Glenwood Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Food Safety Requirements, the facility failed to ensure items stored in the cooler and dry food storage area were labeled, dated, and not beyond their expiration date. The facility also failed to ensure that items in the dry storage area were labeled with a use by date. In addition, the facility failed to ensure that staff hair nets covered all hair, logged steamtable food temperatures, kept food off floor for storage, and had education on how to use the 3-compartment sink. This deficient practice had the potential to adversely affect 44 of 44 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of facility documents, the facility failed to ensure that puree menu serving sizes were followed to provide the correct nutritional value for one of one resident (R) who received a pureed meal. This deficient practice placed the resident receiving pureed meals at risk for inadequate caloric intake, unintentional weight loss, and potential medical complications related to insufficient nutrition. Findings Include: Review of the menu for 03/07/2026 revealed that the supper meal included lasagna Italian style, tossed salad with dressing, breadsticks, chocolate pudding, 2% milk, coffee/tea, and margarine. Review of the pureed menu with serving sizes for the supper meal on 03/07/2026 revealed a suggested 6 oz serving portion of lasagna. [...]

Inspectors wroteBased on record review, staff interviews, and the facility policy titled Residents' Personal Funds, the facility failed to notify six of 44 sampled residents and/or the residents' (R)responsible parties (R12, R32, R20, R34, R5, R15) when the residents' personal funds were within $200 of the Social Security Income (SSI) resource limit. The facility's failure to provide timely notification placed residents at risk of exceeding resource limits required for maintaining Medicaid eligibility during the renewal period. Review of the facility policy titled Resident Personal Funds, implemented on 12/29/2025, documented the following:Policy: The resident has a right to manage his or her financial affairs, including the right to know, in advance, what charges a facility may impose against a resident's personal funds. Notice of Citation Balances: [...]

Inspectors wroteBased on observations, staff interviews, and review of the policy Safe and Homelike Environment, the facility failed to ensure a homelike environment for one of 44 sampled resident rooms (room [ROOM NUMBER]). Findings Include:Review of the policy Safe and Homelike Environment documented that, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. [...]

Inspectors wroteBased on observations, interviews, and review of facility policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three residents (R ) (R38) reviewed for free from verbal and physical abuse.

Inspectors wroteBased on observations, record review, staff interviews, and the facility's Catheter Care policy, the facility failed to ensure that urinary drainage tubing was kept uncoiled to allow unobstructed urine flow and prevent tension for one resident (R) (R49) out of three reviewed for catheter care. This deficient practice had the potential to increase R49's risk for a urinary tract infection.

Inspectors wroteBased on observations, staff interviews, record reviews and review of the facility policy titled, Food Safety Requirements, the facility failed to prepare and store food in accordance with professional standards of food service safety. Specifically, the facility failed to hold hot foods' temperatures appropriately prior to a meal service, failed to monitor the temperatures of hot foods being held prior to serving, and failed to remove decayed foods from refrigeration. The deficient practices had the potential to affect all 43 residents who received food from the facility's kitchen.

Inspectors wroteBased on staff and resident interviews, record review, review of the facility document titled, Resident Grievance/Concern/Complaint Report, and review of facility policy titled, Resident and Family Grievances, the facility failed to provide written grievance decision responses for two out of six residents (R) (R3 and R4) reviewed for grievances.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Food Storage and Sanitation/Infection Control, the facility failed to remove food items by the discard date; failed to label and date food items for storage; failed to remove dented food cans; failed to store food items off the floor; and failed to maintain food temperatures above 135 degrees on the steam table to prevent food borne illness. The deficient practice had the potential to affect 42 residents who received an oral diet and were served food from the kitchen.

Inspectors wroteBased on observations, staff interviews, review of facility documents, and review of a job description titled, Plant Operations Manager, the facility failed to ensure the resident's living area was clean and in good repair for seven of 14 rooms (Rm) on the 100 hall (Rm 108, 109, 110, 111, 112, 113 and 114), and the facility also failed to ensure that two of two shower rooms were free of clutter and in good repair. Specifically, the facility failed to ensure RM [ROOM NUMBER], 111, 112, and 113 had clear running water streaming from the bathroom sink faucet, and that RM [ROOM NUMBER], 110, and 114 were in good repair as evidenced by missing floor tiles in the bathroom and missing base boards on the wall in RM [ROOM NUMBER].

Inspectors wroteBased on observations, staff interview, and review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure one of one medication storage rooms were free of expired medications and that the Medication storage room was secure and only accessible to licensed staff.

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR), the facility failed to submit for a PASRR Level II after a new mental health diagnosis was added, and the development of behaviors for one resident (R) (R37) out of 19 residents reviewed. This deficient practice had the potential to affect the appropriate level of care and services provided for R37.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory System Management Standard, the facility failed to prevent the spread of infections by not cleaning and storing a nebulizer mask for one of two residents (R) (R43), receiving nebulizer treatments.

Inspectors wroteBased on observation, staff interviews, and review of facility's policy titled, Puree Food Preparation, the facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing puree food to prevent compromising the nutritive value and flavor for one resident out of 42 who was ordered a puree consistency diet.

Inspectors wroteBased on observation, record review, staff and resident interview, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of pain during wound treatment, resulting in harm for one resident (R#39) of 15 sampled residents. Actual harm was identified on 7/22/23 when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R#39 prior to providing wound care and upon R#39's nonverbal expressions of and verbalizing of pain, which resulted in severe pain during the treatment for R#39.

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement the care plan for one of 15 sampled residents (R) (R#7).

Inspectors wroteBased on observation, record review and interviews, the facility failed to follow-up on recommendations from the Registered Dietician (RD) related to nutritional assessments for one of 15 sampled residents (R) (R#28).

Inspectors wroteBased on observations, resident and staff interviews, record review and review of the facility policy titled Respiratory System Management Standard the facility failed to ensure one (1) resident (R) R#7 of five (5) residents with an order for oxygen (O2) therapy had an oxygen machine that was clean and sanitized and oxygen tubing was stored in a manner that prevented cross contamination.

Inspectors wroteBased on interviews and record review, the facility failed to have evidence to support that there was Registered Nurse (RN) Coverage for eight consecutive hours for eight days (1/7/23, 2/3/23, 2/6/23, 2/7/23, 2/8/23, 2/9/23, 2/10/23, and 2/16/23) of the last quarter.