Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glen Haven Village during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and chronic kidney disease experienced a delay of six days in obtaining a physician-ordered urinalysis (UA) with culture and sensitivity. Staff were aware of the outstanding order but did not notify the physician in a timely manner when unable to collect the specimen, and communication among staff regarding the order was inconsistent. The lack of a clear policy or procedure contributed to the delay in obtaining the necessary lab work.
Staff failed to consistently implement and document pressure ulcer prevention and care interventions for two residents, resulting in the development and worsening of pressure ulcers. Required devices such as heel protectors were not used as ordered, and changes in skin condition were not promptly communicated to the care team or physician, contrary to facility policy.
The facility did not consistently provide or communicate alternative meal options to residents who declined the food initially served, including residents with communication deficits and those with specific dietary needs. Staff were often unaware of available alternatives or did not offer them, and information about substitutes was not posted or accessible to residents. This resulted in residents not being able to exercise their food preferences as outlined in facility policy.
The facility did not timely update care plans for two residents after significant incidents—a pressure injury and a burn from hot coffee. Although interventions were implemented, the care plans did not reflect current treatments or changes in condition, and staff confirmed that updates were not made as required by facility policy.
A resident with cognitive impairment and physical care needs suffered burns after spilling hot coffee, and review showed that required Hot Liquids Risk Assessments were not completed as per facility policy. Staff were unaware of the incident and relevant procedures, and the facility's policy lacked clear assessment details.
Two residents reported that hot foods were frequently served cold or cool, and observations confirmed that food was not consistently held at safe temperatures during meal service. Staff failed to maintain proper food temperatures, did not report broken equipment, and did not always check food temperatures after reheating, resulting in meals being served below required standards.
A resident with an indwelling catheter and moderate cognitive impairment, who was on Enhanced Barrier Precautions (EBP), did not receive proper infection prevention measures during catheter care. A CNA/CMA performed catheter care using gloves but failed to don a gown as required by facility policy, a lapse confirmed by the DON. The facility's policy mandated both gown and gloves for such care to prevent MDRO transmission.
A resident with intact cognition and on anticoagulant medication fell and sustained a head injury due to the facility's failure to use a gait belt during a transfer. Despite the care plan requiring staff assistance and the use of a gait belt, these measures were not followed, leading to the resident's fall in the bathroom. Staff interviews confirmed the facility's policy on gait belt usage, but it was not adhered to at the time of the incident.
A significant medication error occurred when a resident with severe cognitive impairment was mistakenly given medications intended for her roommate. The error was discovered after the resident exhibited symptoms such as vomiting and lethargy, and lab tests confirmed the presence of unprescribed medications. The incident was attributed to a Registered Nurse's failure to adhere to the facility's medication administration policy, including proper resident identification and medication preparation procedures.
The facility failed to ensure privacy and dignity for residents during personal care and interactions. A resident felt undignified when a window was left open during care, and several residents reported disrespectful treatment by a CNA, including rough handling and unresponsiveness. Staff interviews corroborated these concerns, leading to the CNA's termination.
The facility failed to develop comprehensive care plans for two residents, omitting necessary details for anticoagulant and diuretic therapies. A resident with severe cognitive impairment and hypertension was prescribed a diuretic, but the care plan did not reflect this. Another resident with coronary artery disease and hypertension was prescribed an anticoagulant, yet the care plan lacked documentation for this medication. Staff acknowledged that these therapies should have been included in the care plans.
A facility failed to conduct regular care plan conferences for a resident with no cognitive impairment, as neither the resident nor their family were invited to participate. Staff confirmed that care conferences were not held quarterly as required, with the last documented meeting occurring months prior. The facility's policy encourages resident and family involvement in care planning, but this was not followed in this instance.
The facility failed to follow infection control measures during catheter care for two residents. In one case, staff did not wear a gown as required by Enhanced Barrier Precautions (EBP), and in another, a CNA did not perform hand hygiene between glove changes. The Director of Nursing confirmed the expectation for proper PPE use and hand hygiene.
