Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/22/23 at
10:48AM, V10 RN said that R21 had recent witnessed fall on 8/12/23. Observed R21 lying in bed.
Residents Affected - Some
On 8/23/23 at 12:15PM, Review R21's medical records with V7 Care plan Coordinator. R21 is admitted on
[DATE] with diagnosis listed in part but not limited to Unsteadiness on feet, Lack of Coordination,
Weakness, Senile Degeneration of brain. V7 said that R21's fall assessment is at high risk. Review R21's
Fall incident report on 8/12/23 with V7 indicated: R21 was assisted to the washroom by CNA when her legs
gave out. CNA assisted R21 to the floor. No injury or bruises noted on the resident. Review R21's care plan
with V7 indicates: R21 is at risk for fall due to debility from recent illness, new surroundings, advancing age
with comorbidities, poly pharmacy. V7 said that she did not update R21's fall care plan intervention after her
fall on 8/12/23. V7 said that fall care plan intervention should be updated after each fall incident.
On 8/22/23 at 10:45am, Observed R26 ambulating with walker with V9 Private Care giver. R26 denied any
signs and symptoms of UTI (Urinary Tract Infection). V9 said that R26 did not present signs and symptoms
of UTI.
On 8/23/23 at 9:35am, Review R26's medical record with V2 Nursing Supervisor. R26 is admitted on
[DATE] with diagnosis listed in part but not limited to Chronic lymphocytic leukemia of B-cell type not having
achieved remission. V2 said that R26 is on antibiotic (Cephalexin) 250mg 1 cap orally at bedtime since
4/18/23 upon admission as prophylaxis for UTI (Urinary Tract Infection) indefinitely. V2 said that there is no
care plan in placed in regards with R26's usage of prophylaxis antibiotics. V2 said that there is no
documentation in R26's chart indicating that she is presenting signs and symptoms of UTI. No
documentation that R26 is being monitored for sign and symptoms for UTI.
On 8/23/23 at 12:08PM, Review R26's comprehensive care plan with V4 Care plan Coordinator. V4 said
that she did not develop care plan for R26's usage of antibiotics indefinitely due to prophylaxis for UTI.
On 8/22/23 at 10:38AM, Observed R39 lying in bed with V8 Private Caregiver at bedside. V8 said that R39
had fall incident last month and was admitted to hospital due to fractured hip.
On 8/23/23 at 10:10AM, Review R39's medical records with V2 Nursing Supervisor. R39 is re-admitted on
[DATE] with diagnosis listed in part but not limited to Periprosthetic fracture around internal prosthetic left
hip joint, Aftercare following joint replacement surgery, Presence of artificial hip joint, Fracture of part of
neck of left femur subsequent encounter for closed fracture with routine healing, History of falling, Difficulty
in walking, Cognitive decline, Weakness, Abnormalities in
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
146107
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
gait and mobility, Lack of coordination, Ataxia following Cerebral infraction. V2 said that R39's fall risk
assessment indicated that she is at high risk. V2 said that R39 is care plan for at risk for falling related to
cognitive impairment, disease process, recent illness, new surroundings, advancing age with comorbidities,
poly pharmacy. V2 said that R39 has several fall incidents. Review R39's fall incidents report with V2. Most
recent witnessed fall incident dated 7/24/23 at 12:00pm indicated: CNA notified the Nurse on duty that R39
was observed on the floor. V8 Private caregiver, who was with R39 at the that time, turned around to press
the call light and in that moment R39 stood up from her wheelchair and fell. R39 hit her head and left hip.
R39 was sent to the hospital and admitted with diagnosis of Comminuted Left Intertrochanteric Fracture.
R39 had Left hip revision on 7/25/23 and returned to the facility on 7/28/23.
On 8/23/23 at 12:08PM, V7 Care plan Coordinator said that she updates all the resident care plan in the
facility. V7 said that fall care plan is updated after each fall and when there is change of resident condition.
Review R39's Fall care plan with V7 Care Plan Coordinator. V7 said that she did not update R39's care plan
intervention after she returned from the hospital status post left hip revision from a fall sustaining
Comminuted Left Intertrochanteric Fracture.
