Forest Ridge Health and Rehab LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure housekeepers followed chemical dwell times and appropriately disinfected residents' rooms; and,-Ensure housekeepers performed appropriate hand hygiene when cleaning residents' rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from sexual abuse for one (#54) of three residents reviewed for abuse out of 37 sample residents. Specifically, the facility failed to protect Resident #54 from sexual abuse by Resident #57.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#9) of five residents were free from chemical restraints out of 37 sample residents. Specifically, the facility failed to monitor behaviors, side effects and effectiveness for Resident #9, who was prescribed a psychotropic medication.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication carts and one of four medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts and medication storage rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#1, #2 and #3) of three residents reviewed for abuse out of four sample residents were free from abuse. Specifically, the facility failed to:-Protect Resident #1 and Resident #2 from physical abuse by each other on 8/9/25 and 8/16/25; and,-Protect Resident #3 from physical abuse by Resident #1 on 8/16/25.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#68) of four residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 33 sample residents. Resident #68 was admitted to the facility for long term care on 8/1/23 with diagnoses of dementia with agitation, abdominal pain, vascular disorder of the intestine (blocked blood vessels to the intestines) and cystic disease of the liver (a disease that causes growths in the liver). Upon admission, Resident #68 weighed 212.4 pounds (lbs). The resident was hospitalized from [DATE] to 10/19/23 for a large bowel ischemic (a condition that caused pain and difficulty for intestines to work properly) and necrosis of the colon (part of the colon dies). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure temperatures were taken of refrigerators in the main kitchen; and, -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in four of four units. Specifically, the facility failed to -Ensure clean technique was followed during wound care for Resident #56; and, -Ensure the facility had an active Legionella water management plan in place to prevent or reduce Legionella in the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for eight (#1, #33, #36, #44, #18, #25, #41, and #53) of seventeen residents reviewed for bed rails out of 33 sample residents. Specifically, for Resident #1, #33, #36, #44, #18, #25, #41 and #53, the facility failed to: -Assess the resident for risk of entrapment prior to installing the bed rails; -Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; -Obtain physician's orders for bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate the continued need and safety of the bed rails.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards on two of four units. Specifically, the facility failed to: -Ensure Tuberculin purified protein derivative (PPD) was dated after opening; and, -Ensure refrigerated medications were stored in a sanitary manner, separately from refrigerated food items.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#68 and #70) of five residents reviewed for falls out of 33 sample residents. Specifically, for Resident #68 and #70, the facility failed to: -Identify the root cause of falls and implement timely and effective interventions to prevent further falls; and, -Update and revise the residents' care plans with new interventions after each fall.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to ensure portable oxygen tanks were checked and filled for 11 (#58, #60, #32, #49, #40, #42, #46, #41, #18, #13 and #27 ) of 30 sample residents and out of 32 residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically the facility failed to ensure the residents received continuously oxygen therapy as ordered by the physician.

Inspectors wroteBased on observation and interviews the facility failed to ensure infection prevention and control practices were followed to prevent the spread of infection. Specifically the facility failed to ensure effective infection prevention and control.

Inspectors wroteBased on record review and interviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (#27) of 30 sample residents. Specifically the facility failed to ensure the physician orders related to diabetic management were followed. I. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the March 2020 computerized physician orders (CPO), diagnoses included diabetes mellitus, Alzheimer's disease, dyspnea, and chronic respiratory failure with hypoxia. The 1/6/2020 minimum data set (MDS) assessment, revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. [...]