Pavilion at Glacier Valley

In the surveyor’s words

From the most serious findings on record at Pavilion at Glacier Valley, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 11, 2022

  Based on observation, interview, and record review, the Facility did not ensure Residents (R) that were assessed to be at risk for the development of pressure injuries or residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 (R373, R64, R223, R67) of 6 Residents reviewed for pressure injuries. * R373 was assessed to be at high risk for the development of pressure injures. R373's care plan did not include person centered interventions to prevent the development of pressure injures based on R373's risk assessment. […]

• Actual harm, isolatedF686Mar 31, 2021

  Based on interview and record review the facility did not ensure 1 (R2) of 2 residents with pressure injuries received the necessary treatment to promote healing. R2 was admitted to the facility on [DATE] with some redness to the buttocks and chronic loose stools. On 1/25/21 R2 developed an unstageable pressure injury to the right buttock. On 1/25/21 Wound Physician C changed the treatment order and the new treatment order was not implemented by nursing staff until 2/8/21. No significant changes or healing was noted from 1/25/21-2/8/21. Findings include: R2 was admitted to the facility on [DATE] with a history of cerebral infarction with [CONDITION(S)] on right side, GI bleed, [CONDITION(S)] and neuromuscular dysfunction of bladder. […]

• No harm, potential for more than minimal, widespreadF803Feb 17, 2026

  Based on observation, staff interview, and record review, the facility did not ensure menus and serving sizes were followed. This practice had the potential to affect all 67 residents residing in the facility. On 2/17/26, the lunch menu indicated the vegetable was seasoned broccoli. Residents were served wax beans instead and were not notified of the menu change.On 2/17/26, the lunch menu included a fresh baked roll and cheesecake. Residents with pureed diets did not receive a roll and received applesauce instead of cheesecake. […]

• No harm, potential for more than minimal, widespreadF812Feb 17, 2026

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 67 residents residing in the facility. Temperature logs for meal service were not consistently completed. Hand hygiene was not completed appropriately during the lunch meal on 2/17/26.Staff did not consistently test the internal temperatue of the dishwasher. Serving utensils and bowls were not stored properly to prevent contamination.Staff did not consistently document the parts per million (PPM) of the sanitizing solution in sanitizing buckets.Findings include:On 2/15/26 at 9:15 AM, Surveyor completed an initial kitchen tour with [NAME] (CK)-G who was not sure which food code the facility follows. […]

• No harm, potential for more than minimal, widespreadF801Nov 12, 2024

  Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 72 residents residing in the facility. Dietary Manager (DM)-N did not have an approved dietary manager or food service manager certification course or other related education. Findings include: During an initial kitchen tour on 11/10/24 at 10:33 AM, Surveyor interviewed DM-N who indicated DM-N had been at the facility for a short time and did not have a dietary manager certification. […]