Park Forest Care Center LLC

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure mechanical equipment was maintained in safe, operating condition for one (#2) of three residents reviewed for mechanical lifts out of three sample residents. Specifically, the facility failed to: -Ensure mechanical lift slings were routinely inspected, maintained and replaced according to the manufacturer's recommendations and professional standards, which resulted in a fall for Resident #2; and, -Ensure mechanical lifts were routinely maintained according to the manufacturer's recommendations.

Inspectors wroteBased 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. Record review revealed no documentation that the ordered tube feeding was provided during this time period. [...]

Inspectors wroteBased 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. However, observations during the survey revealed the staff did not utilize the communication board. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#1 and #10) of four residents reviewed, out of a total sample of 22 residents, remained free of significant medication errors. Specifically, the facility failed to:-Ensure staff timely and accurately updated Resident #1's Methadone dose and indicated use in his electronic medical record (EMR) per external provider orders; -Ensure staff accurately administered and documented the dose of Methadone Resident #1 received in his medication administration record (MAR); -Ensure staff implemented and documented care interventions to identify, assess, monitor, or treat Resident #1's specific triggering/craving behaviors related to his documented history of substance use disorder (SUD); [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate and complete medical records for one resident (#1), of four residents reviewed out of a sample of 22 residents. Specifically, the facility failed to ensure Resident #1's addiction provider notes were obtained and uploaded into the resident's electronic medical record (EMR).

Inspectors wroteBased on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances brought up by the resident council.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' bathrooms; -Ensure housekeeping staff applied alcohol-based hand sanitizer per guidelines when cleaning residents' rooms; -Ensure staff donned appropriate personal protective equipment (PPE) when providing direct care for Resident #45, who was on enhanced barrier precautions (EBP); and, -Ensure staff donned appropriate PPE when providing wound care for Resident #16, who was on EBP.

Inspectors wroteBased on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for one of two shower rooms and nine of 16 resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in the north shower room and nine resident rooms were working properly.

Inspectors wroteBased on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) Level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#38) of two residents reviewed for PASRR out of 35 sample residents. Specifically, the facility failed to notify the State Mental Health Agency when a resident received a new diagnosis (bipolar disorder) of a serious mental disorder for a PASRR Level II evaluation.

Inspectors wroteIV. Resident #133 A. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances and attention-deficit hyperactivity disorder. The 5/22/25 minimum data set (MDS) assessment revealed that Resident #133 was severely cognitively impaired and unable to participate in the brief interview for mental status (BIMS) assessment. According to the staff assessment for mental status, Resident #133 had short term and long term memory deficits, severely impaired decision making skills and continuous disorganized thinking. Resident #133 was not cognitively orientated to staff names and faces, where his room was or what type of facility he was in. He was independent in his activities of daily living (ADL) and ambulated independently. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#184) of two residents who required respiratory care received care consistent with professional standards of practice out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #184.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#55) of six residents reviewed for medications errors out of 35 sample residents. Specifically the facility failed to ensure Resident #55 was administered Percocet (pain medication) per physician's orders.

Inspectors wroteBased 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 [AGE], 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. A review of the facility's investigation of the 10/14/24 incident revealed Resident #2 had previously engaged in inappropriate sexual behavior toward other male and female residents in the facility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis Specifically, the facility utilized the DON as a floor nurse several times a week when the facility's average daily census was over 60 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm.

Inspectors wroteBased on observation, record review, and interviews the facility failed to provide the necessary treatment and services to prevent a pressure injury from occurring for one (#32) of two residents out of 36 residents. Specifically, the facility failed to implement interventions to reduce pressure injury risk factors for Resident #32 who was identified by the facility as high risk for developing pressure injuries. The resident required extensive assistance for activities of daily living (ADL) and was dependent upon facility staff for bed mobility and transfers. The facility failed to ensure preventative interventions were implemented which resulted in the development of a facility acquired stage 3 pressure injury to the sacrum (base of lower back).

