Forestville Rehabilitation and Wellness Center

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, the facility failed to protect a resident's dignity (resident #6) by failing to assist the resident with requested adl tasks resulting in the resident leaving his/her room with his/her lower body being partially unclothed. This was evident in 1 of 14 residents reviewed during the facility's complaint survey.

Inspectors wroteBased on investigation into a complaint, observation, and staff interview, the facility failed to maintain a homelike environment for residents. This was evident for 1 of 1 resident bathrooms reviewed during the complaint investigation.

Inspectors wroteBased on record review and staff interview; it was determined that the facility failed to protect a resident (resident #6) from verbal abuse by a facility staff member. This was evident for 1 of 14 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, the facility failed to timely report an alleged verbal abuse of a resident (resident #6) by facility nursing staff to OHCQ. This was evident with 1 of 14 resident records reviewed during a complaint survey.

Inspectors wroteBased on investigation into a complaint, closed record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to address residents' individualized care needs. This was evident for 1 (Resident #2) of 5 residents reviewed for care plans during the complaint survey.

Inspectors wroteBased on investigation of a complaint, record review and interviews, it was determined that the facility failed to ensure physician documentation accurately reflected the resident's dietary plan of care. This was evident for 1 (Resident #2) of 10 residents reviewed during the complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on a review of resident council meeting minutes and interviews with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was evident for 6 of 6 months of the Resident Council meeting minutes reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store and maintain food in accordance with professional standards for food service. This was evident during an initial tour of the kitchen during the recertification/complaint survey.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory communication training. This was evident for 4 (LPN #45, GNA #46, GNA #47, GNA #48) out of 6 direct care staff employees reviewed during the Extended Survey portion of the facility's recertification survey. A facility must include effective communications as mandatory training for direct care staff. Direct care staff are defined as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Effective communication helps staff understand what a resident is trying to communicate so staff can appropriately respond. [...]

Inspectors wroteBased on review of the medical record and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive and ensure that a current copy of residents' advanced directives was in the residents' medical record. This was evident for 1 (Resident #1) out of 5 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to ensure each resident's medication regimen was free from unnecessary medication/chemical restraints. This was evidenced by the facility utilizing psychotropic medication without appropriate assessment and documentation. This deficient practice was identified in one (Resident #17) of five residents reviewed for unnecessary medication regimens during the recertification/complaint survey.

Inspectors wroteBased on review of pertinent documents and interview with facility staff, it was determined that the facility failed to timely report to the State Survey Agency, the Office of Health Care Quality (OHCQ), an allegation of suspected resident abuse, and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the recertification/complaint survey.

Inspectors wroteBased on review of facility records and interview with staff it was determined the facility failed to thoroughly investigate an allegation of suspected resident abuse and an allegation of misappropriation. This was evident for 2 (Resident # 164 and #163) of 2 residents reviewed for abuse during the survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide documented evidence to support that the facility notified a representative of the Office of the State Long-Term Care Ombudsman that the resident was discharged . This was evident for 1 (Resident #162) of 2 Residents reviewed for discharge during the recertification/complaint survey process. Findings Included:On 01/09/2026 at 8:39 AM, a review of Resident #162 medical records revealed that the resident was discharged to home on [DATE]; however, there was no documented evidence to support that the facility notified the State Ombudsman's Office in writing. [...]

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's status. This was evident for 2 (Resident #8 and #17) out of 32 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #1 and #8) out of 52 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on a review of complaints, medical records, and staff interviews, the facility failed to ensure a resident received necessary treatment and services to promote their highest practicable well-being: evidence by failing to 1) follow Physician orders for Gastrointestinal interventions related to appointments, and 2) arrange a critical diagnostic test and a specialty consultation as ordered by the provider. This was evident for 2 (Resident #19 and #145) of 8 residents that were reviewed during this recertification/complaint survey.

Inspectors wroteBased on a review of medical records and staff interviews, it was determined that facility staff failed to provide and document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one resident (Resident #66) of three reviewed for urinary catheter care during this annual survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to timely address and notify the provider for a resident with a significant weight change. This was evident for 3 (Resident #8, #17, and #43) of 5 residents reviewed for nutrition during the facility's recertification/complaint survey.

