Village on the Green

In the surveyor’s words

From the most serious findings on record at Village on the Green, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 12, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision, for 1 of 8 residents reviewed for elopement risk, out of a total sample of 8 residents, (#1). On 1/25/25 at approximately 6:20 AM, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised. Resident #1 exited the building without knowledge of staff through an exit door at the end of the Royal Court Hall, which led to the back parking lot. The door did not have a delayed egress bar and the alarm on the door was not loud enough for staff to hear. […]

• No harm, potential for more than minimal, patternF688Jul 28, 2022

  Based on observation, interview and record review, the facility failed to provide services and treatments to prevent further decrease in range of motion for 2 of 3 residents reviewed for positioning and mobility of a total sample of 23 residents, (#1 and #14). Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 7/15/22 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). […]

• No harm, potential for more than minimal, patternF812Jul 28, 2022

  Based on observation, record review and interview, the facility failed to ensure potentially hazardous foods were at a hot holding temperature of 135 degrees Fahrenheit, or above, to prevent foodborne illness. Finding Review of the facility's lunch menu on 7/27/22, revealed the residents had a choice of Baked Ziti or Turkey Enchilada Casserole. The side items included Green Peas, Red Potatoes and Coconut Cake. On 7/27/22 at 11:55 AM, the lunch tray line was observed. There were two cooks and several dietary aides at or near the tray line. Cook A stated the Baked Ziti and Turkey Enchilada Casserole were in the hot box, a full size temperature controlled, hot holding cabinet. The side items were on the steam table. […]

• No harm, potential for more than minimal, patternF758Jan 21, 2021

  Based on observation, record review and interview, the facility failed to ensure the physician justified the continued use and duration of [MEDICAL CONDITION] medication ([MEDICATION NAME]) on an as needed (PRN) basis beyond 14 days for 3 of 7 residents in a total sample of 32 residents, (#25, #14, #199). Findings: 1. Resident #25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed that resident #25 had an active order dated 12/08/20 for [MEDICATION NAME] 1 milligram (mg) three times daily as needed (PRN) for agitation with no stop date. […]

• No harm, potential for more than minimal, isolatedF550Jul 1, 2026

  Based on observation, interview, and record review, the facility failed to preserve the residents' dignity by serving half of the residents at the table over 20 minutes before the other half on one occasion, and by serving the residents' meals on serving trays at the table the next day, for all residents who ate meals in the main dining room at two different meals, for one of one dining room in the facility.Findings: On 6/29/26 at 12:06 PM, in the main dining room, Certified Nursing Assistant (CNA) C brought a lunch cart out and served meals to three residents seated at a long group table. On 6/29/26 at 12:25 PM, almost twenty minutes later, a second cart arrived at the dining room, and the CNA served the other residents seated at the same table. […]