Inspection Reports for Glen Haven Village

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.

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.

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.

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.

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 #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.

A revisit of the survey ending June 05, 2025 was conducted on July 10, 2025 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective their plan of correction dated July 01, 2025.

The inspection was conducted as the facility's annual recertification survey and included an investigation of complaint #128772-C.

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 #128772-C was investigated during the survey conducted June 2 to June 5, 2025, and resulted in no deficiency.

A complaint investigation for complaint #125732-C was conducted from May 05, 2025 to May 07, 2025.

The facility was found to be in substantial compliance.

Complaint #125732-C was investigated and the facility was found to be in substantial compliance.

A revisit of the survey ending September 21, 2024 was conducted on October 15-16, 2024 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective September 22, 2024.

The inspection was conducted following an investigation of a facility-reported incident #122928-I involving a resident fall and injury.

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.

Facility reported incident #122928-I was substantiated.

A revisit of the survey ending July 11, 2024 was conducted on August 14 to August 15, 2024 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective August 2, 2024.

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.

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 #120557-C was substantiated. Facility reported incident #121559-I was substantiated.

The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.

The facility was found to be in substantial compliance and will be certified effective April 1, 2024, based on the Plan of Correction submitted.

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.

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.

Complaints #116475-C and #116812-C were substantiated but did not result in a deficiency. Facility reported incident #119116-I was substantiated.

The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.

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.

A Recertification and Complaint Survey was conducted on May 8 - May 11, 2023, due to complaint #112629-C which was substantiated.

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 #112629-C was substantiated.

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.

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.

Complaints #104024, #104811, #105132, #107351, and #109024-C were not substantiated.

The inspection was conducted to investigate complaint 102821-C.

The complaint was investigated and found to be not substantiated.

Complaint 102821-C was investigated and not substantiated.

An onsite revisit was conducted regarding the facility's annual health survey, investigation of facility reported incidents, and investigation of a new complaint.

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 102821-C was investigated and found NOT substantiated.

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.

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.

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.

The inspection was conducted as an annual health survey and investigation of facility-reported incidents between December 27, 2021 and January 6, 2022.

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.

The Iowa Department of Inspections and Appeals conducted an investigation in accordance with Medicare Conditions of Participation and Requirements following reported incidents and complaints.

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.

Facility reported incidents and complaint numbers were reviewed; one complaint (#98453-C) was substantiated while others were not substantiated.

The inspection was conducted as part of an investigation into a facility reported incident (#87664-M) involving medication security and safety concerns.

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.

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.

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.

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 #90676-C was substantiated.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.