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Deficiency Records for Glenhaven Retirement Village

A list of the most recent deficiencies for Glenhaven Retirement Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Glenhaven Retirement Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-09-05 2024-10-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-09-05 2024-10-17 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-09-05 2024-10-17 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-10-12 2023-12-05 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-10-12 2023-12-05 N
Assess the resident when there is a significant change in condition Health 2023-10-12 2023-12-05 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2023-10-12 2023-12-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-10-12 2023-12-05 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-10-12 2023-12-05 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-12 2023-12-05 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2023-10-12 2023-12-05 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-10-12 2023-12-05 N
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2023-10-12 2023-12-05 N
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Health 2023-10-12 2023-12-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-12 2023-12-05 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-12-08 2023-02-03 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2022-12-08 2023-02-03 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-12-08 2023-02-03 N
Ensure each resident receives an accurate assessment. Health 2022-12-08 2023-02-03 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-12-08 2023-02-03 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-12-08 2023-02-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-08 2023-02-03 N
Provide enough food/fluids to maintain a resident's health. Health 2022-12-08 2023-02-03 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2022-12-08 2023-02-03 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-12-08 2023-02-03 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-08 2023-02-03 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-12-08 2023-02-03 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-12-08 2023-02-03 Y
Provide and implement an infection prevention and control program. Health 2022-12-08 2023-02-03 Y
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2019-08-19 2019-10-15 N

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