place which applies to 4 of 9 residents (R117, R129, R51, R73) reviewed for pressure wounds in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to manage a resident's indwelling urinary drainage bag in a dignified manner for 1 of 33 residents (R131) reviewed for dignity in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adaptive utensils to a resident at meals for 1 of 3 residents (R147) reviewed for resident accommodation of needs/preferences in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic and anti-psychotic medications that were ordered as needed had a stop/duration date for 3 of 8 residents (R127, R13, and R10) reviewed for pharmacy services in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care to and reposition a resident dependent on staff for these cares for 1 of 33 residents (R27) reviewed for activities of daily living (ADLs) in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure electrical wiring was appropriately insulated and stowed out of reach in one resident's room (R149) and failed to ensure a resident was transferred in a safe manner for 2 of 6 residents (R149, R147) reviewed for safety in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a residents urinary catheter bag below the level of the bladder and off the floor for 2 of 7 residents (R82, R3) reviewed for urinary catheters in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to consistently document meal intakes and monthly weights and failed to ensure a resident (R40) was assessed by the dietician following a significant weight loss. This failure resulted in additional interventions not being implemented and R40 experiencing on going weight loss. The facility failed to ensure nutritional interventions were implemented for 4 residents (R9, R14, R153, R160) and failed to ensure weekly weights were obtained for a resident (R153).

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered by the physician. There were 28 opportunities with 2 errors resulting in a 7.14% error rate. This applies to 2 of 4 residents (R17, R70) observed in the medication pass.

Inspectors wroteBased on interview and record review the facility failed to provide R125 a snack outside of the scheduled meal service times for 1 of 5 residents (R125) reviewed nutrition in the sample of 33. The Findings Include:On 11/18/25 at 9:08AM, R125 said, I do not get snacks. I would like a bedtime snack. When I request a bedtime snack, V14 Dietary Manager tells me, only the diabetics get snacks. On 11/18/25 at 9:35AM, V13 LPN-Licensed Practical Nurse said, the facility only provides diabetic residents and residents with weight loss a snack at night. On 11/18/25 at 10:20AM, V14 Dietary Manager, we do not offer snacks to anyone. Diabetic residents are the only residents the snacks are set up for in the evening. On 11/18/25 at 1:38PM, V15 Dietitian said, we only provide snacks to diabetics. R125's Diet Order dated 10/02/2017 shows, regular texture, thin liquids, consistency for general diet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wear personal protective equipment (PPE) and have signs posted for residents on enhanced barrier precautions (EBP) isolation which applies to 2 of 33 residents (R117, R82) reviewed for infection control in a sample of 33.

Inspectors wroteBased on interview and record review the facility failed to ensure residents pressure injury treatments were being completed for 2 of 3 residents (R2 & R3) reviewed for pressure injury in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by not immediately reporting, investigating and protect residents while and investigation is underway for 1 of 3 residents (R1) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation on abuse to the state survey agency for 1 of 3 residents (R1) reviewed for abuse reporting in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to immediately investigate an allegation of abuse and failed to immediately suspend the alleged perpetrator while the investigation was in process for 1 of 3 residents (R1) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of alleged sexual abuse within the required timeframe to the Illinois Department of Public Health (IDPH). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at a temperature to meet resident satisfaction for 4 of 4 residents (R1, R2, R3, and R13) reviewed for food temperatures in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was held at required temperatures on the second floor steam table and failed to ensure food was served in a manner to prevent cross contamination. This applies to all 94 residents residing on the second floor.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident's pressure injuries in a timely manner and failed to implement pressure injury treatment interventions for 1 of 3 residents (R1) reviewed for pressure injuries. These failures resulted in R1's pressure injuries deteriorating from two Stage 2 pressure injuries into one unstageable pressure injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had his prescribed medication when leaving the facility on a pass home overnight for 1 of 3 residents reviewed for medications in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the administrator of the facility for 1 of 3 residents (R1) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident with a history of embolic strokes (R167) received physician ordered anticoagulants. This failure resulted in R167 requiring emergency transport to the hospital for an acute embolic stroke. R167 was hospitalized until [DATE], when he passed away. The facility also failed to ensure an anticoagulant medication was administered as ordered for R116 for 2 of 8 residents (R167 & R116) reviewed for significant medication error in the sample of 33. The Immediate Jeopardy began on [DATE] when R167 was re-admitted to the facility and the facility failed to ensure the physician prescribed anticoagulant medication was obtained from pharmacy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:02 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow up a report of a stage 1 pressure injury resulting in the progression of the injury,and not being identified and treated until it became a stage 3, and failed to implement interventions to prevent the development of a pressure injury for 2 of 3 residents (R90, R122) reviewed for pressure injuries in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with their last known weight of 1/2024 showing a significant weight loss, failed to conduct, monitor weights and record, failed to ensure a resident with significant weight loss had a quarterly nutritional assessment by a dietician, and failed to ensure a resident with significant weight loss had interventions implemented to prevent further weight loss for 1 of 6 residents (R103) reviewed for nutrition in the sample of 33. These failures resulted in R103 not being weighed or seen by a dietician for 9 months after a significant weight loss occurred.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were in place for a resident with a pressure injury. The facility failed to ensure soiled linen was not discarded on the floor and gloves were changed after care and before touching other contact surfaces to prevent cross contamination for 2 of 2 residents (R122 & R151) reviewed for infection control in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to handle food in a manner to prevent cross-contamination. This failure has the potential to affects all residents residing on the first floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's advanced directive was accurate for 1 of 1 resident (R153) reviewed for advanced directives in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's representative of an involuntary transfer to the hospital for 1 of 3 residents (R167) reviewed for notifications in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure treatment orders were in place for a resident with a new drain site, failed to ensure the ordered dressings were in place for a resident with wounds, and failed to do initial wound assessments for a resident for 2 of 2 residents (R521, R45) reviewed for wounds in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had a catheter secure device in place for 1 of 3 residents (R49) reviewed for indwelling urinary catheters in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to store respiratory equipment in a manner to prevent contamination and failed to date respiratory equipment when changed for 2 of 2 residents (R144, R126) reviewed for oxygen in the sample of 33.

