The facility's Director of Nursing told inspectors she wasn't aware Resident #1 had been sent to a shelter instead of home with family until his parole officer called a week later. She said she thought the resident had discharged to his family member's house as planned.
"I was a member of the IDT and was present for the meeting but did not recall a discussion for Resident #1 to go to a shelter," the DON told inspectors on October 30. She acknowledged her role was to ensure discharge locations were safe and could provide required medical care for each resident.
The DON said she did not recall an IDT meeting to discuss sending Resident #1 to a shelter.
Federal inspectors classified the violation as immediate jeopardy, the most serious category reserved for situations that pose immediate threat to resident health or safety. The designation was removed on October 29 at 3:38 p.m. after the facility implemented corrective measures, though inspectors noted the home remained out of compliance while monitoring continued.
Following the violation, facility administrators launched extensive retraining. On October 29, the Regional Nurse and Area Director educated the Director of Nursing and two Assistant Directors of Nursing on discharge planning processes through an in-service titled "Discharge planning process - Safe discharge."
The same day, facility interdisciplinary team staff including the Social Worker, Human Resources, Admissions, Director of Rehabilitation, two MDS coordinators, medical records, dietary manager, staffing coordinator, central supply staff and two Assistant Directors of Nursing received education from the Regional Nurse, Area Director and Regional Social Worker.
All IDT staff achieved 100% accuracy on a post-test covering discharge processes.
Eighteen licensed nurses completed training on "Discharge Instructions, Compliance, Regulations" delivered by the Regional Nurse on October 29.
The facility's Regional Director of Operations told inspectors he had trained the Social Worker on discharge planning processes and documentation. He said the Regional Clinical Nurse and Regional Social Worker re-educated the entire IDT team on discharge processes and safe discharges.
The Regional Clinical Nurse confirmed she had trained the Director of Nursing and both Assistant Directors of Nursing on discharge planning processes and documentation.
An audit of 30-day discharges revealed no other residents had been sent to homeless shelters. A facility discharge audit dated October 29 found no other residents were discharged to unsafe locations.
The facility held an ad hoc quality assurance meeting on October 29 that included the Regional Director of Operations, Regional Clinical Nurse, Regional Social Worker, Director of Nursing, MDS coordinator, Medical Director, and Director of Rehabilitation.
By contrast, another resident's discharge proceeded smoothly. During an October 30 interview, Resident #2's family member told inspectors the discharge process went well, with the Social Worker arranging home health services. The family said the only remaining step was picking up their relative. Record review confirmed the Social Worker had placed the home health order.
Inspectors conducted extensive interviews on October 30 from 1:11 p.m. to 5:45 p.m., covering staff across all shifts including morning, day, night, PRN and weekend workers. The interviews included the Director of Nursing, both Assistant Directors of Nursing, nine Licensed Vocational Nurses working various shifts, two MDS coordinators, and the Director of Rehabilitation.
All staff confirmed they had participated in discharge process training and passed proficiency tests before starting their shifts. Every interviewed employee demonstrated knowledge of their responsibilities and could identify IDT team members.
Staff universally understood the facility's discharge process requirements for ensuring safe discharges. They knew what documentation was required, who was responsible for each task, and understood that the Area Director and Regional Clinical Nurse would oversee the entire process.
The immediate jeopardy violation affected few residents, according to federal inspection records. However, the case highlighted gaps in the facility's discharge planning that could have resulted in serious harm to a vulnerable resident who required ongoing medical care.
Federal inspectors noted that while the immediate jeopardy designation was removed after corrective actions, the facility remained under scrutiny as administrators monitored the effectiveness of their remedial plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Park Nursing & Rehabilitation from 2025-10-30 including all violations, facility responses, and corrective action plans.
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