Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Park Health Campus during CMS and state inspections, most recent first.
A resident who was cognitively intact, non-ambulatory, and always incontinent of bowel and bladder did not receive timely incontinence care. The resident and family reported a stool episode during activities with stool through the brief and clothing, and the family said staff had been told the resident needed incontinence checks between meals because the resident does not know when they go and will sit in it. The resident later stated they had not been toileted since before breakfast and did not know if they were soiled. The care plan called for incontinent care after each episode and keeping the skin clean and dry, and the resident also had MASD to a gluteal tear skin fold.
Delayed call light response and unmet ADL assistance affected multiple residents. Residents reported waiting 30 minutes to hours for help with toileting, transfers, hygiene, drinks, and meals, and several said the delays made them feel humiliated, frustrated, or like they did not matter. One cognitively intact resident with CHF and emphysema, another with HF and kidney failure, and others needing toileting or transfer assistance described repeated waits, while staff and resident council noted long response times, especially on overnight shifts when only one CRCA was scheduled.
A resident receiving hospice services had missing pajamas reported by a family member, who said she had asked multiple CRCAs and an LPN about the items over several months. The grievance was not found in the facility log, and the ED, SSD, and DES each stated they had not been aware of the missing items until the surveyor interview, despite the facility's grievance process calling for concerns to be entered, reviewed, and followed up on within 24-48 hours.
Failure to provide required nail care for a dependent resident. A resident with acute respiratory failure, metabolic encephalopathy, mild cognitive impairment, and substantial to maximal assistance needs was observed in bed on multiple occasions with long fingernails; on one observation, yellow substance was noted under the nails. The care plan directed staff to provide nail care on shower days and as needed, and the resident stated he wanted his fingernails trimmed. An LPN acknowledged the nails needed trimming, and the DHS stated nail care should be provided weekly during bathing and as needed.
A resident with left hand contracture, mild cognitive impairment, and significant ADL assistance needs was ordered to wear a left palm protector daily to help maintain ROM and skin integrity. During multiple observations, the resident was found in bed with the contracted hand uncovered and without the ordered padding or brace in place; the palmgrip was later found soiled in a bedside drawer, and an LPN stated it should have been in place.
A resident who was totally dependent for transfers and unable to bear weight was repeatedly moved by staff using a gait belt and lifting under the arms instead of following the care profile for a mechanical lift. The resident moaned during transfers, and staff acknowledged the resident should have been transferred 100% by mechanical lift. The resident had CKD, depression, left hemiplegia/hemiparesis, and a CVA history, and the MDS showed severe impairment in daily decision making.
A resident with COPD, CHF, and respiratory failure had a POST form indicating DNR, but the physician order listed full code. The DHS said the admitted nurse and clinical review team were responsible for ensuring the POST form and MD order matched the resident’s wishes, and the record showed the resident had stated she wanted to be full code at that time.
A resident was found with medications at the bedside without a documented assessment or physician's order for self-administration. The resident, who was cognitively intact, self-administered morning medications and breathing treatments. The facility's policy requires an assessment and physician evaluation for self-medication, which was not completed.
The facility failed to provide adequate bathing assistance to three residents, leading to unmet personal hygiene needs. A resident with pulmonary disease and osteoarthritis received only two showers in January, despite being scheduled for three weekly. Another resident with respiratory failure and anxiety received four showers in January, while a third resident with multiple medical conditions received only two showers over three months. The residents expressed dissatisfaction with their hygiene, citing greasy hair and inadequate cleanliness. The DON acknowledged the nursing staff's responsibility to ensure twice-weekly showers.
A facility failed to identify and document a resident's skin alteration, despite a physician order for weekly skin assessments. The resident, with a history of edema and dysphagia, reported an abrasion on the right ankle that had been present for over a year. The MAR only showed staff initials without detailed results, leading to the oversight. The resident self-treated the abrasion, and a nurse was unaware of the condition and self-administration of cortisone spray.
The facility failed to document meal intakes for three residents with significant medical conditions, including pressure ulcers and weight loss. Reviews showed that 7.5% to 13.7% of meals were not documented, and the Administrator confirmed the lack of a specific policy addressing this requirement.