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#18) of three residents reviewed for abuse out of 36 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #18 was kept free from physical abuse by Resident #68.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#19, #34 and #49) of three residents out of 36 sample residents were free from misappropriation of resident property. Specifically, the facility failed to ensure Resident #19, #34 and #49 were reimbursed when the facility had identified that Resident #79 had stolen their cigarettes. Resident #19, #34 and #49 were required to keep their cigarettes in a facility lock box, which was controlled by facility staff. Resident #79 broke into the lock box and stole the cigarettes. When it was identified what Resident #79 had done, the facility failed to ensure Resident #19, #34 and #49 were reimbursed for their missing cigarettes.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure three (#46, #54 and #7) out of 36 sample residents were provided services that meet professional standards of practice. Specifically, the facility failed to: -Ensure narcotic medication was documented on the narcotic log at the time of removal from the locked narcotic drawer for Resident #46; and, -Ensure an assessment was completed by a registered nurse (RN) assessment following a fall for Resident #54 and Resident #7.

Inspectors wroteBased on record review, observation, and interviews the facility failed to ensure one (#8) of two out of 36 sample residents with limited range of motion received the appropriate treatment and services. Specifically, the facility failed ensure interventions identified to address Resident #8's contractures were implemented.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to provide three years worth of survey and investigation findings in a prominent location for public viewing. I. Group interview The group interview was conducted on 11/29/23 at 10:00 a.m., with six alert and oriented residents. The residents said they were not aware they could view the federal and state survey results. The residents said they were not aware the results of the surveys had been posted for them to be able to access and read. [...]

Inspectors wroteBased on observations and interviews, the facility failed to display the nurse staffing date in a clear and readable format and in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure appropriate hand washing and glove usage in the main kitchen.

Inspectors wroteVI. Incident of physical abuse between Resident #12 and Resident #20 A. Facility invesigation The 8/12/22 nursing progress note documented at 5:20 p.m. in Resident #20's medical record indicated that Resident #12 approached Resident #20 and struck Resident #20's shoulders with both hands. The residents were immediately separated and the police, physician and family were notified. A review of Resident #20's electronic medical record did not reveal a physical skin assessment had been completed following the incident of physical abuse by Resident #12. The 8/12/22 nursing progress note documented at 5:17 p.m. in Resident #12's medical record indicated Resident #12 approached Resident #20 and struck Resident #20 on the shoulders with both hands. The 8/12/22 abuse investigation documented staff witnessed Resident #12 approach Resident #20 and hit her on the shoulders. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#10 and #38) of three residents with limited range of motion received appropriate treatment and services out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #10 received treatment to help prevent a contracture after being determine a high risk for developing contractures; and, -Ensure Resident #38's brace was in place as ordered by the physician to prevent the worsening of the resident's right hand.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#12, #61 and #52) of four residents reviewed for accidents out of 38 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Implement a person-centered care plan that identified Resident #12, #61 and #52's fall risk and put effective interventions into place to reduce falls; and, -Ensure a registered nurse (RN) consistently assessed residents prior to moving them after a fall.

Inspectors wroteBased on observations, record review, and interviews 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 three of four units. Specifically, the facility failed to: -Ensure staff and contractors wore personal protective equipment (PPE) appropriately; and, -Ensure nurse staff performed hand hygiene during medication pass and after touching masks.

Inspectors wroteBased on observation, record review and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for one (#30) of three residents reviewed for PASRR compliance out of 38 sample residents. Specifically, the facility failed to implement the communication assistive technology device that was recommended in the residents PASRR level II evaluation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#8) of three residents out of 38 sample residents. Specifically, the facility failed to arrange optometry services timely after Resident #8's glasses were broken.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure one (#12) of four out of 38 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Develop a comprehensive plan of care, to include person-centered interventions of dementia care services to address the behaviors for Resident #12; and, -Provide a person-centered approach to Resident #12's dementia care services to address her physically aggressive behavior in order to prevent physical altercations with another resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five %. Specifically, nursing staff failed to: -Prime the insulin needle prior to administering an insulin injection to Resident #55; and, -Ensure an enteric coated medication for Resident #2 was not crushed resulting in an eight % medication error rate.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#55) of eight reviewed out of 38 sample residents. Specifically, the facility failed to ensure an insulin pen was primed before administered for Resident #55, to ensure the correct insulin dose was given. Cross-reference F759 failure to ensure the facility's medication error rate was not greater than five %.

Inspectors wroteBased on interviews and record review, the facility failed to assist resident in obtaining routine or emergency dental services, as needed for one (#78) of three out of 38 sample residents. Specifically, the facility failed to ensure dental recommendations were followed up timely for Resident #78.