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Complaint Investigation

Forest View Rehab & Nursing Center

November 4, 2025 · Itasca, IL · 535 South Elm
Citations 3
CMS Rating 1/5
Beds 144
Provider ID 145752
Healthcare Facility
Forest View Rehab & Nursing Center
Itasca, IL  ·  View full profile →
Inspection Summary

FOREST VIEW REHAB & NURSING CENTER in ITASCA, IL — inspection on November 4, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

completing self-harm/suicide risk screening assessments accurately, including properly recording the assessment score, completing timely and accurately with appropriate, individualized interventions in place.

Suicide risk assessments need to be completed upon admission, quarterly, upon significant changes, and as needed.The facility created a process to address the results of the self-harm/suicide risk screening assessment to ensure recommendations from the screening, and measurable care plan interventions are put in place to instruct staff on how to keep residents safe.

The facility created a policy and guidelines to the self-harm/suicide risk assessment and implemented on [DATE].Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) starting on [DATE], and will complete on [DATE], to ensure that residents with suicidal ideation will be monitored every shift under behavior monitoring and will be documented in the EMR (Electronic Medical Record).

Residents with a history of obtaining sharp objects will have room searches conducted during angel rounds as permitted by residents or POA (Power of Attorney).Beginning [DATE], an audit tool will be completed by Administrator, DON and or ADON on every resident upon admission, re-admission, quarterly and with significant changes to ensure that suicide risk screening assessments are completed accurately with appropriate individualized care plans as follows: Three times a week for the first two weeks, two times a week for two weeks, one time week for two weeks, and one time a month for two months.QAPI (Quality Assurance Performance Improvement) Committee, which meets monthly, will review for compliance, and determine that compliance has been met. An emergency QAPI meeting was held on [DATE], and attended by the Medical Director and interdisciplinary team.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the administration failed to provide oversight and leadership to ensure staff is qualified to work as a Social Service Director.

The administration also failed to ensure self-harm/suicide risk screening assessments were completed accurately, timely, and individualized and measurable care plan interventions were put in place for residents identified at risk for suicide.

This applies to all 130 residents living in the facility.The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents.

Concerns were identified regarding the accuracy, timeliness, and individualized care plan interventions for multiple residents screened by V12 (SSD-Social Service Director) for self- harm/suicide risk, including R1, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R17. On October 30, 2025, at 3:00 PM, V12's employment record showed on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment record shows V12 has completed four years of high school education. V12 did not have any college education listed in her employment record.

The facility's Job Description for the position title of Director of Social Services shows the education requirements for the position of Director of Social Services as either a bachelor's degree in psychology or sociology, a B.A. (Bachelor of Arts) or M.A. (Master of Arts) in social work, or a Licensed Clinical Social Worker's Certificate.

The facility does not have documentation to show V12 had any of the required education or certificates as shown in her job description. On January 10, 2022, V12 signed the form entitled Job Description for the position title of Director of Social Services.

The form V12 signed shows, I have read this job description and fully understand the requirements set forth therein. On October 30, 2025, at 3:30 PM, V1 (Administrator) said he is not sure if V12 (SSD- Social Service Director) has all the required qualifications to work as the Social Service Director.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis.

This applies to all 130 residents residing in the facility.

The findings include: The Facility Data sheet dated October 24, 2025, shows the facility census as 130 residents. On October 30, 2025, at 3:30 PM, V1 (Administrator) said he is not sure if V12 (SSD- Social Service Director) has all the required qualifications to work as the facility's Social Service Director. On October 30, 2025, at 3:00 PM, V12's employment record shows on July 19, 2021, V12 was hired as the facility's full-time Social Service Director. V12's employment record shows V12 has completed four years of high school education. V12 did not have any college education listed in her employment record.

The facility's Job Description for the position title of Director of Social Services shows the education requirements for the position of Director of Social Services as either a bachelor's degree in psychology or sociology, a B.A. (Bachelor of Arts) or M.A. (Master of Arts) in social work, or a Licensed Clinical Social Worker's Certificate.

The facility does not have documentation to show V12 had any of the required education or certificates as shown in her job description. On January 10, 2022, V12 signed the form entitled Job Description for the position title of Director of Social Services.

The form V12 signed shows, I have read this job description and fully understand the requirements set forth therein.

On November 3, 2025, at 2:37 PM, V18 (Medical Director) said, I was not aware [V12] (SSD) does not have the qualifications necessary to be the Social Service Director.

You cannot hire someone without the right qualifications.

The facility should have followed the regulations and the job description. I did not know this.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ITASCA, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOREST VIEW REHAB & NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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