Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glenwood Care Center during CMS and state inspections, most recent first.
A resident with diabetes, moderate cognitive impairment, and a right eye hematoma did not have a care plan developed to address the wound. Staff observed and documented the hematoma, but no care plan was created, as confirmed by the DON and record review, despite facility policy requiring comprehensive, person-centered care planning.
Staff and visitors were provided with expired N95 masks for use in COVID-19 designated areas, and an LPN was observed preparing medication outside a COVID-19 positive resident's room without removing required PPE, contrary to facility policy and infection control procedures.
Two residents did not receive required care plan interventions: one did not have intake and output monitoring completed or documented as ordered for gastrostomy tube care, and another did not have monitoring for bleeding complications documented while on Apixaban. These failures were confirmed by facility leadership and were not in accordance with facility policy.
A resident with multiple medical conditions experienced an unwitnessed fall while standing from a wheelchair. The required post-fall assessment and care plan update were not entered into the EHR until 36 hours after the incident, despite facility policy mandating same-day updates. Both the DON and DSD confirmed the care plan was not revised promptly to reflect the fall and necessary interventions.
Nursing staff did not document a change of condition after a fall in a timely manner for a resident with multiple health issues, administered blood pressure medication outside of physician-ordered parameters for another resident with hypertension and chronic kidney disease, and left the call light out of reach for a resident with legal blindness and muscle weakness, all in violation of facility policies.
A controlled drug record for Lorazepam was found to be inaccurate when a nurse documented 22 mL remaining, but only 21 mL was present in the medication bottle for a resident. The nurse confirmed the discrepancy, indicating the count sheet did not match the actual amount, in violation of facility policy requiring accurate verification and documentation of controlled substances.
Expired medications, including Trazodone, DuoNeb, Hydrocortisone Suppository, and Bisacodyl Suppository, were found in a medication cart and had not been discarded as required by facility policy. Additionally, vaccines such as Prevnar 20 were stored in a refrigerator whose temperature was only checked once daily, contrary to the policy requiring twice-daily monitoring. The ADON confirmed both the presence of expired medications and the inadequate temperature monitoring.
Staff did not consistently monitor or document temperature and humidity in the dry food storage room, only recording data when the room felt unusually warm or the temperature exceeded 80°F, contrary to facility policy requiring frequent checks and documentation.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS incorrectly noted the absence of an indwelling catheter despite physician orders indicating otherwise. Another resident's MDS inaccurately reported non-use of tobacco. The MDS Coordinator, Administrator, and DON acknowledged these inaccuracies.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies between the MDS and the physician progress notes. The ADON and DOR confirmed that the MDS sections were incorrectly filled out, potentially resulting in inappropriate care.
Failure to Develop Care Plan for Resident's Hematoma
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a right eye hematoma for a resident. The resident, who had a history of type 2 diabetes mellitus, required assistance with personal care and had moderate cognitive impairment. The hematoma was first observed by staff, who documented its presence and questioned the resident about its origin, but the resident was unsure how it occurred. Despite this, there was no care plan created to address the hematoma, as confirmed by a review of the resident's records and an interview with the Director of Nursing (DON). The DON acknowledged that the care plan for the hematoma was missing and should have been developed when the wound was first noted. The facility's policy requires the interdisciplinary team to create a comprehensive care plan with measurable objectives and timeframes for each resident's needs, but this was not followed in this case. The absence of a care plan for the hematoma was confirmed through observation, interviews, and record review.
