Below 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 Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents alleged that a male CNA physically abused them on separate occasions, including being pushed from a wheelchair to the bathroom floor and being struck in the eye, resulting in pain and bruising. Multiple CNAs, LPNs, and a former social services director reported hearing or witnessing concerning interactions, screams, and subsequent bruising, and several staff stated they informed supervisory or administrative staff. Despite a written policy requiring immediate reporting of all abuse allegations to the Administrator and state agencies and completion of an investigation with results reported within five working days, the DON and Administrator stated they were never informed of these allegations, and staff interviews indicated the incidents were not reported to state agencies or properly investigated.
The facility failed to follow its abuse policy requiring immediate, thorough investigation of alleged abuse for two residents. One resident with severe cognitive impairment and behavioral issues later reported that a male CNA pushed him from his wheelchair to the bathroom floor and bent his arm, causing hand and wrist pain, while staff accounts described the CNA threatening and placing the resident on the floor and multiple staff hearing and discussing the allegation without evidence of a documented abuse investigation. Another resident with Alzheimer’s disease and moderate cognitive impairment developed a black eye and reported that a male CNA hit her in the eye; several CNAs and an LPN stated the resident accused the CNA, observed the emerging bruise, and believed the matter had been reported, while explanations were given that the resident had been rubbing or scratching her eye, yet progress notes and skin assessments did not document the injury and staff reported that no proper abuse investigation was conducted or documented as required.
The facility did not consistently implement or develop comprehensive care plans for several residents requiring orthotic devices, resulting in splints and braces not being applied as ordered and necessary interventions, such as range of motion exercises, being omitted. Additionally, a resident with a history of falls did not have the required brightly colored tape applied to the call light as specified in the care plan. Staff interviews revealed confusion about responsibilities and a lack of policy guidance, contributing to the deficiencies.
A resident with hypertension, Alzheimer's disease, and chronic kidney disease was given Lisinopril multiple times by a CMT despite physician orders to hold the medication if systolic blood pressure was below 150 mm Hg. The CMT and other staff misunderstood the hold parameters, resulting in repeated administration of the medication outside the prescribed guidelines, as confirmed by MAR review and staff interviews.
Three residents with orders for hand splints and ROM did not consistently receive these interventions as prescribed, with splints often left unused and staff unclear about responsibilities for application and documentation. The facility lacked policies for splinting and restorative nursing, and staff interviews revealed confusion and inconsistent practices regarding the provision of care for residents with contractures.
The facility did not ensure that three residents with limited ROM received consistent application of prescribed hand splints or appropriate ROM services. For example, a resident with hemiplegia did not have her splint applied for months, another with contractures had her splint left unused on the bedside table, and a third with dementia was not wearing her splint as ordered. Staff interviews revealed confusion about responsibilities and a lack of a restorative nursing program or clear policy for splint use and ROM care.
The facility did not ensure that call light systems were accessible in all resident bathrooms and bathing areas, with observations showing that cords were only available near toilets and not within reach of showers, and some restrooms lacked functioning call systems entirely. A resident reported concerns about being unable to call for help if a fall occurred in the shower, and staff interviews confirmed that workarounds were used due to the lack of accessible call lights.
The facility failed to include residents and/or their representatives in the care planning process, affecting five residents with varying cognitive impairments. There was no documentation of care conference invitations or explanations for non-participation, as confirmed by interviews and record reviews.
The facility failed to properly label, store, and secure medications, including leaving medication carts unlocked and unattended, not discarding expired medications, and not maintaining proper temperature logs for medication storage. Staff interviews confirmed awareness of these requirements but cited distractions and other duties as reasons for the oversight.
The facility failed to provide food at a palatable temperature and with adequate seasoning, affecting several residents. Observations and interviews revealed that hot foods were served below acceptable temperatures, cold foods were too warm, and the food was often bland. Multiple grievances were filed, but the responses did not address the core issue of food temperature for room service meals.
A facility failed to maintain an infection prevention and control program during wound care for a resident with peripheral vascular disease and skin breakdown. An LPN did not use a barrier for wound supplies, failed to change gloves, and did not perform hand hygiene as required. The Interim DON confirmed the nurse did not follow proper infection control procedures.