Inspectors wrote2. R153's admission Record (Face Sheet) showed he was type 2 diabetic. R153's Order Summary Report (dated 10/23/24) showed an active order for fast acting insulin to be given four times a day. The order showed the insulin dosage was based on blood sugar levels. The order showed 8 units of insulin should be given for a blood sugar reading between 301 and 350. On 10/23/24 at 10:54 AM, V6 (Licensed Practical Nurse/LPN) measured R153's blood sugar to be 338. V6 then attached a needle to R153's fast acting pre-filled insulin pen. V6 dialed in 8 units of insulin, entered R153's room, and wiped the back of his right arm with an alcohol wipe. V6 then pressed the needle into R153's arm, depressed the plunger button, and held the button for less than 3 seconds. V6 did not wipe the pen tip with alcohol prior to attaching the needle and she did not prime the insulin pen. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to date opened insulin pens. This applies to 2 of 2 residents (R153, R166) reviewed for medication storage in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe feeding recommendations for 4 of 10 residents (R2,R3,R6,R9) reviewed for safety and supervision in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from physical and sexual abuse from R1 who has a history of physical and sexual behaviors that escalated to staff then to residents. This failure resulted in R1 punching R2 in the face, pushing R3's chair over and causing him to fall to the floor and exposing himself to R4. The facility failed to ensure residents were free from physical abuse. This applies to 6 of 10 residents (R2, R3,R4, R6, R8, R10) reviewed for abuse in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to supervise a resident with escalating behaviors of physical and sexual aggressions with known behaviors. This failure resulted in R1 not being supervised after exhibiting physical behaviors towards residents (R2, R3) and sexually assaulting R4. This applies to 1of 10 residents (R1) reviewed for safety in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and implement pressure wound treatment and prevention interventions for 1 of 3 residents (R1) reviewed for pressure wounds in the sample of 3. These failures contributed to R1 developing an additional Stage 2 pressure wound and worsening of his other wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's family/Power of Attorney were informed of their change in condition and hospitalization for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.

Inspectors wroteBased on observation and interview the facility failed to ensure the shower room was kept clean and sanitary. This applies to all 168 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide shower to a resident that needs extensive assist with Activities of Daily Living (ADL's) to 1 of 3 residents reviewed for ADLs in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant medication errors. This applies to 2 of 4 residents (R1 & R5) reviewed for medications in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received new prosthetics for 1 of 1 residents (R2) reviewed for prostheses in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered medications were administered as prescribed for 1 of 1 resident (R1) reviewed for medication administration in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fall prevention interventions were implemented for 1 of 2 residents (R5) reviewed for safety in the sample of 32. This failure resulted in R5 falling out of bed while being provided personal care and recieving a laceration requiring stitches to his head.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staff to meet the needs of residents. This had the potential to effect all 158 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication refrigerator in manner to safely store medications. This affects all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff were wearing hair nets to prevent cross-contamination. This has the potential to affect all the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy for self-administration of medications when a resident (R40) was allowed to keep nebulizer treatments at the bedside. This applies to 1 of 1 (R40) residents reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with a bariatric bed for 1 of 1 resident (R139) reviewed for accommodation of needs in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offload pressure for a resident with a Stage 4 pressure injury for 1 of 3 residents (R135) reviewed for pressure in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to store a resident's nebulizer mask in a clean area. This applies to 1 of 1 residents (R40) reviewed for respiratory services in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not borrowed from another resident during medication administration for 2 of 4 residents (R155, R101) reviewed for medication administration in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to administer pneumonia vaccinations to 2 of 5 residents (R37, R94) reviewed for immunizations in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 vaccinations after consent was received for 2 of 5 residents (R37, R94) reviewed for immunizations in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to administer and document medications for 4 of 5 residents (R1, R2, R4, and R5) reviewed for medications in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 3 residents (R1 and R3) were free of resident to resident abuse in the sample of 3 reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of resident to resident abuse for 1 of 3 residents (R1) in the sample of 3 reviewed for abuse.