Glenhaven

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R2) received care consistent with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R2 was at risk for PI development. The facility failed to provide adequate and consistent wound care treatments, comprehensive interventions to R2's care plan, and did not document progression of staged PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food served at safe appetizing temperatures. This has the ability to affect all 31 of the facility's residents. Review of resident council minutes and the resident council meeting reveal residents' concerns over meal temperatures. Observation at meals time revealed that foods were not held at proper holding temperatures; hot foods were not held hot, and cold liquids were not held cold. This is evidenced by: On 03/03/2026 at 2:00 PM, Surveyor reviewed Resident Council Meeting Minutes from December 2, 2025, which state in part; Food temps are cold. Resident Council Meeting Minutes from January 26, 2026, state in part: Food temps are on the colder side, and February 23, 2026, Resident Council Meeting Minutes state in part: Food temps are on the colder side. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and distribute food under sanitary conditions. This has the ability to affect all 31 of the facility's residents. Staff washing dishes contaminated their uniform. Staff doing dishes were observed going between dirty and clean items with no hand antisepsis. Staff were observed to change gloves with no hand antisepsis. Staff were observed to touch ready to eat foods with contaminated gloves. Food was carried down halls and from unit to unit uncovered then delivered to residents. Food not stored in its original container was not labeled with identifying information or open date. Open food not labeled with an open or use by dates. Scoop was found in food container, increasing food's risk for contamination. [...]

Inspectors wroteBased on record review, observation, and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size Hoyer (mechanical full body lift) sling to prevent accidents for 3 residents (R) requiring Hoyer full body lifts. (R5, R13, R23). R13 is dependent for rolling, repositioning, and mobility and was lifted with a one person assist mechanical lift which goes against policy and Occupational Safety and Health Administration (OSHA) nursing home standards of practice. R23 was lifted with a one personal assist mechanical lift which goes against Occupational Safety and Health Administration (OSHA) nursing home standards of practice. Lack of supervision of thickened liquids for R14 who was at risk of choking.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 12 sampled residents' (R25) medical records clearly identified the resident's advanced directives, regarding code status. The facility did not ensure R25's medical record was clear in identifying her advanced directives, regarding code status on admission.

Inspectors wroteBased on interview and record review, the facility did not report 1 of 1 (R2) potential misconduct incidents to the State Agency (SA) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. R2 reported to facility staff that a male Certified Nurse Assistant (CNA) M had inappropriately touched R2's penis.

Inspectors wroteBased upon interview, policy review and record review, the facility did not ensure allegations of sexual abuse were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for resident (R) (R2) and other undocumented residents, which has the potential to affect all 11 residents on the D unit. Facility did not protect R2 when allowing Certified Nursing Assistant (CNA) M to continue to work with R2 when accused of sexual abuse. Facility did not complete a thorough investigation of R2's accusation against CNA M.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 2 residents/resident representative (R) (R2 and R30) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, or name and address with telephone number of the Office of the State Long-Term Care Ombudsman. Transfer Discharges Notices do not contain a specific reason for transfer.

Inspectors wroteBased on interviews and record reviews, the facility did not complete and submit Minimum Data Set Assessments (MDSAs) in the required time frames for 2 of 2 sampled residents for hospitalizations. (R2, R30)R30's MDS assessment was completed late on 1/12/25, 11/19/24, 218/25, 4/23/25, and 8/19/25. R30's MDS dated [DATE] transmission timeframe was greater than the 14 days from due date. 1/12/26 MDS transmission to the Centers for Medicare & Medicaid Services (CMS) national database was 51 days late. R2's MDS assessment was completed late on 10/29/25, 1/12/26, and 2/6/26. R2's MDS dated [DATE] transmission timeframe was more than 14 days from due date. 10/22/25 MDS transmission to the CMS national database was 19 days late.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 1 resident (R) reviewed for Activities of Daily Living (ADLs) (R13). R13, who is dependent for cares and incontinent of urine, did not have his brief changed for about 7 hours; prior to 7:10 AM until 2:02 PM.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 of 2 residents (R13 and R5) received necessary care and treatment. R13 and R5 are dependent on assistance for repositioning and mobility. R13 and R5 were not repositioned per care plan and standards of care.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 1 of 2 residents (R2) reviewed for catheters.

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This occurred for 1 of 3 medication carts/storage rooms observed. During the recertification survey, 1 of 3 observations were made of R15's liquid Morphine bottle open with no open date label in medication cart on unit E. Surveyor observed controlled medication Lorazepam not double locked on unit E.

Inspectors wroteBased on interview and record review, the facility did not ensure possibility of abuse was thoroughly investigated for 1 of 3 residents (R), R1 reviewed. R1 obtained multiple bruises of unknown origin; the facility did not complete a thorough investigation of the incident. Federal regulation states, 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. R1's minimum data set (MDS), dated [DATE], notes R1 has severe cognitive impairment, is independent with bed mobility and ambulation using a wheeled walker. R1 requires supervision or touching assistance with transfers, toileting, and eating. [...]