Delayed Incontinence Care for a Dependent Resident
Penalty
Summary
The facility failed to assist a resident timely with incontinence care. Resident B was cognitively intact, non-ambulatory, dependent for toileting and hygiene, and always incontinent of bowel and bladder. The resident’s clinical record also showed diagnoses including major depressive disorder, anxiety, and COPD. During interview, Resident B and a family member reported an incontinent episode of stool while the resident was doing activities, with stool coming through the brief and pants and coming out of the front and backside. The family member stated they had held several meetings with staff because Resident B needed to be checked for incontinence between meals since the resident does not know when they go and will sit in it. Resident B also stated they had not been toileted since before breakfast and did not know whether they were soiled. A progress note documented that Resident B was toileted before breakfast and offered again later that day. The care plan directed staff to provide incontinent care after each incontinent episode, and a later care plan noted MASD to a gluteal tear skin fold with an intervention to keep the resident’s skin clean and dry. The facility’s Resident Rights policy stated each resident has the right to be treated with dignity and respect.
Delayed Call Light Response and Unmet ADL Assistance
Penalty
Summary
The facility failed to maintain residents’ dignity by not answering call lights in a timely manner for multiple residents who needed assistance with activities of daily living, toileting, transfers, and meals. Residents reported waiting 30 minutes, 45 minutes, an hour, and in some instances hours for staff response. Several residents stated they felt upset, frustrated, humiliated, or like they did not matter when help did not come promptly. One resident said delayed assistance made him feel like a "pee-on," and another said waiting too long made her feel like she was not a person. Resident 6 was cognitively intact, occasionally incontinent of bladder, and needed partial to moderate assistance with transferring and toilet hygiene. He reported that call light wait times were bad, that he sometimes waited hours for toileting help, and that he could not always wait for staff when he needed to transfer or use the commode. Resident 24, who was cognitively intact and needed assistance with transferring and toileting, reported average waits of 30 to 45 minutes and sometimes hours, and said she no longer trusted staff to respond when she used the call light. Resident 5 reported waiting 30 minutes for staff to answer her call light when she needed something to drink, and Resident 44 reported waiting over 30 minutes for help getting to the dining room for meals. Other residents described similar delays and unmet needs. Resident 42 said staff did not assist her to the restroom often enough and that she would remain in a soiled brief until staff helped her. Resident 39 had dysphagia and was ordered a regular diet with pureed consistency, with instructions to allow adequate time for self-feeding and assist as needed; however, a family member reported the facility would not allow her to remain in her room for dinner when she did not want to go to the dining room, and she was given a nutritional supplement instead. Resident council members and interviews with staff described long call light wait times, especially on second and third shifts, and one CRCA stated that when she was the only aide on duty overnight, she could not complete all direct care tasks, residents sometimes remained in soiled briefs until the next shift, and call lights could stack up so that the last resident waited at least 30 minutes for response.
Failure to Timely Address Family Grievance About Missing Pajamas
Penalty
Summary
The facility failed to timely address a resident's family grievance regarding missing pajamas for Resident 39, who had diagnoses including dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and was receiving hospice services at the facility. Family Member 5 reported that a red plaid pajama set and a green plaid pajama set had been missing since Christmas 2025 and stated she had asked several staff members about the items multiple times, including several CRCAs and an LPN. Review of the grievance log from 9/1/25 to present did not show any grievance for the missing pajamas. The ED stated she had not heard anything about the missing pajamas, and the SSD also stated she had not heard about the issue. The DES reported that no one had mentioned the missing pajamas to her until the day of the interview and that she found some pajama pieces in the laundry room, but they were not the missing items. The facility's Resident Concern Process policy stated that concerns should be entered electronically, reviewed in morning meeting, and followed up on within 24-48 hours.
