Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Glenbrook Rehabilitation & Skilled Nursing Center during CMS and state inspections, most recent first.
Failure to Follow Insulin and Medication Orders: Staff did not consistently follow physician orders for insulin, blood glucose monitoring, and pain medication for three residents with diabetes and other chronic conditions. MARs showed insulin doses given when blood glucose was below ordered parameters, missed or undocumented insulin doses, blood glucose checks not completed or recorded, and one pain medication dose not documented as given or refused. For one resident who routinely went to dialysis, staff also held daily insulin on dialysis days without physician parameters to do so.
Failure to provide smoking safety equipment and control indoor vaping exposure: A resident with dementia, hemiplegia, and nicotine dependence was observed smoking outdoors without the required smoking apron while an ACM lit cigarettes for him and continued assisting other residents. In addition, a cognitively intact resident was allowed to vape in a shared room while her roommate had cognitive impairment, and the DON stated the roommate could not consent to vaping in the room.
A CNA replaced a resident's oxygen humidifier water container and water entered the nasal cannula tubing, causing water to rise into the resident's nose and drip from the cannula. The CNA removed the cannula, placed the tubing in the oxygen concentrator bag, and turned off the oxygen before leaving to notify the nurse. When an LPN entered, the resident's O2 saturation was 88% on room air and oxygen was restarted. The resident had COPD, asthma, heart failure, Alzheimer's disease, and required oxygen therapy for chronic respiratory failure with hypoxia; facility policy and the state nurse aide curriculum did not support CNAs stopping or initiating oxygen.
Failure to identify and track resident behaviors. A resident with PTSD, schizophrenia, anxiety, and a history of trauma was observed in the hallway with foam toy guns, including firing a foam bullet at a passerby and later pointing the guns at another passerby while staff did not intervene. The care plan, staff profile, and MAR did not identify disruptive behaviors such as screaming, vaping, or loud music, and other residents reported fear and said staff would not intervene.
Refrigerated medication storage was not properly monitored when the freezer and refrigerator log was missing internal temperature entries and one thermometer read 20 degrees F instead of the required 36 to 46 degrees F range. An LPN confirmed the out-of-range reading and notified the DON. Medications stored in the unit included insulin pens, Ozempic, and Aplisol house stock, all of which had manufacturer instructions for refrigeration between 36 and 46 degrees F.
A CNA was observed by a staff member searching a resident's clothing, removing cash from the resident's wallet, and keeping the money for personal use. The incident was reported to supervisory staff, and the CNA later denied taking the money when interviewed. Facility policy prohibits staff from taking or borrowing money from residents, classifying such actions as abuse.
A resident experienced difficulty obtaining necessary catheters for self-catheterization, leading her to reuse them after cleaning with bleach or vinegar. Despite the facility's awareness, there were no documented orders or assessments for her self-catheterization needs. The resident's grievances about supply issues were not adequately resolved, and the facility lacked a policy on safe catheter use.
A facility failed to ensure proper dialysis care and communication for a resident with end-stage kidney disease, leading to incomplete documentation and lack of communication with the dialysis center. The resident's care plan included monitoring for fluid overload, but the facility did not consistently document pre and post-dialysis weights or review return paperwork. The resident was later hospitalized due to fluid overload, highlighting the deficiency in care and communication.
A resident developed multiple pressure injuries due to the facility's failure to provide effective pressure ulcer care and prevention. Despite changes in mobility and positioning, the care plan was not revised, and pressure risk was not reassessed. The resident's refusals of wound care were not documented or addressed, and wound care was often not administered as ordered. The facility did not notify the resident's POA of new wounds, contributing to the resident's condition worsening and subsequent hospitalization.
Failure to Follow Insulin and Medication Orders
Penalty
Summary
The facility failed to ensure staff followed physician orders for insulin administration and blood glucose monitoring for three residents with diabetes and related comorbidities. Resident B had type 2 diabetes, atherosclerosis of the left leg, and a right below-the-knee amputation, with a BIMS score of 14. Physician orders required Humalog or Lispro insulin with meals only when blood glucose was 150 or higher, along with blood glucose checks before meals and at bedtime. The MAR showed insulin was given on some occasions when the blood glucose was below 150, and other ordered doses were not documented as given. The record also showed a Lantus dose ordered at bedtime was not documented as given on one date, and there was no documentation explaining missing doses or documenting administration without an order. Resident C had type 2 diabetes with diabetic polyneuropathy, peripheral vascular disease, congestive heart failure, atherosclerotic heart disease, and chronic kidney disease. Orders required blood glucose checks three times daily, 3 units of Lispro if blood glucose was above 200, 42 units of Lantus at bedtime, and hydrocodone-acetaminophen four times daily. The MAR showed Lantus was not documented as given or refused on some dates, blood glucose was not recorded on one date, Lispro was not documented as given for blood glucose readings of 272 and 255, and one Lantus dose was given between 7:00 PM and 10:00 PM without a recorded blood glucose measurement. Hydrocodone-acetaminophen administration or refusal was also not documented on one date. Resident D had type 2 diabetes with diabetic peripheral angiopathy with gangrene, chronic kidney disease, and a right below-the-knee amputation, and routinely left the facility for dialysis on Mondays, Wednesdays, and Fridays. Orders required blood glucose checks four times daily and 18 units of insulin glargine once daily, with no parameters to hold insulin or to hold on dialysis days. The MAR showed several blood glucose checks were not documented as completed or refused, and the 18-unit insulin dose was repeatedly held by staff for low or normal glucose values, for dialysis, or when the resident was leaving for a procedure, despite no physician parameters to hold the medication. Staff also routinely did not give the insulin on dialysis days except one occasion, and an LPN stated that documentation on the MAR was required and that medications were to be administered as ordered.
