Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glenwood Health And Rehabilitation during CMS and state inspections, most recent first.
Food storage and kitchen sanitation practices were deficient when multiple items in dry storage, the cooler, and freezer were found without required labels, open dates, use-by dates, or expiration dates, and some food was stored improperly. Dietary staff also had hair nets that did not fully cover hair, the DM was not wearing a beard guard, staff were unsure how to use the 3-comp sink, sanitizer was mixed and used incorrectly, steamtable temps were not documented before meal service, and emergency water boxes were stored on the floor.
A dietary staff member did not follow the pureed menu serving size for lasagna, using 1 1/2 spatulas to portion the meal instead of the specified 6 oz serving. The DON confirmed that using a spatula did not ensure the correct portion size, and that although a 6 oz scoop was available, it was not used during supper meal service.
The facility failed to prevent resident-to-resident abuse when a resident with schizoaffective disorder, bipolar type, traumatic brain injury, and a known history of aggressive behaviors escalated from yelling profanities at staff to verbally and physically assaulting another resident with Alzheimer's disease and associated psychotic and mood disturbances. While the victim was ambulating in the hallway, the aggressive resident struck him repeatedly in the head, causing a fall and head impact on the ground, after which nursing documented bruising to the victim's cheek and his inability to recall the event.
Failure to Notify Residents of Excess Personal Fund Balances: The facility did not notify six sampled residents and/or their RP when personal fund balances were within $200 of the SSI resource limit. Record review showed account balances above the $2,000 threshold, and the BOM confirmed no notifications were made. The Administrator was unaware the accounts had exceeded the limit.
A resident room had stained ceiling tiles and evidence of water dripping during heavy rain, with the resident using a trash can to catch water. The resident said he reported the issue to nursing staff, who also observed the dripping. During a walkthrough, the Maintenance Supervisor and Administrator confirmed a possible water leak and said they were unaware of it until the surveyor identified it.
A resident with an indwelling urinary catheter, urinary retention, dementia, and a stage 4 sacral pressure ulcer was repeatedly observed with catheter drainage tubing coiled in a loop and obstructing urine flow while in a wheelchair and later in bed. The MDS Coordinator confirmed the tubing position and repositioned it, and the DON confirmed direct care staff failed to ensure the tubing was not kinked or looped as ordered.
Staff failed to properly hold and monitor hot food temperatures prior to meal service, with items such as creamed corn and mechanically chopped ham with pineapple being held at insufficient temperatures and without required checks. Additionally, decayed tomatoes and oranges with visible mold were found in the walk-in refrigerator, indicating a lapse in daily inspection and removal of expired items. The Dietary Manager and Registered Dietician confirmed that food safety protocols were not consistently followed, and the DON and Administrator acknowledged the need for improved staff education and oversight.
Two residents with intact cognition who filed grievances did not receive written decision responses as required by facility policy and federal regulations. Instead, the Social Services Director provided only verbal notifications of grievance outcomes, and both the DON and Administrator were unaware of the written response requirement. Documentation for multiple grievances confirmed the absence of written responses.
The facility failed to follow its food storage and sanitation policies, resulting in several deficiencies. Observations showed that food items were not removed by discard dates, and opened items lacked labels and dates. A dented can was improperly stored, and cases of bottled water were on the floor. Additionally, food on the steam table was not maintained at the required temperatures, with several items below 135 degrees. The Dietary Manager and staff acknowledged these issues.
The facility failed to ensure a clean and safe environment, with deficiencies observed in resident rooms and shower areas. Seven rooms on the 100 hall had issues like missing tiles, baseboards, and brown water from faucets. Shower rooms were cluttered with equipment, leaving limited access for residents. The Maintenance Director was unaware of these issues, and the facility's water system was managed by the city. The Administrator expected cleanliness and proper storage, highlighting a disconnect between expectations and reality.
The facility failed to secure the medication storage room and remove expired medications. Nurses accessed the room without a key, and expired medications were found, contrary to policy. The DON confirmed the room was unlocked during the surveyor's visit.
