Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
Failure to Maintain Resident Grooming and Dignity: A resident with Parkinson’s disease, moderate cognitive impairment, and extensive ADL dependence was observed with multiple long chin hairs that staff did not address. The resident stated staff did not assist with her care needs and was not given a razor or informed about the facial hair, while a CNA confirmed the resident could not shave herself, needed staff help, did not refuse shaving, and had not been shaved despite a recent bed bath. An RN also confirmed the resident should be offered shaving with each bath.
Failure to Timely Report Abuse Allegations: A resident with major depressive disorder and dementia with severe cognitive impairment was involved in multiple incidents of being found naked with another resident, including in bed and kissing/fondling. Staff separated the residents and continued 15-min checks, but the abuse allegations were not reported to the state agency within the required 2-hour timeframe; the DON/Administrator stated she believed she had 24 hours because there was no bodily injury.
A resident with dementia with agitation and major depressive disorder had repeated aggressive and agitated behaviors, including spitting at an LPN, becoming combative during redirection, and attempting physical contact with male residents. The care plan did not address these behaviors, and the MDS coordinator confirmed there was no behavioral care plan in place despite documented aggression and severe cognitive impairment.
A resident with CHF, DM2, sepsis, A-fib, and brain compression had a care plan that listed an 1800 ml fluid restriction, but the current MD order changed the restriction to 2000 ml/24 hr. MDS staff verified the care plan was not updated to match the new order and still reflected the old restriction, despite the facility policy stating care plans are revised as resident information and conditions change.
A memory care unit failed to adequately supervise two residents with severe cognitive impairment who were repeatedly found naked together in bed, kissing, and fondling each other despite 15-min checks and later 1:1 supervision being initiated. The facility also failed to ensure a proper transfer for a resident with hemiplegia, moderate cognitive impairment, and dependence for transfers; a CNA continued a wheelchair-to-recliner transfer even though the resident did not stand fully, causing the resident to strike the wheelchair and develop bruising while on Eliquis.
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.
Failure to Maintain Resident Grooming and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when staff did not address long unwanted facial hair on the resident’s chin. Resident #01 was admitted with diagnoses including Parkinson’s disease without dyskinesia, osteoarthritis, contracture of the left hand, and muscle wasting and atrophy of both thighs. The quarterly MDS documented moderate cognitive impairment, range of motion impairment in both upper and lower extremities, and dependence on staff for multiple ADLs, including partial assistance with oral hygiene and substantial to total assistance with bathing, personal hygiene, toileting hygiene, dressing, transfers, bed mobility, and wheelchair mobility. Observations showed the resident resting in bed with multiple chin hairs present, including hairs approximately 1/2 inch long and later inch-long hairs. During an interview, the resident stated staff did not assist with her care needs and confirmed no one gave her a razor or told her about the chin hair, even though she had received a bed bath the day before. A CNA confirmed the resident was unable to shave herself, needed staff assistance, did not refuse shaving, and had multiple inch-long chin hairs present, but the CNA did not shave her and did not know an electric razor was available in the bathroom. An RN also confirmed she was unaware of the long chin hairs and stated the resident should be offered shaving with each bath. The facility’s ADL policy stated residents unable to perform their own care would receive services to maintain good grooming and personal hygiene.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the state agency within the required timeframe. Resident #48, who had diagnoses of major depressive disorder and dementia with behavioral disturbance and a BIMS score of 3 indicating severe cognitive impairment, was involved in multiple incidents in which staff found the resident naked with another resident, including one incident in another resident’s bed, one incident of kissing a male resident, and one incident of both residents being naked and fondling one another. In each event, staff separated the residents and continued 15-minute safety checks. The facility’s self-reported incident forms showed that the abuse allegations were reported to the state agency 10 hours and 17 minutes after the first discovery, 2 hours and 2 minutes after the second discovery, and 8 hours and 8 minutes after the third discovery. During interview, the Administrator stated she did not file the reports within two hours because she was confused about the timing of reporting and believed she had 24 hours since there was no bodily injury. The facility policy stated alleged abuse must be reported immediately, but not later than two hours if the allegation involves abuse or serious bodily injury.
