Glen Haven Village

Inspectors wroteBased on clinical record review, observations, staff interviews, facility investigation review and policy review the facility failed to ensure the residents were free of significant medication errors when medication were given to residents from another residents medication card and failure to prime an insulin pen to 6 of 8 residents reviewed (Resident #6, #32, #34, #9, #56 and #64). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, observation, facility investigation review, facility policy review and staff interviews the facility failed to protect a resident from misappropriation a resident's medications for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, facility investigation review, and facility policy review the facility staff administered psychotropic medications without an order to residents who were up at night to sedate them for 2 out of 7 residents reviewed (Resident #6, and #34). The facility also failed to have a duration or rationale for a resident with a psychotropic medication (Resident #8). The facility reported a census of 65 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, document review, staff interview, family interview and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by not obtaining a Urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for 1 of 3 residents (Resident #1). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, facility investigation review, staff interviews, and policy review the facility failed to protect residents from accidents and injuries for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 64.

Inspectors wroteBased on observations, staff interviews and clinical record review the facility failed to provide adequate treatment and interventions to prevent the worsening of pressure ulcers for 1 resident (Resident #23) and failed to implement interventions timely for 2 of 4 residents reviewed (Resident #23, #15). Staff failed to apply the pressure-reducing boots for Resident #23 and failed to document or follow up on a new area for Resident #23 and #15. The facility reported a census of 65 residents.

Inspectors wrote2. According to the MDS dated [DATE], Resident #3 had a BIMS score of 15 (intact cognitive ability). He was independent with eating and required supervision and touch assistance with transfers. He had highly impaired hearing ability. His diagnoses included neurogenic bladder, diabetes mellitus, aphasia, anxiety communication deficit. The Care Plan updated on 4/24/25, showed that Resident #3 was at risk for choking related to dysphagia staff would offer a regular, mechanical soft diet. The resident had significant anxiety and wanted to know what to expect throughout the day. He was deaf, and it was important for him to be involved in his cares. Writing material was provided to the resident, he was able to write and understand short phrases. [...]

Inspectors wroteBased on observations, family interview, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 16 residents reviewed (Resident #15 and Resident #24). The facility failed to revise the interventions for a resident who sustained a burn and a resident who had a pressure area develop. The facility reported a census of 65 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not completing assessments for 1 of 16 residents (Resident #24) reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews and policy review the facility failed to provide food at an appetizing temperature to 2 of 20 residents reviewed (Resident #6 and #30). The facility reported a census of 65 residents.

Inspectors wroteBased on observation, Electronic Health Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with an indwelling catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed (Resident #30). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to transfer a resident with a gait belt and the resident fell resulting in an injury for 1 of 10 residents (Resident #1) reviewed for falls and safe transfers. The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, staff interviews, camera footage review and facility policy review the facility failed to assure residents were free from significant medication errors for 1 of 7 resident reviewed (Resident #24). The facility reported a census of 65 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of high blood pressure, Diabetes Mellitus (DM) and hemiplegia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The Care Plan for Resident #24 dated 12/1/23 showed the following: - I have the potential for hypoglycemia and hyperglycemia episodes secondary to the diagnosis of DM. - I have the potential for complications related to antiplatelet therapy. [...]

Inspectors wroteBased on observations, resident interviews, and staff interviews the facility failed to provide privacy during personal care to 1 of 3 residents reviewed (Resident #15). The facility also failed to respect each resident's dignity to 4 of 10 residents reviewed (Resident #1, #3, #13 and #44) throughout all care and services provided. The facility reported a census of 65 residents.

Inspectors wroteBased on electronic record review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or approaches for use of anticoagulant therapy and diuretic therapy for 2 of 5 residents reviewed (Resident #38 and #43). The facility reported a census of 65 residents.

Inspectors wroteBased on electronic health record review, policy review, resident interview, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care for 1 of 3 residents reviewed (Resident #34). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, staff interviews, policy review and the Center for Disease Control guideline review the facility failed to use universal infection control measures (hand hygiene) and Enhanced Barrier Precautions (EBP) during catheter cares for 2 of 3 residents reviewed for infection control (Resident #34, and #47). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to provided the appropriate interventions and assessments after 1 of 3 residents (Resident #3) fell. The facility reported a census of 62 residents.

Inspectors wroteBased on interview and record review, the facility failed to employ an Infection Preventionist who had completed specialized training in infection prevention and control. This failure increased the potential for the facility to improperly assess, develop, implement, monitor, and manage their infection control program.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure four of four residents and their representatives (Resident (R) 18, R33, R34 and R64) reviewed for facility initiated emergent hospital transfer, from a total sample of 19 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to label and date opened food items in the refrigerator and freezer in the kitchen in Cottage 132. This had the potential to affect 12 of 12 residents who consumed food from the kitchen in Cottage 132.

Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough investigation was documented regarding the injury of unknown origin for one of one resident (Resident (R) 17). This failure had the potential to have missed a possible case of abuse of a resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of one Resident (R 43) reviewed for not having a Minimum Data Set [MDS] assessment for greater than 120 days. This failure had the potential to delay healthcare payments due to the payer source having R43 as residing in a long-term healthcare facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two eligible Certified Nurse Aides (CNAs) had an annual performance review completed. This failure could affect the skills and knowledge required to correctly provide care for residents.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to follow appropriate infection control precautions for one (Resident (R) 63), of one resident reviewed in isolation for Methicillin-resistant Staphylococcus aureus (MRSA). This failure had the potential to spread to other residents, staff, and visitors.

Inspectors wroteBased on record review and interview, the facility failed to ensure four of four Certified Nurse Aides (CNAs) and two of two Registered Nurses (RNs) reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated on the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present.