Glenwood Care Center

In the surveyor’s words

From the most serious findings on record at Glenwood Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880May 30, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF803Jun 24, 2021

  Based 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. […]

• No harm, potential for more than minimal, isolatedF656Nov 24, 2025

  Based 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. […]

• No harm, potential for more than minimal, isolatedF656May 30, 2025

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, isolatedF657May 30, 2025

  Based 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. Findings: During an interview on 05/28/25 at 3:30 p.m. with Resident 55, Resident 55 stated, that he had a fall this morning when he stood up from the wheelchair to put his jacket on and the wheelchair slid back. Resident 55 stated that he did not sustain injury but that this was his 3rd fall in the facility. […]