Expired N95 Mask Use and Improper PPE Removal During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure that N95 masks provided for staff and visitors were not expired, as observed on multiple isolation carts at the entrances of COVID-19 designated rooms and the lobby receptionist area. Both 3M and BYD brand N95 masks were found to be past their expiration dates. Staff assigned to these rooms were observed wearing the expired N95 masks, and visitors were encouraged to use them as well. Although the Administrator referenced CDC and Public Health guidance regarding the extended use of N95 masks beyond their shelf life, it was clarified that such use was only permitted during a declared emergency, which was not in effect at the time of the observation. Additionally, a licensed nurse was observed exiting a resident's room, who was on transmission-based precautions for COVID-19, without removing personal protective equipment (PPE) as required. The nurse was seen wearing an isolation gown, mask, and face shield while preparing medication outside the resident's room, and confirmed that the PPE should have been removed before exiting. The facility's infection prevention policy also specified that PPE must be doffed and discarded, and hand hygiene performed before leaving the patient room to contain pathogens.
Failure to Implement and Document Care Plan Interventions for Fluid Monitoring and Anticoagulant Complications
Penalty
Summary
The facility failed to implement and document required interventions in the comprehensive care plans for two residents. For one resident with a gastrostomy tube, physician orders required intake and output monitoring every shift and a 24-hour tally each evening. Record reviews revealed missing documentation of intake and output on several shifts and days, and the Director of Nursing confirmed that these interventions were not completed as ordered. Facility policy required that medication and treatment records reflect administration as prescribed by the physician, which was not followed in this case. For another resident taking the anticoagulant Apixaban for NSTEMI prophylaxis, the care plan included an intervention to monitor and document for signs and symptoms of bleeding complications. However, there was no documentation of such monitoring in the clinical record. The MDS Coordinator acknowledged that staff should have entered the monitoring intervention in the resident's order summary for sign-off, and the Administrator confirmed the lack of implementation. Facility policy required monitoring for possible side effects of anticoagulant therapy, including bleeding, which was not documented for this resident.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised following a fall, as required by facility policy and procedure. A resident with a history of Type 2 Diabetes, Paroxysmal Atrial Fibrillation, anemia, and difficulty walking experienced an unwitnessed fall when attempting to stand from a wheelchair, which slid back. This was the resident's third fall in the facility. The resident reported the incident during an interview, stating that no injury was sustained. Review of the care plan and progress notes revealed that the post-fall assessment and care plan update were not entered into the electronic health record until approximately 36 hours after the fall occurred. Both the DON and DSD acknowledged that the care plan should have been updated on the day of the event, in accordance with facility policy, which requires care plans to be revised to reflect changes in interventions after a fall. The delay in updating the care plan was confirmed during interviews and record reviews.
Failure to Follow Policies for Documentation, Medication Administration, and Call Light Accessibility
Penalty
Summary
Nurses and nurse aides failed to follow facility policies and procedures in the care of three residents. For one resident with a history of diabetes, atrial fibrillation, anemia, and mobility issues, a change of condition following an unwitnessed fall was not documented in the electronic health record until 36 hours after the incident, despite facility policy requiring documentation as soon as possible after needs are met. The Director of Staff Development confirmed that the resident's needs were addressed immediately after the fall, but the required documentation was delayed. Another resident with hypertension, diabetes, and chronic kidney disease received the antihypertensive medication Hydralazine HCl on three occasions when their systolic blood pressure was below the physician-ordered hold parameter. The Director of Nursing acknowledged that staff did not follow the prescribed blood pressure parameters. Additionally, a resident with legal blindness and muscle weakness was observed with their call light out of reach, contrary to facility policy requiring the call device to be within reach before staff leave the room. These failures were observed through interviews, record reviews, and direct observation.
Inaccurate Controlled Drug Record for Lorazepam
Penalty
Summary
The facility failed to ensure the accuracy of the controlled drug record for Lorazepam, a medication prescribed to treat anxiety and classified as a controlled substance due to its potential for abuse and dependence. During a review of the controlled drug record for a resident, it was documented that there should be 22.0 mL of liquid Lorazepam remaining. However, upon direct observation of the medication bottle in the medication room refrigerator, only 21 mL was present. This discrepancy was confirmed by a licensed nurse, who acknowledged that the count sheet was incorrect and did not match the actual amount in the bottle. The facility's policy required nurses to verify and sign off on the correct count after each supply check, but this procedure was not followed, resulting in an inaccurate controlled drug record.
