Inspection Reports for Glen Haven Village
133 Indian Hills Drive, IA, 515341129
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 17, 2025, identified deficiencies related to delays in obtaining a urinalysis and notifying the physician. Earlier inspections showed a pattern of deficiencies involving resident safety, care plan management, infection control, and medication administration. Several complaint investigations were substantiated, including issues with supervision leading to resident injuries, medication security breaches, and failure to follow professional standards of care. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has shown some improvement with corrections verified in follow-up inspections, but deficiencies have recurred over time in similar areas.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
62 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Dec 17, 2025
Visit Reason
The inspection was conducted as a result of complaints #2688343-C from December 16 to December 17, 2025, to investigate alleged deficiencies related to professional standards of care.
Findings
The facility failed to meet professional standards of quality by not obtaining a Urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for one resident. Documentation and interviews revealed delays and communication issues regarding UA orders and results.
Complaint Details
The investigation was triggered by complaints #2688343-C. The complaint was substantiated as deficiencies were found related to failure to obtain a UA timely and notify the physician.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide needed services in accordance with professional standards by not obtaining a Urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for Resident #1. | SS = D |
Report Facts
Resident census: 62
Complaint number: 2688343
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Sep 25, 2025
Visit Reason
The inspection was conducted as a result of complaints #2589043-C, #2608401-C, #2622294-C, and a facility reported incident #2620324-I between September 22 and September 25, 2025.
Findings
The facility failed to protect residents from accidents and injuries, specifically involving Resident #2 who sustained a head laceration due to bed brakes not being locked. Multiple staff interviews and document reviews confirmed the incident and identified deficiencies in supervision and equipment maintenance.
Complaint Details
Complaint #2608401-C resulted in a deficiency. The investigation included review of clinical records, staff interviews, and facility documents related to Resident #2's injury and supervision. The complaint was substantiated by evidence of inadequate supervision and equipment failure.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the resident environment remains free of accident hazards and that each resident receives adequate supervision and assistance devices to prevent accidents. | G |
Report Facts
Resident census: 64
Number of complaints investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Involved in care and reporting of Resident #2's injury |
| Staff B | Certified Nursing Assistant (CNA) | Repositioned Resident #2 and involved in incident details |
| Staff C | Registered Nurse (RN) | Notified of Resident #2's injury and assisted with care |
| Staff D | Director of Maintenance and Housekeeping | Reported on bed brake maintenance and issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies on bed brake checks |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 10, 2025
Visit Reason
A revisit of the survey ending June 05, 2025 was conducted on July 10, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective their plan of correction dated July 01, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding correction of deficiencies from prior survey |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 7
Jun 5, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included an investigation of complaint #128772-C.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, quality of care, skin integrity and pressure ulcer prevention, nutritive value and food temperature, resident allergies and preferences, infection control, and admissions, transfer, and discharge procedures. The facility failed to update care plans timely, provide adequate treatment for pressure ulcers, maintain proper food temperatures, and ensure infection control protocols were followed.
Complaint Details
Complaint #128772-C was investigated during the survey conducted June 2 to June 5, 2025, and resulted in no deficiency.
Severity Breakdown
SS=D: 4
SS=G: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - failure to review and revise care plans for 2 of 16 residents reviewed. | SS=D |
| Quality of Care - failure to provide needed services in accordance with professional standards for 1 of 16 residents reviewed. | SS=D |
| Treatment/Services to Prevent/Heal Pressure Ulcer - failure to provide adequate treatment and interventions for pressure ulcers for 1 resident and failure to implement timely interventions for 2 of 4 residents reviewed. | SS=G |
| Nutritive Value/Appearance, Palatable/Prefer Temperature - failure to provide food at an appetizing temperature to 2 of 20 residents reviewed. | SS=D |
| Resident Allergies, Preferences, Substitutes - failure to accommodate resident food preferences and provide appealing options for 2 of 20 residents reviewed. | null |
| Infection Prevention and Control - failure to establish and maintain an infection prevention and control program including failure to follow enhanced barrier precautions. | SS=D |
| Admissions, Transfer, and Discharge - failure to submit veteran information for 1 of 3 residents reviewed. | null |
Report Facts
Residents reviewed for care plans: 16
Residents reviewed for quality of care: 16
Residents reviewed for pressure ulcer treatment: 4
Residents reviewed for food temperature: 20
Residents reviewed for food preferences: 20
Residents reviewed for infection control: 2
Residents reviewed for veteran admission information: 3
Facility census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Bachman | Registered Nurse (RN) | Reviewed and updated care plans for residents #15 and #24 |
| Marie Burkhart | Licensed Practical Nurse (LPN) | Completed assessments and wound treatments for residents #15 and #23 |
| Julianne Marriott | Unknown | Signed plan of correction response |
| Dustin Archer-McClain | Director of Nursing Services (DNS) | Signed plan of correction response and involved in education and audits |
| Staff J | Registered Nurse (RN)/Care Coordinator (CC) | Involved in wound care and notification for resident #15 |
| Staff B | Director of Nursing (DON) | Provided statements regarding care plans and wound care |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 7, 2025
Visit Reason
A complaint investigation for complaint #125732-C was conducted from May 05, 2025 to May 07, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #125732-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 16, 2024
Visit Reason
A revisit of the survey ending September 21, 2024 was conducted on October 15-16, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 22, 2024.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Sep 21, 2024
Visit Reason
The inspection was conducted following an investigation of a facility-reported incident #122928-I involving a resident fall and injury.
