Glen Haven Village

In the surveyor’s words

From the most serious findings on record at Glen Haven Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 6, 2022

  Based on observation, record review, facility policy/procedure review, and staff interviews, the facility failed to ensure that each resident received adequate nursing supervision and assistive devices to prevent hazards for 2 of 7 residents reviewed (Residents #34 and Resident #56). On 12/24/21, Resident #34 eloped (when a resident exits the facility without staff knowledge or permission) from the facility. A short time later, facility staff noticed the resident walking in front of the facility near the road and brought her back to her cottage. Although the door alarm activated when Resident #34 left the facility, neither of the staff in the cottage responded to the alarm as soon as it activated because they were in rooms (a resident room and a bathroom) and could not hear it. […]

• Actual harm, isolatedF689Sep 25, 2025

  Based 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.Findings include: Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of anxiety disorder, and Alzheimer's disease. The MDS then revealed a Brief Interview for Mental Status (BIMS) score of being incomplete. The MDS further revealed Resident #2 was totally dependent on staff for assistance with eating, oral hygiene, toileting hygiene, shower/bathing, dressing, personal hygiene, rolling right to left while in bed, and transferring. The MDS dated [DATE] reflected Resident #2's was rarely/never understood. […]

• Actual harm, isolatedF686Jun 5, 2025

  Based 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. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF689Sep 21, 2024

  Based 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. Findings include: The Minimum Data Set (MDS) assessment of Resident #1 dated 7/2/24 reflected the Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The resident required partial/moderate assistance for transfers, ambulation, and lower body dressing. In the past 7 days of the assessment period the resident used a walker and wheelchair. […]

• Actual harm, isolatedF760Jul 11, 2024

  Based 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. […]