Forest Glen Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Forest Glen Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 10, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observations, resident and staff interview, review of hospital report, review of employee education and in service records, review of the facility fall investigation, review of policy, review of facility audits, the facility failed to ensure Resident #84 was safely assisted during a wheelchair transport resulting in an avoidable fall. […]

• Actual harm, isolatedF690Jul 29, 2022

  Based on medical record review, resident, staff, and urology staff interview, observation, review of the urology consult, review of the hospital record, and policy review, the facility failed to ensure a resident received catheter care and was transported timely to urology follow-up appointments. This resulted in Actual Harm when Resident #29, who had a newly placed suprapubic catheter, missed three follow up appointments and subsequently was sent to the local emergency room where she was given intravenous antibiotics for a urinary catheter complication and a urinary tract infection. This affected one resident (#29) of three residents reviewed for catheter care. […]

• No harm, potential for more than minimal, widespreadF730Apr 11, 2023

  Based 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. Findings include: 1. Review of Certified Resident Care Associate (CRCA) #3's employee file revealed a start date of 06/07/22. Review of the employee file found CRCA #3 had no record of a 90-day evaluation. 2. Review of CRCA #21's employee file revealed a start date of 01/08/20. Review of the employee file found CRCA #21 had no record of a 90-day or annual evaluations. 3. Review of CRCA #32's employee file revealed a start date of 09/20/22. […]

• No harm, potential for more than minimal, patternF812Aug 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, isolatedF550Feb 10, 2026

  Based 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. Findings include: Review of the medical record for Resident #01 revealed an admission date of 04/02/24 with diagnoses of Parkinson's disease without dyskinesia, osteoarthritis, contracture, left hand, muscle wasting and atrophy right thigh, and muscle wasting and atrophy, left thigh. […]