Findings
The facility failed to transfer a resident with a gait belt, resulting in a fall and injury. The resident sustained a laceration and head injury requiring hospital admission. Staff failed to consistently use required gait belts during transfers, violating safety protocols.
Complaint Details
Facility reported incident #122928-I was substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to transfer a resident with a gait belt resulting in a fall and injury. | SS=G |
Report Facts
Resident census: 67
BIMS score: 14
Medication dosage: 3
Deficiency count: 1
Audit frequency: 1
Nursing management rounds: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in failure to use gait belt resulting in resident injury and subsequent termination |
| Staff G | Registered Nurse (RN), Care Coordinator | Provided assessment and statements regarding resident fall and gait belt use |
| Staff F | Certified Nursing Assistant (CNA) | Provided statements about gait belt use and training |
| Staff I | Physical Therapist Assistant (PTA) | Provided assessment of resident's transfer needs and gait belt requirements |
| Administrator | Administrator | Stated facility policy on gait belt use and training |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 14, 2024
Visit Reason
A revisit of the survey ending July 11, 2024 was conducted on August 14 to August 15, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective August 2, 2024.
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 5
Jul 11, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaints #120557-C and facility reported incidents #119625-I, #119628-I, #121556-I, #121559-I, and #121902-I.
Findings
The facility was found to have deficiencies related to resident rights, comprehensive care plans, care plan timing and revision, medication administration errors, and infection prevention and control. Several residents reported mistreatment and lack of privacy, and the facility failed to ensure care plans were comprehensive and updated timely. Medication errors were identified, resulting in staff termination and policy revisions. Infection control practices were also found deficient.
Complaint Details
Complaint #120557-C was substantiated. Facility reported incident #121559-I was substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to provide privacy during personal care and respect residents' dignity. |
| Failure to develop and implement comprehensive care plans including measurable objectives and specialized services. |
| Failure to timely revise care plans and conduct care plan conferences as required. |
| Failure to ensure residents are free from significant medication errors, including improper medication administration by staff. |
| Failure to establish and maintain an effective infection prevention and control program, including proper use of personal protective equipment and hand hygiene. |
Report Facts
Census: 65
Medication Administration Audits: 4
Care Plan Conference Audit Completion Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julianne Marriott | Administrator | Signed the plan of correction response on August 2, 2024. |
| Staff A | Certified Nursing Assistant (CNA) | Named in findings related to mistreatment and rude behavior toward residents; suspended and terminated. |
| Staff D | Registered Nurse (RN) | Named in medication error incident; terminated and reported to authorities. |
| Sara Wise | Care Coordinator | Reviewed infection control processes with staff. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 1, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified effective April 1, 2024, based on the Plan of Correction submitted.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Mar 15, 2024
Visit Reason
The inspection was conducted as a result of investigations into complaints #116475-C, #116812-C, and facility reported incidents #116612-I, #117216-I, and #119116-I between March 13 and March 15, 2024.
Findings
The facility failed to provide appropriate interventions and assessments after one of three residents (Resident #3) fell, resulting in a deficiency in quality of care. The investigation found that Resident #3 sustained an acute right 3rd metatarsal fracture, and staff did not properly assess or report the incident in a timely manner.
