Resident 24 documented the concern on December 26, 2024, telling the facility's administrator at the time that they did not receive their insulin during the Christmas Day shift. The complaint form, reviewed by federal surveyors on November 3, 2025, revealed the medication oversight occurred during what should have been routine diabetes care.
The Assistant Director of Nursing explained to inspectors that staffing complications contributed to the problem. During the 3 PM to 11 PM shift on December 25, 2024, she was performing dual roles — serving as the assigned supervisor while also working as a floor nurse with patient assignments.
"It is difficult to do both roles," she told surveyors during an interview on November 3, 2025.
The missed insulin dose exposed broader medication management issues at Forestville Healthcare Center. Federal inspectors found that staff struggled to identify which medications were scheduled for "liberalized" timing, meaning doses could be given within flexible time windows rather than at exact scheduled times.
When surveyors asked nursing staff to show documentation identifying liberalized medications, they discovered the facility lacked a system to track them. The Registered Nurse Director of Care, identified as RNDCO 15, acknowledged the problem during an interview on October 31, 2025.
The nursing director told the survey team at 12:10 PM that day that they would conduct a facility-wide resident audit to address medication scheduling errors. The audit aimed to ensure medications were properly documented within medical orders for liberalized timing.
Federal regulations require nursing homes to ensure residents receive medications as prescribed by their physicians. For diabetic residents, missing insulin doses can lead to dangerous blood sugar spikes that require immediate medical attention.
The inspection, completed on November 6, 2025, classified the violation as causing minimal harm with few residents affected. However, the nearly year-long gap between the resident's complaint and the federal review raised questions about the facility's internal monitoring systems.
The current facility administrator acknowledged the concerns when surveyors shared their findings on November 5, 2025, at 9:38 AM. The administrator confirmed understanding of the medication scheduling problems identified during the inspection.
Forestville Healthcare Center, located at 7420 Marlboro Pike, serves residents requiring skilled nursing care and rehabilitation services. The facility's medication management policies came under scrutiny following the Christmas Day incident and subsequent resident complaint.
The missed insulin dose represented more than a single medication error. It highlighted systemic challenges in maintaining proper staffing levels during holidays and ensuring accurate documentation of flexible medication timing protocols.
Dual-role assignments, where supervisors also carry patient care responsibilities, can compromise oversight of critical functions like medication administration. The Assistant Director of Nursing's acknowledgment of the difficulty managing both roles simultaneously underscored staffing pressures that can affect patient care quality.
The facility's plan to conduct a comprehensive medication audit suggested recognition that the problem extended beyond a single resident's missed dose. Such audits typically review all residents' medication orders to identify scheduling discrepancies and documentation gaps.
For Resident 24, the Christmas Day without insulin represented a failure of the basic care they expected from their nursing home. The resident's decision to formally document the concern the following day demonstrated awareness that missing diabetes medication posed serious health risks.
The inspection findings revealed a facility struggling with fundamental medication management practices nearly a year after a resident's formal complaint. Despite the administrator's acknowledgment of the problems, the delayed response raised questions about how quickly Forestville Healthcare Center addresses resident safety concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forestville Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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