A facility failed to submit a PASRR Level II for a resident after a new mental health diagnosis and the development of aggressive behaviors. The Social Services Director did not update the PASRR, despite the resident's diagnosis of unspecified psychosis and use of psychotropic medications. Interviews confirmed the oversight, which had the potential to impact the resident's care.
A facility failed to properly clean and store a nebulizer mask for a resident with respiratory issues, as required by their policy. The mask was found uncleaned, unbagged, and unlabeled on the bedside table, contrary to the facility's guidelines. This deficiency was confirmed through observations and staff interviews.
A facility failed to ensure dietary staff followed recipes and measured ingredients for pureed meals, affecting a resident on a pureed diet. Dietary cook BB added unmeasured milk to pureed chicken tenders, resulting in a soup-like consistency, and used milk instead of pea juices for pureed peas. The Dietary Manager confirmed the improper preparation and noted the absence of recipes for these items.
Food Storage, Labeling, and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to ensure food items in the cooler, freezer, dry storage area, and kitchen were properly labeled, dated, and within required use-by or expiration dates. During the initial kitchen tour, multiple cans of tuna in dry storage had an in-date of 03/03/2026 but no use-by date, a box of shredded wheat cereal had no date showing when it was opened, and bread products sitting on a rack in front of the walk-in cooler had no open dates or expiration dates. In the walk-in cooler, tomatoes were observed with a blackened area, mayonnaise had an open date of 3/2 but no expiration date, Italian dressing had an in-date of 02/17/2026 but no expiration date, and a black bag with a white carry-out container holding a sandwich was not labeled. Frozen vegetables in the walk-in freezer also did not have expiration dates. Staff practices observed during the survey showed additional failures in food handling and sanitation. Dietary staff were observed wearing hair nets that did not fully cover their hair, and the Dietary Manager was not wearing a beard guard despite having a beard. Staff were also observed to be confused about how to use the three-compartment sink and reported they usually washed dishes in the dishwasher but were unsure of the sink process. A cook washed a puree blender bowl, top, and blade in the three-compartment sink, placed the items in sanitizing solution for less than 10 seconds for the bowl and top, and more than one minute for the blade, while the sanitizing solution was poured directly into the sink without measurements because the sanitizer dispenser was not fully connected and was dispensing only plain water. Additional observations showed that steamtable food temperatures prior to supper service were not documented because the cook forgot to take them before meal service began. The Dietary Manager also confirmed that a spatula had been used to serve lasagna during the previous supper and there was no way to ensure residents received the correct serving size because the facility did not have a six-ounce scoop. During a storage tour, emergency water supply boxes in the conference room were observed sitting directly on the floor with other items placed on top of some of the boxes, and the Dietary Manager confirmed the water should not have been stored on the floor.
Pureed Meal Portioning Did Not Match Ordered Serving Size
Penalty
Summary
The facility failed to ensure that pureed menu serving sizes were followed for one resident who received a pureed meal, placing the resident at risk for inadequate caloric intake, unintentional weight loss, and potential medical complications related to insufficient nutrition. The supper menu for 03/07/2026 included lasagna Italian style, tossed salad with dressing, breadsticks, chocolate pudding, 2% milk, coffee/tea, and margarine, and the pureed menu specified a suggested 6 oz serving portion of lasagna. During observation at 4:26 PM, a dietary staff member used 1 1/2 spatulas to portion the lasagna for the pureed meal, scooping one full spatula and then a smaller portion on the spatula into the blender before pureeing it. The Dietary Manager later confirmed that using a spatula did not ensure the correct serving size of lasagna, stated that the facility did not have a 6 oz scoop available at first, and then demonstrated that a container with multiple scoop sizes was available and confirmed that a 6 oz scoop was present but was not used during the supper meal service.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident, contrary to its policy titled "Abuse, Neglect and Exploitation." On the date of the incident, one resident with Alzheimer's disease with late onset, psychotic disturbance, mood disturbance, and anxiety (R38) was ambulating in the hallway when another resident (R44) began yelling profanities at staff and then became aggressive toward R38. According to the facility incident report and progress notes, R44 verbally and physically assaulted R38, striking him repeatedly in the head, which caused R38 to fall and hit his head on the ground. Nursing assessment documented bruising to R38's left cheek, and R38 was unable to recall what had happened. Record review showed that R44 had been admitted with schizoaffective disorder, bipolar type, and an unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, and had a documented history of behaviors related to schizophrenia, including a prior altercation with another resident and verbal and physical aggression toward staff. On the day of the incident, R44 was attempting to get into a bathroom near the nurse station and was being redirected by nursing staff when R38 was walking up the hall, at which point R44 escalated from yelling profanities at staff to physically attacking R38. The incident demonstrates that the facility did not prevent resident-to-resident abuse, resulting in one resident being verbally and physically assaulted by another resident with a known history of aggressive behaviors.
