Glenhaven Retirement Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 8, 2024

  On 10/07/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff followed proper procedure for the use of a mechanical lift to prevent accidents. The failure resulted in a fractured hip for Res #1. An undated facility Hydraulic Lift policy documented to check to be sure hooks are secure. A care plan intervention, dated 11/03/23, documented Res #1 required two staff assistance with a Hoyer (full body mechanical lift) for transfers. On 09/08/24, Res #1 had a fall due to the strap on the transfer sling failing to remain attached to the Hoyer lift. The resident was sent to the hospital and diagnosed with a closed hip fracture. […]

• Actual harm, isolatedF686Dec 8, 2022

  Based on record review, observation, and interview, the facility failed to notify the physician of an unstageable pressure ulcer, provide appropriate treatment, and provide wound care in a way to help prevent infection for one (#33) of two residents reviewed for pressure ulcers. The facility documented an unstageable ulcer on 11/04/22 and the physician was not notified. On 12/07/22, during an observation of wound care, an additional pressure ulcer was observed. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents resided in the facility who had pressure ulcers. Findings: A Risk Assessment and Pressure Ulcer Policy revised 06/24/08, read in parts, .3. […]

• No harm, potential for more than minimal, widespreadF851Oct 12, 2023

  Based on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 10/10/23 at 9:43 a.m., the BOM was asked how often the facility submitted staffing data to CMS. They stated quarterly. They were asked if they had submitted data for the third quarter of 2023. 10/10/23 at 11:18 a.m., the BOM stated they did not submit the data for the quarter and should have.

• No harm, potential for more than minimal, patternF925Jan 16, 2025

  Based on observation, record review, and interview, the facility failed to maintain an effective pest control program. The DON identified 52 residents resided in the facility. Findings: An undated facility Pest policy, read in part, [name of facility withheld] will have monthly pest services to ensure that the facility remains pest free. On 01/16/24 at 8:32 a.m., the DON stated they had reports of spiders, roaches, and mice at least four times a week. On 01/16/25 at 8:46 a.m. an initial tour of the building was conducted. The following observations were made, a. in room C16 there were 14 dead roaches on the floor and roach egg sacks were visible, b. in room C16 there was one live roach located inside the dresser drawer next to the bed with roach eggs and dead baby roaches, and c. […]

• No harm, potential for more than minimal, patternF657Dec 19, 2024

  Based on observation, record review and interview, the facility failed to ensure: a. a diuretic was included on the care plan for one (#23) of five sampled residents reviewed for unnecessary meds; and b. assist rails were included on the care plan for one (#43) of two sampled residents reviewed for restraints. The administrator in training identified 51 residents resided in the facility and 15 residents received diuretics. MDS Coordinator #1 identified three residents had assist rails. Findings: 1. Resident #23 had diagnoses which included hypertensive heart disease with heart failure. […]