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 Glenview Terrace during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a documented elopement risk was able to access the elevator area without nursing supervision, enter a service elevator, and exit through an alarmed door. Staff did not respond immediately to the wander guard alarm and did not initiate a head count when the alarm sounded, despite the resident’s care plan calling for frequent monitoring and use of an electronic monitoring device.
A resident on a regular diet reported that dietary staff would not provide pancakes or an extra meat item as an alternative to waffles at breakfast, stating that only white or wheat toast was allowed as a substitute. The Dietary Supervisor confirmed that the breakfast alternative menu did not include pancakes and that toast was the only alternative for waffles, with no meat substitution offered. This practice conflicted with the facility’s written food preference policy requiring alternatives when food is refused and with resident rights policies intended to support resident satisfaction and choice, resulting in a failure to fully honor the resident’s dietary preferences and dignity.
A resident with a colostomy and care plan requiring colostomy care every shift and as needed repeatedly requested assistance to have a filling colostomy bag emptied. An agency CNA declined to perform the task and did not promptly notify an RN or LPN, and the PM receptionist routed the resident’s calls to voicemail instead of overhead paging nursing staff or a supervisor. As a result, the resident ultimately called 911, and when staff entered with medications they were unaware of the colostomy care need, finding the bag leaking feces, contrary to the facility’s ostomy care policy.
The facility failed to maintain an environment free from abuse when one resident physically assaulted his roommate after staff briefly left the room to obtain requested items. An older adult with cognitive and mental health diagnoses was being assisted to bed by a CNA, who stepped out momentarily for pillowcases, leaving him alone with his roommate, an alert resident with multiple fractures. During this time, the first resident fell from his wheelchair, crawled to the roommate’s bed, and repeatedly struck the roommate’s legs with his fists. The CNA returned upon hearing the roommate cry out and found the aggressor on the roommate’s side of the room, holding onto him, confirming that the facility did not effectively prevent resident-to-resident physical abuse as required by its abuse policy.
A resident with a suprapubic catheter was found with a soaked brief, moderate serosanguineous drainage, and redness at the stoma site, without a required dressing or catheter securement. Staff failed to monitor, document, or notify the physician about the condition, and a nurse used a personal phone to photograph the site, violating privacy policies. Facility protocols for catheter care and skin breakdown were not followed.
The facility did not ensure that LAL mattresses were set to the correct weight for several high-risk residents, as staff either did not know the proper settings or failed to adjust them according to manufacturer guidelines. This resulted in mattresses being set too high or too low for residents with significant risk factors for skin breakdown, despite care plans and policies requiring individualized settings and limited linen layers. The deficiency was observed in three out of four residents reviewed for pressure injury prevention and treatment.
Two residents did not receive appropriate pain management: one non-verbal, cognitively impaired resident was assessed using an incorrect pain scale instead of the PAINAD tool, and another resident with chronic pain did not receive ordered narcotic pain medication for over five hours due to delays in reordering and lack of stock. These failures occurred despite facility policies requiring proper pain assessment and timely medication administration.
An LPN was observed pre-pouring medications for two residents and leaving them unattended in a medication cart, contrary to facility policy requiring immediate administration. Discrepancies were also found between the actual count and documentation of controlled medications, as the LPN failed to sign the controlled drug administration record after removing doses. The facility could not provide a specific policy prohibiting pre-pouring, despite existing procedures for medication administration and controlled drug counts.
An LPN failed to disinfect a blood pressure machine and cuff before and after use while taking a resident's blood pressure during medication administration. The equipment was placed on the medication cart and not cleaned between uses, contrary to facility policy requiring disinfection of reusable medical equipment between residents.
A resident with advanced dementia, Parkinsonism, and a history of falls, who required two-person assistance for mechanical lift transfers, was left with only one CNA during a transfer. While waiting for additional help, the resident had a sudden involuntary movement and fell, sustaining multiple fractures and head injuries. The facility's policy required two staff for such transfers, but this was not followed, resulting in serious harm.
The facility failed to protect two cognitively impaired residents from physical and verbal abuse by an agency CNA. The residents, both with severe cognitive impairment, were subjected to aggressive handling and yelling during care. The facility's inadequate screening and orientation of agency staff contributed to these incidents, resulting in Immediate Jeopardy.
The facility failed to follow its abuse policy, resulting in the verbal and physical abuse of two residents by an agency CNA. The incidents were not reported promptly, and the CNA did not receive adequate orientation or training on the facility's abuse policies and dementia care.
The facility failed to protect residents from abuse and did not follow its abuse policies and procedures. Two residents with severe cognitive impairments were affected, one allegedly assaulted by a staff member and the other found with multiple injuries. The investigation revealed inadequate orientation and training for agency staff, contributing to the incidents.
