The Glebe

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 4, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (15) fifteen current sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to only 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. […]

• Actual harm, isolatedF909Jun 4, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a bariatric (a specialized medical support surface engineered for patients with a high body mass index) mattress was compatible with a bed frame for (1) one of (15) fifteen sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. […]

• No harm, potential for more than minimal, isolatedF700Jun 4, 2026

  Based on observation, staff interview, and clinical record review, the facility staff failed to attempt to use appropriate alternatives prior to installing side rail(s) for (2) two of (15) fifteen sampled residents, Resident #5 and Resident #24. Findings included: 1. For Resident #5, the facility staff failed to provide evidence that appropriate alternatives were attempted prior to the installation of bilateral side rails. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, right leg below knee amputation, osteoporosis, right artificial shoulder joint, muscle weakness, and adult failure to thrive. […]

• No harm, potential for more than minimal, isolatedF842Jun 4, 2026

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to accurately document the correct size of side rails utilized on a resident's bed on a medical provider order and on the comprehensive person-centered care plan for (1) one of (15) fifteen sampled residents, Resident #5. Findings included:Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, right leg below knee amputation, osteoporosis, right artificial shoulder joint, muscle weakness, and adult failure to thrive. […]

• No harm, potential for more than minimal, isolatedF880Jan 22, 2021

  Based on observations, interviews, and the review of documents, it was determined the facility staff failed to properly implement COVID-19 prevention and/or control measures. The findings include: Observations of the facility on 1/20/21 revealed one (1) staff member using a N95 mask with an exhalation valve. On 1/20/21 at 2:55 p.m., a facility registered nurse (RN #1) was observed to be wearing a N95 mask with an exhalation valve; no additional covering was in place over the exhalation valve. RN #1 reported they had been successfully fit-tested for the N95 mask in question. […]