Facility's policy on Care Plan Protocol revised date November 2011 indicates:
Standard of Practice:
2. When establishing care plan, in as far as is possible, the dame personnel are assigned to care for each
patient. Steps to be taken in developing the care plan include:
*Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient.
Facility's policy on Fall Prevention Protocol revised October 2017 indicates:
Purpose: This protocol describes mechanism for assessing residents at risk for falls and providing
interventions to reduce the likelihood of falls.
Desired outcome: To reduce both the number of resident falls and injuries related to those falls.
Post fall Guidelines:
3. For residents who are determined to be at risk for falls on admission, a care plan is developed, and the
appropriate Minimum Date Set Documentation is completed. These documents are updated for falls that
occur after admission.
Based on interview and record review the facility failed to update fall care plan interventions after each fall
incidents on resident who are at risk for fall. The facility also failed to update resident care plan who is on
prophylaxis antibiotic indefinitely. These deficiencies affect four (R11, R21, R26 and R39) of eight residents
in the sample of 16 reviewed for care plan revision and updates.
Findings include:
On 8/23/2023 at 12:20pm V4 (Care Plan Coordinator) observed an unwitnessed fall incident report dated
11/28/2022 resulting in R11 complaining of right hip pain and an unwitnessed fall incident report
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
on 1/25/2023. A care plan review dated on 11/21/2022 with a problem of falls on 11/28/2022 and no fall
intervention approach in place.
Level of Harm - Minimal harm
or potential for actual harm
On 8/23/2023 at 12:25pm V4 said the care plan should be updated after every fall incident.
Residents Affected - Some
Facility Policy: Care Plan Protocol Revised in 2011
Care Plan Protocol
This protocol provides care plan guidelines for the Agency.
2. Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to follow its fall prevention protocol by failure to
notify the State Agency Illinois Department of Public Health (IDPH) in a timely manner of a resident fall
incident that required hospitalization. The facility also failed to ensure effective intervention were in place to
reduce the risk of falls. This deficiency affects two (R11 and R39) residents in the sample of 16 reviewed for
Resident safety.
Findings include:
On 8/22/23 at 10:38AM, Observed R39 lying in bed with V8 Private Caregiver at bedside. V8 said that R39
had fall incident last month and was admitted to hospital due to fractured hip.
On 8/23/23 at 10:10AM, Review R39's medical records with V2 Nursing Supervisor. R39 is re-admitted on
[DATE] with diagnosis listed in part but not limited to Periprosthetic fracture around internal prosthetic left
hip joint, Aftercare following joint replacement surgery, Presence of artificial hip joint, Fracture of part of
neck of left femur subsequent encounter for closed fracture with routine healing, History of falling, Difficulty
in walking, Cognitive decline, Weakness, Abnormalities in gait and mobility, Lack of coordination, Ataxia
following Cerebral infraction. V2 said that R39's fall risk assessment indicated that she is at high risk. V2
said that R39 is care plan for at risk for falling related to cognitive impairment, disease process, recent
illness, new surroundings, advancing age with comorbidities, poly pharmacy. V2 said that R39 has several
fall incidents. Review R39's fall incidents report with V2. Most recent witnessed fall incident dated 7/24/23 at
12:00pm indicated: CNA notified the Nurse on duty that R39 was observed on the floor. V8 Private
caregiver, who was with R39 at the that time, turned around to press the call light and in that moment R39
stood up from her wheelchair and fell. R39 hit her head and left hip. R39 was sent to the hospital and
admitted with diagnosis of Comminuted Left Intertrochanteric Fracture. R39 had Left hip revision on 7/25/23
and returned to the facility on 7/28/23.
On 8/23/23 at 12:08PM, V7 Care plan Coordinator said that she updates all the resident care plan in the
facility. V7 said that fall care plan is updated after each fall and when there is change of resident condition.
Review R39's Fall care plan with V7 Care Plan Coordinator. V7 said that she did not update R39's care plan
intervention after she returned from the hospital status post left hip revision from a fall sustaining
Comminuted Left Intertrochanteric Fracture.
On 8/23/23 at 12:32PM, Review R39's Fall incident report of 7/24/23 was reported to IDPH on 7/26/23 with
V1 Administrator. V1 said that the fall incident with injury should be reported to IDPH within 24 hours. V1
said she does not know why there was a delayed in reporting to IDPH because she was vacation when it
happened.