The facility failed to develop and implement comprehensive abuse care plans for two residents with severe cognitive impairment, despite assessments indicating they were at risk for abuse. Interviews with staff revealed confusion over responsibility for developing these care plans, leading to delays in their initiation.
Elopement Alarm Not Responded to Immediately and Resident Not Monitored
Penalty
Summary
The facility failed to follow its elopement policy when a resident with severe cognitive impairment and a documented elopement risk exited the building. The resident had been admitted to a locked third-floor unit, had an elopement risk assessment identifying him as at risk, and had a care plan that included frequent monitoring and use of an electronic monitoring device. Video review showed the resident manipulating the third-floor elevator keypad without staff supervision for several minutes, then entering the service elevator and later exiting through an alarmed door to the outside of the building. The facility did not respond immediately to the wander guard alarm and did not conduct a head count at the time the alarm sounded. Video review showed the first responder to the alarm did not arrive at the exit door until more than 5 minutes after the resident exited. Staff interviews indicated that the alarm was not heard by multiple staff members on the unit, and several staff stated they were unaware the resident was missing until later rounds. One nurse supervisor stated she was informed the alarm was going off but did not go to the door because the alarm had already stopped, and she did not direct staff to perform a head count. The report also states that the resident’s elopement risk care plan interventions were not implemented as written, because he was not frequently monitored while on the unit. Staff interviews and the video review showed the resident was able to move around the unit and access the elevator area without nursing supervision. The facility’s elopement policy required staff to immediately respond to a door alarm and initiate a head count on all units, but those steps were not followed when the resident exited the building.
Failure to Honor Resident Breakfast Preferences and Alternatives
Penalty
Summary
The facility failed to maintain a resident’s dignity and right to self-determination by not ensuring meaningful breakfast alternatives consistent with resident preferences were available and communicated. One resident (R2), on a general regular diet, reported that the dietary department would not allow residents to have pancakes as an alternative to waffles and would not provide an extra meat item in place of waffles, stating that the only alternative offered was white or wheat toast. The Dietary Supervisor confirmed that the breakfast alternative did not include pancakes and that the only alternative for waffles was white or wheat toast, with no meat alternative offered. This practice occurred despite the facility’s Food Preference Policy stating that if a resident refuses the food being served, the facility should offer alternatives consistent with the usual food items provided by the facility, and despite the Resident’s Rights policy requiring services that support residents’ physical and mental health and sense of satisfaction. The Executive Director and DON later stated that residents could have pancakes as an alternative and that all residents had the choice of a liberal diet and could ask for pancakes even if not listed on the alternative menu, indicating a discrepancy between facility leadership’s expectations and the actual options and information provided to residents by dietary staff.
Failure to Provide Timely Colostomy Care and Response to Resident Requests
Penalty
Summary
The facility failed to provide necessary colostomy care for a dependent resident who required assistance with emptying her colostomy bag. The resident, who had diagnoses including irritable bowel syndrome and an encounter for a colostomy, had a care plan dated 10/20/2023 that required colostomy care every shift and as needed. On the evening of 2/1/2026, the resident activated her call light around 8:00 p.m. and requested that an agency CNA empty her colostomy bag. The CNA stated she did not feel comfortable performing the task. The resident then asked the CNA to inform the nurse because the colostomy bag was filling up. After approximately 30 minutes, the resident again used the call light; the same CNA returned and reported she had asked other CNAs, but not the nurse, and said she would ask the nurse. The resident subsequently called the front desk multiple times requesting to speak with a supervisor. The AM receptionist stated that when residents call the front desk, she overhead pages the supervisor or nurse to the room. However, the PM receptionist reported that on the night in question, she transferred the resident’s calls to the voicemail of the unit manager and house supervisor and did not overhead page. The unit manager and DON both stated they expected the receptionist to overhead page and the CNA staff, including agency staff, to notify the nurse when there is a skill-related issue or when a resident requests to see the nurse. The executive director stated the resident should not have had to call 911 for assistance. When emergency services arrived, the agency nurse entered the room with medications and was unaware the resident needed colostomy care, at which point the resident’s colostomy bag was leaking feces. The facility’s colostomy care policy dated 6/30/2025 required that ostomy appliances be emptied every shift and as needed.
