Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Glen Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff served meals in the memory care unit from an unsanitized table in a hallway, placing utensils and food containers directly on the surface without cleaning it beforehand. Food temperatures were not checked before serving, and additional food was served onto a used plate for a resident. These actions did not follow facility policy for safe food handling and had the potential to affect all residents eating in the unit.
A resident with multiple chronic conditions had a critically low potassium level identified, but the facility did not ensure a follow-up laboratory test was completed before discharge. Although medication changes were made, the potassium level was not re-checked, and the nurse practitioner was not informed of the discharge. The resident was later admitted to the hospital for hypokalemia after being instructed to seek emergency care on the day of discharge.
A resident with a complex medical history was discharged from the hospital with an order for warfarin, but the facility failed to administer the medication as ordered. The resident only received a one-time dose, and interviews revealed a lack of communication and follow-up among staff regarding the medication order. The facility's policy to maintain a current list of orders in the electronic record was not followed, resulting in a significant medication error.
Unsanitary Meal Distribution in Memory Care Unit
Penalty
Summary
Staff failed to distribute meals in a sanitary manner in the memory care unit, affecting all 20 residents who eat there. During lunch service, meals were served from a plastic table set up in the hallway outside the dining area. Utensils, plates, cups, and pitchers were placed directly on the table, which was not sanitized before meal service began. The table, located in a hallway accessible to staff, residents, and visitors, had last been cleaned after breakfast, several hours prior. Food was brought to the hallway in a heated carrier, but metal pans containing food were set directly on the unsanitized table, and there was no equipment present to maintain food temperatures during service. No food temperatures were taken before serving, and food was served using utensils that had been placed directly on the table. When a resident requested more food, a used lunch plate was brought back and additional food was served onto it without using a clean plate. Staff interviews confirmed that the table was not sanitized immediately before meal service and that food temperatures were not checked upon arrival or before serving. Facility policy requires food to be handled and served in a manner that minimizes the risk of foodborne illness, but these procedures were not followed.
Failure to Follow Up on Critically Low Potassium Level Prior to Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate follow-up for a critically low potassium laboratory result for a resident with multiple diagnoses, including bacterial pneumonia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The resident was admitted and later discharged without appropriate re-evaluation of a critical potassium level. Medical record review showed that the resident's potassium was critically low at 2.5 mEq/L, and although medication adjustments were made, there was no evidence that the potassium level was re-checked prior to discharge. The discharge paperwork did not include instructions for follow-up laboratory testing. Interviews with facility staff and the nurse practitioner revealed that the nurse practitioner had ordered a repeat metabolic panel to monitor the potassium level, but was not informed of the resident's impending discharge. The resident and family were only notified of the critical potassium level on the day of discharge, at which point they were instructed to go to the hospital. Hospital records confirmed the resident was admitted for hypokalemia with a persistently low potassium level. The facility's policy required a discharge summary and post-discharge plan, but these were not adequately implemented in this case.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, resulting in a significant medication error. Resident #72, who had a complex medical history including a displaced intertrochanteric fracture of the left femur, hemiplegia, and chronic kidney disease, was discharged from the hospital with an order for the anticoagulant medication warfarin. The hospital discharge summary indicated that the resident required 7.5 mg of warfarin, but the facility's medication administration record showed that the resident only received a one-time dose of 7.5 mg during their entire stay. Interviews with various staff members, including LPNs and a Certified Nurse Practitioner (CNP), revealed a lack of communication and follow-up regarding the warfarin order. LPN #270 did not enter the order into the electronic medical record due to needing clarification, and the order was not verified with the provider. CNP #243 was aware of the order but did not instruct the nursing staff to contact the prescriber for clarification. The facility's policy required maintaining a current list of orders in the electronic clinical record, which was not adhered to in this case, leading to the medication error.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwood Skilled Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 4 | 0 |
| Aventura At Oakwood Village | 1.3 mi | ★★★★★ | 8 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 1.8 mi | ★★★★★ | 0 | 0 |
| Allen View Healthcare Center | 2.1 mi | ★★★★★ | 3 | 0 |
| Springfield Nursing & Independent Living | 3.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.