Failure to Report Alleged Physical Abuse to State Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to state agencies as required by its own policy and federal regulations for two sampled residents. The facility’s abuse policy, reviewed in June 2025, required all alleged violations to be reported immediately, but no later than two hours after the allegation is made when abuse or serious bodily injury is involved, and to report investigation results to the appropriate state agency within five working days. Despite this, multiple staff interviews and record reviews showed that serious allegations involving two residents were not reported to the Administrator or state agencies, and in at least one case staff believed the incident was not investigated. For one resident with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and other conditions, records showed an event report dated mid‑June 2025 describing the resident being "assisted to floor due to behaviors" in the bathroom with no injuries noted. Progress notes over the next days documented complaints of right hand and wrist pain, an x‑ray, and a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, bent his arm back, and hurt his hand and wrist, and that he told multiple nurses about the incident. One LPN reported hearing that the resident threw himself on the floor, that a CNA refused to pick him up and told him to get up on his own, and that the resident hurt his hand; this LPN stated she did not think the incident was ever investigated, although she believed the DON and Administrator knew about it. A CNA who was orienting at the time reported witnessing the CNA screaming at the resident, threatening to put him on the floor, and then putting him on the bathroom floor, and stated she reported this to the DON. The former social services director stated the resident told her that the CNA put him on the floor and threw him in bed, hurting his wrist, and that she informed the DON and Administrator. For another resident with Alzheimer’s disease, hearing loss, and a history of falls, documentation from August through October 2025 contained no record of eye bruising. However, multiple staff and the resident described an incident in which the resident had a black eye and alleged that a male CNA hit her in the eye. One CNA stated that the resident told her and another CNA that the CNA had hit her eye, and that dayshift staff said it had been reported to the DON and Administrator; she also stated HR told her to stay out of it. The resident reported that a black male staff member hit her left eye with the back of his hand, causing a large bruise, and that no one later questioned her about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then finding the resident screaming that the CNA hit her in the eye, with bruising beginning; she stated the DON instructed her to chart that the bruising was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated or reported as abuse. Other staff, including another CNA and the former social services director, recalled the resident having a black eye and stating that the CNA hit her, but were told by leadership that the resident had been rubbing or scratching her eye. The current DON and Administrator both stated in interviews that they were never informed of the abuse allegations involving these two residents, despite the facility policy requiring immediate reporting of all alleged abuse and the Administrator’s role as abuse coordinator. The combined record review and interviews demonstrate that, although multiple staff and both residents described events they believed to be physical abuse by the same CNA, these allegations were not reported to the Administrator or state agencies within the required time frames, and in some instances staff believed the incidents were not investigated at all. The facility’s own policy required immediate reporting of all alleged violations, including to state agencies, and mandated that investigation results be reported within five working days, but there was no evidence that the allegations involving these two residents were reported as required.
Failure to Investigate Abuse Allegations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of abuse for two residents, despite having a policy requiring immediate and comprehensive investigations of suspected or reported abuse, neglect, or exploitation. The facility’s abuse policy, reviewed in June 2025, required immediate investigation upon suspicion or report of abuse, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation of the investigation. Interviews and record review showed that these steps were not carried out as required for the allegations involving two residents. For one resident with severe cognitive impairment, dementia with behavioral disturbance, and a BIMS score of 1, the record showed an event report dated mid‑June 2025 describing the resident as being “assisted to floor due to behaviors” in the bathroom with no injuries noted. Progress notes over the next two days documented complaints of right hand and wrist pain, an x‑ray, and later a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, told him he was going to put him back in bed, and bent his arm back, hurting his hand and wrist. The resident reported telling multiple nurses and stated that the staff member no longer came into his room. Multiple staff interviews revealed that staff had heard about the incident, that it was widely discussed among staff, and that some believed it had been reported to the DON and administrator. One CNA who was orienting at the time stated she saw the CNA involved screaming at the resident, threatening to put him on the floor, and then putting him on the floor, and