Resident #186 entered the facility in March 2020 with Alzheimer's disease, major depressive disorder, and hypertension. By January 2025, she was receiving prescription eye drops for glaucoma at bedtime. Her care plan, created in March 2025, specifically noted impaired visual function and her glaucoma diagnosis.
The facility had clear instructions. A physician's order from April 2023 directed that she be seen by an outside eye doctor as needed. Her care plan included two explicit interventions: arrange consultation with an eye care practitioner as needed, and observe and report acute eye problems to medical providers.
But nothing happened for years.
During a care conference in June 2025, the Social Services Designee educated Resident #186 about available services. The resident said she wanted to see the facility eye doctor. Staff sent in a referral.
Still, no appointment materialized.
Federal inspectors arrived at the 122-bed facility in November following a complaint. They found a resident whose vision needs had been documented, planned for, and ignored.
Director of Social Services #335 confirmed to inspectors that the facility had submitted a referral for Resident #186 in June 2025. But she also confirmed something more troubling: the resident had never seen an eye doctor since her 2020 admission.
Five years. No eye care. Despite glaucoma medication. Despite care plan requirements. Despite a physician's order.
When inspectors interviewed Resident #186 on November 6, she confirmed she wore glasses. But she didn't know where they were.
Certified Nursing Assistant #775 had worked at the facility for nine months. She told inspectors she had never seen Resident #186 wearing glasses.
Not once in nine months of care.
The administrator confirmed what everyone already knew: staff couldn't locate Resident #186's glasses. The administrator also confirmed the resident hadn't seen the facility eye doctor since admission.
Medical records painted a picture of declining vision care. Multiple assessments from December 2024 through June 2025 noted that Resident #186 had adequate vision and corrective lenses. But by September 2025, her assessment showed she was no longer coded for using corrective lenses.
Her glasses had simply vanished from the record, along with any meaningful attempt to address her eye care needs.
The resident's cognitive abilities deteriorated during her stay. The September assessment revealed severely impaired cognition and a need for staff assistance with daily activities. Her ability to advocate for her own vision needs had diminished along with her mental capacity.
Meanwhile, her glaucoma medication continued. Eye drops at bedtime, every night, for a condition that requires regular monitoring by eye care professionals. The medication without the medical oversight. The treatment without the doctor.
Federal regulations require nursing homes to help residents access vision and hearing services. The facility's own 2017 policy promised that residents would be referred for eye care appointments as needed.
Forest Hills Healthcare Center had the policy. They had the physician's orders. They had the care plan interventions. They had a resident who explicitly requested eye care services.
What they didn't have was follow-through.
The inspection found minimal harm, but the implications extend beyond one resident's missing glasses. When a facility loses track of basic medical equipment and fails to arrange routine specialist care for five years, it raises questions about systematic oversight of resident needs.
Resident #186 represents a particular vulnerability in long-term care: patients whose cognitive decline makes them less able to repeatedly request services, even as their medical needs persist or worsen. Her glaucoma didn't disappear because staff misplaced her glasses. Her need for eye care didn't diminish because administrators failed to schedule appointments.
The complaint that triggered this inspection suggests someone noticed the gap between documented needs and actual care. But it took an outside complaint to reveal what should have been obvious to facility staff: a resident with glaucoma and missing glasses probably needs attention from an eye doctor.
Forest Hills Healthcare Center now faces federal citation for failing to ensure one resident received necessary vision services. The citation stems from complaint number 2655929, filed by someone who recognized that five years without eye care isn't acceptable medical practice.
Resident #186 continues to receive her nightly glaucoma medication. Whether she'll ever see clearly enough to know where her glasses went remains an open question.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Hills Healthcare Center. from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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