Inspection Reports for
Glen Haven Village

The complaint investigation found that Resident #1 had a UA ordered on 12/1/25 which was not obtained until 12/7/25. Staff did not notify the physician of the inability to obtain the UA in a timely manner. Family members expressed concern about the delay and lack of communication. Staff interviews revealed inconsistent knowledge and communication about the UA order and procedures for notifying the physician.

The facility failed to provide needed services in accordance with professional standards by not obtaining a UA timely and not notifying the physician when the UA was not obtained for Resident #1. The UA was ordered on 12/1/25 but not obtained until 12/7/25, and the physician was not notified of the delay. Staff interviews and family statements confirmed communication and procedural issues related to the UA collection.

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 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 complaint investigation found that Resident #2 was injured when the bed brakes were not locked, causing the resident to roll and hit their head on the wall. The incident was substantiated with actual harm to the resident.

The facility failed to ensure bed brakes were properly locked, resulting in Resident #2 rolling in bed and hitting their head on a concrete wall, causing a laceration requiring hospital treatment. The bed's pedal brake was found defective and was replaced. Staff failed to check bed brakes prior to repositioning the resident.

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.

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.

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

The facility failed to update and revise care plans for residents with pressure injuries and burns, did not complete required hot liquids risk assessments, failed to provide adequate pressure ulcer care and prevention, served food at unsafe temperatures, did not accommodate resident food preferences adequately, and failed to implement proper infection prevention practices for a resident on Enhanced Barrier Precautions.

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

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.

The investigation was complaint-driven, substantiated by findings that staff did not use a gait belt during transfer of Resident #1, who fell and sustained injuries. The resident was on anticoagulant therapy, increasing risk of complications.

The facility failed to transfer Resident #1 with a gait belt, resulting in a fall and injury including a laceration and head injury. Staff interviews, record reviews, and observations confirmed non-compliance with facility policy requiring gait belt use during transfers.

Facility reported incident #122928-I was substantiated.

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.

The complaint investigation was substantiated with findings of staff disrespectful behavior towards residents, failure to maintain privacy, incomplete care plans, medication administration errors, and inadequate infection control practices.

The facility was found to have multiple deficiencies including failure to respect residents' dignity and privacy, incomplete care plans for anticoagulant and diuretic therapy, failure to conduct timely care plan conferences, a significant medication error involving administration of wrong medications to a resident, and inadequate infection prevention practices including improper use of PPE during catheter care.

The investigation was triggered by complaints from multiple residents about Staff A's disrespectful and rough care. The medication error complaint involved Staff D administering medications to the wrong resident, confirmed by lab tests and resident symptoms.

The facility failed to respect residents' dignity and privacy, with multiple residents reporting disrespectful and rough treatment by Staff A, CNA. Additionally, a significant medication error occurred involving Staff D, RN, who administered medications to the wrong resident, resulting in actual harm to one resident. The facility terminated Staff A and Staff D following these findings.

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

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.

The complaint investigation found that Resident #3 was found sitting on the floor on 2/22/24, assisted off the floor by a CNA without nurse assessment or notification. The resident sustained an acute right 3rd metatarsal fracture. Staff failed to follow fall protocols requiring immediate nurse assessment before moving the resident. Staff education was provided after the incident.

The facility failed to properly assess and intervene after Resident #3 was found on the floor with a right foot fracture. Staff did not notify nursing or perform timely assessments following the fall, and the incident was not documented promptly. Camera footage revealed the resident was assisted off the floor without nurse assessment, violating fall protocols.

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

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.

The complaint investigation focused on alleged failures in resident injury investigation, transfer/discharge notification, resident assessment, staff performance reviews, food safety, infection control, infection preventionist qualifications, and behavioral health training for staff.

The facility failed to document a thorough investigation of a resident's injury, failed to provide written transfer/discharge notices to residents and their representatives, failed to complete a Minimum Data Set assessment for a resident, failed to conduct annual performance reviews for eligible CNAs, failed to label and date opened food items in the kitchen, failed to follow proper infection control precautions for a resident in isolation, lacked a qualified infection preventionist with completed training, and failed to provide behavioral health training to nursing staff as required by the facility assessment.

The complaint investigation found that the facility did not conduct a complete investigation including staff and resident interviews related to the injury of Resident 17. The investigation lacked documentation of interviews with staff working between the dates of the falls and did not include resident interviews. The facility administrator acknowledged limited investigation.

The facility failed to document a thorough investigation into Resident 17's injury, including incomplete staff and resident interviews. The resident had multiple falls with a resulting tibia and fibula fracture, and the investigation did not include interviews with all relevant staff or the resident. The facility's abuse and neglect policy outlines detailed investigation procedures which were not fully followed.

Complaint #112629-C 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.

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 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 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.

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

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.

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 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 #90676-C 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.