Inspectors wroteBased on observations, interview and record review, the facility did not ensure the resident environment remains free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed. (R1)R1 had multiple bruises to arms and legs. The facility did not find root cause of the arm bruises or put interventions in place to prevent reoccurrence and did not educate staff on ways to prevent injury or recurring bruises. Federal regulation states facilities must ensure that resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that an alleged violation involving abuse by a Resident (R1) was reported immediately to the Nursing Home Administrator (NHA) and to the State Survey and Certification Agency. An incident involving R1 and R2 occurred on 02/27/25. R1 hit R2 with a closed fist. The facility did not report the abuse to the State Survey and Certification Agency. Findings Include: Facility policy titled, Abuse Policy, shows a most recent review date of 10/04/16, stated, Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure, in response to resident-to-resident physical abuse, a thorough investigation was conducted to prevent further potential abuse for 1 of 2 (R1) residents reviewed for abuse. The facility did not conduct a thorough investigation of the resident-to-resident-altercation that occurred to R2 on 02/27/25. The facility did not conduct other resident interviews for potential abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident environment remained as free of accidents hazards as possible. The facility did not update resident's care plan after each event of a fall. This has the potential to affect 1 of 3 residents (R) (R1) reviewed for accidents. Facility did not update R1's care plan after R1's fall risk score increased from 12 to 16 on 02/16/25, and did not update care plan following a bruise noted on 03/05/25 from a fall.

Inspectors wroteBased on observation, interview and policy review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. When staff heated up Resident (R) 124's food in the microwave, staff did not check to ensure the food was at safe eating temperatures. In the kitchen refrigerator there was food that was not dated appropriately to ensure food safety. This has the potential the affect all 19 of 19 residents (R) residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 01/01/24-09/30/24 was complete, accurate, and auditable. The submitted data from 01/01/24-09/30/24 was not complete, accurate, or auditable. This has the ability to affect all 19 of 19 residents in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered No RN Hours for the dates of 01/08/24 (MO), 02/02/24 (FR), 03/15/24 (FR), 03/29/24 (FR). The PBJ Staffing Data Reports that were generated quarterly document that the facility triggered Failed to have Licensed Nursing Coverage 24 Hours/Day for the dates of 05/13/24 (MO), 05/16/24 (TH), 05/17/24 (FR), 06/02/24 (SU), 06/03/24 (MO), 06/09/24 (SU), 06/30/24 (SU), 07/06/24 (SA), 08/03/24 (SA), 09/06/24 (FR), 09/29/24 (SU). [...]

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 19 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to affect 19 of 19 residents reviewed. -The facility did not have a complete tracking program in place for the early detection of infections and potentially exposed residents (R). -Observations were made of the facility not implementing Transmission Based Precautions (TBP) for 1 of 1 sampled resident on TBP. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for residents on blood thinners and bleeding risk. This occurred for 1 of 2 residents (R) reviewed (R3).

Inspectors wroteBased on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for one of three residents (R) reviewed for pressure injuries (R2) R2 was admitted to the facility on [DATE], with no skin impairments and developed a stage 2 pressure injury to the coccyx area (tailbone), which remains unhealed, has lack of timely care plan interventions, and lack of repositioning.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident safety through assessment and ensure the environment remains as free of accident hazards as is possible for 3 of 4 residents (R) reviewed (R12, R16, and R15). -R12 was evaluated by the facility to be a fall risk with assist of 1 during ambulation. R12 was observed self-ambulating to R12's room from dining room. -R16 was evaluated by the facility to be a fall risk with assist of 1 during ambulation. R16 was observed self-ambulating to R16's room from dining room. -R15 was evaluated by the facility for choking hazard during mealtimes. R15 was observed eating meals alone without supervision.

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter. R2's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This occurred for 1 of 2 residents reviewed for urinary catheters. (R2).

Inspectors wroteBased on observation, interview and record review, the facility did not provide medically related social services to address Post Traumatic Stress Disorder (PTSD) for 1 of 19 residents (R) reviewed to ensure appropriate social services are provided for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being (R17). -The facility failed to provide medically related social service for developing a plan of care addressing R17's PTSD. -The facility failed to provide non-pharmacological interventions for R17 to cope with PTSD and anxiety. This is evidenced by:

Inspectors wroteBased on interview and record review, the facility did not ensure that a communication process was implemented, including how the communication will be documented between the long term care (LTC) facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. The facility did not have a communication binder for hospice services to relay information to the facility regarding hospice services. This has the potential to effect 1 of 1 resident (R) investigated for hospice services (R2).

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 19 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety; uncovered food, handling dirty potholder, low holding food temperatures. This has the potential to affect all residents (R) in the facility; 19 of 19 residents could be affected.

Inspectors wroteBased on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 4/1/23-6/30/23 was complete, accurate, and auditable. This has the ability to affect the census of 19. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day from 4/1/23-6/30/23 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q3 (Quarter 3) 2023 (April 1-June 30): 4/1, 4/3, 4/8, 4/10, 4/17, 4/19, 4/23, 4/25, 4/27, 4/29, 4/30, 5/6, 5/16, 5/20, 6/28. The facility was not able to produce the data that was submitted during this time frame for the specified dates therefore the Surveyor was not able to audit the exact document(s) that were submitted. [...]

Inspectors wroteBased on record review and interview, the facility did not review and revise the comprehensive care plan for falls interventions for 1 of 8 sampled residents (R), R2. This is evidenced by: The facility policy, entitled Updated Care Plans, date reviewed October 2023, stated: It is the policy of Glenhaven that the resident care plans are updated with any changes to ensure that the residents are receiving the care that is specific to their needs and wants. R2 was admitted to the facility on [DATE] and has diagnoses that include acute on chronic diastolic (congestive) heart failure, type 2 diabetes mellitus without complications, unspecified systolic (congestive) heart failure, hyperlipidemia, anxiety disorder, and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not notify a provider or put nutritional interventions in place for a resident who had significant weight loss for 1 of 2 residents (R) reviewed for weight loss. (R10) R10 had a weight loss of greater than 15 pounds in the past six months and lost 10.8 pounds in the past month. The provider was not notified, and no new dietary interventions were put in place.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections; no documented control measures for the Legionella Water Management. This had the potential to affect 19 of 19 residents residing in the facility.