Village Health Care at The Glen

In the surveyor’s words

From the most serious findings on record at Village Health Care at The Glen, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 16, 2026

  Based on record review, surveillance video review, observation, and interviews, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for Resident #1, who was cognitively impaired, on 01/09/2026 at approximately 7:58 a.m. when S4 CNA was observed on surveillance video physically abusing Resident #1. S4 CNA was observed to forcibly lift Resident #1 from a sitting to standing position three times by gripping Resident #1's left upper arm while yelling at Resident #1 Get up! resulting in multiple areas of bright purple purpura (bruising) to posterior left upper arm. […]

• No harm, potential for more than minimal, patternF656Jun 24, 2026

  Based on record reviews and interviews, the facility failed to develop an individualized care plan for 3 (#11, #12, #70) of a total sample of 38 residents reviewed. The facility failed to develop a care plan for Resident #11's indwelling catheter, Resident #12's dementia and Resident #70's pressure ulcer. Findings: Resident #11 Review of resident #11's comprehensive plan care with S4 MDS (Minimum Data Set) Coordinator failed to reveal the facility develop a plan of care for resident #11's indwelling Foley catheter. Review of resident #11 's Physician's orders revealed an order dated 05/14/2026 for Indwelling Foley catheter 16 Fr (French) /10 ml (milliliters) change every month and as needed for occlusion, leaking, or dislodgment. Once a day on the 3rd of the month; 07:00 a.m. - 3:00 p.m. […]

• No harm, potential for more than minimal, patternF692Jun 24, 2026

  Based on record reviews and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to ensure weights were obtained monthly for 2 (#2, #9) of 3 (#2, #3, #9) residents reviewed for nutrition. Findings:Review of undated Policy titled Weighing and Measuring the Resident revealed:PurposeThe purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident.Preparation1. Review the resident's care plan to assess for any special needs of the resident.4. […]

• No harm, potential for more than minimal, patternF695Jun 24, 2026

  Based on record review, observations and interview, the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards of practice for 1 (#4) of 3 (#4, #61, #80) residents reviewed for respiratory care. The facility failed to ensure Resident #4's oxygen tubing was changed weekly, nebulizer tubing was dated, and nebulizer mouthpiece was stored properly when not in use. Findings:Review of undated policy titled Departmental (Respiratory Therapy) - Prevention of Infection revealed:PurposeThe purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.Preparation1. […]

• No harm, potential for more than minimal, patternF604May 15, 2025

  Based on observations, record reviews, and interviews the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#30, #52, and #78) of 5 (#9, #30, #41, #52, and #78) residents reviewed for restraints. The facility failed to ensure: 1) Consent was obtained for the use of a gerichair with lap tray for Resident #30; 2) The facility failed to have documented evidence of monitoring of resident condition when lap trays were in use for Resident #30 and Resident #78; 3) Resident care plans were developed with problems and approaches related to the use of a gerichair with lap tray for Resident #30 and Resident #78 and; 4) Quarterly restraint assessments were conducted for the use of bed and chair alarms for Resident #52. […]