The exposed black and white wires hung from a conduit tube under the window at Forest City Rehab & Nursing Center, wrapped only in black electrical tape instead of proper wire caps. When maintenance staff tested the wires with a voltage detector on November 18, the device immediately started flashing and emitting warning tones.
"There is 120 volts of electrical power coming through the wires," the maintenance worker told inspectors. "The wires should be enclosed with wire caps rather than electrical tape."
The facility's own preventative maintenance program, dated February 2019, requires all electrical equipment to be checked for safety.
Meanwhile, nursing assistants repeatedly ignored safety protocols when transferring residents at high risk for falls.
R147 required partial to moderate assistance for all transfers due to his history of frequent falls, a previous stroke, and bilateral carotid stenosis that restricts blood flow to his brain. His restorative assessment specifically documented his need for staff assistance with transfers and toileting.
On November 17 at 9:01 AM, two certified nursing assistants entered R147's room to provide care. One wheeled him into the bathroom via wheelchair, then transferred him from the chair to the toilet by placing her arm under his left arm and guiding his buttocks onto the seat.
She never used a gait belt.
The second nursing assistant stood in the bathroom doorway and watched the entire transfer without intervention.
The facility's restorative nurse explained the next day that R147 required partial to moderate assistance from one staff member for all transfers, which must include use of a gait belt to ensure his safety. She emphasized that R147 was at high risk for falls due to his previous falls within the facility.
Forest City Rehab's own gait belt policy, updated in January 2025, states the equipment's purpose: "To provide support and safety during ambulation, lifting, or transferring residents." The policy requires staff to place the belt around the resident's waist, ensure it fits snugly, then grasp the belt webbing securely at the resident's back and side to support balance during transfers.
The nursing assistants ignored these requirements entirely.
Federal inspectors found these safety violations during a complaint investigation completed November 19. The deficiencies affected few residents but created minimal harm or potential for actual harm, according to the inspection report.
The exposed electrical wires presented an immediate shock hazard in a resident's living space. Proper electrical safety requires live wires to be enclosed with appropriate caps and secured within conduits, not left dangling with only tape covering.
For R147, the failure to use required safety equipment during transfers created unnecessary fall risk. His medical conditions already made him vulnerable to losing balance or experiencing sudden weakness. The gait belt provides crucial support and control during the vulnerable moments when residents move between surfaces.
The nursing assistant who performed the transfer demonstrated either ignorance of safety protocols or willful disregard for them. Her colleague's passive observation suggested the unsafe practice was routine rather than an isolated incident.
Both violations reflected broader breakdowns in the facility's safety oversight. Maintenance staff had apparently failed to properly secure electrical work in resident living areas. Nursing supervisors had not ensured their assistants followed basic transfer protocols for high-risk residents.
The inspection occurred nearly six years after the facility established its preventative maintenance program and ten months after updating its gait belt policy. The time gap suggested ongoing implementation failures rather than newly identified problems.
R147's stroke history and carotid stenosis made him particularly vulnerable to injury from falls. Bilateral carotid stenosis reduces blood flow to the brain, potentially causing dizziness, weakness, or sudden loss of consciousness. His documented history of falls within the facility should have prompted extra caution from staff.
Instead, nursing assistants treated his transfer as routine, skipping the safety equipment designed to prevent exactly the kind of fall that had already occurred multiple times.
The exposed electrical wires in R149's room created a different but equally serious hazard. Live 120-volt current can cause severe burns, cardiac arrhythmia, or death upon contact. Electrical tape provides minimal insulation compared to proper wire caps and secure conduit installation.
The resident's decision to point out the wires to inspectors suggested ongoing concern about the hazard in his living space. The maintenance worker's immediate recognition that proper wire caps were needed indicated staff awareness of the safety violation.
Forest City Rehab's preventative maintenance program promised regular safety checks of electrical equipment. The dangling live wires demonstrated either inadequate inspection procedures or failure to address known hazards promptly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest City Rehab & Nrsg Ctr from 2025-11-19 including all violations, facility responses, and corrective action plans.