Forest Park Health Campus
FOREST PARK HEALTH CAMPUS in RICHMOND, IN — inspection on February 25, 2026.
Found 6 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.
Inspection Findings
normally one or two nurses also scheduled to work the night shift with her, but not all of them would
shift to have his shower.
When she worked alone on third shift, she would answer a resident's call
resident. By the time she got to the final call light, that resident had waited at least thirty minutes for her to answer their call light.
This was typically how a night working alone as the only CRCA in the facility went.
The nursing schedules, dated 1/30/26 through 2/24/26, were provided by the ED on 2/20/26 at 2:00 p.m.
They indicated only one CRCA worked or was scheduled to work from 10:00 p.m. to 6:00 a.m. on the following dates: 1/30/26, 2/3/26, 2/6/26, 2/16/26, 2/20/26, and 2/24/26.
An interview was conducted with the DHS on 2/23/26 at 1:00 p.m.
She indicated they started tracking call light response times in November of 2025, after it was identified as a concern.
The activity director usually responded to resident council about their concerns.
The Perineal Care for Incontinence policy was provided by the ED on 2/25/26 at 12:20 p.m. It indicated, OVERVIEW To provide incontinence care that will keep skin from being exposed to prolonged periods of urine and feces.
The Guidelines for Answering Call Lights policy was provided by the ED on 2/25/26 at 12:20 p.m. It indicated, The purpose of this policy is to: To respond to the resident's request and needs.Answer the resident's call light as quickly as possible.
The Resident Rights Guidelines policy was provided by the ED on 2/23/26 at 1:44 p.m. It indicated, The purpose of this policy is to: To ensure resident rights are respected and protected and provide an environment in which they can be exercised.1.
Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus.
The following is a list of rights recognized by staff at [name of facility:] 2.
Our residents have a right to.a. Be treated with dignity and respect. 410 IAC (Indiana Administrative Code) 3.1-3(t)
155762 02/25/2026
Forest Park Health Campus 2401 South L St Richmond, IN 47374
establish a grievance policy and make prompt efforts to resolve grievances.
family grievance, regarding missing pajamas, for 1 of 1 resident reviewed for personal property.
p.m.
Her diagnoses included, but were not limited to: dysphagia, chronic kidney disease, chronic obstructive pulmonary disease (a progressive, treatable, but generally irreversible lung disease characterized by long-term inflammation and restricted airflow,) and diabetes.
She received hospice services at the facility. An interview was conducted with Family Member 5 on 2/20/26 at 12:18 p.m.
She indicated Resident 39 was currently missing a set of red plaid pajamas and a set of green plaid pajamas.
The pajamas had been missing since Christmas of 2025.
She'd asked staff about it several times since then, including several Certified Resident Care Assistants (CRCAs) and a nurse, described as Licensed Practical Nurse (LPN) 7.
The Executive Director (ED) provided the grievance log from 9/1/25 to present on 2/23/26 at 12:38 p.m. It did not include any missing pajamas for Resident 39. An interview was conducted with the ED and Social Services Director (SSD) on 2/24/26 at 2:50 p.m.
The ED indicated she had not heard anything about missing pajamas for Resident 39.
Typically, staff should fill out a grievance form for missing items.
The SSD indicated she hadn't heard anything about missing pajamas for Resident 39 either. Resident 39's family member did not mention the missing pajamas at her care plan meeting a few days ago, but they did not ask specifically about missing items, just about any general concerns. An interview and observation were conducted with the Director of Environmental Services (DES) on 2/24/26 at 3:07 p.m.
The DES was coming out of Resident 39's room, holding several pajama pieces in her hand.
She indicated no one mentioned anything to her about the missing pajamas until today.
They kept notes posted in the laundry room of missing items, but none of them were for Resident 39.
She found the articles she was currently holding in the laundry room and had just checked to see if they were the ones missing, but they weren't.
The Resident Concern Process policy was provided by the ED on 2/23/26 at 12:38 p.m. It indicated, Purpose To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service.
Procedures: 1.
The facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon. 2.
The facility will be committed to the on-going education of their employees on immediately responding to and resolving customer concerns. 3.
The facility staff will follow the Resident Concern Process flow chart when any concern or complaint is voiced.5.
Enter the concern using the desktop icon labeled ?Resident Concern Form'.
All concerns should be entered electronically, however Environmental and Dining departments may use a paper Resident Concern Form, submitting to their supervisor who will enter.
We never ask a family member to complete the form. 6.
Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution. 7.
Follow up from the department leader will occur within 24-48 [sic] with resolution entered in [name of database.] 8.
