Glenwood Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) to address a right eye hematoma (a closed wound that develops when an injury causes blood to collect and pool under the skin) for 1 of 2 sampled residents (Resident 1). This failure had the potential for Resident 1 to have wound complications go unnoticed by staff, leading to a potential delay in treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure N95 masks provided for use to staff and visitors were not expired; and 2. Ensure staff followed proper infection control procedures when Licensed Nurse (LN) 2 did not remove personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against infectious agents) before exiting Resident 101's room. This failure had the potential to significantly reduce the effectiveness of PPE and compromise infection prevention practices.

Inspectors wroteBased on record review and interview, the facility failed to ensure interventions in the comprehensive care plan for two of 10 sampled residents (Residents 70 and 5) were implemented when: 1. Monitoring of Resident 70's intake and output (process of tracking the amount of fluid) was not completed. 2. Monitoring for bleeding complications was not implemented and documented in the clinical record of Resident 5 who is taking the anticoagulant medication Apixaban (a medication used to prevent and treat blood clots). These failures had the potential to result in the inappropriate delivery of care and services for these residents and their needs not being met.

Inspectors wroteBased on interviews, record review and facility policy and procedure, the facility failed to ensure one of five sampled residents (Residents 55), care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) was revised after a fall. This failure had the potential for Resident 55's evolving needs for fall prevention to go unmet and potentially leading to preventable fall.

Inspectors wrote2. During a review of Resident 9's admission Record (AR), dated 5/30/25, the AR indicated in part Resident 9 was a [AGE] year old male who was initially admitted to the facility on [DATE] with admission diagnoses including essential hypertension (high blood pressure), Type II Diabetes Mellitus (a chronic disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces leading to high blood sugar levels) and Chronic Kidney Disease (a condition where the kidneys are damaged and cannot function properly over a prolonged period). During a review of Resident 9's Order Summary Report (OSR), dated 5/30/25, the OSR indicated the medication order, Hydralazine HCl tablet 25 mg (milligram) give one table by mouth four times a day for hypertension, hold if SBP (systolic blood pressure) less than 110, (Order Date: 2/28/25). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the controlled drug record for Lorazepam (a prescription medication to treat anxiety that has a potential for abuse, misuse, and can lead to dependence) was accurate for Resident 547. This failure resulted in an inaccurate count and had the potential for drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired medications were discarded and not available for use for one sampled resident (Resident 5) and two unsampled residents (Resident 1 and Resident 79). 2. The medication refrigerator temperature was monitored twice a day per facility policy when storing vaccines. These failures had the potential for residents to receive expired and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure temperature and humidity levels in the dry food storage room were properly monitored and documented. This failure had the potential to result in inaccuracies of information which can affect interventions to increase the shelf-life (the length of time that a commodity may be stored without becoming unfit for use , consumption or sale) of the stored food items.

Inspectors wroteBased on interviews, record reviews, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 (Resident #15 and Resident #18)) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and 2), had their health status accurately assessed using the Minimum Data Set ((MDS) a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This facility failure had the potential to result in staff providing inappropriate care and the residents not achieving or maintaining their highest practical level of well-being.

Inspectors wroteBased on record review and interview the facility failed to monitor and verify one of five sampled certified nursing assistants (CNA) certification credentials prior to expiration dates. This failure risks residents being cared for by individuals who lack valid authorization to practice as a CNA.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as planned when: 1. Sherbet was placed on the lunch meal plate for one of 20 sampled residents (Resident 280) on a Renal (diet for kidney disease) CCHO diet (controlled carbohydrate/diabetic diet), instead of diet pineapple as planned. This had the potential to not meet the resident's nutritional needs per the planned menu. 2. Whole parsley, with stems, was placed on the lunch meal plate for one of 20 sampled residents (Resident 71) and 27 non-sampled residents (Resident's 71, 37, 7, 3, 13, 53, 23, 25 , 2, 48, 70, 27, 1, 26, 69, 56, 21, 5, 35, 74, 284, 282, 433, 432, 285, 281, and 179) on a mechanical soft diet, instead of parsley flakes as planned for a garnish. This facility failure had the potential to place residents at increased risk for choking who received a mechanical soft diet order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' right to be treated with dignity when it posted personal care instructions in a viewable area above the head of the bed (HOB) for four of five sampled residents (Residents 9, 26, 28, 78). This facility failure had the potential to result in a loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate baseline care plans for one of 20 sampled residents (Resident 431), for (1) The use of an anticoagulant medication (medication that helps prevent blood clots); and (2) The presence of a left chest Automatic Implantable Cardioverter-Defibrillator device ([AICD] - a small, electronic device implanted into the chest to monitor and correct abnormal heart rhythm). These failures had the potential for Resident 431 to have complications of abnormal bleeding from the anticoagulant use, and possible unrecognized AICD device compliations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document in the clinical records for one of 20 sampled residents (Resident 430). Resident 430's high blood sugar level and subsequent physician telephone order were not documented in the resident's medical record. This failure had the potential for Resident 430 not to receive appropriate care and treatment interventions which could result in health complications.