Facility's policy on Fall Prevention Protocol revised October 2017 indicates:
Purpose: This protocol describes mechanism for assessing residents at risk for falls and providing
interventions to reduce the likelihood of falls.
Desired outcome: To reduce both the number of resident falls and injuries related to those falls.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Post fall Guidelines:
Level of Harm - Minimal harm
or potential for actual harm
4. The nursing staff notifies the following individuals of the resident's fall:
a. Appropriate State Agency, as required by regulation.
Residents Affected - Few
Documentation:
1. Documentation of the event, the assessment of the resident and post fall interventions is recorded in the
resident's medical record.
2. An incident report is completed and maintained as per the incident report policy
3. For residents who are determined to be at risk for falls on admission, a care plan is developed, and the
appropriate Minimum Date Set Documentation is completed. These documents are updated for falls that
occur after admission.
On 8/23/2023 at 12:00pm V4 (Care-Plan Coordinator) reviewed with the surveyor the fall log from the
facility dated 7/11/2022 to 8/22/2023. R11 had an unwitnessed fall on 11/28/2023 where R11 complained of
pain to right hip, and on 1/25/2023 R11 had an unwitnessed fall with no injury.
On 8/23/2023 at 12:20pm V4 said that R11 should have had interventions for prevention of falls on
11/28/2023 to try and prevent any further falls which occurred on 1/25/2023.
A Physician order report dated 7/25/2023 to 8/25/2023 indicates that R11 has an history of falling. A Fall
Risk assessment tool dated on 11/21/2023 indicates that R11 has a score of 11 which is a moderate fall
risk. A care-plan dated 11/21/2022 a problem of falls and no approach to fall interventions on 11/28/2022.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0740
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and
services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide psychiatric/ psychological evaluation
as ordered and behavioral management interventions for resident who presented delusion of being food
poisoned. This deficiency affects one (R26) of three residents the sample of 16 reviewed for Behavioral
Management.
Findings include:
On 8/22/23 at 10:45AM Observed R26 ambulates with rolling walker. She said that somebody has been
tampering her food for several months since she was admitted . She does not feel well after she eat
because someone is tampering her meals. She has not been eating and has been losing weight. She
reported it, but nothing is being done. V9 R26's Private caregiver said that R26 has is confused and
thinking that someone is tampering her food or poisoning her. V9 said she needs reassurance and able to
convince her if she refused to eat. She has fair to good appetite and did not lose weight.
On 8/22/23 at 10:48AM, V10 RN said that she is the nurse assigned to R26. She said that R26 has
behavioral problems of refusing care and medications but able to response to redirections. She has
delusion and paranoid that her food is being tampered or poisoned. She denied R26 of losing weight.
On 8/22/23 at 10:52AM, V11 CNA said that she is the CNA assigned for R26. She said that R26 has
behavioral problems of refusing care and medications but able to response to redirections. R26 has
delusion and paranoid that her food is being tampered or poisoned. She denied R26 of losing weight.
On 8/22/23 at 10:55 AM, V3 Food Service director said that she is aware that R26 has behavioral issues of
refusing to eat due to paranoia of food being poisoned. V3 denied R26 of losing weight but rather has
gained weight.
On 8/22/23 at 10:59AM, Review R26's care plan with V10 RN. Noted there is no behavioral care plan found
addressing the issues of delusion and paranoid of food being tampered or poisoned.
On 8/22/23 at 11:10AM, Review R26's medical records with V2 Nursing Supervisor. R26 is admitted on
[DATE] with diagnosis listed in part but not limited to anxiety disorder due to known physiological condition.
Physician order sheet indicates: Psychiatry, Psychology evaluation and treatment as indicated. She is on
Quetiapine (Seroquel) for Delirium. Quetiapine 25mg 1 tab orally twice a day for agitation and 25mg orally 1
tab daily as needed, Alprazolam 0.25mg 1 tab orally at bedtime for anxiety. R26's progress notes indicated
behavioral of resistance to care, refusing medications, and delusion and paranoia of her food is being
tampered or poisoned. R26's dietary notes indicated that she often says that her food is poisoned. R26 is at
risk for possible weight. R26's comprehensive care plan did not address her behavioral issues of delusion
and paranoid of food being tampered or poisoned. V2 said that R26 is not referred or seen by
psychiatrist/psychologist regarding her behavioral issues. R26's Primary Care Physician (PCP) does not
come to the facility. R26's last visit to her PCP was last June 2023. R26's PCP notes during her visit no
documentation addressing behavioral issues of R26's delusion and paranoid of being food poisoned.