The Executive Director will review and manage the follow up of the concerns. 410 IAC (Indiana Administrative Code) 3.1-7(b)
155762 02/25/2026
Forest Park Health Campus 2401 South L St Richmond, IN 47374
During an observation and interview, on 2/19/2026 at 1:06 p.m., Resident 10 was observed in bed. Resident 10's fingernails were long and had yellow substance under them. Resident 10 indicated he would like his fingernails trimmed.During an observation and interview, on 2/20/2026 at 11:30 a.m., Resident 10 was observed in bed. Resident 10's fingernails were long and he indicated he would like his fingernails trimmed.During an observation and interview, on 2/23/2026 at 11:46 a.m., Resident 10 was observed in bed. Resident 10's were long. LPN 4 indicated Resident 10's fingernails nailed needed to be trimmed and Resident 10 was not a diabetic so it should be completed with Resident 10's bathing.
During an interview, on 2/23/2026 at 2:14 p.m., Director of Health Services indicated nail care should be provided to residents weekly during bathing and as needed.
The direct care nurses and aides were responsible for providing nail care. 410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(E)
155762 02/25/2026
Forest Park Health Campus 2401 South L St Richmond, IN 47374
During an interview, on 2/23/2026 at 2:14 p.m., Director of Health Services indicated direct care nurses and aides were responsible for ensuring the palmgrip or other padding was in place for Resident 10's left hand contracture.410 IAC (Indiana Administrative Code) 3.1-42 (a)(2)
155762 02/25/2026
Forest Park Health Campus 2401 South L St Richmond, IN 47374
During an observation on 2/23/2026 at 10:45 a.m., the Assistant Director of Health Services (ADHS) and Certified Resident Care Assistant (CRCA) 5 placed a gait belt around Resident 43's waist, the staffs' hands were underneath the resident's arms and transferred the resident from the geriatric chair to the bed.
The resident was unable to bare weight on either of her legs and moaned during the transfer.
The ADHS and CRCA 5 had to lift the resident underneath her arms to get her to the bed, the resident was totally dependent on the staff during the transfer. CRCA 5 indicated the resident needed to be transferred a 100% (percent) by a mechanical lift, it was not fair to the resident because staff had to tug on her.
The ADHS and CRCA transferred the resident with a gait belt and their hands underneath the resident's arms from the bed back to the geriatric chair and the resident did not bare weight and moaned during the transfer.
The ADNS indicated he would report the resident was not baring weight during transfers and have therapy assess the resident.
Review of the clinical record for Resident 43 on 2/23/26 at 1:00 p.m., indicated the resident's diagnoses included, but were not limited to, chronic kidney disease, depression, hemiplegia and hemiparesis (paralysis) left non dominant side and cerebral infarction (stroke caused by blockage).
The admission Minimum Data Set (MDS) assessment for Resident 43, dated 1/29/26, indicated the resident severely impaired for daily decision making.
The resident was totally dependent on staff for transfers.
The care profile for Resident 43, dated 1/26/26, indicated the resident was to be transferred using a mechanical lift.
During an interview with the Director of Health Services (DHS) on 2/23/2026 at 12:50 p.m., the DHS indicated a lift assessment should have been completed for Resident 43 if the resident was unable to bare weight during a transfer.
During an interview with the ADHS on 2/23/2026 at 1:19 p.m., the ADHS indicated it was communicated to staff how to transfer residents by the care profile in the electronic health record.
During an interview with CRCA 5 on 2/23/2026 at 1:25 p.m., the CRCA indicated she reported that Resident 43 was unable to bare weight during transfer to nursing, but was unable to remember which nurse she had reported it to. 410 IAC (Indiana Administrative Code) 3.1-45(a)(2)
155762 02/25/2026
Forest Park Health Campus 2401 South L St Richmond, IN 47374
Review of the clinical record of Resident 67 on 2/23/2026 at 1:45 p.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypercapnia and acute and chronic respiratory failure with hypoxia, acute.
The post form for Resident 67, dated 10/30/25, indicated the resident wished to be a Do Not Resuscitate (DNR).
The post form was signed by Resident 67 and the physician.
The physician's order for Resident 67, dated February 2026 indicated the resident was ordered to be a full code.
The advanced directives policy provided by the Executive Director (E.D.) on 2/23/26 at 1:44 p.m., indicated the facility would ensure to obtain and follow the resident's advanced directives regarding end of life care.
The resident would be advised on admission and quarterly regarding their wishes for end of life directives and code status.
The nursing staff would confirm the code status and obtain a physician order.
The DNR form would be completed documenting these desires and scanned in the medical record. 410 IAC (Indiana Administrative Code) 3.1-50(a)(2)