Village Health Care at the Glen

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to ensure resident's medical records reflected the resident's advance directive wishes for 1 (#92) of 1 resident reviewed for advance directives. The facility failed to ensure resident #92's medical records were consistent with the resident's wishes.

Inspectors wroteBased 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. S4 CNA further picked up Resident #1 by her underarms and S4 CNA dropped Resident #1 in wheelchair at the time of transfer. [...]

Inspectors wroteBased on record review, observation, and interviews, the provider failed to develop and implement a comprehensive person centered care plan for each resident as evidenced by failing to implement care plan intervention for falls for 1 (#1) Resident out of 3 residents reviewed for falls.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident's environment remained free of accident hazards by failing to ensure a resident's room floor maintained non-skid traction for 1 (Resident #3) of 3 residents reviewed for falls.

Inspectors wroteBased 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.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medication had a Gradual Dose Review (GDR) attempted for 1 (#30) of 5 (#4, #5, #30, #51, #77) residents reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews the facility failed to develop and implement resident's comprehensive person-centered care plans by: 1. The facility failed to develop a care plan with a focus and appropriate approaches on bed rails/side rails for 2 (#9, #41) of 5 (#9, #30, #41, #52, #78) residents reviewed for restraints. 2. The facility failed to implement 1 (#24) of 3 (#19, #24, #90) residents reviewed for nutrition. The facility failed to ensure Resident #24 was weighed weekly as per the physician order.

Inspectors wroteBased on record reviews, observation and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#6) of 2 (#6, #24) residents reviewed for pressure ulcers. The facility failed to identify, assess, and treat pressure wounds for Resident #6.

Inspectors wroteBased on record review, observations, and interviews the facility failed to provide respiratory care consistent with professional standards for 1 (#72) of 1 resident reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer mask and tubing were labeled, dated and stored properly when not in use, and failed to develop a care plan for respiratory treatments with appropriate approaches.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure medications (inhalations vials) for nebulizer treatments were stored properly for 1 (#72) of 1 resident reviewed for respiratory.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure equipment was in safe operating condition. The facility failed to perform glucometer control checks for 2 Households (X and Z) according to the facility's policy and procedures. This deficiency has the potential to effect 6 residents (#74, #43, #5, #31, #7, #41) residing in Household X and 3 residents (#14, #21, #346) residing in Household Z.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set) assessments accurately reflected the resident's status for 1 (#24) of 20 (#3, #5, #6, #9, #19, #24, #26, #28, #30, #41, #51, #52, #58, #59, #72, #77, #78, #90, #94, #95) sampled residents reviewed. The facility failed to ensure for Resident #24's most recent MDS assessment dated [DATE] accurately reflected Resident #24's functional ability.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' environment was as free of accident hazards as possible by failing to evaluate residents' fall risk and implement interventions to reduce fall risk for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents.

Inspectors wroteBased on record reviews, observations and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #3) of 3 sampled residents. The facility failed to ensure medications were administered for Resident's #1 and #3 in accordance with the physician's orders and /or within their liberalized medication time blocks.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure 1 (#3) of 3 sampled resident's environment remains as free of accident hazards as possible. The facility failed to have Resident #3's fall mats in place as ordered to prevent injuries.

Inspectors wroteBased on record reviews, observations, and interview, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, obtaining a written order from the physician for bed rails and an informed consent from resident or resident representative prior to installation for 2 (#1, #2) out of 3 (#1, #2, #3) residents reviewed for falls.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to ensure Resident #1 had a written consent for a self-releasing seatbelt and was able to intentionally remove the self-releasing seatbelt in the same manner as it was applied by the staff.

Inspectors wroteBased on record review and interviews the facility failed to ensure pain management is provided to residents who may require such services consistent with professional standards of practice for 1 (#1) of 3 (#1, #2, and #3) sample residents reviewed for pain management after a fall/injury. The facility failed to ensure an initial assessment for pain was completed for resident #1 after a fall/injury.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that 1 (#82) resident out of 35 sampled residents reviewed for a significant change in status was comprehensively assessed using the CMS (Center for Medicare & Medicaid Services) specified Resident Assessment Instrument after Resident #82 was hospitalized following a cerebral infarction and right femoral head fracture on 02/10/2024.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure resident assessments were transmitted within the required timeframe for 10 (#3, #41, #47, #61, #76, #50, #51, #72, #34, #62) of 10 residents reviewed for assessments out of a total of 35 sampled residents.

Inspectors wroteBased on observations and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. This had the potential to affect 12 residents who received trays out of the main kitchen on 04/08/2024.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey agency for 1 (#1) of 3 (#1, #2, & #3) residents reviewed for abuse.

Inspectors wroteBased on record reviews, observation and interviews, the facility failed to provide services that met professional standards for 1 (#371) of 24 sampled residents reviewed. The facility failed to ensure safe medication administration practices by leaving medication at the bedside.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure resident's medical records reflected the resident's wishes for 1 (#36) of 1 (#36) resident reviewed for advanced directives out of a total sample of 29. The facility failed to ensure the physician's orders were consistent with the resident's wishes for Do Not Resuscitate (DNR).