Glenview Terrace

Inspectors wroteBased on interview and record review, the facility failed to follow its elopement policy by not responding to the wander guard alarm immediately and by not conducting a head count to confirm whether anyone had eloped. The facility also failed to implement the elopement risk care plan interventions, as they did not frequently monitor R1. The Immediate Jeopardy began on 4/23/26 at 9:42:57 pm when R1 exited through the front door. Immediate Jeopardy was identified on 4/28/26. V1 (Administrator) and V13 (Nurse Consultant) were notified of the IJ on 4/28/26 at 12:15 PM. Although the immediacy was removed on 5/1/26, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies, procedures, audits, and Quality Assurance monitoring.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's dignity was maintained related to having a choice of a different breakfast alternative menu for one of three residents (R2) reviewed for residents rights. Findings Include:On 2/13/2026 at 12:00pm R2 said the dietary department will not allow the residents to have an alternative to breakfast waffles. They can only have toast white or wheat not pancakes and if she wants an extra meat instead of waffles dietary will not allow an extra meat. On 2/13/2026 at 1:30pm V6(Dietary Supervisor) said the facility does provide a breakfast alternative. It does not have pancakes and that the facility does not alternate waffles for an meat alternative, the alternative for waffles is white or wheat toast. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure colostomy care was provided for a dependent resident for one (R2) of two reidents reviewed for Colostomy Care. Findings Include:On 2/13/2026 at 12:00pm, R2 said that on 2/1/2026 at about 8:00pm she put on her call light and about 10-15 minutes later V11(Agency Certified Nursing Assistant-CNA) arrived and I asked her to empty my colostomy bag, V11 said she didn't feel comfortable. R2 said she asked V11 to inform the nurse because her colostomy bag was filling up. R2 said after about 30 minutes she put on her call light, V11 returned and said she asked the CNA's but not the nurse, and said she would ask the nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse prevention policy by not providing an environment free from abuse to protect one resident (R2) from physical abuse by another resident (R1), resulting in R2 being hit several times by R1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtain appropriate treatment from the Physician. This deficiency affects one (R195) of three residents in the sample of 35 reviewed for Suprapubic catheter care management and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weight setting for residents who are at risk for developing pressure injuries. This failure has the potential to affect three (R61, R186 and R200) out of four residents reviewed for pressure injury prevention and treatment in a final sample of 35 residents. Findings Include: 1. On 6/10/25 at 12:50PM, observed R61 in bed with low air loss mattress in use. Air loss mattress is set to 7. Confirmed with V25 (Unit Nurse Manager) that the setting is on 7. V25 looked at a paper with R61's weight record and reset the mattress to 4. R61 is 116.0 lbs. dated 6/10/25. R61 Braden Scale and Clinical Evaluation dated 6/5/25, reads: High Risk 7.0 and R61 with history of healed pressure injuries to left and right buttocks and coccyx. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an ordered narcotic pain medication available for five and a half hours for a resident (R330) with severe pain and the facility failed to utilize a pain assessment tool for a cognitively impaired/non-verbal resident (R186) for pain management for two out of four residents reviewed for pain in a total sample of 35. Findings Include: 1. R330 is a [AGE] year old with the following diagnosis: lupus erythematosus; fibromyalgia; fracture of the right humerus, right tibia, and right fibula; and wedge compression fracture of the T11-T12 vertebra. On 6/11/25 at 11:10 AM, R330 stated R330 was hit by a car which fractured R330's right arm and lower right leg. R330 reported they live with chronic pain due to R330's lupus diagnosis. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication on the controlled drug administration record sheet. This deficiency affects 1 of 3 medication carts reviewed for Controlled Medication count Management. The facility also failed to follow its policy on medication administration on prohibiting pre-pouring of medications. This deficiency affects two (R110 and R525) of twelve residents in the sample of 35 reviewed for administration of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to use appropriate infection control practices when taking blood pressure during medication administration. This deficiency affects one (R526) of one resident observed taking blood pressure during medication administration observation in the sample of 35 reviewed for Infection Prevention and Control Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent serious injury to a resident. This failure affects one of three residents (R1) reviewed for falls in a total sample of six residents. This failure resulted in injuries to R1. R1 sustained facial fractures and skull fractures, acute nondisplaced fractures of bilateral sphenoid sinuses, non-displaced fractures of basilar portion of the occipital bone bilaterally, and acute nondisplaced fractures involving the postero-lateral walls of bilateral maxillary sinuses. R1 also had a small possible C6 fracture requiring a neck collar. R1 is a [AGE] year-old male. R1's diagnoses are but not limited to fracture at the base of the skull, eye bone fracture, Parkinsonism, heart disease, atrial fibrillation, history of falling, diabetes, high blood pressure, dementia, and hypothyroidism. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect cognitively impaired residents from physical and verbal abuse; and failed to follow the facility abuse policy for two (R1 and R2) of three residents reviewed for abuse. These failures resulted in R1 and R2 being physically and verbally abused during provision of care. R1 and R2 were sent to the hospital for further evaluation and treatment and R2 sustained a right frontal hematoma and abrasion, left lateral periorbital ecchymosis and lower lip abrasion. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] when R1 and R2 were physically and verbally abused by V5 (Certified Nurse Aide) during provision of care. V1 (Administrator), V2 (Executive Director) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by a) failing to protect residents to be free from physical and verbal abuse; and failing to follow abuse policies and procedures. These failures affected two (R1 and R2) of three residents reviewed for abuse and has the potential to affect all 234 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for abuse for two (R1 and R2) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to administer medications in a timely manner for 1 of 3 residents (R4) reviewed for medication administration in the sample of 27.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their Privacy, Dignity and Discharge Planning and Instruction policy when a resident was discharged ; and another resident's medication was found in the discharge medication pile. This deficient practice affects one resident (R3) of three residents reviewed for privacy and confidentiality and discharge medication. Findings Include: R2 discharged from the facility on 9/29/23. On 10/5/23 at 11:00 AM, V6 (Complainant) reported that R2 received R3's one medication upon review of medication when already home. V6 was able to give the information from the medication label, such as R3's full name, medication name, direction, and prescription number (Rx # XXXXXXXX). V6 also reported that she informed the facility of this incident on 10/2/23 (Monday). Concern form dated 10/3/23, reads in part: [...]

Inspectors wroteBased interviews and record reviews, the facility failed to follow their policy and procedures for providing care and services in a timely manner by not ensuring nursing staff respond to call lights in a timely manner. This failure applied to four (R343, R443, R445, R446) of four residents reviewed for assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide documentation of administering a narcotic medication that was in use. This failure applied to one resident (R121) whom was reviewed during medication storage and labeling.