Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glendale Gardens Nursing & Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple chronic conditions, who required assistance with ADLs, requested basic items such as water, oral care supplies, and pain medication. A CNA, who reported feeling overwhelmed while covering two halls, told the resident that some items would have to wait and then, after the resident questioned why the CNA was talking in the hallway, responded with profane and disrespectful language, including telling the resident to "leave me the f*** alone" and to go back to their room and shut up. Multiple staff, including a CMT, RNs, LPNs, CNAs, and the DON, stated that cursing at or around a resident is disrespectful and violates resident rights, and the resident reported that the interaction was hurtful and not respectful of their home and dignity.
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency within the required two-hour timeframe after staff became aware of it. A resident with dementia, Parkinson’s disease, COPD, and atrial fibrillation, who used a wheelchair and was frequently incontinent, allegedly told a family member that a male CNA working nights had tossed the resident roughly into bed and cursed at them. The family reported this to an LPN, who documented the concern and immediately notified the DON. Although facility policy and staff interviews confirmed that abuse allegations, including rough care and cursing, must be reported to the State within two hours, the DON delayed notifying the Administrator until the next night, and the Administrator did not report the allegation to DHSS until two days after the initial report, resulting in noncompliance with required abuse reporting timelines.
The facility did not analyze or document causes of falls, nor did it update care plans or implement new interventions after multiple residents with complex medical conditions experienced repeated falls. Staff interviews revealed inconsistent knowledge about care plan updates, and the facility lacked a specific falls policy.
The facility did not consistently notify physicians and families after resident falls, as required. Two residents experienced multiple falls, with staff sometimes failing to document or communicate these incidents to the appropriate parties. Staff interviews revealed inconsistent understanding and application of notification procedures, and the facility lacked a clear policy on fall and physician notification.
Staff failed to follow physician orders and care plan requirements for two residents with edema, including not documenting follow-up on swelling, not obtaining or documenting orders for Tubi grips, not updating care plans to reflect current treatments, and not consistently completing or recording daily weights as ordered. Multiple staff confirmed that Tubi grips and edema management should be included in care plans and require physician orders, but these steps were not taken or documented.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment was slapped by an RN after biting the RN's finger during an attempt to remove a plastic straw from the resident's mouth. The incident, witnessed by two NAs, was reported to the DON and Administrator. The RN's action violated the facility's abuse prohibition policy, which protects residents from physical abuse.
The facility failed to report an allegation of abuse involving a CNA and a resident within the required two-hour timeframe. The incident was reported by the resident to a CNA, who informed an RN. However, the RN delayed reporting to the DON, who then delayed informing the Administrator. The incident was reported to the State Survey Agency five hours after the initial report, exceeding the required two-hour window.
The facility failed to follow their abuse policy and protect all residents during an investigation of alleged abuse. A resident alleged that a CNA physically abused them, and the CNA continued to work independently with other residents. Despite the facility's policies requiring immediate suspension of accused staff, the CNA was allowed to continue working their shift without supervision or suspension.
Failure to Treat a Resident With Dignity and Respect Due to Profane Language by CNA
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with dignity and respect when a CNA used profane and disrespectful language toward a resident. Facility resident rights documents state that residents should be treated with consideration and respect, with full recognition of their dignity and individuality. Resident #1 had multiple diagnoses, including metabolic encephalopathy, chronic kidney disease, Type 2 diabetes with neuropathy, unspecified dementia without behavioral disturbances, and major depressive disorder, and required supervision or assistance with activities of daily living such as toileting, dressing, personal hygiene, and showers. On the morning in question, the resident activated the call light and requested items including a new water pitcher because the current one was leaking, a toothbrush, toothpaste, and a pain pill. CNA A reported being overwhelmed and busy covering two halls and told the resident that only some items could be addressed immediately and the rest would have to wait. Multiple written and verbal statements from staff and the resident consistently describe that, after the resident questioned why the CNA could stand in the hallway talking if too busy to obtain the requested items, CNA A responded with profanity. Witnesses and the resident reported that CNA A told the resident it was none of their “f***ing business” what the CNA was doing, that the resident would “f***ing wait,” and to go back to their room and “shut up.” CNA A admitted in a text to the DON and in an interview that they told the resident to “leave me the f*** alone,” acknowledging it was not appropriate. Interviews with multiple staff members, including a CMT, RNs, LPNs, CNAs, and the DON, confirmed that cursing at or around a resident is considered disrespectful and against resident rights. The resident reported feeling that the CNA was being hateful, stated that this was their home and they expected to be treated with respect, and indicated that the CNA’s comments hurt their feelings. The consistent accounts from the resident, witnesses, and CNA A’s own admission demonstrate that the resident was spoken to in a rude and profane manner, in violation of the facility’s stated resident rights and the requirement to treat residents with dignity and respect.
