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? |
|---|---|---|---|---|
| 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-06-26 | 2018-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Have an externally vented heating system. | Fire Safety | 2018-06-26 | 2018-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-26 | 2018-06-27 | N |
