Glenview Terrace

Based 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. On 2/16/2026 at 10:10am V1(Executive Director) said she was not aware that the resident's wanted pancakes instead of waffles and that the residents can have pancakes as an alternative.On 2/1/2026 at 10:30am V2(Director of Nursing) said all residents have the choice of a liberal diet and can ask for an alternative of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. R2 said at 9:00pm she called the receptionist and asked her to page the supervisor over head she needed assistance and the receptionist sent R2 to the unit manager voice mail whom only works in the morning and not on weekends. R2 said she called the receptionist again and again she was sent to another voice mail. After the third time calling the receptionist, R2 said she called 911 emergency. When they arrived…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:R1 was an [AGE] year-old former resident of the facility, deceased [DATE], with medical diagnosis including but not limited to encounter for palliative care; cognitive communication deficit; anxiety disorder; and depression.R2 is an [AGE] year-old resident of the facility with a Brief Interview for Mental Status (BIMS) score of 15/15, with medical diagnosis including but not limited to unspecified fracture of first lumbar vertebra; nondisplaced fracture of sternal end of right clavicle; displaced simple supracondylar fracture without intercondylar fracture of left humerus; and history of falling.On [DATE] at 10:18 AM, R2 said he was asleep in bed at night on [DATE], when his roommate, R1, fell from his wheelchair to the ground,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 6/11/25 at 9:27AM, observed R195 lying in bed with low air loss mattress. V19 CNA (Certified Nurse Assistant) lifted the top sheet and observed R195's disposable brief soaked with serosanguineous drainage on suprapubic area. V19 opened his brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin noted with redness and irritation. The suprapubic catheter is not secured to the abdomen. The catheter is connected to the urinary drainage bag covered with privacy bag. R195 denied any pain. He said that he had a shower yesterday and did not have dressing after it was removed for the shower. R195 said that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 6/12/25 at 10:30AM, V8 (Wound Care Coordinator) stated that R61 does not have any active pressure injury at this time, however R61 has a history of pressure injury.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R330 stated R330 normally lives at a pain level of seven out of ten with scheduled pain medication. R330 reported the best pain relief is the narcotic pain medication which is ordered as needed so R330 has been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 6/10/25 at 9:10AM, checked medication cart with V4 LPN (Licensed Practical Nurse). Observed pre-poured medications in plastic medication cup inside the top drawer and controlled/narcotic drawer. V4 said that she prepared the medication for R525 and R110. V4 said that she is about to give the medication, but she answered another resident's call light. V4 said that she should not pre-pour the medications. Medications prepared should be given to the resident immediately. Reviewed and counted controlled/narcotic medications with V4. Observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 6/10/25 at 12:28PM, V7 Agency LPN (Licensed Practical Nurse) said that he has to take BP (blood pressure) of R526 before administering her medications. V7 placed the BP cuff on upper arm of R526 without disinfecting the BP monitor portable machine prior to use. V7 obtained 110/75mmHg. After taking the BP, he placed the BP portable machine on top of the medication cart without disinfecting it after using. V7 prepared medication for R526 and administered the medication orally. On 6/10/25 at 12:34PM, V7 Agency LPN said that he is done with his noon time scheduled medications administration. V7 pushed his medication cart in front of the nursing station. V7 still did not disinfect the BP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Per facility census, there are 234 residents currently residing in the facility. R1 is an [AGE] year-old, male, admitted in the facility on 02/19/24 with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse. On 04/30/24 at 10:58 AM, V4 (RN) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R1 is an [AGE] year-old resident admitted to facility on 02/19/2024 with medical diagnoses including but not limited to: Dementia, Major Depressive Disorder, Generalized Anxiety, Alzheimer's Disease, and Delusional Disorder. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Service user defined assessment (UDA) with effective date of 04/18/2024 scores resident a 2+ for abuse/neglect which means at risk for abuse/neglect. R1's care plan for abuse/neglect was initiated 04/29/24 which was three days after an abuse allegation. R2 is an [AGE] year-old resident admitted to facility on 02/14/2023 with diagnoses including but not limited to: Dementia, Generalized Anxiety and Parkinson's Disease. MDS dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: R4's Physician Order Sheet dated 11/23 showed R4 has an order of Atorvastatin (cholesterol medications), Tylenol and Tramadol (both pain medications.) R4's electronic medication administration record showed that R4 has an order of Atorvastatin 20 milligram (mg) to be given at 2100 (9 PM). R4's Tylenol order of 325 mg 2 tabs every 6 hours to be given at midnight, 6 AM, 12 PM and 6 PM. R4's Tramadol order of 60 mg, 1 tab four times a day to be given at midnight, 6 AM, 12 PM and 6 PM. On 2/23/24 at 10:15 AM, V14 (R4's granddaughter) said that on 11/6/23, R4's 6 PM medications were given very late or were not given at all. V14 said she looked for the nurse who told her he was busy taking care of so many residents and was not sure when he would be able to give R4's 6 PM medications. R4's Medication Audit Report dated 11/6/23 showed R4 got her Atorvastatin 9 PM dose at (2345) 11:45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: R2 was discharged on 9/29/23 and was sent home with a medication which does not belong to R2. Action taken: Spoke with Nurse and education one to one was given regarding medication reconciliation during discharge. Resident/Responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 03/06/23 at 10:44 AM R343 stated she has been at the facility with diarrhea for 3 days. R343 stated sometimes it takes 40 minutes for someone to respond to her call light when she uses it for incontinence care. On 03/06/23 at 12:50 PM R443 stated no one ever gets her out of bed other than for therapy and she stopped using her call light because no one ever responds. On 03/06/23 at 12:03 PM R445 stated he threw up on himself after eating lunch one day and pressed his call light for assistance. R445 stated it took 20-30 minutes for someone to respond to clean him up. R445 stated sometimes it takes this long for a response to his call light. On 03/06/23 at 11:00 AM R446 stated, this morning it took an hour for someone to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R121 is an [AGE] year old male who was admitted to the facility 7/1/22 with diagnoses that include Alzheimer's, Dementia. According to R121's MDS (Minimum Data Set) he exhibits severe cognitive impairments scoring a BIMS (Brief Interview of Mental Status) of 2 out of 15. According to Physicians Order Sheet (POS) dated 2/17/23 R121 has been receiving hospice services while living in the facility. On 03/08/23 3:50 PM, during medication and storage review with V19 LPN, lorazepam 1mg/ml gel narcotic sheet for this resident was found in the narcotic control book and the medication was not on the cart. V19 said that they did not know where the medication was located at that time. Surveyor and V19 checked the medication cart and the refrigerator. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.