Failure to Notify Residents of Excess Personal Fund Balances
Penalty
Summary
The facility failed to notify six of 44 sampled residents and/or their responsible parties when the residents' personal funds were within $200 of the SSI resource limit. Record review and staff interviews showed no documented evidence that notification was provided for R12, R32, R20, R34, R5, and R15 when their accounts exceeded the resource limit threshold described in the facility policy titled Residents' Personal Funds. The policy stated that residents receiving Medicaid benefits must be notified when the amount in the resident's account reaches $200 less than the SSI resource limit for one person. Record review showed current account balances of $3,248.89 for R5, $6,369.92 for R15, $2,766.49 for R12, $10,800.98 for R20, $4,193.67 for R32, and $2,421.79 for R34. The Business Office Manager, who started on February 9, 2026, stated that resident accounts should not exceed $2,000 because it would affect SSI eligibility, and confirmed she had not notified any residents regarding their account balances. She also confirmed that the March 2026 patient liability had already been deducted and that the remaining balances were the actual balances in the cited residents' accounts. The Administrator stated he was not aware that resident accounts had exceeded $2,000 and confirmed that resident accounts should not exceed the $2,000 resource limit.
Water Leak and Stained Ceiling Tiles in Resident Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment in one resident room, room [ROOM NUMBER], because the ceiling tiles had water stains and there was evidence of water dripping from the ceiling during heavy rain. On observation, the resident, R8, stated that he had placed a trash can in the room to catch water when it rained heavily and said the last time he used it was about three weeks earlier during the most recent heavy rainfall. R8 also stated that he reported the issue to nursing staff, who told him they had also observed the water dripping. During a later walkthrough, the Maintenance Supervisor and Administrator confirmed there was a possible water leak and stated they were not aware of the issue until the state surveyor brought it to their attention. The Maintenance Supervisor, who had started three weeks earlier, stated he would replace the ceiling tiles but needed to identify and address the source of the leak first.
Coiled catheter tubing obstructed urine flow
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with an indwelling urinary catheter when the urinary drainage tubing was observed coiled in a loop and obstructing urine flow. The resident, identified in the record as having urinary retention, a stage 4 sacral pressure ulcer, and dementia, had a BIMS score of 14 on the most recent MDS assessment and required catheter use. The physician order directed staff to secure the catheter tubing with a clean leg strap or securement device and keep the drainage bag below bladder level every shift. Record review also showed the resident had prior UTI diagnoses in April 2025, June 2025, and July 2025, and the care plan included catheter use to deter UTI and trauma related to urinary retention/obstructive and reflux uropathy, a stage four sacral wound, and hospice. During multiple observations, the resident’s catheter tubing was seen coiled while the resident was in a wheelchair and later while in bed, with the tubing obstructing downward urine flow. The MDS Coordinator confirmed the tubing was in a circular position and later repositioned it, and the DON reviewed photographic evidence and confirmed direct care staff failed to ensure the tubing was not coiled in a loop.