Failure to Prevent Resident-to-Resident Physical Abuse in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy and provide an environment free from abuse, resulting in one resident physically assaulting his roommate. Resident 1 (R1), an older adult with diagnoses including encounter for palliative care, cognitive communication deficit, anxiety disorder, and depression, was being assisted to bed by a CNA (V20) at approximately 10:00 PM. During this process, R1 requested two pillowcases. V20 left the room briefly to obtain the pillowcases, leaving R1 and his roommate, Resident 2 (R2), alone in the room. While R2 was asleep in bed, R1 fell from his wheelchair to the floor, crawled over to R2’s bed, and began hitting R2’s legs with his fists multiple times. R2, an older adult with a BIMS score of 15/15 and medical diagnoses including fractures of the first lumbar vertebra, right clavicle, and left humerus, reported that he felt a little pain and was more afraid than anything during the incident. When V20 re-entered the room, she heard R2 cry out and observed R1 on R2’s side of the room, holding on to R2. V20 immediately separated the two residents and notified the floor nurse (V22). The facility’s final investigation notes corroborated that V20 had stepped away briefly to obtain pillowcases at R1’s request and, upon returning, heard R2 say that R1 was grabbing him. This sequence of events demonstrates that the facility did not ensure an environment free from abuse as required by its Abuse and Neglect Policy, which states that professional care and services must be provided in an environment free from any type of abuse.
Failure to Monitor and Treat Suprapubic Catheter Site
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident with a suprapubic catheter, resulting in unaddressed drainage and skin impairment at the stoma site. During observation, the resident was found with a disposable brief soaked in serosanguineous drainage, no dressing on the suprapubic catheter site, and visible redness and irritation of the surrounding skin. The catheter was not secured to the abdomen as required. The resident reported that dressings were usually applied twice daily, but none was present after a recent shower. The assigned CNA was unaware of the missing dressing and had not yet provided morning care. Nursing staff, including an agency nurse and wound care nurse, were not informed of the absence of the dressing or the condition of the site until prompted by the surveyor. Documentation in the medical record did not accurately reflect the observed condition, as the wound care nurse documented intact skin with no redness or drainage, contrary to what was seen during the survey. The nurse also took a photo of the site using a personal cell phone, which was acknowledged as a violation of resident privacy. The nurse did not contact the physician for new treatment orders, instead applying a barrier cream not ordered for the suprapubic site. Facility policy required daily and as-needed dressing changes for suprapubic stoma sites with drainage, monitoring for redness or maceration, and securing the catheter to the abdomen. Policies also mandated prompt identification, documentation, and physician notification for skin breakdown. These protocols were not followed, as evidenced by the lack of dressing, improper documentation, failure to secure the catheter, and absence of physician notification for the observed drainage and skin impairment.
Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were set to the correct weight settings for residents at risk for developing pressure injuries. Multiple observations revealed that staff members, including agency LPNs and wound care team members, were either unaware of the appropriate mattress settings or did not verify them according to manufacturer guidelines. For example, one resident's LAL mattress was set for 110 lbs despite the resident weighing only 84 lbs, and another mattress was set at 150 lbs for a resident weighing 98 lbs. In both cases, staff had to be prompted to adjust the settings to more appropriate levels. Residents involved in these incidents were identified as high risk for skin impairment, with documented histories of pressure injuries, chronic wounds, and comorbidities such as diabetes, vascular disease, and limited mobility. Care plans and physician orders specified the use of specialized mattresses and detailed wound care regimens, but the observed mattress settings did not align with these requirements. Staff interviews confirmed that the settings should be based on resident weight, and that incorrect settings could compromise the effectiveness of the mattresses. Facility policy required limiting the number of linen layers on LAL mattresses and using the correct settings to manage comfort, positioning, and moisture for residents with stage 3 or 4 pressure sores. Despite these policies, the survey found that three out of four residents reviewed for pressure injury prevention and treatment had LAL mattresses set incorrectly, indicating a systemic failure to follow established protocols for pressure ulcer prevention and care.
Failure to Provide Appropriate Pain Assessment and Timely Pain Medication
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents. For one resident with multiple chronic wounds, advanced dementia, and on hospice care, staff used an inappropriate pain assessment tool. Despite the resident being non-verbal and cognitively impaired, nurses documented pain assessments using a numeric pain scale, which is designed for alert and oriented individuals. The appropriate tool, PAINAD, was only implemented after surveyor intervention, contrary to the facility's policy and the resident's needs. For another resident with a history of lupus, multiple fractures, and chronic pain, the facility failed to ensure the availability of ordered narcotic pain medication. The resident, who relies on scheduled and PRN pain medications, reported severe pain and was unable to participate fully in therapy due to uncontrolled pain. Nursing staff acknowledged that the narcotic medication was not reordered in a timely manner, resulting in a gap of over five hours without the medication. The medication was also unavailable in the facility's pyxis system, and staff were unable to provide an alternative during this period. Both deficiencies were confirmed through observation, interviews, and record review. The facility's own policies required appropriate pain assessment and timely administration of pain medication, but these were not followed. The failures affected two out of four residents reviewed for pain management in a sample of 35.