On 8/22/23 at 11:18AM V7 Care plan Coordinator said that she formulates and updates the resident's care
plan in the facility. V7 said that care plan should be individualized based on the resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
(X3) DATE SURVEY
COMPLETED
A. Building
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0740
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
needs. Care plan should be addressing the needs/issues of resident. She said that R26 has behavioral
problems of refusing care and medications but able to response to redirections or encouragement. She has
delusion and paranoid that her food is being tampered or poisoned. V7 said that she did not write
behavioral care plan addressing the issues of delusion and paranoid of food being tampered or poisoned.
V7 said that she should written care plan intervention addressing the behavioral needs of R26. V7 said that
R26 is not seen by psychiatrist or psychologist for her behavioral issues. R26's MDS (Minimum Date
set)/Resident Quarterly assessment dated [DATE] indicated: Section E Behavior: E0100 Potentials
indication of Psychosis: B. Delusions (Misconception or beliefs that are firmly held, contrary to reality);
Section N Medications: N0410 Medications Received: A. Antipsychotic B Antianxiety
On 8/22/23 at 2:30PM Informed V1 Administrator and V2 Nursing Supervisor that R26 is on antipsychotic
(Quetiapine) medication related to diagnosis of delirium as indicated in physician order sheet. Asked both if
this is appropriate diagnosis for usage of Quetiapine. Both said that they will have to review their policy and
get back to the surveyor.
On 8/23/23 at 10:30am V2 Nursing Supervisor said that she called R26's Nurse Practitioner for appropriate
diagnosis for R26 usage of Quetiapine. V2 said that they are not aware that Delirium is not appropriate
diagnosis for usage of anti-psychotic medication (Quetiapine). The diagnosis given is Dementia with
behavioral disturbance.
On 8/24/23 at 2:58pm Informed V1 Administrator informed of above concerns identified.
Facility's policy on Behavior Management- Psychotropic/Antipsychotic Drugs revision date October 2017
indicates:
Process:
2. Residents will not be given psychotropic drugs unless necessary to treat a specific condition that is
documented in the resident's clinical record based upon a comprehensive assessment.
5. Documentation of behavioral monitoring includes:
*Symptoms demonstrated which require the use of psychotropic medication
*If the symptoms are transient or ongoing
*Evaluation of other reason or potential cause of behavior
* Ruling out of other medical causes for the behavior
6. In addition to pharmacologic treatments for residents with behavior issues, behavioral management
interventions may be utilized either as directed by a health care provider with prescriptive authority or as
part of the interdisciplinary plan of care. These interventions may include but not limited to those listed
below:
*Consultation with a psychologist or psychiatrist for team and for the resident
1. Psychiatrist/psychological consults are documented in the resident's medical record.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0740
Level of Harm - Minimal harm
or potential for actual harm
3. Changes in the resident's behavior or issues related to the psychotropic medication regime are directed
to the psychiatrist. The health care provider with prescriptive authority. The change in plan is also discussed
with the resident's responsible agent if needed.
Facility's policy on Care Plan Protocol revised date November 2011 indicates:
Residents Affected - Few
Standard of Practice:
2. When establishing care plan, in as far as is possible, the dame personnel are assigned to care for each
patient. Steps to be taken in developing the care plan include:
*Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to adequately monitor the resident on antibiotics
without adequate indication. This deficiency affects one (R24) of three residents in the sample of 16
reviewed for Unnecessary medication.
Residents Affected - Few
Findings include:
On 8/22/23 at 10:45am, Observed R26 ambulating with walker with V9 Private Care giver. R26 denied any
signs and symptoms of UTI (Urinary Tract Infection). V9 said that R26 did not present signs and symptoms
of UTI.