Failure to Timely Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe after staff became aware of the allegation. Facility policy, dated March 2016, required that any and all cases of alleged resident neglect, abuse, or misappropriation of resident property be reported immediately, but not later than two hours after forming the suspicion, to the hotline and/or DHSS. Multiple staff, including LPNs, CNAs, the ADON, and the Administrator, acknowledged in interviews that the facility had two hours to report abuse allegations to the State and that rough care and cursing constituted abuse that should be reported immediately. The resident involved had been admitted with diagnoses including Parkinson’s disease, COPD, atrial fibrillation, and dementia, with moderate cognitive impairment, wheelchair use for mobility, and frequent bowel and bladder incontinence. The resident’s care plan noted cognitive impairments related to psychotropic medications and risk for falls due to weakness, medications, and gait disturbance. On a late afternoon, the resident’s family member reported to an LPN, in the presence of another LPN, that the resident said a male CNA working the night shift had tossed the resident roughly into bed and cursed at the resident, and demanded that this CNA no longer provide care. The LPN documented this allegation in a handwritten statement and immediately notified the DON. Despite this immediate internal reporting, the DON did not promptly notify the Administrator or DHSS. The DON stated that the family “was complaining to complain” and did not contact the Administrator until the following night, more than 24 hours after the allegation was reported to facility staff. The Administrator then became aware of the allegation and, on a later morning, notified DHSS, the Ombudsman, and the police, and initiated interviews. DHSS records confirmed that the facility self-reported the allegation two days after staff first became aware of it. Both the DON and the Administrator acknowledged that the allegation of rough care and cursing constituted physical and verbal abuse and that it should have been reported to DHSS immediately, within the two-hour requirement, which did not occur.
Failure to Update Care Plans and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by not analyzing or identifying risks for falls, not implementing new interventions to prevent future falls, and not updating care plans after residents experienced falls. Multiple residents with significant medical histories, including cancer, osteoarthritis, COPD, and heart failure, experienced repeated falls. Despite these incidents, staff did not document investigations into the causes of the falls or update care plans with new interventions tailored to prevent recurrence. For one resident, several falls occurred over a period of months, including unwitnessed falls in the restroom, sliding from a recliner and bed due to weakness, and falling while using a walker. Each incident was documented in nursing progress notes, but the care plan was not revised to reflect these events or to add new preventive measures. There was also no documentation of investigations into the causes of these falls or any analysis to identify contributing factors. Similar patterns were observed with other residents who had falls related to reaching for objects, attempting to get a soda, or experiencing lightheadedness. In each case, the care plans were not updated to include the new falls or interventions, and there was no documentation of investigations into the causes. Interviews with staff revealed inconsistent understanding of when and how to update care plans after falls, with some staff unsure if updates were necessary. The facility also lacked a specific policy regarding falls, further contributing to the deficiency.
Failure to Notify Physician and Family After Resident Falls
Penalty
Summary
The facility failed to notify residents' families and physicians of changes in condition and incidents, specifically regarding falls, in a timely manner for two residents. Documentation revealed that after multiple falls, staff did not consistently notify the physician or family, nor did they always document these notifications. In several instances, falls were either not documented at all or lacked clear records of physician and family notification, despite facility policy requiring such actions. One resident, with diagnoses including non-Hodgkin lymphoma and osteoarthritis, experienced multiple falls over a short period. Progress notes showed that after these incidents, staff sometimes notified the family but failed to notify the physician, and in some cases, neither party was notified. Staff interviews revealed confusion about what constitutes a fall and when notifications should occur, with some staff believing that sliding from a bed or chair did not require physician notification if there were no injuries. Another resident, with high blood pressure and lung cancer, also experienced a fall that was not followed by documented notification of the physician or family. Interviews with nursing staff, the MDS Coordinator, the DON, and the Administrator confirmed inconsistent practices regarding post-fall notifications. Some staff stated that physician notification was not always performed, especially during night shifts or if there were no injuries, despite the expectation that both family and physician should be notified after any fall. The facility did not provide a specific policy regarding falls or physician notification, and the existing documentation policy did not substitute for required event reporting and notifications.