Failure to Accurately Document Controlled Medications and Prohibit Pre-Pouring
Penalty
Summary
The facility failed to ensure an accurate count of controlled medications and did not adhere to its policy prohibiting the pre-pouring of medications. During an observation of a medication cart with an LPN, pre-poured medications were found in a plastic medication cup inside both the top drawer and the controlled/narcotic drawer. The LPN stated that the medications were prepared for two residents but had not yet been administered, as she was interrupted by another resident's call light. The LPN acknowledged that medications should be administered immediately after preparation and that pre-pouring is not permitted. A review and count of controlled medications revealed discrepancies between the actual number of tablets present and the number documented on the controlled drug administration record for two residents. Specifically, the count for Tramadol 50mg and Alprazolam 0.25mg did not match the documentation, with the LPN admitting she forgot to sign the date, time, and amount on the controlled administration record after removing the medications. The facility was unable to provide a medication policy specifically prohibiting pre-pouring, though their existing policies require accurate controlled medication counts and adherence to medication pass procedures.
Failure to Disinfect Blood Pressure Equipment During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during medication administration for a resident. The LPN took the resident's blood pressure using a portable BP machine and cuff without disinfecting the equipment before or after use. After obtaining the blood pressure reading, the LPN placed the BP machine on top of the medication cart and proceeded to prepare and administer oral medication to the resident, still without disinfecting the equipment. The LPN completed the medication pass and left the BP machine on the medication cart without cleaning it. When questioned about the lack of disinfection, the LPN acknowledged forgetting to disinfect both the BP machine and cuff before and after use. The facility's policy requires that reusable medical equipment be cleaned with an approved disinfectant between each resident use, a procedure that was not followed in this instance.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Serious Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including dementia, Parkinsonism, a history of falls, and recent fractures, was not provided adequate supervision and assistance during a transfer. The resident was care planned as a high fall risk and required total assistance of two staff members with a mechanical lift for all transfers. Despite this, only one certified nursing assistant (CNA) was present in the room while preparing to transfer the resident from a wheelchair to the bed. The CNA was waiting for a second staff member but remained alone with the resident, who exhibited involuntary jerky movements associated with Parkinson's disease. During this period of inadequate supervision, the resident experienced a sudden movement and fell face down onto the floor, resulting in multiple serious injuries, including facial and skull fractures, a possible cervical spine fracture, and extensive bruising. Interviews with staff and other residents confirmed that the transfer was attempted without the required two-person assistance, and the facility's policy explicitly stated that two staff members must be present for mechanical lift transfers. The incident was witnessed by staff responding to the fall, and the resident was found on the floor with significant bleeding and injuries. The resident's medical records and care plan documented his high risk for falls and need for two-person assistance due to his physical and cognitive impairments. Staff interviews revealed that the CNA was aware of the requirement for two-person transfers but proceeded to prepare the resident alone while waiting for help. The lack of immediate supervision and failure to follow established transfer protocols directly led to the resident's fall and subsequent injuries.
Failure to Protect Cognitively Impaired Residents from Abuse
Penalty
Summary
The facility failed to protect cognitively impaired residents from physical and verbal abuse, specifically involving two residents, R1 and R2. Both residents were subjected to abuse by a Certified Nurse Aide (CNA) identified as V5. R1, a male resident with severe cognitive impairment and a history of delusional disorders and Alzheimer's disease, was verbally and physically abused by V5 during care. Video footage showed V5 yelling at and pushing R1, who was heard pleading for her to stop. Despite the presence of a camera in R1's room, V5 continued her aggressive behavior, which was later reported by R1's family member who had installed the camera. R1 was sent to the hospital for evaluation but returned with no visible injuries. R2, another male resident with severe cognitive impairment and Parkinson's disease, was also abused by V5. During care, V5 was seen on video footage yelling at and aggressively handling R2. R2 sustained multiple injuries, including a right frontal hematoma, left lateral periorbital ecchymosis, and a lower lip abrasion. V5 claimed that R2 became combative during care, causing her to sustain a scratch on her finger. However, the injuries observed on R2 were inconsistent with V5's explanation. R2 was sent to the hospital for further evaluation and treatment. The facility's failure to follow its abuse policy and properly screen and orient agency staff contributed to these incidents. V5, an agency CNA, was not adequately oriented or trained in dementia care and abuse prevention. The facility relied on the agency's background checks and did not conduct its own screening. Additionally, the facility's onboarding process for agency staff was insufficient, as evidenced by the incomplete orientation checklist for V5. These deficiencies resulted in Immediate Jeopardy, which was later removed, but noncompliance remained due to the need for further evaluation of the in-service training's effectiveness.