Inspectors wroteBased on a review of medical records and staff interviews, it was determined that the facility failed to monitor, including assessment and documentation, for a resident who was on a tube-feeding program. This was evident for one (Resident #78) of three residents reviewed tube feeding during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to ensure that attending physicians visited residents at the required frequency of at least once every 60 days following the initial 90-day admission period. This deficiency was identified for two residents (Resident #38 and #94) out of three reviewed during the extended survey of the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 3 (Resident #4, #17, and #43) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (Resident #129 and Resident #99) of 11 residents observed with 30 medication administration opportunities which resulted in an error rate of 6.67% by 2 of 5 nurses observed during the recertification survey. Findings Included:The national library of medicine indicates that Faster Insulin Aspart (Fiasp) is a novel formulation of insulin aspart with an accelerated time-action profile. This results in twice the insulin exposure and 74% greater insulin action within the first 30 minutes post-injection compared to conventional insulin aspart. This highlights a critical difference in the absorption rate and clinical effect between Fiasp and standard insulin aspart. [...]

Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility failed to provide Dental services timely. This was evident for 1 (Resident #19) of 2 residents in review of dental during the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to maintain medical records that were complete and accurately documented for residents. This was evident for 2 (Resident #8 and #55) out of 52 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on surveyor observation, interview with facility staff, and review of medical records, it was determined that the facility failed to ensure that they maintained an effective infection control program evidence by: 1) failing to ensure appropriate personal protective equipment (PPE) was worn when entering a resident's room who was on Contact Precautions, and 2) failing to implement appropriate infection prevention and control practices during the medication administration task. This was evident for 1 (Staff #6) out of 1 employees observed entering the Contact Precautions room, and 1 License Practical Nurse (LPN#29) of 5 Staff observed during the medication administration task during the recertification/complaint survey.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received mandatory Quality Assessment and Performance Improvement training. This was evident for 2 (GNA #47 and HH/FT #50) out of 7 employees reviewed during the Extended Survey investigation portion of the facility's recertification survey.

Inspectors wroteBased on interviews with facility staff and review of facility documentation and employee files, it was determined that the facility failed to ensure staff received compliance and ethics training. This was evident for 2 (GNA #47 and HH/FT #50) out of 7 employees reviewed during the Extended Survey portion of the facility's recertification survey.

Inspectors wroteBased on surveyor observation and interviews with facility staff, it was determined that the facility failed to post the required nursing staffing data. This was evident on 2 out of 2 units for 2 out of 2 days of the recertification survey.

Inspectors wroteBased on record review and interviews it was determined the facility failed to investigate and take appropriate action to further prevent abuse. This was evident during the surveyor's review of facility reported incident #2635881 for Resident #2.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure timely administration of medications, follow medical care orders, and follow professional standards. This was evident for 1 out of 1 Resident (Resident #24) reviewed for medication administration during the facility's complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to follow professional standards for food service safety. This was evident during 1 out of 1 random observations made by the surveyor during review of complaint 292569.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure staff performed hand hygiene. This was evident during 2 out of 2 random observations made by the surveyor during review of complaint #292569.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure that residents resided in a safe, comfortable and homelike environment related to an adequate response and maintenance for water damage which was present in the room and bathroom of two residents (# 3 and # 66) and 7 rooms. This was found to be evident during multiple observations and tours conducted during the survey.

Inspectors wroteBased on resident interviews, record review, review of other pertinent documentation and staff interviews, it was determined that the facility failed to: 1) treat in a timely manner Resident (#91) complained of pain and a possible fracture and 2) ensure a resident's helmet was in place as ordered by the physician. This was evident for 2 (Resident #91 and #82) of 37 residents reviewed during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to properly store food, maintain sanitary conditions, and consistently monitor freezer temperatures. This deficient practice was discovered during the survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to treat a resident (#111) with dignity by exposing the resident in a public area. This was evident in 1 of 8 residents reviewed for dignity during the survey.

Inspectors wroteBased on record review, interviews, and observations the facility failed to ensure that a resident's choice to receive a shower twice per week as requested was provided. The determination was found to be true for 1 (#55) out of 5 residents reviewed for choices during the survey.

Inspectors wroteBased on resident interview, record review, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for a resident (#91). This was evident for 1 out 8 residents reviewed for accidents during the survey.

Inspectors wroteBased on resident and staff interview and review of Facility Reported Incident MD00202293, it was determined that the facility failed to ensure resident #18 was free from misappropriation of property. This was evident for 1 of 60 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interviews with the resident and facility staff it was determined the facility failed to ensure that care plan meetings were provided to the resident quarterly and as needed. This was found to be evident for 1 (Resident # 13) of 4 residents reviewed for care plans during the survey. Findings Include: An interview was conducted with resident #13 on 5/21/24 at 10:16 AM and the resident was asked if s/he is invited to participate in the care plan meetings that the facility conducts with the residents and the resident stated, no. The resident went on to say that s/he has not had a care plan this year and didn't recall having one the previous year. [...]