Failure to Follow Physician Orders and Care Plan for Edema Management
Penalty
Summary
Staff failed to provide care according to physician orders, resident preferences, and established standards of practice for two residents with edema. For one resident with a history of non-Hodgkin lymphoma, varicose veins, hypertension, and cardiovascular disease, staff did not document follow-up regarding observed swelling in the feet, ankles, and legs. Although the resident was observed wearing Tubi grips on both lower extremities, there was no physician order for their use, and the care plan did not address the use of Tubi grips or the management of edema. Multiple staff interviews confirmed the absence of an order and lack of care plan documentation for Tubi grips, despite their regular application by CNAs. For another resident with diagnoses including edema, hypertension, and chronic respiratory failure, staff failed to consistently complete and document daily weights as ordered by the physician. The resident's care plan was not updated to reflect new orders for fluid restriction, Tubi grips, and Lasix. Review of the Medication Administration Record (MAR) revealed multiple days where weights were neither documented nor refusals recorded, and there was no documentation of physician notification when significant weight changes occurred. The resident reported ongoing swelling, difficulty walking, and issues with shoe fit due to edema, and expressed that daily weights were not being performed as expected. Interviews with various staff members, including CNAs, LPNs, the MDS Coordinator, the DON, and the Administrator, confirmed that Tubi grips require a physician order and should be included in the care plan, as should edema management and daily weights. Staff acknowledged that daily weights were the responsibility of CNAs, with the charge nurse providing a list of residents requiring weights. Despite these expectations, documentation and care planning were not completed as required, resulting in deficiencies in the provision of care for residents with edema.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
RN's Inappropriate Response to Resident's Bite
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a Registered Nurse (RN) slapped the resident in response to being bitten. The incident occurred when the RN, along with two Nurse Aides (NAs), attempted to remove an object from the resident's mouth. The resident, who was severely cognitively impaired and required supervision while eating, was chewing on a plastic straw and refused to spit it out. In an attempt to retrieve the straw, the RN used their fingers to open the resident's mouth, resulting in the resident biting the RN's finger. Following the bite, the RN reacted by slapping the resident on the left cheek, which was witnessed by the two NAs. The RN claimed that the slap was a reflexive response to the pain from the bite and described it as a very light tap. However, both NAs reported the incident to the Director of Nursing (DON), who then informed the Administrator. The facility's policy clearly prohibits any form of abuse, including physical abuse, which is defined as hitting or slapping a resident. The resident involved in the incident had a history of anxiety, unspecified dementia, and major depressive disorder, which contributed to their cognitive impairment. The facility's investigation revealed that the RN's actions were inappropriate and not in line with the facility's abuse prohibition policy. The incident highlights a failure in ensuring the resident's right to be free from abuse, as outlined in the facility's policies and the resident's rights documentation.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a Certified Nursing Assistant (CNA) and a resident within the required two-hour timeframe. The incident occurred when the resident reported that CNA B had grabbed their wrist and forcefully put them back to bed, causing pain and a small bruise. The resident reported the incident to another CNA (CNA K) around 1:50 A.M., who then informed the Registered Nurse (RN A). However, RN A did not report the incident to the Director of Nursing (DON) until approximately 4:30 A.M., and the DON subsequently informed the Administrator at 6:19 A.M. The Administrator then reported the incident to the State Survey Agency at 7:00 A.M., which was five hours after the initial report by the resident, exceeding the required two-hour reporting window for abuse allegations. The facility's policies clearly state that any allegations of abuse must be reported immediately to the Administrator and the State Survey Agency within two hours if the event involves abuse or results in serious bodily injury. Despite these policies, there was a significant delay in reporting the incident. Interviews with various staff members, including CNAs, RNs, and the DON, revealed inconsistencies in their understanding of the reporting procedures and timelines. Some staff members believed that the DON had up to 24 to 48 hours to report such incidents, while others were aware of the two-hour requirement but failed to act accordingly. The resident involved had a history of dementia, depression, hemiplegia, and reduced mobility, requiring substantial assistance for daily activities. The delay in reporting the abuse allegation not only violated the facility's policies but also potentially compromised the resident's safety and well-being. The failure to adhere to the mandated reporting timelines highlights a critical gap in the facility's abuse reporting protocol and staff training, leading to the identified deficiency.
Failure to Follow Abuse Policy and Protect Residents During Investigation
Penalty
Summary
The facility failed to follow their abuse policy and protect all residents during an investigation of alleged abuse. A resident alleged that a CNA physically abused them, and the CNA continued to work independently with other residents. The facility's policies require that any staff member accused of abuse be suspended immediately to prevent further potential abuse, but this was not followed in this case. The resident involved had a history of dementia, depression, hemiplegia, and reduced mobility, requiring substantial assistance for daily activities. The resident reported that the CNA took them by the wrist and slammed them down hard onto the bed, resulting in a small bruise. Despite this allegation, the CNA was allowed to continue working their shift without supervision or suspension. Interviews with staff revealed that there was a lack of clear direction and adherence to the facility's abuse policies. The RN and DON did not ensure the immediate suspension of the CNA, and the CNA continued to care for other residents. The Administrator acknowledged that the other residents were not protected from the CNA during the investigation, highlighting a significant lapse in following established protocols to ensure resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| James River Nursing And Rehabilitation | 1.2 mi | — | 1 | 0 |
| Spring Valley Health & Rehabilitation Center | 2.9 mi | — | 3 | 0 |
| Springfield Villa | 3.5 mi | — | 8 | 1 |
| Cox Medical Centers Meyer Orthopedic And Surgical | 3.5 mi | — | 1 | 0 |
| Birch Pointe Health And Rehabilitation | 4.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.