Glenhaven Healthcare

Inspectors wroteBased on observation, interviews, and record review the facility failed to implement proper food sanitation and infection control practices as indicated in the facility's policy and procedure titled Hand Hygiene and Personal Hygiene for 3 of 3 sampled residents (Residents 6,10 and 29) and 41 residents served meals from the kitchen by failing to ensure: 1. Certified Nursing Assistant (CNA1) involved in food handling and resident care performed proper hand washing techniques prior to and after dispensing meal trays to the residents (Residents 6,10 and 29). 2. The [NAME] (Cook 1) covered his beard while preparing food in the kitchen food preparation area for 41 residents that were served meals from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document accurately in the resident's medical record in accordance with accepted professional standards and practices and facilities policy and procedure for three (3) of three sampled ( Resident 1, 33 and 45) residents by failing to: 1. For Resident 1's medical record did not document Zoloft ( a medication used to treat depression- a feeling of severe sadness and hopelessness) in the CAR consent (Client Authorization Request - a form completed by the licensed staff and the physician before administration of psychotropic medications). The consent form did not indicate the name of the medication the resident or responsible party was informed about the risk and benefits and side effect of medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for four of four sampled Residents ( Resident 2,8,27, and 39) in accordance with the facility's policy and procedure titled Scope of Infection Control Program, by failing to ensure: 1. Resident 2's and 8's humidification bottle (bottled of water that adds moisture to the oxygen flow to reduce dryness and irritation during oxygen therapy) was observed without date, and residents name. 2. Resident 27's nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was observed without a label or date the last time it was changed (NC are changed every seven days). 3. Resident 39's NC was observed on the floor. [...]

Inspectors wroteBased on observation and interview, the facility failed to promote dignity and respect in accordance with the facility's policy and procedure for 1 out of 8 residents (Resident 2) who was observed wearing a soiled gown. This deficient practice had violated Resident 2's rights and the potential to result in the resident's feeling decreased self - worth, dignity that could lead to psychosocial declined.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the resident's need to ensure that the call lights (a device used by residents to signal his or her needs for assistance) was within reach for one of four sampled Resident (Resident 39) who required assistance from staff with activities of daily living and care. This deficient practice had the potential for Resident 39 not able to call when needed assistance with activities of daily living or could not call in an event of an emergency that could lead to a fall and or injury.

Inspectors wroteBased on interview and record review, the facility failed to inform and obtain an Advanced Directive (a legal document indicating resident preference on end-of-life treatment decisions) or properly fill out an acknowledgement of advanced directive form for two (2) of 13 sampled residents (Resident 9 and 53) in accordance with facility policy titled Advance Directives and regulatory requirements. This deficient practice has the potential for Residents 9 and 53 not to receive care and services according to the residents wishes especially during medical emergencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with good grooming and personal hygiene during routine nursing care to one (1) of four sampled residents (Resident 27) with unshaved facial hair. This deficient practice had the potential to negatively impact Resident 27's self-image, quality of life, self-esteem (overall sense of personal worth), that can lead to feelings of helplessness and diminished self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services for one of one sampled resident (Resident 52) who received the incorrect tube feeding (a liquid form of food when unable to eat or drink by mouth) formula. Resident 52 received Jevity 1.5 calorie (a type of tube feeding/nutritional formula) instead of Jevity 1.2 calorie that was ordered by the physician. This failure had the potential to result in Resident 52 to receive added calories that could lead to unplanned weight gain and/or not achieve the goal to received adequate nutrients to maintain the ideal weight.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide continuous supplemental oxygen therapy as ordered by the physician for one of two sampled residents (Resident 39) who was ordered to receive oxygen at 2-4 liters per minute (a unit volume flow rate) continuously via nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen). Resident 39's NC was on the floor and not connected to the resident. This deficient practice had the potential to result in Resident 39's lack of oxygenation and lead to respiratory decompensation (when respiratory system fails to meet the body's oxygen needs, requiring immediate intervention like oxygen) shortness of breath (SOB) and respiratory distress, that could negatively affect the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's bedrooms measured at least 80 square feet (sq. ft., a unit of measurement) per resident in the room with multiple residents in the bedrooms for 12 of 16 rooms. Resident Rooms 2, 3, 4, 7, 8, 9, 10, 11, 12, 14, and 15 measured less than 80 sq. ft per resident. This deficient practice had the potential to have insufficient space for staffs and residents that can impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent and immediately report and/or no later than two hours the alleged allegation of abuse (an action that intetionally cause harm to another person) that involves verbal and physical abuse altercation of two of two sampled residents (Resident 2 and Resident 3) on 6/5/2025 before 10 AM when Resident 2 kicked Resident 3 ' s wheelchair and both residents had a verbal altercation. Resident 2 with history of abusive behavior hit License Vocational Nurse (LVN) 1 on the cheek on 6/2/2025 around 9 PM (prior medication pass) and was not supervised and monitored for his abusive behavior to prevent recurrent abuse as indicated in the facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedside