F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of resident
property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or
neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of
the facility for 1 of 1 resident reviewed for reporting abuse. CNA A failed to notify the ADM and DON about
an accident/hazard regarding Resident #1 that happened on 08/27/25. This failure could place residents at
risk for abuse and neglect. Findings included:Record Review of Resident #1's face sheet, dated 09/09/25,
reflected a [AGE] year-old female with an initial admission date of 03/24/25 and a re-admission date of
09/03/25. Resident #1 had diagnoses of Paraplegia (loss of voluntary movement and sensation in the lower
half of the body), Personality Disorder (mental health conditions characterized by long-term patterns of
thinking, feeling, and behaving that deviate significantly from societal expectations and cause distress or
impairment in various aspects of life), Anxiety (a common mental health condition characterized by
excessive and persistent worry, fear, and unease), Post-Traumatic Stress Disorder (a mental health
condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster,
violent crime, or serious accident), Paralytic Syndrome (a medical condition characterized by muscle
weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of Bladder (a condition where the nerves
and muscles that control bladder function are impaired)Lack of Coordination (the inability to perform
smooth, precise, and controlled movements).Record review of Resident #1's Comprehensive Minimum
Data Set, dated [DATE], reflected: Section B Hearing, Speech, and Vision reflected that Resident #1 had
clear speech and Vision, had the ability to make herself understood and had the ability to understand
others. Section C Brief Interview for Mental Status score reflected a score of 15, which indicated the
resident's cognition was normal. Record review of Resident #1's Care Plan, dated 09/09/25, reflected the
following:‘Focus'Resident #1 utilizes a motorized wheelchair to move around in the room/facility. Resident
#1 has been evaluated by Therapy in the usage of a power wheelchair.‘Goal'Safe use daily of the electric
wheelchair by Resident #1.‘Interventions/Tasks'Transfer: The resident is able to transfer self but should use
x1 staff for participation in safety.Resident#1 educated on safe use of electric wheelchair, not to allow other
residents to hold on to the back on her wheelchair while in operation. In an interview on 09/09/25 at 9:54
AM, Resident #1 stated on 08/27/25 CNA A came in her room pissed off that she had work the 300 hall.
Resident #1 stated she was soaked in urine and CNA A changed her diaper, but her bed was soaked in
urine. Resident #1 stated she had asked CNA A if she was going to change the bed sheets, and CNA A
responded she would change the sheets when Resident #1 got out of bed. Resident #1 stated she told
CNA A that she was ready to get out of bed and that's when CNA A started transferring her to the
motorized wheelchair. Resident #1 stated CNA A then pushed a
(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 5
Event ID:
455494
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
455494
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glenview Wellness & Rehabilitation
7625 Glenview Dr
North Richland Hills, TX 76180
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the
wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no
longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was
getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized
wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that
she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall
and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1
stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated
that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant
to report it to a nurse when the incident happened, but she had forgot to report it because she was doing
multiple things at once. She stated the risk of not reporting incident/accidents in a timely manner can
prolong care and it is bad to not report. CNA A stated she was inserviced on how to properly use the
motorized wheelchair by unlocking the wheelchair from the bottom and pushing it manually next time. In an
interview on 09/09/25 at 2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated
she did not find out about the incident until the next day on 08/28/25 when Resident #1 went to the DON
and voiced that she was going to make a complaint to the state and that's when Resident #1 told her that
her foot was hurting because of the motorized wheelchair hitting her foot and she requested some pain
medicine. The DON stated that she immediately assessed Resident #1's foot, and orders were submitted
for x-rays on 08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no
injuries. The DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was
not available then she expects staff to report all incidents to her immediately. She stated the risk of staff not
reporting incidents in a timely manner can cause care to be delayed. The DON stated if they would have
known about the incident when it first occurred staff could have implemented the next steps right away. In
an interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting
Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an
incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized
wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she
was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be
sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly
use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a
motorized wheelchair can cause residents to get hurt. ADM stated her expectations of the CNA are to get
assistance from therapy before operating the motorized wheelchair. Review of the facility policy, Abuse &
Neglect, date revised 08/20 reflected: I. The facility is committed to protecting residents from abuse by
anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other
agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.