Complaint Details
Complaints #116475-C and #116812-C were substantiated but did not result in a deficiency. Facility reported incident #119116-I was substantiated.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate interventions and assessments after Resident #3 fell, resulting in injury. | Level D |
Report Facts
Complaint numbers investigated: 5
Resident census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julianne Marriott | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 20, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective June 11, 2023.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 8
May 11, 2023
Visit Reason
A Recertification and Complaint Survey was conducted on May 8 - May 11, 2023, due to complaint #112629-C which was substantiated.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to thoroughly investigate an injury of unknown origin for one resident, failure to provide timely and proper transfer/discharge notices, failure to complete accurate assessments, failure to conduct nurse aide performance reviews, food safety violations, infection prevention and control deficiencies, and failure to provide behavioral health training to staff.
Complaint Details
Complaint #112629-C was substantiated.
Deficiencies (8)
| Description |
|---|
| Failure to ensure a thorough investigation regarding the injury of unknown origin for one resident. |
| Failure to provide proper notice before transfer or discharge to residents and representatives. |
| Failure to ensure accuracy of assessments (MDS) and timely completion. |
| Failure to complete annual nurse aide performance reviews. |
| Food safety violations including unlabeled and undated food items in refrigerator and freezer. |
| Failure to establish and maintain an effective infection prevention and control program. |
| Failure to employ an Infection Preventionist with specialized training. |
| Failure to provide behavioral health training to all certified nurse aides and registered nurses. |
Report Facts
Survey Census: 67
Correction Date: Correction date noted as 06-11-23 in initial comments.
Dates of Survey: Survey conducted May 8 - May 11, 2023.
Number of Certified Nurse Aides reviewed: 4
Number of Registered Nurses reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julianne Marriott | Administrator | Signed the plan of correction and response to deficiencies. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transfer/discharge notices and infection preventionist role. |
| Care Coordinator | Care Coordinator (CC) | Interviewed regarding resident injury investigation and infection control. |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding food safety findings. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Dec 21, 2022
Visit Reason
An investigation was conducted from 12/12/22 to 12/21/22 regarding complaints #104024-C, #104811-C, #105132-C, #107351-C, and #109024-C.
Findings
The survey determined the facility to be in compliance with the Code of Federal Regulations (42CFR) Part 482, Subpart B-C, with no deficiencies found. All complaints investigated were not substantiated.
Complaint Details
Complaints #104024, #104811, #105132, #107351, and #109024-C were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 23, 2022
Visit Reason
The inspection was conducted to investigate complaint 102821-C.
Findings
The complaint was investigated and found to be not substantiated.
Complaint Details
Complaint 102821-C was investigated and not substantiated.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 23, 2022
Visit Reason
An onsite revisit was conducted regarding the facility's annual health survey, investigation of facility reported incidents, and investigation of a new complaint.
Findings
All deficiencies identified during the survey and investigations have been corrected, the new complaint was not substantiated, and the facility was found in substantial compliance with all regulations surveyed effective February 17, 2022.
Complaint Details
Complaint 102821-C was investigated and found NOT substantiated.
Report Facts
Facility reported incidents: 5
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Jan 18, 2022
Visit Reason
The inspection was conducted as an investigation of complaint 99195-A and facility reported incidents 99194-M and 99324-M occurring between January 3 and January 18, 2022.
Findings
The facility failed to keep controlled substances secured in a locked medication cart or locked storage room accessible only to authorized personnel, resulting in misappropriation of narcotics by a staff member. The investigation included review of records, staff interviews, and video footage confirming the unauthorized access and misuse of controlled substances.
Complaint Details
The complaint investigation was related to incidents involving misappropriation of controlled substances by staff. The findings were substantiated by observations, record reviews, staff interviews, and video evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to keep controlled substances within locked medication cart or locked storage room accessible only to authorized personnel. | SS=D |
Report Facts
Resident census: 59
Lorazepam concentrate count: 26.75
Morphine sulfate solution count: 25.25
Lorazepam concentrate count: 24
Morphine sulfate solution count: 19.75
Fentanyl patches: 4
Fentanyl patches: 3
Fentanyl patches: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julianne Marriott | Administrator | Signed the report and plan of correction |
| Staff A | Named in findings for misappropriating controlled substances and admitted to taking narcotics | |
| Staff B | Named in findings for loaning keys to Staff A and interviewed regarding narcotics count discrepancies | |
| Director of Nursing | Director of Nursing | Interviewed regarding investigation and narcotics security |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 6
Jan 6, 2022
Visit Reason
The inspection was conducted as an annual health survey and investigation of facility-reported incidents between December 27, 2021 and January 6, 2022.
Findings
The facility was found to have multiple deficiencies including failure to conduct comprehensive assessments after significant changes, failure to coordinate assessments, failure to meet professional standards in care plans, inadequate supervision to prevent accidents, food safety violations, and infection control deficiencies. The facility reported a census of 61 residents during the survey.
