Forest Glen Health Campus: Critical Lab Result Ignored - OH
Forest Glen Health Campus sent Resident #74 home on May 31 with a potassium level of 2.5 milliequivalents per liter from blood work taken two days earlier. Normal potassium ranges from 3.5 to 5.3 mEq/L. Levels below 2.5 can cause dangerous heart rhythm problems.
The resident had been at the facility for 17 days recovering from bacterial pneumonia, diabetes complications, chronic lung disease, and obesity. They were cognitively intact throughout their stay.
When the critical lab result came back on May 29, staff called Nurse Practitioner #112, who immediately changed medications to correct the dangerous deficiency. He increased the resident's daily potassium supplement from 20 mEq to 40 mEq and gave two additional 40 mEq doses that day.
The nurse practitioner wanted a metabolic panel to recheck the potassium level after the medication changes.
Nobody told him the resident was being discharged two days later.
"I would have had her potassium level re-checked sooner and before discharge," the nurse practitioner told inspectors during a phone interview on August 20.
Instead, the facility's former assistant director of nursing called the resident and family on May 31 to report the critical potassium level from two days earlier. The assistant director didn't realize medication changes had already been made, according to the current director of nursing.
The discharge paperwork contained no instructions for laboratory follow-up.
Hospital records show the resident arrived with a potassium level of 2.9 mEq/L, still critically low despite the medication adjustments. The patient was admitted for hypokalemia and remained hospitalized for treatment.
The breakdown occurred despite facility policy requiring discharge summaries and post-discharge plans "to assist the resident to adjust to his/her new living environment." The policy, dated October 2022, emphasizes that facilities must allow residents to remain rather than transfer or discharge them inappropriately.
Director of Nursing staff confirmed during interviews that the resident's potassium was never rechecked between the critical result on May 29 and discharge on May 31.
The communication failure left the nurse practitioner unaware of the discharge timeline while facility staff proceeded without confirming whether his medication changes had corrected the life-threatening electrolyte imbalance.
Federal inspectors found this represented a failure to provide appropriate treatment according to medical orders and resident needs. The violation affected one of four closed medical records reviewed during the complaint investigation at the 71-bed facility.
Low potassium can cause muscle weakness, cramping, and potentially fatal heart arrhythmias. Patients with diabetes, like Resident #74, face higher risks of electrolyte imbalances, particularly during illness recovery.
The resident's case illustrates how communication gaps between medical providers and nursing staff can create dangerous situations for patients transitioning from facility care back to their homes.
Resident #74 ultimately required emergency hospitalization for the same condition the nursing home was supposed to be monitoring and treating during their rehabilitation stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Glen Health Campus from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Forest Glen Rehabilitation and Healthcare Center in SPRINGFIELD, OH was cited for violations during a health inspection on August 26, 2025.
Forest Glen Health Campus sent Resident #74 home on May 31 with a potassium level of 2.5 milliequivalents per liter from blood work taken two days earlier.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.