Failure to Include Behavioral Care Planning
Penalty
Summary
The facility failed to ensure that Resident #55’s comprehensive care plan addressed aggressive behaviors. The resident was admitted on 11/25/25 with diagnoses including dementia with agitation and major depressive disorder. The care plan dated 11/26/25 did not include a plan for aggressive behaviors, and the MDS showed a BIMS score of 6, indicating severe cognitive impairment with disorganized thinking that fluctuated. Nursing notes documented multiple behavior-related incidents, including the resident attempting to initiate physical contact with a male resident and becoming agitated when staff redirected her, spitting in a nurse’s face during medication administration, and becoming increasingly agitated and combative when redirected away from another male resident. During interview, the MDS coordinator confirmed there was no behavioral care plan for aggressive behaviors and verified that the resident had exhibited aggressive behaviors. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident and incorporate identified problem areas.
Care plan not revised after fluid restriction changed
Penalty
Summary
The facility failed to timely revise a resident's care plan after a change in fluid restriction. Resident #10 was admitted on 10/29/25 with diagnoses including type two diabetes, sepsis, atrial fibrillation, congestive heart failure, and compression of brain. The resident's care plan dated 10/29/25 identified risk for fluid volume deficit related to congestive heart failure, diuretic use, and fluid restriction, and noted the resident was non-compliant with the fluid restriction. The interventions listed an 1800 ml fluid restriction divided among meals and nursing/snacks, along with labs as ordered and weight monitoring per physician order. Review of current physician orders showed a later fluid restriction order of 2000 ml in 24 hours, with specific amounts assigned to dietary and nursing across shifts. During interview, MDS #198 stated care plans are updated when an acute process occurs, when the MDS update is due, and that anyone can update or revise care plans, and verified the care plan had not been updated to reflect the new 2000 ml restriction. The care plan still reflected the prior 1800 ml fluid restriction. The facility policy stated that assessments are ongoing and care plans are revised as information about residents and their conditions change.
Inadequate supervision of residents with sexual behaviors and improper transfer causing injury
Penalty
Summary
The facility failed to provide adequate supervision related to residents’ sexual behaviors on the memory care unit. Resident #48 had diagnoses including major depressive disorder and dementia with behavioral disturbance and a BIMS score of 3, indicating severe cognitive impairment. Resident #73 also had dementia, major depressive disorder, generalized anxiety disorder, and a BIMS score of 3. The record shows repeated incidents in which the two residents were found naked together in bed, kissing, or fondling one another in each other’s rooms. Staff separated the residents after each event, and the facility initiated 15-minute checks and later one-on-one supervision, but the residents continued to be found together during subsequent rounds. The facility’s own incident reporting and staff interviews showed that the supervision in place was not maintained. After the first incident, 15-minute checks were started, and after the second incident one-on-one supervision was implemented. However, on a later occasion, while staff were occupied with cleaning up Resident #73’s roommate after the roommate had died, the staff member assigned to stay with Resident #73 also left to help, leaving Resident #73 unattended. During that time, Resident #73 went into Resident #48’s room and both residents were found lying in bed naked and fondling each other. The Administrator stated that if one-on-one supervision had been completed as intended, the residents would not have been able to get into bed together. The facility also failed to ensure a proper transfer for Resident #28, who had hemiplegia and hemiparesis following cerebral infarction, COPD, hypertensive CKD, CHF, moderate cognitive impairment, and required substantial assistance with transfers. Resident #28 reported that while being transferred from a wheelchair to a recliner, staff did not lift her all the way and she hit her side on the wheelchair. Bruising was observed from the right lateral chest to the right hip and groin, and the resident was on Eliquis. A CNA confirmed she continued the transfer even though the resident was not able to stand fully and did not ask for assistance when she noticed the resident was not standing up fully. The facility’s investigation identified the transfer as improper, and the witness statement and root cause analysis confirmed the event.
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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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 July 2026) and official state health department websites.