that she reported this to the DON. The former SSD stated the resident told her the CNA put him on the floor and threw him in bed, and that she reported this to the DON and administrator and was later told in a meeting that the resident had lowered himself to the floor. The former DON, however, stated she did not recall any abuse allegation being reported to her, and there was no documentation of a thorough abuse investigation as required by policy. For another resident with Alzheimer’s disease, moderate cognitive impairment (BIMS 9), and a history of falls and muscle weakness, interviews indicated that the resident developed a black eye for which there was no corresponding documentation of bruising or discoloration in progress notes or skin assessments from August through October 2025. A CNA reported that the resident told her and another CNA that a male CNA had hit her in the eye, and that dayshift staff said it had been reported to the DON and administrator; HR allegedly told her to stay out of it. The resident later stated that a black male staff member hit her left eye with the back of his hand on purpose, causing a large bruise, and that no one came to ask her questions about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then entering the resident’s room with the DON, where the resident was screaming that the CNA had hit her eye and a bruise was starting; the LPN stated the DON told her to chart that the bruise was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated. Other staff reported hearing that the resident accused the CNA of hitting her and that explanations were given that she had been rubbing or scratching her eye. The former SSD recalled the resident telling her the CNA hit her in the eye and being later told by the DON that the resident had just been rubbing her eye. The current DON and administrator both stated they were not informed of these abuse allegations and described an abuse investigation process that was not implemented in these cases, and there was no evidence of the comprehensive interviews, assessments, or documentation required by the facility’s abuse policy for these allegations.
Failure to Implement and Develop Comprehensive Care Plans for Orthotic Devices and Fall Prevention
Penalty
Summary
The facility failed to implement and develop comprehensive, person-centered care plans for several residents requiring orthotic devices and for a resident needing a specific fall prevention intervention. For four residents with orders for splints or braces, the care plans either lacked necessary interventions, such as range of motion (ROM) exercises, or the interventions listed were not carried out as specified. Observations revealed that splints and braces were not applied as ordered, and staff interviews confirmed inconsistent application and lack of awareness regarding care plan details. In some cases, splints were found unused in residents' rooms, and staff admitted to not performing required ROM prior to splint application. Additionally, the facility failed to ensure that interventions for fall prevention were implemented as documented in the care plan. One resident, who had experienced multiple falls, had a care plan intervention to apply brightly colored tape to the call light as a visual reminder to request assistance before ambulating. However, repeated observations showed that the call light did not have the required colored tape, and staff interviews confirmed that the intervention was not in place. There was also a lack of clarity among staff regarding responsibility for ensuring that such interventions were implemented and maintained. The facility's policies required that care plans be comprehensive, person-centered, and regularly updated by the interdisciplinary team, with staff notified of their responsibilities. However, interviews with staff, including CNAs, the MDS Coordinator, the DON, and the Administrator, revealed gaps in communication, training, and policy availability. Some staff were unaware of their roles in applying splints or following up on care plan interventions, and the facility lacked specific policies on restorative nursing services and splinting. These deficiencies resulted in residents not receiving care as planned and documented.
Failure to Adhere to Physician-Ordered Blood Pressure Parameters During Medication Administration
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) administered Lisinopril 20 mg to a resident diagnosed with essential hypertension, Alzheimer's disease, and chronic kidney disease, despite the physician's order to hold the medication if the resident's systolic blood pressure was less than 150 mm Hg. On the observed date, the resident's systolic blood pressure was 132 mm Hg, yet the medication was still given. The CMT later realized the error after reviewing the medication parameters and acknowledged that the medication should not have been administered. The facility's policy required medications to be administered as ordered and for vital signs to be checked and recorded, with medications held if outside prescribed parameters. Further review of the resident's Medication Administration Record (MAR) revealed that Lisinopril had been administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold of 150 mm Hg. Specifically, in the month of May, the medication was given 21 times despite the highest recorded systolic blood pressure being 136 mm Hg, and in June, it was administered on three occasions with all readings below 150 mm Hg. Interviews with staff indicated a misunderstanding of the hold parameters, with the CMT and nursing leadership referencing more common lower thresholds, rather than the specific order for this resident.