curtains for one (1) of two sampled residents (Resident 2) was fully closed, when Resident 2 tested positive for influenza (a severe lung infection) and required to be on droplet precaution (a set of infection control measures used to prevent the spread of respiratory infections from a patient to others) in accordance to public health guidelines on influenza outbreak taking place in the facility. This deficient practice had the potential to result in wide spread influenza infectiion spreading to other residents and staffs in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and interventions to prevent pressure injury (PI-damage to an area of the skin caused by constant pressure on the area for a long time) for one (1) of three (3) sampled residents (Resident 1) by failing to turn, reposition and to off-offload (release pressure) from an area of the body every two hours while in bed, keep clean and dry after a bowel movement or wetness from urine due to incontinence (unwanted passage of urine or stool that you can ' t control). These deficient practices resulted in: 1. Resident 1 developed a facility-acquired Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on sacrococcyx (tailbone) area on 10/15/24, and proceeded to Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) with drainage on 10/22/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (food waste, scraps) properly by not covering one of one metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing trash bags filled with garbage, and leaving additional trash bags, boxes, and an old mattress on the ground by the garbage area. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents and staffs in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of three of three sampled residents (Resident 1, 9, and 45) by failing to ensure residents call light (a device used by residents to signal his or her needs for assistance) was within reach. These deficient practices had the potential for Resident 1, 9, and 45 not able to call the facility staff to ask for help or assistance.

Inspectors wroteBased on observation and interview and record review the facility did not follow policy and procedure for Food Storage Principle, on food storage, and in accordance with professional standards for food service safety by failing to: 1. Discard 15 ham sandwiches in a steel pan in the refrigerator with an expired used by date of 11/14/2024. 2. Label and date an open plastic bag with two hotdog buns in the refrigerator. 3. Discard six breaded fish in an open plastic bag in the freezer with an expired used by date of 11/10/2024. 4. Label and date a pitcher of prune juice in the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility 's policy and procedure on infection control to prevent the spread of infection for 3 of 6 sampled residents (Resident 101, Resident 5, and Resident 39) by failing ensure Certified Nurse Assistant (CNA) 6 practice proper hand hygiene and wear gloves or gowns in Resident 5's contact precaution (a set of measures to prevent the spread of infectious agents through direct or indirect contact with individuals or an environment) room. These deficient practices had the potential to result in the spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure certified nurse assistant (CNA) 3 was seated when assisting one of eight sampled Residents (Resident 2) during mealtime. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life Sustaining Treatment (POLST, a medical order form that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) was accessible in residents medical records (physical paper chart) for one of eight sampled residents (Resident 41). Resident 41's paper chart did not have a copy of the Advance Directive Acknowledgement and the original POLST. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for two of two sampled residents (Residents 4 and 23) when: 1. Resident 4, who was a high risk for fall, was observed in bed reaching for his drinks by the bedside table, without a floor mat as per plan of care to prevent injury from fall. 2. Resident 23, who was a high risk for fall, and had a fall incident on 11/18/2024 in Room B (RB-not Resident 23's room) witnessed by a Resident in Room B (RRB), was not frequently monitored, or supervised as per plan of care. These deficient practices had the potential for to cause major injury from a fall and negatively affect Residents 4's and 23's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use appropriate alternative interventions before the installation of bilateral ¼ siderails (quarter bars that are attached to the side of the bed to help with safety and comfort) for one of four sampled residents (Resident 31). This failure had the potential for Resident 31 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in tight spaces around the siderail) and physical injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with the facility ' s policy and procedure (P&P) titled, Documentation Guidelines, for two of four sampled residents (Resident 14 and Resident 50) by failing to: 1. Ensure the Infection Preventionist document wound care treatment as provided to Resident 14 on 9/5/24. The IP stated she was covering for the treatment nurse and forgot to document it in the Treatment Administration Record (TAR). 2. Document Resident 50 ' s discharge disposition (the location to which the resident was transferred to) in the resident ' s discharge record. These deficient practices had the potential to negatively impact the delivery of services to Resident 14 and had resulted in Resident 50 ' s discharge record to be inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident ' s bedrooms measured at least 80 square feet (sq ft, a unit of measurement) per resident in multiple bedrooms for 12 of 16 rooms. Resident Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, and 15 measured less than 80 sq. ft per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment care and services, in accordance with professional standards of practice, for one of three sampled residents (Resident 1) by: 1. Failing to honor Resident 1 ' s request to transfer to the acute hospital on 9/6/26 due to a change in condition for more than 4 hours. 2. Failing to assess, recognize, intervene, after Resident 1 had a change of condition on 9/6/24. 3. Failing to document Resident 1 ' s condition in the facility forms titled SBAR (Situation, Background, Action, Respond). These deficient practices had the potential to delay in the delivery of necessary care and services for Resident 1 and negatively affect Resident 1 ' s psychosocial wellbeing.