Failure to Timely Obtain Urinalysis and Notify Physician
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not obtaining a urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for one resident. The resident, who had moderate cognitive impairment and chronic kidney disease, had a physician's order for a one-time UA with culture and sensitivity, which was to be completed within a specified timeframe. However, the UA was not obtained until six days after the order was placed, despite multiple staff being aware of the outstanding order and the resident's ongoing need for the test. Documentation and interviews revealed that staff were unclear about the procedures for timely notification of the physician when unable to obtain a UA. The nurse responsible stated she would wait up to 48 hours before notifying the physician or requesting a straight catheterization, but in this case, the delay extended to five days. Communication among staff was inconsistent, with some staff unaware of the order and others not taking steps to facilitate urine collection, such as placing a collection hat in the bathroom. The resident's family also questioned why the physician was not notified sooner about the inability to obtain the UA. The delay in obtaining the UA was further compounded by confusion regarding specimen collection and communication breakdowns between shifts. The order for the UA was acknowledged by staff, but there was no clear policy or procedure guiding how quickly the lab should be obtained or when to escalate to the physician. The Director of Nursing confirmed that the expectation was for the UA to be obtained before the six-day delay occurred, but acknowledged the absence of a formal policy on the matter.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Staff failed to provide adequate pressure ulcer prevention and care for two residents, resulting in the development and worsening of pressure ulcers. One resident, who was at moderate risk for pressure injury and had significant cognitive and physical impairments, was not consistently provided with required heel protectors as ordered. Observations showed the resident without protective boots, with feet unsupported and dangling while seated in a wheelchair for extended periods. Multiple open wounds and unblanchable red areas were noted on the resident's feet and heels, with staff unaware of the status or treatment of these sores. Documentation was incomplete, lacking timely updates on new wounds and notification to the physician or hospice regarding changes in skin condition. Another resident, with a history of stroke, dementia, and other chronic conditions, experienced repeated episodes of redness and later blackened and scabbed areas on the toes. Despite ongoing skin assessments documenting these changes over several weeks, there was a delay in notifying the care coordinator and physician, and interventions were not implemented promptly. The care coordinator was not aware of the skin condition until several weeks after initial signs were documented, and the director of nursing confirmed that earlier intervention should have occurred. The facility's policy required immediate notification and documentation of impaired skin integrity, which was not followed in these cases. Both cases demonstrated a failure to monitor, document, and respond to changes in skin condition as required by facility policy and care plans. Staff did not ensure that prescribed interventions, such as heel protectors and pressure-reducing devices, were consistently used, nor did they update care plans or notify appropriate medical personnel in a timely manner when new or worsening wounds were identified. These lapses contributed to the development and progression of pressure ulcers in residents who were at risk.
Failure to Provide and Communicate Alternative Meal Options
Penalty
Summary
The facility failed to provide food that accommodated resident preferences and did not consistently offer or communicate appealing alternative meal options to residents who declined the food initially served. Several residents, including those with intact cognitive abilities and those with communication deficits, reported not being aware of available meal substitutes or how to request them. For example, one resident with dysphagia, anxiety, and deafness communicated via writing that he was unaware of meal options beyond what was served and did not know what vegetable substitutes were available. Another resident with diabetes, anxiety, and autism expressed uncertainty about what would happen if he did not eat the served meal and was also unaware of food substitute options. Staff interviews revealed inconsistent knowledge and practices regarding alternative meal options. Some staff members, including CNAs and cooks, were unsure of what alternatives were available or where such options were listed. The dietary manager confirmed that a list of alternatives existed but was not posted or provided to residents, being kept only in a kitchen binder. Staff generally relied on their knowledge of resident preferences or pocket care plans, but did not consistently offer alternatives unless specifically requested, and alternatives were not clearly communicated or visible to residents. Observations during meal service showed that when a resident refused a food item, such as corn, staff did not always offer an alternative, and in some cases, staff were unsure what alternatives could be provided. The menu board listed only the main meal, and there was no system in place for residents to select or be informed of alternative options. Documentation in the admission packet stated that food preferences would be considered, but in practice, residents were not consistently assisted in exercising choice regarding their meals.
Failure to Timely Update Care Plans After Resident Incidents
Penalty
Summary
The facility failed to review and revise care plans for two residents following significant changes in their conditions. For one resident with moderate cognitive impairment and multiple diagnoses, including stroke and dementia, a pressure area developed on the left great toe. Although interventions such as a blanket cradle and wound care were implemented, the resident's care plan and pocket care plan were not updated to reflect the removal of the air mattress or the new interventions for the toe wound. Observations and interviews confirmed that the care plan did not accurately reflect the resident's current needs or the interventions in place. Another resident, who had cognitive impairment and required setup for eating, sustained burns on the inner upper thighs after spilling hot coffee. The pocket care plan was updated to include the addition of ice cubes to coffee, but the main care plan was not revised to document the burn incident or the interventions trialed and refused by the resident. The care plan also did not include the family's responses to the incident. Staff interviews confirmed that the care plan should have been updated following the incident, and facility policy required individualized interventions for hot liquids to be noted in the care plan. Facility policies reviewed indicated that care plans should be updated after changes in condition and after each comprehensive review or quarterly assessment. Despite these policies, the care plans for both residents were not revised in a timely manner to reflect new interventions or changes in condition, as confirmed by staff and administrative interviews.
