Glenburnie Rehab & Nursing Center

In the surveyor’s words

From the most serious findings on record at Glenburnie Rehab & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Apr 17, 2025

  Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to thoroughly investigate the circumstances surrounding a fire and to implement interventions to prevent future fires for a census of 116 residents. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, widespread. The findings include: On 12/30/24, staff observed a burn smell in Resident #1's (R1's) room and observed the resident with a lighter. On 1/1/25, R1's roommate (R6) reported he extinguished a fire on his mattress. Staff observed a burn area on the lower right side of R6's mattress and some burn spots on the privacy curtains. […]

• No harm, potential for more than minimal, widespreadF865Apr 17, 2025

  Based on staff interview and facility document review, the facility staff failed to implement an effective QAPI (quality assurance and performance improvement) program for one of one facility. The findings include: The facility staff failed to ensure their 3/28/25 QAPI plan regarding a fire incident was effective. The facility staff failed to ensure a resident who smoked utilized a lock box for her smoking materials and failed to ensure staff were knowledgeable regarding the education documented in the plan. An initial facility synopsis of events submitted to the SA (state agency) on 3/28/25 documented, Incident date: 3/28/2025. Residents involved: (R1) (R2). Resident [R1] lit a roll of toilet paper on fire in his bathroom. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2026

  Based on observation, staff interview, and facility documentation review, the facility staff failed to serve food in a sanitary manner by failure to wear proper hair restraints in the main kitchen, which had the potential to affect residents on two of two units. The findings included:Facility kitchen staff failed to wear proper hair restraints while preparing food to prevent contamination. On 6/24/26 at 12:50 PM, observations were conducted in the main kitchen. Facility staff were actively working the tray line, preparing lunch meals for residents. A Dietary Aide (other employee #1) was observed handling the plates of food and had significant facial hair. Other Employee #1 was wearing a procedure mask that was under his chin and did not cover his beard, moustache, or sideburns. […]

• No harm, potential for more than minimal, patternF657Oct 29, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to revise the care plan for three of eight residents in the survey sample, Residents #2, #1, and #3.The findings include:1. For Resident #2 (R2) the facility staff failed to revise the care plan when the resident developed pressure injuries (1).A review of R2's admission nursing assessment dated [DATE] revealed no evidence of skin impairment related to a pressure injury when the resident was admitted .A review of ASM (administrative staff member) #3's, the wound nurse practitioner's, progress note dated 9/18/25 revealed, in part: Date of Service: 9/16/25.Sacrum.Stage 2 (2) (present on admission).Treatment Recommendations: 1. Cleanse with wound cleanser. 2. […]

• No harm, potential for more than minimal, patternF686Oct 29, 2025

  Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent and treat pressure injuries (1) for three of eight residents in the survey sample, Residents #2, #1, and #3.The findings include:1. For Resident #2 (R2), the facility staff failed to implement the wound nurse practitioner's recommendations to treat a pressure injury (1) in a timely manner in September and October 2025.On 10/28/25 at 9:03 a.m., LPN (licensed practical nurse) #2, the facility wound nurse, was observed preparing to provide wound care to R2. As LPN #2 prepared to enter R2's room, no signage or personal protective equipment related to any sort of isolation precautions was observed in plain view. […]