Glenwood Health & Rehabilitation

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Preadmission Screening Resident Review (PASRR) was completed for a resident with a diagnosis of a serious mental illness for 2 of 3 residents reviewed for PASRR (Resident #80 and Resident #87).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to maintain a medication error rate of less than 5%, as evidenced by the administration of medications that were ordered and manufactured to be administered whole after they were crushed prior to administration. This resulted in 2 medication errors out of 25 medication administration opportunities, for a medication error rate of 8% for 1 of 3 residents (Resident #77) observed during the medication pass.

Inspectors wroteBased on record review, observations, and staff, Pharmacist, and Medical Director interviews, the facility failed to ensure a resident was free of significant medication errors when extended-release medications that were ordered to be administered whole were crushed prior to administration for 1 of 3 residents (Resident #77) observed during the medication pass.

Inspectors wroteBased on observations, record review, Nurse Practitioner (NP), Speech Language Pathologist (SLP) and staff interviews, the facility failed to implement an effective system to ensure that a severely cognitively impaired resident with a diagnosis of dysphagia received the correct food texture (mechanical soft) as ordered by the physician (Resident #32). On 7/6/26, Resident #32 was observed in her bed sitting upright with her lunch tray in front of her on her overbed table. The lunch plate revealed a whole, soft dinner roll, ground turkey chili with beans over cream of rice, and whole asparagus spears. Resident #32 was observed trying to pick up the asparagus spears with her right hand and attempted to chew one spear but was unsuccessful in eating any of the asparagus. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date open food items and discard items that were beyond their expiration date in 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator in the kitchen.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with new mental health diagnoses for 2 of 3 residents (Resident #18 and #61) reviewed for PASRR.

Inspectors wroteBased on observations, record review and staff and Resident interviews, the facility failed to obtain an order for the size of a urinary catheter and change the catheter as ordered for 1 of 1 resident (Resident #87) reviewed for urinary catheters.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to post cautionary oxygen signage on 1 of 2 oxygen storage rooms where full portable oxygen cylinders were stored. The facility also failed to maintain a clean oxygen concentrator filter for 1 of 5 residents reviewed for respiratory care (Resident #46).

Inspectors wroteb. On 05/13/25 at 9:45 AM the Wound Nurse prepared to perform wound care on Resident #61 who had an Enhanced Barrier Precaution sign on his door. The sign indicated wearing gloves and a gown for high contact resident care activities which included wound care. The Wound Nurse washed her hands and applied her gloves then prepared the work field on the over bed table. She then positioned Resident #61 on his right side to expose the stage IV pressure ulcer on his left ischium (hip bone) which had no dressing on it. The Wound Nurse cleansed the wound then removed her gloves and applied clean gloves without washing her hands. The Wound Nurse then applied the ordered treatment and covered the wound with a border dressing to complete the wound care. The Wound Nurse did not don a gown per the Enhanced Barrier Precautions. An interview was conducted with the Wound Nurse on 05/14/25 at 2:34 PM. [...]

Inspectors wroteBased on record reviews, and facility staff, Physician Assistant (PA) and Medical Director interviews, the facility failed to immediately notify the PA when Resident #1 had an acute change in condition after a fall. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. The PA was not notified until 4:50 PM on 03/26/25 of the acute change in condition. [...]

Inspectors wroteBased on record reviews, Emergency Medical Services (EMS) records, facility staff, Emergency Department (ED) Physician, Physician Assistant (PA) and Medical Director interviews, the facility failed to recognize the severity of an acute change in condition after a fall for Resident #1. Resident #1 had a past medical history that included atrial fibrillation with anticoagulation, recent pulmonary embolism, recent COVID-19, history of traumatic brain injury (TBI), history of hemiplegia (paralysis on one side of body) following a cerebral infarction, and history of previous subdural hematoma. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. [...]

Inspectors wroteBased on resident and staff interviews, and record reviews, the facility failed to protect a resident's right to be free from physical abuse when a Nursing Assistant woke a resident from his sleep to provide incontinent care against his will and held the resident's arms while the resident was fighting for 1 of 3 sampled residents (Resident #2). A skin tear to the resident's left lower forearm was noted after this incident.

Inspectors wroteBased on record review, staff, news article review, North Carolina Board of Nursing Investigator, power of attorney, and detective interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to immediately initiate protective measures to safeguard residents from misappropriation of property and complete a thorough investigation when they received a report from local law enforcement of misappropriation of resident property. On 05/18/23 the facility received a call from Detective #1 informing them that Nurse #1 had been involved in a traffic stop and was in possession of Resident #156's driver's license, social security card, and debit card. There was a high likelihood that Nurse #1 misappropriated the property of other residents leading to the loss of financial resources for residents who resided at the facility at the time of Nurse #1's employment. [...]