Failure to Complete Hot Liquids Risk Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards by not completing a Hot Liquids Risk Assessment for one resident with cognitive impairment and physical care needs. The resident, who had diagnoses including coronary artery disease, hypertension, and chronic pain, was noted to have short and long-term memory problems and required setup assistance for eating. Despite these needs, the resident was observed drinking coffee on multiple occasions, and a progress note documented that the resident spilled a cup of coffee, resulting in red blistering burns on both inner upper thighs. A review of assessments from January to June revealed that no Hot Liquids Risk Assessment had been completed for this resident, contrary to facility policy, which required such assessments upon admission and quarterly. Staff interviews confirmed a lack of awareness regarding the incident and the facility's policy on serving hot liquids. The Director of Nursing and Administrator both acknowledged that the required assessment was missing, and the facility's Hot Liquid Safety Policy was found to be incomplete regarding assessment procedures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to two residents who were cognitively intact, as evidenced by their BIMS scores. Both residents reported that hot foods were served cold or cool on multiple occasions, with one resident specifically stating that food had been served cold in the past week. During meal service observation, staff removed food from the oven and placed it on a stove top that was not turned on, and one of the burners was broken. Staff did not report the broken burner, and food was held on the stove without heat. Temperatures of the food at the start of service were within appropriate ranges, but by the end of service, some items had dropped below the expected holding temperature, with mashed potatoes at 121 degrees and beef stroganoff at 130 degrees. Staff reheated a plate in the microwave for one resident but failed to check the temperature before serving it. Staff interviews revealed inconsistent understanding of required holding and serving temperatures, with expectations ranging from 135 to 150 degrees for holding and 165 degrees for reheating. The facility's policy required hot foods to be served at a minimum of 120 degrees and held at 140 degrees or above, but these standards were not consistently met. Staff and dietary management acknowledged that residents had complained about cold food, and the issue was not communicated or addressed effectively.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to follow appropriate infection prevention practices for a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). The resident, who had moderate cognitive impairment and required EBP due to the presence of an indwelling catheter, had care plans and physician orders specifying catheter care and the use of EBP supplies. During an observed catheter care procedure, a Certified Nursing Assistant/Certified Medication Assistant performed hand hygiene and wore gloves but did not don a gown as required by the facility's EBP policy. The staff member completed the catheter care without the gown, despite the policy stating that both gown and gloves must be worn during high-contact resident care activities for residents with indwelling medical devices. The Director of Nursing confirmed that the facility's expectation was for staff to wear a gown during any catheter care or contact with a catheter for residents on EBP. The facility's policy, implemented prior to the incident, clearly outlined the need for both gown and gloves during such care to prevent the transfer of multidrug-resistant organisms (MDROs). The failure to adhere to these established infection prevention protocols was observed and acknowledged by facility leadership.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a fall and injury. The resident, who had intact cognition and required partial to moderate assistance for transfers, was on anticoagulant medication and had a history of heart failure and renal insufficiency. The care plan indicated the need for staff assistance during transfers and the use of a gait belt, but these measures were not followed at the time of the incident. On the day of the incident, the resident was found on the floor with a laceration to the back of the head after a fall in the bathroom. The resident was not wearing a gait belt or knee brace, which were required for safe transfers. Staff H, the CNA assisting the resident, admitted to not using a gait belt and being unprepared to prevent the fall. The resident was subsequently sent to the hospital due to the risk of complications from anticoagulant therapy. Interviews with staff revealed that the facility policy required the use of gait belts for all non-mechanical transfers, and staff were aware of this requirement. However, the policy was not adhered to during the incident, leading to the resident's fall and injury. The facility had provided gait belts and communicated the resident's assistance needs, but these protocols were not followed, resulting in the deficiency.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident #24. Resident #24, who had severe cognitive impairment and a history of diabetes mellitus and hemiplegia, was mistakenly administered medications intended for her roommate, Resident #13. This error occurred during the 7 PM medication pass on June 9, 2024, when Staff D, a Registered Nurse, administered Risperdal and Depakote to Resident #24, medications that were not prescribed for her. The error was discovered after Resident #24 exhibited symptoms such as vomiting and lethargy, and lab tests confirmed the presence of these medications in her system. The incident was initially reported by Staff C, a Certified Nursing Assistant, who observed discrepancies in the medication administration process. Staff C noted that Resident #13 had not received her medications and reported the situation to Staff B, a Licensed Practical Nurse and Care Coordinator. Despite attempts to clarify the situation, it was not until the following day that the error was confirmed through lab results. The facility's medication administration policy, which includes verifying resident identity and ensuring medications are administered as prescribed, was not adhered to by Staff D, leading to the medication error. Camera footage from the evening of the incident showed Staff D administering medications to Resident #24 without proper verification and preparation procedures. The footage also captured Staff D's actions that were inconsistent with the facility's medication administration policy, such as crushing pills and mixing them with pudding without proper documentation or verification. The facility's failure to follow established procedures for medication administration resulted in a significant medication error, affecting Resident #24's health and well-being.