145268
02/13/2026
Glenview Terrace
1511 Greenwood Road Glenview, IL 60025
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 pancakes if they would like, even if it's not on the alternative diet. R2's order summary report has a diagnosis of general diet regular texture dated 5/6/2024, A care plan dated 10/26/2022 provide assistance with meals if indicatedFacility Policy: Resident's Rights for people in Long Term Care FacilitiesSafety and Good CareYour facility must provide services to keep your physical and mental health, and sense of satisfaction.Food Preference Policy: revised 6/30/2025Purpose;The facility will provide food that accommodates allergies and preferences.Policy:3. If the resident refuses the food being served, the facility should offer alternatives that is consistent with the usual food item provided by the facility.
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145268
145268
02/13/2026
Glenview Terrace
1511 Greenwood Road Glenview, IL 60025
F 0691
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
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 the agency nurse entered the room with her medications unaware that she needed a colostomy change, and at this point her bag was leaking out feces. On 2/13/2026 at 1:30pm V9(AM Receptionist) said if a resident called down to the front desk asking for anything she will over head page the supervisor or nurse to that room.On 2/16/2026 at 9:30am V10 (PM Receptionist) said R2 did call the front desk several times asking to speak with a supervisor. I sent her call to the voicemail of the unit manager and the house supervisor that night. I did not over head page. On 2/16/2026 at 11:30am V3 (Unit Manager) said I received the call on Monday when I returned to work about the incident and did inform V2 (Director of Nursing-DON), I expect the receptionist to over head page for assistance to that room and the CNA staff to inform the nurse if their is an issue with any skill.On 2/16/2026 at 11:45am V2(Director of Nursing-DON) said I expect the receptionist to over head page and follow up on any resident calling for assistance, I only discovered on Monday that R2 had called 911 for assistance I also expect the nursing staff including agency to follow up with the nurse if that is a request from the resident.On 2/16/2026 at 10:40am V1(Executive Director) said that R2 should not have ever had to call 911 for assistance. I expect the staff to inform the nurse if that's whom the resident ask to see. I expect the receptionist to notify staff on that unit to provide assistance. An admission record indicates that R2 has a diagnosis of irritable bowel syndrome, encounter for a colostomy, a care plan dated 10/20/2023 intervention to colostomy care every shift and as needed.Facility Policy: Colostomy Care 6/30/2025.Policy Statement : It is the policy of the facility to perform proper ostomy care in order to prevent exposure of the resident skin/stoma sites from fecal matter.12.Empty ostomy care every shift and as needed.
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