Glenview Terrace

In the surveyor’s words

From the most serious findings on record at Glenview Terrace, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 2, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600May 14, 2024

  Based 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. […]

• Actual harm, isolatedF689Apr 6, 2025

  Based 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. […]

• Actual harm, isolatedF689Jul 1, 2022

  Based on interview and record review, the facility failed to accurately conduct a fall risk assessment to prevent accidental falls; failed to safely monitor a cognitively impaired resident at risk for falls and with a history of falls; and failed to train staff on fall precautions for residents. This failure affected 1 (R1) of 3 residents in the sample. This failure resulted in R1 being emergently transferred to the hospital with a femur fracture requiring surgical intervention. Findings include: R1 is a [AGE] year old cognitively impaired resident diagnosed with cerebral infarction, muscle weakness, difficulty in walking, [CONDITION(S)], and displaced fracture of base of neck of right femur. […]

• Actual harm, isolatedF689May 19, 2022

  A. Based on interviews and record reviews, the facility failed to have effective fall interventions in place for a resident assessed to be at high risk for falls, confused, and with poor safety awareness. This failure applied to one (R281) of one resident reviewed for accidents and supervision and resulted in R281 being emergently transferred to the hospital with a diagnosis of an acute comminuted periprosthetic fracture in the mid to distal left femur. B. Based on interviews and record reviews, the facility failed to safely assist a resident with feeding who is diagnosed as legally blind and is dependent on staff for assistance with feeding. […]