Deficiencies (6)
| Description |
|---|
| Failed to conduct a significant change assessment for a resident transitioning to Hospice care. |
| Failed to submit a timely Minimum Data Set (MDS) assessment reflecting discharge for a resident. |
| Failed to follow physician orders in accordance with professional standards for 1 of 15 residents reviewed. |
| Failed to ensure adequate nursing supervision and assistive devices to prevent hazards for 2 of 7 residents reviewed, including an elopement incident. |
| Failed to ensure food service staff followed sanitary meal preparation practices. |
| Failed to maintain an effective infection prevention and control program, including inadequate hand hygiene and failure to comply with COVID-19 testing requirements. |
Report Facts
Residents present: 61
Residents reviewed: 15
Residents reviewed for supervision: 7
Residents with deficiencies: 2
Residents with elopement risk: 1
Residents with falls: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Logan | Maintenance Director | Educated on alarm battery replacement and door checks following elopement incident |
| Dustin Archer-McClain | Director of Nursing (DON) | Reported on elopement incident and staff education |
| Heidi Henderson | Care Coordinator | Tested audibility of alarms and involved in elopement prevention measures |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Jul 15, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted an investigation in accordance with Medicare Conditions of Participation and Requirements following reported incidents and complaints.
Findings
The facility was found to be not in compliance due to failure to notify the family of a resident about an incident causing a significant bruise requiring physician intervention. The facility reported a census of 63 residents.
Complaint Details
Facility reported incidents and complaint numbers were reviewed; one complaint (#98453-C) was substantiated while others were not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to notify the family of an incident causing a significant bruise requiring physician intervention for one resident. |
Report Facts
Total residents: 63
Complaint numbers reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated there was an incident with Resident #10 where staff did not report to family and the staff member was released from employment |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Oct 12, 2020
Visit Reason
The inspection was conducted as part of an investigation into a facility reported incident (#87664-M) involving medication security and safety concerns.
Findings
The facility failed to safely secure and limit access to controlled drugs, specifically the narcotic lock box, which was accessed using a code by unauthorized staff. The investigation revealed that the narcotic safe was accessed with a code instead of keys as per policy, and morphine was replaced with cough syrup for one resident. Cameras were later installed as a precaution.
Complaint Details
The investigation was triggered by a complaint related to the replacement of morphine with cough syrup for Resident #1. The complaint was substantiated by staff interviews and observations confirming unauthorized access to the narcotic safe using a code.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to safely secure and limit access to controlled drugs; narcotic lock box accessed with a code instead of keys as required by policy. | SS=D |
Report Facts
Resident census: 54
Resident #1 Brief Interview of Mental Status score: 10
Morphine dosage: 0.25
Number of cottages: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Accessed narcotic lock box using a code; programmed narcotic safes for quicker access; implicated in morphine replacement incident | |
| Staff B | Discovered altered morphine bottle; reported incident to Director of Nursing | |
| Staff E | Nurse | Used code to open narcotic safe; received code from Staff A |
| Staff F | Nurse | Observed initial finding of altered morphine; reported code use concerns; unlocked medication storage and closet with keys |
| Staff D | Former Nurse | Had access to narcotic safe with code; received code from Staff A |
| Director of Nursing | Director of Nursing | Reported discovery of unauthorized code use to access narcotic safe |
| Administrator | Administrator | Provided information on investigation and facility security measures |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Jul 3, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey conducted on 06/10/2020, related to the investigation of complaint #90676-C, which was substantiated.
Findings
The facility was found to be in compliance with CDC recommended COVID-19 practices but had deficiencies related to pressure ulcer prevention and treatment, and medication administration errors. Immediate jeopardy was identified due to failure to prevent and treat pressure ulcers leading to a resident's death from sepsis. The facility implemented corrective actions to address these issues.
Complaint Details
Complaint #90676-C was substantiated.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents received care to prevent pressure ulcers and provide necessary treatment, resulting in new ulcers and a resident's death from sepsis related to wound infection. | Immediate Jeopardy |
| Failure to ensure residents were free from significant medication errors, specifically failure to administer apixaban as ordered for Resident #1. | — |
Report Facts
Resident Census: 61
Date Survey Completed: Jul 3, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jana Lewis | Registered Nurse | Completed Resident #1 skin assessment on 4-25-20 |
| Julianne Marriott | Administrator | Signed the plan of correction response on 8-21-20 |
Inspection Report
Routine
Census: 61
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 61
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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