Failure to Maintain Safe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards of food service safety, as evidenced by improper hot holding of foods, lack of temperature monitoring, and failure to remove decayed foods from refrigeration. Observations revealed that creamed corn was removed from the oven and placed on a steam table well before meal service without checking its temperature, and then transferred to an oven set at only 100 degrees F for hot holding, which is below the required temperature. Mechanically chopped ham with pineapple was also held in the oven at 100 degrees F without temperature checks before or during holding. Additionally, green beans were left uncovered in a stock pot on a stove that was turned off, rather than being transferred to a proper hot holding unit at the correct temperature. Interviews with dietary staff and the Dietary Manager (DM) confirmed that food temperatures were not checked as required, and that the practice of using an oven set to 100 degrees F for hot holding was routine, despite not meeting the facility's policy or professional standards. The DM and Registered Dietician (RD) both acknowledged that hot foods should be held at a minimum of 135-140 degrees F and that the steam table should only be used shortly before meal service. The DM also stated that she expected cooks to follow recipe guidance and food safety protocols, but these were not consistently followed. Further deficiencies were observed in the facility's walk-in refrigerator, where multiple tomatoes and oranges with visible mold and discoloration were found stored in cardboard boxes. The DM stated that she checked the refrigerated storage daily but admitted to missing these spoiled items during her most recent inspection. The RD reiterated the expectation for daily checks and removal of expired items. The Director of Nursing (DON) and Administrator (ADM) both acknowledged the need for improved education and oversight regarding kitchen sanitation and safe food handling practices.
Failure to Provide Written Grievance Responses
Penalty
Summary
The facility failed to provide written grievance decision responses to two residents who had filed grievances, as required by both facility policy and federal regulations. The policy in place specified that residents or their representatives must receive a written decision at the conclusion of a grievance investigation, including details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. However, documentation for multiple grievances showed that only verbal notifications were given, and there was no evidence that written responses were provided. One resident, admitted with intact cognition, filed a grievance regarding another resident and was verbally informed of the resolution by the Social Services Director (SSD). The resident confirmed during an interview that they had not received a written response and were unaware that such documentation could be provided, expressing a desire to receive written outcomes for their grievances. Similarly, another resident with intact cognition filed several grievances, including dietary concerns and issues involving other residents. In each instance, the documentation indicated verbal notification only, with no written decision provided to the resident. Interviews with the SSD, DON, and Administrator revealed a lack of awareness regarding the requirement to provide written grievance responses. The SSD, who had been responsible for investigating and resolving grievances, stated she was not aware of the written response requirement and had only provided verbal updates. Both the DON and Administrator also indicated they were unaware of this requirement, though they expected the grievance official to follow facility policy.
Deficiencies in Food Storage and Temperature Maintenance
Penalty
Summary
The facility failed to adhere to its policies on food storage and sanitation, leading to several deficiencies. Observations revealed that food items were not removed by their discard dates, with sandwich meat remaining in the refrigerator past its discard date. Additionally, opened food items such as BBQ sauce and gravy mix were not labeled or dated, and cut onions were stored without labels or dates. The facility's dietary staff, including the Dietary Manager (DM) and dietary cook, acknowledged these oversights, indicating a lapse in following the established procedures for labeling and dating food items. Further deficiencies were noted in the storage and handling of food items. A dented can of fruit cocktail was found among other canned goods, contrary to the facility's practice of segregating dented cans. Cases of bottled water were stored directly on the floor in both the dry storage area and a kitchen closet, which is against the facility's policy of keeping food items elevated. Additionally, food temperatures on the steam table were not maintained at the required levels, with several items, including chicken tenders and puree peas, being served at temperatures below 135 degrees. The DM confirmed these temperature discrepancies, although the facility had not previously experienced issues with maintaining appropriate food temperatures.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by several deficiencies observed in the living areas and shower rooms. Specifically, seven out of fourteen rooms on the 100 hall had issues such as missing floor tiles, missing baseboards, and brown rust-colored water coming from bathroom faucets. Additionally, some rooms had slow-draining sinks and a strong urine odor. The Maintenance Director was unaware of these issues, suggesting a lack of regular inspections and maintenance. Furthermore, both shower rooms in the facility were cluttered with various items, including wheelchairs, mattresses, IV poles, and other equipment, leaving only one stall available for resident use in each room. The Maintenance Director acknowledged that these items had been stored in the shower rooms since he started working at the facility three months ago. Interviews with the Corporate Maintenance Director and the VP of Environmental Services revealed that the facility's water system was managed by the city, and there had been no reported issues with water or sewage problems. The Administrator expected the facility to be clean and in good repair, with supplies stored outside the facility, indicating a disconnect between expectations and the current state of the facility.