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that LVN (Licensed Vocational Nurse)1 who was from a Nursing Registry [a business or agency that provides nursing staff to hospitals], demonstrated the necessary competency to provide adequate care for one of three sampled residents, (Resident 1). This deficiency had the potential to negatively impact Resident 1's psychosocial well-being and delay the delivery of critical care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of dementia (the loss of cognitive process) with combative behavior (aggressiveness/eagerness to fight) was free from physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident) for purposes of discipline or convenience, by failing to: 1. Protect Resident 1 from physical injury on 8/20/2024, when Licensed Vocational Nurse (LVN) 1 restrained Resident 1's right and left arms by crossing Resident 1's arms across the chest and above the head and pull/drag the resident from the resident's room to the Nursing Station when Resident 1 exhibited episodes of mood swings [a sudden or intense change in a person's emotional state]. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when one of two dietary staff, Dietary Staff (DS) did not perform hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) and/or change gloves in between preparing sandwiches for 40 residents, and also touching the coffee machine, and the menu, sheet during tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) observation for lunch. This deficient practice had the potential to result in a harmful bacteria cross contamination (transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (caused by consuming contaminated foods or beverages) that could negatively affect residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and dignity to 1 of 4 sampled residents (Resident 25) when Certified Nurse Assistant (CNA 6) did not cover the Resident 25's naked body and did not close door while transporting Resident 25 from bedside commode to bed. This deficient practice had the potential for others to see Resident 25's naked body which may cause psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent from the responsible party for one of two sampled residents (Resident 28) who was prescribed Lorazepam (medication used to treat anxiety [a mental disorder that result in having the fear of the unknown]); Zyprexa (a medication used to treat psychotic conditions such as schizophrenia [a serious mental illness that affects how a person thinks, feels, and behave] and bipolar disorder [mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration], Depakene (medication used to treat seizure disorders [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements] that stabilizes mood, and Clozapine (a medication to treat medication for treatment-resistant schizophrenia). [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess, reflective of the resident's status at the time of the assessment for one of four residents (Resident 41). The Social Service Designee (SSD) did not assess Resident 41's communication needs due to the resident being asleep during the assessment and documented Resident 41 was not interview able. As a result of this deficient practice, Resident 41 did not receive the communication tools needed to communicate needs which had the potential for the resident not to receive the care and services needed to maintain the highest well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASARR - a federally required screening for mental health; PASARR Level I identifies suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of two sampled residents (Resident 22 and 3). This failure had the potential to result in Resident 22 and Resident 3 not to receive necessary mental health services which can negatively affect their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a person- centered care plan addressing resident specific interventions for one of four sampled residents (Resident 16). This deficient practice had the potential to negatively affect the delivery of care and services related to the residents' health conditions and needs.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of four sampled residents (Resident 29) to indicate diet modifications. These deficient practices had the potential to result in Resident 29 not receiving the proper diet.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain good personal hygiene and activities of daily living (ADL) by ensuring the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for 2 of 2 sampled residents (Resident 38 and Resident 18) who needed assistance with ADLs as indicated in the facility's policy and procedure, titled Answering the Call Light and the resident's care plan. This deficient practice had the potential for Resident 38 and 18 not to receive needed assistance to achieve their highest potential and wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an assistive device, such as a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach for two of two sampled residents (Resident 38 and Resident 18) who were at high risk for fall. This deficient practice had the potential for Resident 38 and 18 not to be assisted when needed assistance with activities of daily living (ADL) or in an event of emergency and result in accidents and injury.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services to one of four residents sampled (Resident 41). The Social Service Designee (SSD) failed to accurately assess and arrange Resident 41's communication needs through the resident's primary method of communication or in a language that the resident understood. As a result of this deficient practice, Resident 41 had the potential not to receive the care and services especially during an emergency needed to maintain or achieve the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation and interview, and record review, the facility failed to ensure 12 of 16 residents' bedrooms (Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 15) met the required 80 square feet (sq. ft. a unit of measurement) per resident area as indicated in the federal regulation or the CMS (Centers for Medicare and Medicaid Services). The rooms were occupied by residents and consisted of six resident beds in each room, a total of 38 residents occupied the 12 rooms. This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the resident.