Expired Medications and Inadequate Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors observed that expired medications, including Trazodone, DuoNeb, Hydrocortisone Suppository, and Bisacodyl Suppository, were present and available for use in a medication cart. These expired drugs were associated with one sampled resident and two unsampled residents. The Assistant Director of Nursing (ADON) confirmed during the observation that these medications were expired and should have been discarded, as per the facility's policy, which requires all expired medications to be removed from active supply and destroyed regardless of the amount remaining. Additionally, the facility failed to monitor the temperature of the medication refrigerator twice daily as required by its policy and CDC guidelines when storing vaccines. During an observation in the medication storage room, a bottle of Prevnar 20 vaccine was found stored in the refrigerator. Review of the refrigerator temperature log revealed that temperatures were only checked once daily, a fact confirmed by the ADON. The policy specifies that refrigerator temperatures should be checked at least twice a day, but this was not being followed.
Failure to Monitor and Document Dry Food Storage Conditions
Penalty
Summary
The facility failed to properly monitor and document temperature and humidity levels in the dry food storage room. During an observation with the Dietary Supervisor, it was noted that although an analog thermometer with hygrometer was present, staff only created a log when the temperature felt warmer than normal or exceeded 80°F, rather than maintaining regular documentation. Both the Administrator and Dietary Supervisor acknowledged that readings should be consistently monitored and logged. Review of the facility's policy confirmed that temperature checks should be frequent, with recommended storage temperatures between 50°F and 85°F.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. Resident #15 was admitted with diagnoses including urinary calculus, obstructive and reflux uropathy, and benign prostatic hyperplasia. The admission MDS indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2 and incorrectly noted that the resident did not have an indwelling catheter. However, physician orders from the day after admission included an order for an indwelling catheter due to benign prostatic hyperplasia with obstructive uropathy. The MDS Coordinator confirmed the inaccuracy during an interview. Similarly, Resident #18, admitted with a need for assistance with personal care, had an annual MDS indicating moderate cognitive impairment with a BIMS score of 12 and incorrectly noted that the resident did not use tobacco. The MDS Coordinator acknowledged this inaccuracy as well. Both the Administrator and the Director of Nursing confirmed that the MDS should be accurate, highlighting the facility's failure to ensure precise resident assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received accurate assessments using the Minimum Data Set (MDS). For Resident 1, the MDS did not accurately reflect the resident's major surgery, functional range of motion (ROM) impairments, and use of a wheelchair. The discrepancies were noted between the MDS and the physician progress notes (PPN) and progress notes (PN), which indicated major surgery, impaired ROM, and the use of a wheelchair. The Assistant Director of Nursing (ADON) confirmed these inconsistencies during a review of the records, acknowledging that the MDS sections were incorrectly filled out. For Resident 2, the MDS also contained conflicting information regarding the resident's functional ROM and use of a wheelchair. The PPN indicated that Resident 2 had a history of right leg amputation and left great toe amputation, and was wheelchair-bound. However, the MDS did not reflect these conditions accurately. The ADON and the Director of Rehabilitation (DOR) confirmed that the MDS sections did not match the PPN and contained conflicting information. The discrepancies in the MDS assessments for both residents were identified during a concurrent interview and record review with the ADON and DOR. The ADON acknowledged that the MDS sections were not accurately completed, which could lead to inappropriate care for the residents. The DOR stated that their assessment was limited to the time during therapy, indicating a lack of comprehensive assessment for the MDS entries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oxnard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oxnard Manor Healthcare Center | 0.7 mi | ★★★★★ | 13 | 0 |
| Maywood Acres Healthcare | 2.7 mi | ★★★★★ | 18 | 0 |
| Shoreline Care Center | 2.8 mi | ★★★★★ | 7 | 0 |
| Victoria Care Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Coastal View Healthcare Center | 5.1 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.