Forest Glen Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, observations, resident and staff interviews and policy review, the facility failed to ensure residents were treated with dignity when they failed to ensure residents did not have long unwanted facial hair. This affected one (#01) out of one residents reviewed for dignity. The facility census was 74.

Inspectors wroteBased on record review, review of facility self-reported incidents (SRI), staff interview, and policy review, the facility failed to ensure an allegation of abuse was reported to the state agency in a timely manner as required. This affected one (#48) of three residents reviewed for abuse. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the comprehensive care plan was developed to address a resident's aggressive behaviors. This affected one (#55) of two residents reviewed for behaviors. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to timely revise a resident's care plan regarding a change in fluid restrictions. This affected one (#10) of 23 residents reviewed for care plan revisions. The facility census was 74.

Inspectors wroteBased on record review, review of facility self-reported incidents (SRI's) observations, staff interviews, and policy review, the facility failed to provide adequate supervision regarding residents sexual behaviors on the memory care unit. This affected two (#48 and #73) of two residents reviewed for supervision. Additionally, the facility failed to ensure residents were transferred in a proper manner. This affected one (#28) of one reviewed for transfers. The facility census was 74.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to distribute meals in a sanitary manner in the memory care unit. This had the potential to affect all 20 residents that eat in the memory care unit. The census was 71. Findings Include:Observation of lunch being served in memory care unit on 08/19/25 at 11:28 A.M. revealed meals are served from a plastic table set up in the hallway outside the dining area. Utensils used to serve food, plates, cups, and pitchers of drinks were sat directly on the table. The table was not observed to be sanitized before the start of meals service. Food was brought to the hall by a heated carrier at 11:50 A.M. Metal pans of mashed potatoes, salisbury steak, and brussel sprouts were set directly on the table by Activity Assistant (AA) #102. There was not a steam table or any appliance to maintain food temperatures. [...]

Inspectors wroteBased on medical record review, staff interview, nurse practitioner (NP) interview, and review of facility policy, the facility failed to ensure adequate follow up to a critically low laboratory result. This affected (#74) of four closed records reviewed. The census was 71. Findings Include:Review of Resident #74's closed medical record revealed an admission date of 05/14/25. Diagnoses listed bacterial pneumonia, type two diabetes mellitus, chronic obstructive pulmonary disease, and obesity. Resident #74 was discharged on 05/31/25. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively intact. Review of laboratory results dated [DATE] revealed Resident #74 potassium level was critically low at 2.5 milliequivalents per liter (mEq/L) on 05/29/25. [...]

Inspectors wroteBased on medical record review, review of hospital documentation, staff interview, nurse practitioner interview, and facility policy review, the facility failed to ensure residents received medications as ordered which resulted in a significant medication error. This affected one (#72) of three residents reviewed for medication administration. The facility census was 69. Findings Included: Review of the medical record for Resident #72 revealed an admission dated of 12/13/24. Diagnoses included displaced intertrochanteric fracture of the left femur, hemiplegia, hemiparesis following cerebral infarction affecting the left dominant side, hypertensive chronic kidney disease, tachycardia, and personal history of transient ischemic attack. The resident was discharged on 12/27/24. [...]

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure a resident was transported to and from off campus medical appointments in a timely manner resulting in delayed treatment. This affected one (Resident #24) of three residents reviewed for transportation to outside appointments. The facility census was 66.

Inspectors wroteBased on employee file review and staff interview, the facility failed to ensure nurse aides received performance evaluations at 90 days and annually thereafter. This affected four (#3, #21, #32, and #71) Certified Resident Care Associate (CRCAs) of four employee files reviewed and had the potential to affect all residents. The census was 63.

Inspectors wroteBased on medical record review, staff interview, review of a self-reported incidents, and policy review, the facility failed to timely report an allegation of resident-to-resident physical abuse. This affected two (#46 and #57) out of four residents reviewed for abuse. The census was 63.

Inspectors wroteBased on observation, daily staffing posting review, review of staffing schedules, and staff interview, the facility failed to post an accurate staff posting daily. This had the potential to affect all 63 residents residing in the facility. The census was 63.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure a resident's pain was properly managed when the resident ran out of narcotic pain medication and no alternative pain relief was offered. This resulted in actual harm to Resident #171 who had uncontrolled pain. This affected one (Resident #171) of one resident reviewed for pain management. The facility identified 24 residents on a pain management program. The census was 71.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the pain assessment was completed in Minimum Data Set (MDS) under Section J. This affected one (Resident #171) of one resident reviewed for pain. The facility identified there were 24 residents who were under a pain management program. Medical record review for Resident #171 revealed an admission date of 10/06/19. Diagnoses included a Baker's cyst behind the left knee and pain from the cyst. Review of admission MDS assessment dated [DATE] revealed Resident #171 was cognitively intact. Under Section J for pain management, the pain assessment interview was dashed out and the staff assessment for pain was not completed. Interview with MDS Registered Nurse #4 on 10/23/19 at 9:00 A.M. verified the pain assessment wasn't completed.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure a care plan was developed for a resident with high blood pressure and receiving blood pressure medications. This affected one (Resident #12) of five residents reviewed for unnecessary medications. The census was 71. Medical record review for Resident #12 revealed an admission date of 04/30/19. Diagnoses included Non-Alzheimer's dementia. Review of physician orders dated 05/01/19 revealed the resident was receiving Amlodipine 2.5 milligram (mg) once daily and Metoprolol Tartrate 25 mg, twice daily for blood pressure management. Review of the medical record revealed no care plan related to the patient's high blood pressure or use of blood pressure medication. Interview with the Director of Nursing (DON) on 10/24/19 at 1:48 P.M. [...]

Inspectors wroteBased on record review, observation, staff and resident interviews and policy review, the facility failed to ensure a physician order was obtained for oxygen administration and failed to ensure oxygen tubing was dated. This affected two (Residents #19 and #49) of 11 residents identified as receiving respiratory treatment. The facility census was 71.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to deliver clean laundry for three (Residents #222, #226 and #66) in a sanitary manner. There were 71 facility residents.