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to provide privacy and dignity to residents during personal care, as evidenced by multiple observations and interviews. Resident #15, who had no cognitive impairment, expressed feeling undignified when the window was left open during a wound vacuum dressing change, allowing visibility from outside. Staff involved acknowledged the oversight, and the Director of Nursing confirmed that the facility's expectation was to ensure privacy by closing doors or curtains during care. Additionally, the facility's investigation revealed that Staff A, a Certified Nursing Assistant, was reported by several residents to have treated them disrespectfully. Resident #1, with no cognitive impairment, reported that Staff A was mean and uncommunicative. Resident #3, also cognitively intact, described Staff A as rough and expressed relief when she left. Resident #13, with moderately impaired cognition, reported that Staff A refused to provide ice water, called them a whiner, and ignored them. Resident #44, also with moderately impaired cognition, reported that Staff A did not respect their choices and was sometimes sassy. Interviews with other staff members corroborated these reports, with some describing Staff A as rude or snappy. Staff B, an LPN, noted that residents felt safer after Staff A was no longer present. The facility's administrator confirmed that an investigation was conducted, and Staff A was terminated following confirmation of a pattern of disrespectful behavior towards residents.
Failure to Include Anticoagulant and Diuretic Therapies in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which included necessary details for anticoagulant and diuretic therapies. Resident #43, who has severe cognitive impairment and diagnoses of essential hypertension and localized edema, was prescribed furosemide, a diuretic, but the care plan did not reflect this treatment. The diuretic was discontinued during a hospital stay and restarted about a month prior to the survey, yet the care plan remained incomplete. Staff F, an LPN, acknowledged that the facility's expectation was for the use of a diuretic to be included in the care plan. Similarly, Resident #38, with diagnoses of coronary artery disease, hypertension, and transient ischemic attack, was prescribed Xarelto, an anticoagulant, but the care plan lacked documentation for this medication. Staff F, responsible for completing care plans for Resident #38's unit, confirmed that anticoagulants should have been included in the care plans. The Director of Nursing also stated that the facility's expectation was for care plans to include the use of anticoagulants and diuretics for the respective residents.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team, including the resident and their representative, for one of the residents reviewed. Resident #34, who entered the facility on April 1, 2021, and had no cognitive impairment as indicated by a BIMS score of 14, reported that neither she nor her family were invited to care plan conferences. This lack of involvement in care planning was confirmed by staff interviews and a review of the facility's electronic health records. Staff I, the Recreation Coordinator, and Staff J, the Resident Services Director, acknowledged that care conferences for Resident #34 were not held every three months as required. The last documented care conference was in January 2024, and there was no evidence of quarterly meetings being conducted. The Director of Nursing also confirmed the absence of documentation for quarterly care conferences. The facility's policy encourages resident and family participation in care planning, but this was not adhered to in the case of Resident #34.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during catheter care for two residents. In the first instance, a Certified Nursing Assistant (CNA) and a Medication Aide performed catheter care for a resident without wearing a gown, as required by EBP. Although they completed hand hygiene and donned gloves, they neglected to wear the necessary gown while draining the urinary collection bag, which resulted in urine spilling onto the floor. The staff acknowledged forgetting to wear the gown, and the Director of Nursing (DON) confirmed that the expectation was for the correct personal protective equipment (PPE) to be worn during such procedures. In the second instance, a CNA performed catheter care for another resident but failed to perform hand hygiene consistently between glove changes. The CNA completed hand hygiene initially and donned gloves and a gown, but after removing gloves and performing various tasks, such as moving the resident and emptying the urine graduate, the CNA did not perform hand hygiene before donning new gloves. The DON stated that the facility's expectation was for hand hygiene to be completed with all glove changes and before and after all resident care. The facility's hand hygiene policy emphasized that gloves are not a substitute for hand hygiene and that hand hygiene should be performed before and after glove use.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Glenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prestige Care Center Of Plattsmouth | 9.2 mi | ★★★★★ | 0 | 0 |
| Tabor Manor Care Center | 10.3 mi | ★★★★★ | 22 | 0 |
| Hillcrest Health & Rehab | 11.9 mi | ★★★★★ | 5 | 0 |
| Chapters Living Of Council Bluffs | 13.7 mi | ★★★★★ | 59 | 1 |
| Prairie Gate | 15.3 mi | ★★★★★ | 3 | 0 |
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