Medication Storage Room Security and Expired Medications
Penalty
Summary
The facility failed to ensure that the medication storage room was secure and only accessible to licensed staff, as well as to remove expired medications from the storage. Observations on two separate occasions revealed that nurses were able to enter the medication storage room without using a key, indicating that the room was not kept locked as required by the facility's policy. This was confirmed by a Registered Nurse (RN) during the time of discovery. Further observations identified expired medications stored in the floor stock medication cabinet, including two boxes of Bisacodyl suppositories, four bottles of zinc 50 mg, and four bottles of Vitamin B6 50 mg, all of which had expiration dates prior to the observation. The Director of Nursing (DON) confirmed that the drug storage room door was not locked during the surveyor's observation, which is contrary to the facility's policy that medication rooms should be locked at all times and expired medications should be properly destroyed.
Failure to Submit PASRR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a PASRR Level II for a resident after a new mental health diagnosis was added and behaviors developed. The facility's policy requires a PASRR Level II review when there is a change in diagnosis or status that may necessitate specialized services. However, the Social Services Director did not update the PASRR for the resident, who had been diagnosed with unspecified psychosis and exhibited behaviors such as physical and verbal aggression. The resident's care plan included the use of psychotropic medications and noted these behaviors, but the necessary PASRR Level II was not completed. Interviews with facility staff revealed that the Social Services Director was responsible for updating the PASRR but failed to do so, acknowledging that it "slipped through the cracks." The Director of Nursing confirmed the resident's behaviors and the need for a PASRR Level II submission. The resident was receiving behavioral health services, and care plan meetings were held with the resident's sister. Despite these measures, the lack of a PASRR Level II review had the potential to affect the appropriate level of care and services provided to the resident.
Improper Storage and Cleaning of Nebulizer Mask
Penalty
Summary
The facility failed to adhere to its policy on respiratory system management, specifically regarding the cleaning and storage of nebulizer masks. Observations revealed that a resident's nebulizer mask was left on the bedside table, uncleaned, unbagged, and unlabeled with the resident's name and room number. This was contrary to the facility's policy, which requires nebulizer masks to be rinsed, air-dried, and stored in a labeled plastic bag or in the machine if a storage shelf is available. The resident involved had been admitted with diagnoses including pleural effusion and shortness of breath, and was receiving respiratory therapy. The deficiency was confirmed through observations and interviews with the Director of Nursing and the assigned Registered Nurse, who acknowledged the responsibility of ensuring nebulizer masks are cleaned and stored properly after use. The failure to follow the established protocol for nebulizer mask maintenance was identified as a deficiency during the survey.
Improper Preparation of Pureed Meals
Penalty
Summary
The facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing pureed food, compromising the nutritive value and flavor for a resident on a pureed consistency diet. During an observation, dietary cook BB was seen preparing pureed chicken tenders by adding an unmeasured amount of milk, resulting in a soup-like consistency. To correct this, she added a packet of food thickener to achieve the proper consistency. The cook admitted to not measuring the milk and acknowledged that she sometimes measures liquids when pureeing food items. She also revealed uncertainty about the availability of recipes for pureed food items. Further observation showed dietary cook BB preparing pureed peas by adding an unmeasured amount of cooked peas and milk to the blender. The Dietary Manager confirmed that the cook did not properly puree the chicken tenders and peas, adding too much liquid to the chicken tenders and using milk instead of the juices from the cooked peas. The Dietary Manager also noted the absence of recipes for pureed chicken tenders and peas for staff to use, which contributed to the improper preparation of the pureed meals.
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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 Glenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows Park Health And Rehabilitation | 14.5 mi | ★★★★★ | 0 | 0 |
| Treutlen County Health And Rehabilitation | 14.8 mi | ★★★★★ | 3 | 0 |
| Mcrae Manor Nursing Home | 15.7 mi | ★★★★★ | 11 | 0 |
| Oaks - Bethany Skilled Nursing, The | 17.5 mi | ★★★★★ | 12 | 0 |
| Woods At Lumber City Of Journey Llc, The | 19.6 mi | ★★★★★ | 8 | 0 |
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