Inspectors wroteBased on record review, news article review, North Carolina Board of Nursing Investigator, staff, power of attorney, and detective interviews the facility failed to assure that a resident's (Resident #156) property was safeguarded, and that staff did not misappropriate the resident's property. Nurse #1 was found to have in her possession Resident #156's driver's license, social security card, and debit card without his permission or knowledge and was alleged to have made unauthorized charges on the debit card which included reoccurring charges to a taxi services, online shopping services, and a gas station in a nearby county (Gastonia). The unauthorized charges started in February 2023 and recurred until the card was cancelled in [DATE] for an undisclosed amount of money. [...]

Inspectors wroteBased on staff interviews the facility failed to employ a qualified director of food and nutrition services.

Inspectors wroteBased on observations, record review, video footage review, staff, and Nurse Practitioner interviews the facility failed to redirect and implement effective interventions to prevent a severely cognitively impaired resident with a history of wandering and exit seeking behaviors and wore a wander guard (alarm used to prevent resident from exiting the building) from exiting the building unsupervised (Resident #155). The facility also failed to effectively supervise and remain with a resident with dementia and had a history of wandering and wore a wander guard who was observed by the Receptionist to exit the building (Resident #95). This deficient practice affected 2 of 2 residents reviewed for accidents.

Inspectors wroteBased on observations, record reviews, staff and consultant pharmacist interviews the facility failed to: 1) label medications with the minimum information required, including the first and last name of the resident on 1 of 7 medication (med) carts observed (300 Distal); 2) store medications in accordance with the pharmacy storage instructions on 3 of 7 med carts (100 Even, 200 and 200/600 Split); 3) failed to remove lose and unsecure pills/capsules from 6 of 7 med carts (300 Distal, 100 Even, 300 Proximal, 200 Hall, 200/600 Split and 600 Hall) and 4) failed to remove expired medication from the refrigerator in 1 of 2 med rooms (100 Hall) reviewed for medication storage.

Inspectors wroteBased on observations, staff, and resident interviews, and test tray observation the facility failed to serve food that was palatable in temperature and appearance for 3 of 8 residents reviewed for food (Resident #42, Resident #65, and Resident #107).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigations that occurred on 01/14/22, 09/20/22 and the recertification and complaint investigations that occurred on 04/15/21 and 07/15/22. This failure was for seven deficiencies that were originally cited in the areas of Resident Assessment (F641), Quality of Life (F677), Quality of Care (F689), Pharmacy Services (F761), Resident Rights (F550 & F584) and Comprehensive Resident Centered Care Plan (F661) and were subsequently recited on the current recertification and complaint survey on 02/01/24. [...]

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to treat residents in a dignified manner when staff spoke to a resident in a disrespectful manner. The resident expressed feelings of anger, upset, and disrespect. This affected 1 of 3 residents reviewed for dignity and respect (Resident #74).

Inspectors wrote2. Resident #33 was admitted to the facility on [DATE]. A review of Resident #33's physician orders revealed an order dated 08/15/23 for an Antidiarrheal Suspension 262 milligrams (MG) per 15 milliliters (ML) give 30 ml by mouth every 4 hours as needed for stomach pain or diarrhea. Review of Resident #33's electronic medical record (EMR) revealed no physician orders were received for the Resident to self-administer any medications. Further review of the EMR revealed there was no documentation of a medication self-administration assessment having been completed for the Resident. Review of Resident #33's current care plan (revised 10/10/23) revealed the Resident was not care planned for self-administration of medications. Review of Resident #33's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice, diagnoses and range of motion for 2 of 31 sampled residents (Resident #16 and Resident #60) reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a discharge summary recapitulation of stay fully and accurately for 1 of 3 residents reviewed for discharges (Resident #155).

Inspectors wroteBased on observations, record review, family, resident, and staff interviews the facility failed to trim a female resident's chin hairs and toenails (Resident #34) for 1 of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on observations, record reviews, staff and Resident interviews the facility failed to apply a left-hand splint, as ordered by the physician, to prevent further contracture for 1 of 1 resident (Resident #60) reviewed for limited range of motion.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 1 of 3 residents (Resident #45) observed during the medication administration observation.

Inspectors wroteBased on observations, record review, staff and Resident interviews the facility failed to maintain accurate medical records related to documentation of a splint application for 1 of 1 resident (Resident #60) reviewed for limited range of motion.

Inspectors wroteBased on record review and staff interviews the facility failed to included documentation in the medical record of education regarding the benefits and potential side effects of the Influenza immunization for 2 of 5 (Resident #87 and Resident #34) residents reviewed and failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Pneumococcal immunization for 2 of 4 residents reviewed (Resident #65 and Resident #34).

Inspectors wroteBased on record review and staff interviews the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization for 3 of 5 residents reviewed for infection control (Resident #12, Resident #34, and Resident #65).