Glen Haven Health and Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Glen Haven Health and Rehabilitation, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 26, 2023

  Based on interviews and record reviews, the facility failed to check the pacemaker function as ordered for discharged Resident #428, Resident #11, and Resident #93, three of seven sampled residents identified by the facility as having a pacemaker. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, implanted in the chest to regulate the heart's rhythm) every month. The facility did not have evidence to indicate the resident's pacemaker was checked monthly as ordered by the physician from April of 2021 until after discharge on [DATE]. On [DATE], Resident #428 was found unresponsive, pale in color, with a heart rate of 38 beats per minutes (a normal resting heart rate range for adults range from 60 to 100 beats per minute). […]

• Immediate jeopardy, patternF867Jul 26, 2023

  Based on interviews, record review, and review of the facility policy, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly review all factors related to Resident #428 emergent discharge to the hospital on [DATE]. The facility QAPI committee further failed to develop and implement corrective action. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, usually placed in the chest to help regulate slow electrical problems with the heart) every month. The facility did not have evidence to indicate the resident's pacemaker was checked as ordered by the physician after [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jul 26, 2023

  Based on observations, interviews, and Food and Drug Administration (FDA) recommendations, the facility failed to ensure staff consistently wore hairnets in one of one facility kitchen areas where all resident food was prepared. The failure had the potential to affect all residents who received food items from the kitchen. The facility further failed to ensure staff did not handle ready-to-eat food with their bare hands. This affected one (Resident #118) of 34 sampled residents. Findings included: 1. Review of the 2022 FDA Food Code at FDA Food Code 2022: Full Document (01/18/2023 version) indicated, .2-402.11 Effectiveness. […]

• No harm, potential for more than minimal, patternF677Jul 26, 2023

  Based on observations, interviews, record review, and facility policy review, the facility failed to provide timely nailcare for three (Residents #108, #152, and #146) of eight residents reviewed for activities of daily living (ADLs). Findings included: Review of a facility policy titled, Nail Care, dated 10/01/2010, indicated, .PURPOSE: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well-being for the resident. STANDARD: Nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath . […]

• No harm, potential for more than minimal, patternF726Jul 26, 2023

  Based on document review and interviews, the facility failed to train their nurses on how to perform a pacemaker check or have any documentation that a competency skill check was done to determine if nurses possessed the knowledge/skills to perform a pacemaker check. This failure had the potential to affect all 13 residents who resided in the facility identified as having a pacemaker. Findings included: Cross Reference F867 QAPI/QAA Improvement Activities and F684 Quality of Care. On 07/24/2023 at 10:26 AM, the Administrator presented the survey team with a list that indicated 13 residents, who resided in the facility, had a pacemaker (a small electronic device, usually placed in the chest to help regulate slow electrical problems with the heart). […]