Failure to Provide Required Nail Care
Penalty
Summary
The facility failed to provide nail care to a dependent resident who required staff assistance for self care and mobility. Resident 10’s clinical record showed diagnoses including acute respiratory failure and metabolic encephalopathy, and an annual MDS dated 1/8/2026 indicated mild cognitive impairment, no rejection of care behaviors, impairments of one upper extremity and both lower extremities, and substantial to maximal assistance with personal hygiene needs. The ADL care plan, revised 1/19/2026, directed staff to provide nail care on shower days and as needed. During observations on 2/19/2026, 2/20/2026, and 2/23/2026, Resident 10 was in bed with long fingernails, and on two occasions the resident stated he wanted his fingernails trimmed. On 2/19/2026, the fingernails also had yellow substance under them. On 2/23/2026, an LPN stated the resident’s fingernails needed to be trimmed and that, because the resident was not diabetic, it should be completed with bathing. The DHS stated nail care should be provided weekly during bathing and as needed, and that direct care nurses and aides were responsible for providing it.
Failure to Maintain Ordered Palmgrip for Resident with Left Hand Contracture
Penalty
Summary
The facility failed to ensure that a palmgrip was in place as ordered for a resident with left hand contracture. The resident’s record showed diagnoses including acute respiratory failure and metabolic encephalopathy, and the annual MDS indicated mild cognitive impairment, impairments of one upper extremity and both lower extremities, and substantial to maximal assistance with personal hygiene needs. A pain care plan identified the resident as at risk for skin breakdown and pain related to the left hand joint contracture, with interventions including protective padding to prevent skin-on-skin contact and a palmgrip per MD orders. A physician’s order directed the resident to wear a left palm protector daily to decrease the risk of further loss of ROM and maintain skin integrity, with removal for ADLs and laundering as needed. During multiple observations, the resident was found in bed with the left hand contracted and no padding or brace in place. On one observation, the palmgrip was found in the top drawer of the bedside table and was soiled, and an LPN stated it should have been in place. The DHS stated direct care nurses and aides were responsible for ensuring the palmgrip or other padding was in place for the resident’s left hand contracture.
Improper Transfer Technique and Failure to Follow Mechanical Lift Care Profile
Penalty
Summary
The facility failed to transfer a resident in a manner that was safe and comfortable and failed to follow the resident’s care profile for a mechanical lift. Resident 43’s family member stated the resident was unable to bear weight during transfers on either leg and that staff had been lifting the resident underneath the arms with two people and no gait belt, which the family member believed was painful because the resident would moan during transfers. During observation, the resident was transferred from a geriatric chair to the bed and back again with a gait belt and staff’s hands underneath the resident’s arms, even though the resident was unable to bear weight on either leg, moaned during the transfer, and was totally dependent on staff. Staff involved in the transfer indicated the resident needed to be transferred 100% by a mechanical lift and that it was not fair to the resident because staff had to tug on her. Resident 43’s clinical record showed diagnoses including chronic kidney disease, depression, hemiplegia and hemiparesis of the left non-dominant side, and cerebral infarction. The admission MDS indicated the resident was severely impaired for daily decision making, and the care profile dated 1/26/26 directed staff to transfer the resident using a mechanical lift. The DHS stated a lift assessment should have been completed if the resident was unable to bear weight during a transfer. The ADHS stated staff were informed to follow the care profile in the electronic health record, and a CRCA reported that she had told nursing the resident was unable to bear weight during transfers but could not remember which nurse she told.