Failure to Follow Abuse Policy
Penalty
Summary
The facility failed to follow its abuse policy related to prevention, protection, screening, training, and reporting for two residents. One resident, an elderly male with severe cognitive impairment and a history of delusional disorders and dementia, was verbally and physically abused by an agency CNA. The incident was captured on video, showing the CNA yelling at and pushing the resident. The family member reported the incident to the Executive Director, who then suspended the CNA and notified the agency. The resident was sent to the hospital but returned with no visible injuries. The police were involved, but the abuse was only reported to them after the resident was sent to the hospital, leading to a delay in the investigation process. Another resident, also an elderly male with severe cognitive impairment and a history of dementia and Parkinson's disease, was found with multiple injuries, including scratches and bumps on the forehead and bleeding on the lips. The CNA involved claimed the resident was aggressive during care, but other staff members noted that the resident did not typically display aggressive behavior. The incident was reported to the Nurse Supervisor, who then called the Executive Director and the police. The CNA was supervised and removed from the schedule. The police report documented the incident as aggravated battery, but the resident was unable to recall the event due to cognitive impairment. The facility's failure to properly screen, train, and orient agency staff contributed to these incidents. The agency CNA involved in both incidents did not receive adequate orientation or training on the facility's abuse policies and dementia care. The facility relied on the agency to conduct background checks and provide training, but there were gaps in the verification process. The facility's abuse policy requires thorough screening, training, and reporting procedures, but these were not adequately followed, leading to the abuse of two vulnerable residents.
Failure to Protect Residents from Abuse and Inadequate Staff Orientation
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse and did not follow its own abuse policies and procedures. This deficiency affected two residents, both of whom had severe cognitive impairments and were at risk for abuse. One resident was allegedly assaulted by a staff member, resulting in a hospital visit, although no visible injuries were found. The other resident was found with multiple scratches and bruises but could not recall the incident due to cognitive impairment. The investigation revealed that the facility did not properly orient and screen agency staff, which contributed to the incidents. The agency CNA involved in the alleged abuse did not receive a proper orientation or training on the facility's policies and procedures. The onboarding checklist was not completed accurately, and the staff responsible for orientation denied providing it. Video footage confirmed that the orientation process was rushed and inadequate. Interviews with facility staff, including the Executive Director and Director of Nursing, highlighted inconsistencies in the orientation and training process for agency staff. The facility's policy on abuse and neglect was not followed, and there was a lack of supervision and proper onboarding for agency staff. This failure to adhere to established guidelines and procedures led to the incidents of abuse and the overall deficiency in care quality.
Failure to Develop and Implement Abuse Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for abuse for two residents, R1 and R2, who were reviewed for abuse. R1, an elderly resident with severe cognitive impairment and multiple diagnoses including Dementia and Alzheimer's Disease, was admitted on 02/19/2024. Despite being assessed as at risk for abuse/neglect on 04/18/2024, R1's care plan for abuse/neglect was not initiated until 04/29/2024, three days after an abuse allegation. Similarly, R2, another elderly resident with severe cognitive impairment and diagnoses including Dementia and Parkinson's Disease, was admitted on 02/14/2023. R2 was assessed as at risk for abuse/neglect on 02/28/2024, but the care plan was not initiated until 04/27/2024, one day after an abuse allegation. Interviews with facility staff, including the Director of Nursing (V3), Social Services Director (V21), and Special Care Unit Director (V10), revealed a lack of clarity and responsibility regarding the development of abuse care plans. V3 stated that all dementia residents should have abuse care plans upon admission, and V21 confirmed that it was their responsibility to develop these care plans. However, V10 believed it was the responsibility of social services to develop the initial abuse care plan. The facility's Care Plan Policy mandates that a baseline care plan be completed within 48 hours of admission and a comprehensive care plan within 7 days after the comprehensive assessment, but this was not adhered to for R1 and R2.
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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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Nursing homes near Glenview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Abington | 0.7 mi | ★★★★★ | 1 | 0 |
| Vi At The Glen | 1.3 mi | ★★★★★ | 0 | 0 |
| Niles Nsg & Rehab Ctr | 1.4 mi | ★★★★★ | 3 | 0 |
| Elevate Care Niles | 1.7 mi | ★★★★★ | 10 | 0 |
| Citadel Of Glenview,the | 2.2 mi | ★★★★★ | 0 | 0 |
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