Inspectors wroteBased on medical record reviews and interviews it was determined that facility staff failed to ensure resident's plan of care was followed and/or updated according to professional nursing standards as evidenced of residents not receiving showers twice a week. This deficient practice was evident for 2 (#126 & #134) out of 2 resident records reviewed for Activities of Daily Living care during the survey.

Inspectors wroteBased on observations, staff interviews, and review of the medical record, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (#82) of 2 residents reviewed for activities.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure safety of a resident who was being transferred via a Hoyer lift. This was evident for 1 out of 1 resident (#91) observed to be transferred via a Hoyer lift.

Inspectors wroteBased on observation, review of the medical record, and interview with staff it was determined the facility staff failed to provide appropriate and sufficient care for a resident with an indwelling urinary catheter. This was evident for 1 (#41) of 2 residents reviewed for urinary catheter or urinary tract infection (UTI).

Inspectors wroteBased on observations, staff interview, and resident medical record review it was determined the facility failed to administer oxygen to resident #74 as prescribed by physician orders. This was evident for 1 (resident #74) of 1 residents that was reviewed for respiratory care services during survey.

Inspectors wroteBased on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure a medication error rate of 5% or less. This was evident for 2 of 27 opportunities for error observed during the medication administration, resulting in an error rate of 7.41%.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that medications were date labeled upon opening them and that medications/biologicals were stored and secured in a locked medication/treatment cart. This was found to be evident for 3 of 3 medication carts and 1 treatment cart reviewed during the survey.

Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident in 1 of 1 food test tray samples reviewed during the survey.

Inspectors wroteBased on record reviews review of MD00201072 and interviews it was determined that the facility to ensure a new hire nursing staff had an active, valid registered nurse license. This was evident for 1 (#56) of 5 licensed healthcare professional employee files reviewed during the survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to accurately document the dates on a resident's Preadmission's Screening and Resident Review (PASARR) form. This was evident for 1 (Resident #152) of 2 residents reviewed for PASARR.

Inspectors wroteBased on record reviews, observations and interviews it was determined that the facility staff failed to maintain infection control precautions and ensure that the policies and procedures related to infection control were updated. This deficient practice was discovered during survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents had access to call bells. This was evident for 3 residents (#3, #66, #49) observed during the surveyor's initial tour of the facility during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to provide a safe, sanitary, and comfortable environment for staff. This deficient practice was discovered during the survey in multiple areas within the facility.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to place a discharge summary on a resident's (#579) medical record after discharge. This was evident for 1 of 21 residents reviewed during the survey.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to ensure all resident rooms and hallways were maintained in a homelike manner. This was evident for 11 of 19 rooms reviewed during the survey.

Inspectors wroteBased on observation and staff interview it was determined facility staff failed to maintain an environment free of unnecessary accident hazards as evidenced by: 1) Residents #1, #35 and #84 using their own lighters during a smoke break while Resident #46 was being observed; and 2) a medication cart that was found unlocked and unattended. Observations of the residents smoking were evident during 2 smoking breaks. The findings regarding the medication cart were noted on 1 of 4 days of observation during the survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to correctly code the Minimum Data Set (MDS) for Residents #153 and #68. This was evident for 2 of 46 residents investigated during the survey. The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions (also referred to as MDS Items). Each triggered care area must then be assessed in order to determine if care planning is needed. [...]

Inspectors wroteBased on observation, medical record review, and interviews it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives to meet the medical, nursing, mental and psychosocial needs for 1 out of 39 residents (Resident #68) reviewed during investigative portion of the annual survey. A plan of care is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of resident care.

Inspectors wroteBased on review of resident records and interview with facility staff, it was determined that the facility failed to ensure that residents' plans of care were reviewed and revised by the interdisciplinary team at least quarterly. This was evident for 1 of 2 residents reviewed for care plans (Resident #103).

Inspectors wroteBased on medical record review and staff interview it was determined staff failed to: 1) clarify an order for pain medication; and 2) consistently document thorough pain assessments for Resident #402. This was evident for 1 of 46 residents investigated during the survey.

Inspectors wroteBased on review of resident medical records, it was determined that the facility failed to ensure that pharmacy record reviews were acted on in a timely manner. This was evident for 1 of 6 residents (Resident #123) reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview it was determined there was an error in the diagnostic list in the admission Record for 1 of 46 residents investigated during the survey (Resident #35).