Mismatch Between POST Form and Physician Order for Code Status
Penalty
Summary
The facility failed to ensure Resident 67’s code status POST form and physician order matched the resident’s wishes for end-of-life care. During interview, the Director of Health Services stated the admitted nurse and clinical review team were responsible for making sure the POST form and physician orders matched, and that the facility had spoken with Resident 67, who said she wanted to be a full code at that time. Review of the record showed Resident 67 had diagnoses including COPD with acute exacerbation, acute on chronic diastolic CHF, acute respiratory failure with hypercapnia, and acute and chronic respiratory failure with hypoxia. The POST form dated 10/30/25 indicated DNR and was signed by the resident and physician, while a physician order dated February 2026 indicated full code. The facility’s advanced directives policy stated it would ensure residents’ end-of-life directives were obtained and followed, that residents would be advised on admission and quarterly regarding code status wishes, and that nursing staff would confirm code status and obtain a physician order.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) determined and documented the clinical appropriateness of self-administration of medications for Resident 39. During an observation, Resident 39 was found with a full cup of open pills and a vial of fluid for breathing treatments at his bedside, which he indicated were his morning medications and self-administered breathing treatment. Despite being cognitively intact for daily decision-making, as indicated by an Annual Minimum Data Set assessment, there was no physician's order or self-administration assessment documented in Resident 39's clinical record. The Director of Nursing (DON) confirmed that medications should not be left at the bedside and that it was the IDT's responsibility to complete a self-medication administration assessment for any resident self-administering medications. Additionally, the DON stated that nursing staff should ensure a physician's order is in place for residents who self-administer medications. The facility's policy on self-administration of medications requires an assessment and physician evaluation before allowing residents to self-medicate, which was not followed in this case.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for three residents, leading to a deficiency in meeting their personal hygiene needs. Resident 7, who has pulmonary disease and osteoarthritis, was scheduled for showers three times a week but reported receiving only two showers and two baths in January 2025. She expressed dissatisfaction with her hygiene, noting greasy hair and a lack of cleanliness. The resident attributed the missed showers to staffing shortages, as communicated by a CNA. Resident 41, diagnosed with respiratory failure and anxiety, was scheduled for showers twice a week but received only four showers and one bath in January 2025. She expressed a preference for more frequent showers, ideally two to three times a week. Similarly, Resident 31, with multiple medical conditions including hemiplegia and osteoarthritis, was scheduled for two showers a week but received only two showers and nine bed baths over a three-month period. He expressed dissatisfaction with the bed baths, noting that his hair was not always washed, leaving it greasy and uncombed. The Director of Nursing acknowledged the responsibility of the nursing staff to ensure residents receive showers twice a week.
Failure to Identify and Document Skin Alteration
Penalty
Summary
The facility failed to identify and appropriately document a skin alteration for a resident with a history of edema and dysphagia. Upon admission, the resident was assessed as having no skin impairments, and a physician order was in place for weekly skin assessments. However, the Medication Administration Record (MAR) only reflected the initials of the staff completing the assessments, with no detailed results recorded. This lack of documentation led to the oversight of a skin abrasion on the resident's right ankle, which the resident reported had been present for over a year. During an observation and interview, the resident disclosed self-treating the abrasion with over-the-counter cortisone spray and covering it with a paper towel. A registered nurse confirmed the presence of the abrasion but admitted to never having seen the resident's ankle before and was unaware of the resident's self-administration of cortisone spray. The facility's policy required weekly skin observations to be documented, indicating any new or existing skin impairments, which was not adhered to in this case.
Failure to Document Meal Intakes for Residents
Penalty
Summary
The facility failed to ensure the documentation of meal intakes for three residents, all of whom had significant medical conditions including pressure ulcers, weight loss, and required assistance with meals. Resident B, diagnosed with Lewy body dementia, dysphagia, and recurrent coccyx ulcer, experienced significant weight loss since admission. A review of her meal intakes from February 1 to March 20 revealed that 7.5% of her meals were not documented. The Administrator confirmed that all meal intakes should be documented but could not locate a specific policy addressing this requirement. Resident C, diagnosed with a pressure wound, gallstones, and cognitive developmental delay, also experienced weight loss and required meal assistance. A review of his meal intakes for the same period showed that 7.6% of his meals were not documented. Similar to Resident B, the Administrator confirmed the expectation for documentation but acknowledged the absence of a specific policy. Resident D, diagnosed with dementia, severe protein-calorie malnutrition, and a sacral area pressure ulcer, had recent weight fluctuations. A review of his meal intakes indicated that 13.7% of his meals were not documented. The Administrator reiterated the requirement for documentation of meal intakes but again noted the lack of a specific policy. This deficiency was identified during a complaint investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Trace Health & Living Community | 1 mi | ★★★★★ | 1 | 0 |
| Brickyard Healthcare - Golden Rule Care Center | 1.6 mi | ★★★★★ | 16 | 0 |
| Rosebud Village | 3.4 mi | ★★★★★ | 0 | 0 |
| Willows Of Richmond | 3.4 mi | ★★★★★ | 1 | 0 |
| Springs Of Richmond, The | 3.7 mi | ★★★★★ | 14 | 0 |
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