Forest Glen Reahabilitation and Healthcare Center

Based on observation, staff interview, review of the Safety Data Sheet, and policy review, the facility failed to ensure resident medication were secured. This had the potential to affect all residents. The facility census was 23.

Findings include:

Observation on 10/30/25 at 11:02 A.M. on the 500 hall revealed an unlocked treatment cart with topical medication Voltaren Arthritis Pain External Gel one percent prescribed for Resident #8 in an unlocked drawer of the cart. There were no staff visible in the hallway at this time.

Interview on 10/30/25 at 11:04 A.M. the Medication Technician (MT) #21 verified the treatment cart was not locked and there was Voltaren Gel one percent for Resident #8 located in the second drawer of the unlocked cart. The MT #21 verified the treatment cart should be locked when staff were not around.

Review of the Safety Data Sheet (SDS) dated 08/31/16 revealed the medication could be harmful if swallowed or inhaled, and could cause skin irritations.

Review of policy titled Medication Storage undated, revealed the facility should keep all medications, including over the counter medications locked in storage.

Based on review of the fire drill records and staff interview, the facility failed to complete third shift fire drills for three quarters in 2025. This had the potential to effect all 23 residents who resided in the facility. The facility census was 23.

Findings include:

Review of the fire drill records revealed the facility completed a third shift fire drill on 10/24/25 at 5:35 A.M. Further review revealed no third shift fire drills for quarter one of 2025 (January, February, March), quarter two of 2025 (April, May, June) and quarter three of 2025 (July, August, September) were completed.

Interview on 10/30/25 at 4:15 P.M., the Assisted Living Director (ALD) verified the facility had not completed night shift fire drills for quarters one, two and three of 2025.

Based on staff interview and employee file review, the facility failed to ensure employee physicals were completed within 30 days or on the first day of work. This had the potential to affect all 22 residents in the facility. Three employees (Licensed Practical Nurse (LPN) #60, LPN #70, and Resident Care Assistant (RCA) #65) out of five employee files reviewed hired within the last year. The facility census was 22.

Finding include

Review of the employee file revealed LPN #60 had a start date of 08/02/22 and a physical completion date of 08/03/22.

Review of the employee file revealed LPN #70 had a start date of 06/28/22 and a physical completion date of 06/29/22.

Review of the employee file revealed RCA#65 had a start date of 12/20/22 and a physical completion date of 12/21/22.

Interview on 01/04/22 at 4:44 P.M., with Human Resources (HR) #100 revealed the facility had the nurse practitioner complete physicals during the first few days of an employees start date. The HR #100 revealed she was not aware of the requirement for physicals to be done within 30 days prior to the first day of work or on the first day of work.

Based on staff interview and employee file review, the facility failed to ensure employee tuberculosis (TB) assessments were completed and turned in for part of their employee file. This affected all 22 residents who reside in the facility. The facility census was 22.

Finding include

Review of the employee file for Licensed Practical Nurse (LPN) #60 revealed a start date of 08/02/22 no TB testing was on file.

Review of the employee file for LPN #70 revealed a start date of 06/28/22 no TB testing was on file.

Review of the employee file for LPN #80 revealed a start date of 12/20/22 no TB testing was on file.

Interview on 01/04/22 at 4:44 P.M., with the Human Resources (HR) #100 revealed the facility staff consistently fail to submit TB testing information into HR upon completion. HR revealed staff completed a two step TB testing upon hire and would expect the results to be submitted after each step was completed.

Based on medical record review, staff interview and review of the hospital record, the facility failed to ensure the physician was notified of continuity of care changes in medications ordered. This affected one resident (#24) out of three reviewed for medication. The facility census was 22.

Finding include

Review of the medical record for the Resident #24 revealed an admission date of 10/25/22. Diagnoses included acute and chronic respiratory failure, cellulitis, heart failure, atrial fibrillation, diabetes, and dysphagia.

Review of the admission assessment revealed Resident #24 was cognitively intact.

Review of the discharge summary from the nursing home to the assisted living dated 10/25/22 revealed Resident #24 medication list included one half tablet of digoxin (antiarrhythmic medication) 0.125 milligram (mg) daily.

Review of the admission orders revealed Resident #24 was ordered and was entered by the nurse on 10/25/22 for one tablet of digoxin 0.125 mg daily. The order was signed by the physician on 10/30/22. Resident #24 was started on Levaquin (antibiotic) for pneumonia and was on lasix (antidiuretic medication).

Review of the notes dated 11/08/22 to 11/11/22 revealed Resident #24 was having symptoms of dizziness, confusion, and weakness and was transferred to the hospital on 11/11/22.

Review of the hospital discharge summary dated 11/15/22 revealed Resident #24 was diagnosed with digoxin toxicity, pneumonia, and an acute kidney injury and revealed the resident was started on Levaquin for pneumonia and since then had been feeling strange.

Review of the Medication Administration Report (MAR) dated 11/2022 revealed upon Resident #24's return from the hospital on 11/15/22, the order for digoxin was discontinued.

Interview on 01/05/22 at 5:18 P.M., with the Corporate Nurse (CN) #55 verified the timeline according to the residents medical records from the nursing home, assisted living and hospitalization. The CN #55 revealed the facility was informed of the transcribing error when Resident #24 was at the hospital and revealed upon transfer from the nursing home to the assisted living, the nurse transcribed the digoxin dose from one half tablet 0.125 mg to one tablet 0.125 mg. The CN #55 revealed a nursing training was completed on 11/17/22. The CN #55 revealed the admission and transfer process has been changed since this incident. The CN #55 reported the physician that signed off on the order was no informed of the error in question and had not been educated on signing off orders without further review.

Interview on 01/06/22 at 10:25 A.M., with the Physician #99 revealed she was not aware of the transcription medication error (doubling digoxin from a one half tablet 0.125 mg to a full tablet and was unaware she had signed off on a transcription error that took place. The Physician #99 revealed she had not been informed by facility staff or management of the error nor any changes to the admission process because of it. The Physician #99 revealed she would expect communication of an incident such as a possible medication transcription error.

This violation represents non-compliance investigated under Complaint Number OH00138435.