On 8/23/23 at 9:35am, Review R26's medical record with V2 Nursing Supervisor. R26 is admitted on
[DATE] with diagnosis listed in part but not limited to Chronic lymphocytic leukemia of B-cell type not having
achieved remission. V2 said that R26 is on antibiotic (Cephalexin) 250mg 1 cap orally at bedtime since
4/18/23 upon admission as prophylaxis for UTI (Urinary Tract Infection) indefinitely. V2 said that R26 is not
on antibiotic stewardship program. V2 said that they only put resident on stewardship program when
resident was started antibiotic in the facility. R26 was not included because she came in with antibiotics. V2
said that there is no documentation of R26's PCP (Primary Care Physician) regarding justification of
antibiotic usage. V2 said that R26's PCP has not been in the facility. R26 goes to her PCP's office. V2 said
that R26's urinalysis was done on 6/7 PCP's office, but the test result was not sent to the facility. V2 said
that there is no urine culture was done since admission. V2 said that she called R26's PCP to fax his
progress notes regarding usage of antibiotics and UA test results. V2 said that there is no care plan in
placed in regards with R26's usage of prophylaxis antibiotics. V2 said that there is no documentation in
R26's chart indicating that she is presenting signs and symptoms of UTI. No documentation that R26 is
being monitored for sign and symptoms for UTI. V2 said that V7 DON (Director of Nursing) is the infection
Preventionist and is on vacation, not available for interview.
On 8/23/23 at 12:08PM, V4 Care Plan Coordinator said that she responsible for developing and updating
care plan for all residents in the facility. Review R26's comprehensive care plan with V4. V4 said that she did
not develop care plan for R26's usage of antibiotics indefinitely due to prophylaxis for UTI. Review R26's
MDS (Minimum, date set)/ Resident Quarterly assessment dated [DATE] indicated: Section N Medications:
N0410 Medications Received. F Antibiotic
On 8/24/23 at 2:58pm Informed V1 Administrator informed of above concerns identified.
Facility's policy on Antibiotic Stewardship program indicates:
Purpose: This policy establishes directives for Antibiotic Stewardship to develop antibiotic use protocols and
a system to monitor antibiotic use.
Process:
3). The Antibiotic Stewardship Committee will support and promote antibiotic use protocol which include:
1. Assessment of residents for infection using standardized tools and criteria. The criteria used
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146107
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at the Glen
2401 Indigo Lane
Glenview, IL 60026
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
will be adapted from McGeer's Criteria.
Level of Harm - Minimal harm
or potential for actual harm
2. Therapeutic decisions regarding antibiotics prescriptions based on evidence (Clinical guidelines)
appropriate for the care of long-term care facility residents.
Residents Affected - Few
3. Specific dose, duration, and indication on all antibiotic's prescriptions.
4. Reassessment of empiric diagnostic test, laboratory reports and or changes in the clinical status of
resident.
5. Use of narrow spectrum antibiotics that are appropriate for the condition being treated whenever
possible.
4)The Antibiotic Stewardship Committee will develop and maintain a system to monitor antibiotic use which
includes:
1. Review of antibiotics prescribed to residents upon admission or transfer to the facility and those
prescribed during evaluation by an outside practitioner.
2. Quarterly review of a subset of antibiotic prescriptions for inclusion of dose, duration, and indication (or
for length of therapy, documentation of an antibiotic time-out, appropriateness based on antibiotic use
protocol and written documentation of clinical justification for antibiotic use that does not comply with the
facility antibiotic use protocol). Periodically review rates of prescription for any antibiotics or conditions
identified by the committee as being of special interest.
Facility's policy on Minimum Criteria for Antibiotic Use Protocol indicates:
Purpose: This protocol aims to improve appropriate antibiotic use and establish minimum criteria/clinical
guidelines for the use of antibiotics based on McGeer's Criteria for Infection Surveillance/minimum criteria
for antibiotic initiation.
Desired outcome: Reduce the unnecessary use of antibiotics when the clinical condition being treated does
not meet clinical guidelines for the use of an antibiotic.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146107
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the August 25, 2023 survey of VI AT THE GLEN?
This was a inspection survey of VI AT THE GLEN on August 25, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VI AT THE GLEN on August 25, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.