Failure to Provide Ordered Splinting and ROM Care for Multiple Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents who required range of motion (ROM) and orthotic devices. The facility did not have policies for splinting/orthotic devices or for Restorative Nursing Services, as confirmed by the Administrator. Staff interviews revealed a lack of clarity regarding responsibility for applying splints and performing ROM, with some staff unaware of which residents required these interventions or how to document them. One resident with hemiplegia and hemiparesis had a physician order for a resting hand splint to be applied daily, but reported that the splint had not been applied for about four months and that ROM was not performed prior to application, causing discomfort. Another resident with dementia and contractures had a splint order, but repeated observations showed the splint was left unused on the bedside table over several days. A third resident with dementia and contractures also had a physician order for a hand splint, but was repeatedly observed without the splint in place, and staff documentation showed inconsistent application. Interviews with CNAs, a CMT, and the Director of Rehabilitation indicated confusion about who was responsible for applying splints and performing ROM, with some staff stating that there was no restorative nursing program and that ROM was only provided during ADL care. The DON and Administrator acknowledged the lack of a restorative program and emphasized the expectation to follow physician orders, but confirmed that residents were not consistently receiving the ordered care.
Failure to Provide Consistent Range of Motion Care and Splint Application
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM for three residents. For one resident with hemiplegia and hemiparesis, staff did not consistently apply the prescribed resting hand splint as ordered by the physician. The resident reported that the splint had not been applied for approximately four months, and when it was applied, no ROM exercises were performed beforehand. The resident also experienced discomfort when the splint was first put on, and staff had to search for the splint in the closet, indicating a lack of routine and consistent care. Another resident with Alzheimer's disease and contractures had physician orders for both therapy evaluation and the application of a hand grip splint. Observations revealed that the splint was not being applied as ordered, as it was seen lying unused on the bedside table during multiple checks. Occupational therapy had recommended consistent use of the splint to maintain function, but there was no evidence of a restorative nursing program or consistent staff follow-through to ensure the splint was used as directed. A third resident with dementia and contractures also had orders for a resting hand splint and passive ROM exercises. Observations showed the splint was not being worn and was found in a chair in the resident's room. Interviews with staff revealed confusion about responsibilities for applying splints and a lack of restorative nursing services in the facility. Staff were unclear about which residents required splints, and there was no established policy or program to ensure the consistent application of splints or provision of ROM exercises, despite physician orders and therapy recommendations.
Inaccessible Call Light Systems in Resident Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to provide an accessible and functioning call system in each resident's bathroom and bathing area, as required by its own policy. Observations revealed that in multiple private bathrooms, the call light cord was installed only near the toilet and did not extend to the shower area, leaving a significant distance between the shower and the call light. In one resident and staff accessible restroom, the call light system was present but lacked a pull cord, rendering it inoperable. Additionally, the therapy gym restroom had no call light system installed at all. These deficiencies were confirmed through direct observation and interviews with staff and residents. A resident expressed concern that the call light cord did not reach the shower, noting that if someone fell while showering, they would be unable to call for help. Staff interviews indicated that CNAs would remain in the room during showers due to the call light limitations, and the ADON stated she would stand outside the bathroom door if a resident showered independently without access to a call light. The DON and Administrator acknowledged the issue, with the Administrator stating she would further investigate. The facility's failure to ensure accessible call systems in all toileting and bathing areas directly contravened its policy and left residents without a reliable means to summon assistance in these areas.
