A list of the most recent deficiencies for Glenhaven Healthcare. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2023-12-22 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-30 | 2023-12-22 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2023-12-22 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-30 | 2023-12-22 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2023-12-22 | 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 | 2023-11-30 | 2023-12-22 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2023-12-22 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-22 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-30 | 2023-12-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-22 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-30 | 2023-12-22 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-07 | 2023-12-22 | N |
Construct fire resistant interior walls. | Fire Safety | 2023-12-07 | 2023-12-22 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-07 | 2023-12-22 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-07 | 2023-12-22 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-22 | 2022-12-19 | Y |
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-11-17 | 2022-12-14 | Y |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-11-17 | 2022-12-14 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-11 | 2022-03-17 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-17 | N |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-11 | 2022-03-17 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-11 | 2022-03-17 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-17 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-03-17 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-11 | 2022-03-17 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-03-17 | N |
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 | 2022-02-11 | 2022-03-17 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-11 | 2022-03-17 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-11 | 2022-03-17 | N |
Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-17 | N |
Implement a program that monitors antibiotic use. | Health | 2022-02-11 | 2022-03-17 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-11 | 2022-03-17 | N |
Provide emergency officials' contact information. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Construct fire resistant interior walls. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-11 | 2022-03-11 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-09 | 2022-02-24 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-09 | 2022-02-24 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-09 | 2022-02-24 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-06 | 2021-05-11 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-06 | 2021-05-11 | Y |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-31 | 2019-06-25 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-31 | 2019-06-25 | N |
Provide activities to meet all resident's needs. | Health | 2019-05-31 | 2019-06-25 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-31 | 2019-06-25 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-31 | 2019-06-25 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-31 | 2019-06-25 | N |
Provide and implement an infection prevention and control program. | Health | 2019-05-31 | 2019-06-25 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-31 | 2019-06-25 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-28 | 2019-06-25 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-28 | 2019-06-25 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-05-28 | 2019-06-25 | N |
Construct fire resistant interior walls. | Fire Safety | 2019-05-28 | 2019-06-25 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-28 | 2019-06-25 | N |