Glenhaven Healthcare

In the surveyor’s words

From the most serious findings on record at Glenhaven Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604Aug 28, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF603Nov 17, 2022

  Based on observation, interview. and record review, the facility failed to ensure residents were free from involuntary seclusion (separation of a resident from other residents) for two of 4 sampled residents by failing to: 1. On [DATE], Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 confined (keep someone in a closed space by force) a resident (Resident 1) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 being secluded (hidden or isolated) against her will and resulting in psychosocial harm to Resident 1. Resident 1 verbalized crying, yelling, and calling out for help, scared when doors were closed or being in dark/closed spaces, unable to sleep at night, and feeling terrified. 2. […]

• Actual harm, isolatedF580Apr 6, 2021

  Based on interview and record review, the facility failed to follow its policies for Fall and Change of Condition by failing to notify the physician for one of three sampled residents (Resident 1) when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/2/20 at 6 a.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 on the floor next to the resident's bed with her legs bent to the right. CNA 1 and Housekeeper 1 (HK 1) transferred Resident 1 from the floor to the resident's bed without reporting the fall. As a result, Resident 1 experienced severe pain (pain that prevent the resident from performing daily living activities), and the resident did not receive timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF814Nov 21, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF812Jan 9, 2026

  Based 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. […]