Failure to Include Residents and Representatives in Care Planning
Penalty
Summary
The facility failed to include the resident and/or the resident's representative in the care planning process. This deficiency was identified through interviews, record reviews, and policy reviews, which revealed that the facility did not invite the residents or their representatives to care plan conferences, nor did they document an explanation in the medical records when participation was not practicable. This failure affected five residents out of a sample of twenty-five, all of whom had varying degrees of cognitive impairment and required involvement from their representatives in care planning decisions. For Resident 45, who was severely cognitively impaired, there was no documentation of care conference notes or invitations extended to the resident's Power of Attorney (POA). The POA confirmed not being invited to any care plan meetings and was unaware of the resident's care areas. Similarly, Resident 15, who had moderate cognitive impairment, showed no evidence of being invited to care plan meetings in the progress notes. Resident 48, with severe cognitive impairment, also had no documentation of care plan meeting invitations extended to their responsible party, who confirmed not receiving any invitations. Resident 43, with severe cognitive impairment, and Resident 10, who was cognitively intact, both had no evidence in their records of being invited to care plan meetings. Interviews with the MDS Coordinator and Social Services Director (SSD) revealed that the SSD was responsible for inviting families and documenting attendance, but this was not being done. The interim Director of Nursing and the Administrator confirmed that care plan conferences should be documented and that families or POAs should be invited, but this was not consistently happening as per the facility's policy and regulatory requirements.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure all drugs and biological agents were properly labeled, stored, and secured in accordance with accepted professional principles. On multiple occasions, medication carts were left unlocked and unattended by Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs). This included instances where the medication cart was out of the line of sight of the staff, posing a risk of unauthorized access to medications. Interviews with the staff confirmed that they were aware of the requirement to lock the carts but failed to do so, citing distractions and other duties as reasons for the oversight. The facility also failed to discard expired medications as per their policy. Observations revealed expired medications in both the east and west side medication carts and storage rooms. These included benzonatate capsules, acetaminophen, ondansetron, and an opened vial of Tubersol, among others. Interviews with the LPNs and the Interim Director of Nursing (IDON) indicated a lack of consistent practice in checking and discarding expired medications. The staff acknowledged that expired medications might not be as effective and could pose a risk to residents. Additionally, the facility did not maintain proper temperature logs for medication storage. The west medication storage room had a combined refrigerator/freezer unit with thermometers but lacked a temperature log for the refrigerator. The existing log for the freezer documented temperatures that were not within the acceptable range. Interviews with the LPNs and the IDON revealed uncertainty about the correct temperature ranges and the procedures to follow if temperatures were out of range. The pharmacist recommended discarding the entire stock in the west side refrigerator due to the lack of confirmation of correct temperatures.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was at a palatable temperature and flavorful, affecting three of twenty-five sampled residents and potentially impacting 34 residents who prefer to eat in their rooms. Observations revealed that hot foods were below the acceptable temperature levels, while cold foods and beverages were above the acceptable temperatures at the point of service. Residents reported that the food was bland, lacked seasoning, and was often served cold. Grievance logs indicated multiple complaints about the food temperature, with responses suggesting residents eat in the dining room instead of addressing the temperature issues for room service meals. During a tray line observation, it was noted that hot foods were plated on room temperature plates and placed in a non-temperature-controlled cart. A test tray confirmed that the food was not at the required temperatures, with hot foods being only warm and cold items being too warm. Interviews with the Interim Director of Nursing and the Administrator acknowledged the issues with food services and the need for the kitchen to follow guidelines for maintaining food temperature. The facility's failure to ensure food was served at appropriate temperatures and with adequate seasoning led to dissatisfaction among residents and multiple grievances.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident reviewed for wounds. During wound care, an LPN did not use a barrier to lay out wound supplies and failed to change gloves or perform hand hygiene when indicated. The LPN placed treatment supplies directly on the resident's bed without a barrier, donned gloves without performing hand hygiene, and did not change gloves after removing the soiled dressing before proceeding with the wound care. This was confirmed by the LPN during an interview, where she acknowledged the mistakes made during the procedure. The resident involved had been admitted with diagnoses including peripheral vascular disease and skin breakdown. The current treatment order for the resident's right heel wound required specific steps to be followed, including cleansing the wound with normal saline and applying Polymem Pink. However, the LPN did not adhere to the facility's infection control policies and procedures, as confirmed by the Interim Director of Nursing/Infection Preventionist, who stated that the nurse should have changed gloves and washed hands before applying the clean dressing.
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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 Glasgow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tj Samson Community Hospital | 0 mi | — | 0 | 0 |
| Glasgow State Nursing Facility | 0.3 mi | ★★★★★ | 3 | 0 |
| Nhc Healthcare, Glasgow | 0.4 mi | ★★★★★ | 15 | 0 |
| Barren County Nursing And Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Glasgow Rehab & Wellness C | 2.1 mi | ★★★★★ | 0 | 0 |
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