This policy statement also includes deprivation by any individual, including a caretaker, of goods, services
or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial
wellbeing. The administrator is responsible for coordinating and implementing the Facility' abuse prevention
policies, ii. Facility Staff will report known or suspected instances of abuse to the administrator, and his/her
designee. A. Reporting Requirements i. If the reportable event does not result in serious bodily injury, the
administrator, and his/her designee, will make a telephone report to the local law enforcement agency
within 24 hours of the observation, knowledge, or suspicion of physical/sexual
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455494
If continuation sheet
Page 2 of 5
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
455494
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glenview Wellness & Rehabilitation
7625 Glenview Dr
North Richland Hills, TX 76180
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 0609
abuse.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455494
If continuation sheet
Page 3 of 5
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
455494
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glenview Wellness & Rehabilitation
7625 Glenview Dr
North Richland Hills, TX 76180
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
interview, and record review, the facility failed to ensure that each resident received adequate supervision
for one (Resident #1) of three residents reviewed for supervision and ensured the environment remained
free of accidents hazards. The facility failed to ensure CNA A appropriately transferred Resident #1 from the
bed to the motorized wheelchair to ensure accidents did not occur. This failure could place residents at risk
of being in an unsafe environment and at risk of accidents and injury. Findings included: Record Review of
Resident #1's face sheet, dated 09/09/25, reflected a [AGE] year-old female with an initial admission date
of 03/24/25 and a re-admission date of 09/03/2025. Resident #1 had diagnoses of Paraplegia (loss of
voluntary movement and sensation in the lower half of the body), Personality Disorder (mental health
conditions characterized by long-term patterns of thinking, feeling, and behaving that deviate significantly
from societal expectations and cause distress or impairment in various aspects of life), Anxiety (a common
mental health condition characterized by excessive and persistent worry, fear, and unease), Post-Traumatic
Stress Disorder (a mental health condition that can develop after experiencing or witnessing a traumatic
event, such as a natural disaster, violent crime, or serious accident), Paralytic Syndrome (a medical
condition characterized by muscle weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of
Bladder (a condition where the nerves and muscles that control bladder function are impaired), Lack of
Coordination (the inability to perform smooth, precise, and controlled movements).Record review of
Resident #1's Comprehensive Minimum Data Set, dated [DATE], reflected: Section B Hearing, Speech, and
Vision reflected that Resident #1 had clear speech and Vision, had the ability to make herself understood
and had the ability to understand others. Section C Brief Interview for Mental Status score reflected a score
of 15, which indicated the resident's cognition was normal. Record review of Resident #1's Care Plan,
dated 09/09/25, reflected the following:‘Focus'Resident #1 utilizes a motorized wheelchair to move around
in the room/facility. Resident #1 has been evaluated by Therapy in the usage of a power
wheelchair.‘Goal'Safe use daily of the electric wheelchair by Resident #1.‘Interventions/Tasks'Transfer: The
resident is able to transfer self but should use x1 staff for participation in safety.Resident#1 educated on
safe use of electric wheelchair, not to allow other residents to hold on to the back on her wheelchair while in
operation. In an interview on 09/09/25 at 9:54 AM, Resident #1 stated on 08/27/25 CNA A came in her
room pissed off that she had work the 300 hall. Resident #1 stated she was soaked in urine and CNA A
changed her diaper, but her bed was soaked in urine. Resident #1 stated she had asked CNA A if she was
going to change the bed sheets, and CNA A responded she would change the sheets when Resident #1
got out of bed. Resident #1 stated she told CNA A that she was ready to get out of bed and that's when
CNA A started transferring her to the motorized wheelchair. Resident #1 stated CNA A then pushed a
button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the
wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no
longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was
getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized
wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that
she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall
and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1
stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated
that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant
to report it
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455494
If continuation sheet
Page 4 of 5
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
455494
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glenview Wellness & Rehabilitation
7625 Glenview Dr
North Richland Hills, TX 76180
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to a nurse when the incident happened, but she had forgotten to report it because she was doing multiple
things at once. She stated the risk of not reporting incidents in a timely manner can prolong care and it is
bad to not report. CNA A stated she was inserviced on how to properly use the motorized wheelchair by
unlocking the wheelchair from the bottom and pushing it manually next time. In an interview on 09/09/25 at
2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated she did not find out
about the incident until the next day on 08/28/25 when Resident #1 went to the DON and voiced that she
was going to make a complaint to the state and that's when Resident #1 told her that her foot was hurting
because of the motorized wheelchair hitting her foot and she requested some pain medicine. The DON
stated that she immediately assessed Resident #1's foot, and orders were submitted for x-rays on
08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no injuries. The
DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was not available
then she expects staff to report all incidents to her immediately. She stated the risk of staff not reporting
incidents in a timely manner can cause care to be delayed. The DON stated if they would have known
about the incident when it first occurred staff could have implemented the next steps right away. In an
interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting
Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an
incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized
wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she
was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be
sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly
use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a
motorized wheelchair can cause residents to get hurt. The ADM stated her expectations of the CNA are to
get assistance from therapy before operating the motorized wheelchair. On 09/09/25 at 4:04 PM, surveyor
requested a policy for accidents/hazards, but the ADM stated that they did not have a policy on
accidents/hazards.
Event ID:
Facility ID:
455494
If continuation sheet
Page 5 of 5