Failure to Provide Smoking Safety Equipment and Control Indoor Vaping Exposure
Penalty
Summary
The facility failed to ensure protective smoking equipment was provided for a resident who was identified as needing a smoking apron and supervision while smoking. Resident 40 had diagnoses including vascular dementia with behavioral disturbance, hemiplegia and hemiparesis following a cerebrovascular disease affecting the left dominant side, diabetes mellitus with diabetic neuropathy, and nicotine dependence. His annual MDS showed a BIMS score of 13, and his smoking assessment noted careless smoking with a potential to drop his cigarette and indicated he should have a smoking apron. His care plan also directed that he be provided a smoking apron and supervised while smoking. During observation, Resident 40 was seen smoking outdoors without a smoking apron. The ACM lit a cigarette for him and then assisted other residents in the smoking area while his back was turned to Resident 40. When the Administrator entered the smoking area and asked another staff member to get an apron for Resident 40, Resident 40 stated he was not going to wear it. No additional conversation about the refusal or smoking risks occurred at that time, and the Administrator returned to the building. Resident 40 then requested another cigarette, which the ACM gave and lit, and the ACM observed him until he finished smoking and then assisted him back to the building. The facility also allowed electronic cigarette use in a resident room where another resident was present. Resident 13, who had diagnoses including anxiety disorder and nicotine dependence and a BIMS score of 15, stated she kept her vaping supplies herself and was allowed to vape in her room or outside during assigned smoking times. She reported that her roommate, Resident 17, was present when she vaped. Resident 17 had diagnoses including anxiety disorder, bipolar disorder, and psychotic disorder, and her quarterly MDS showed a BIMS score of 7 with disorganized thinking and difficulty focusing in conversation. The DON stated Resident 17, as a cognitively impaired resident, was unable to give consent to another resident vaping in the room, while the Administrator stated the facility followed city ordinance exceptions for indoor electronic cigarette use.
Improper handling of oxygen humidifier and tubing
Penalty
Summary
The facility failed to ensure respiratory care was consistent with professional standards of practice for one resident who had diagnoses including COPD, asthma, anemia, heart failure, and Alzheimer's disease. The resident's quarterly MDS indicated a BIMS score of 6 and that oxygen therapy was required for chronic respiratory failure with hypoxia. Physician orders directed oxygen at 3 liters per minute, later updated to 2 liters per minute with the ability to increase to 4 liters per minute to keep oxygen saturation above 90%. During observation, a CNA replaced the water container for the resident's oxygen humidifier and water entered the nasal cannula tubing. When the container was connected to the oxygen, water rose up the cannula to the resident's nose and dripped large droplets. The CNA removed the nasal cannula, placed the tubing in the bag attached to the oxygen concentrator, turned off the oxygen flow, and left to notify the nurse. When the LPN entered the room, the resident's oxygen saturation was 88% on room air, and a new nasal cannula was applied with oxygen restarted. The LPN stated CNAs are allowed to change the oxygen water humidifier and said she had been told the resident was out of water, not that the resident was without oxygen. Facility policy stated the humidifier was to be attached, the oxygen flow adjusted, then the tubing attached and the nasal cannula fitted to the resident. The state nurse aide curriculum stated nursing assistants never stop, adjust, or initiate the use of oxygen, and the CNA procedure for nasal cannula care did not indicate the CNA could remove or turn off the oxygen.
Failure to Identify and Track Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including anxiety, insomnia, pain disorder, PTSD, and schizophrenia had behaviors identified, tracked, and addressed with interventions. The resident’s care plan documented a history of substance use disorder, anxiety risk, PTSD related to poor family support, childhood abuse, surviving being shot during an attempted murder, special education services, and incarceration, but it did not identify disruptive behaviors such as screaming, blaring loud music, vaping in the hallway, or attempting to shoot people with foam guns. The resident’s profile for direct care staff also did not include these behaviors or any interventions to address them, and the MAR did not contain any tracking or interventions related to behavior. Surveyors observed the resident in the hallway with scarves covering the face and head and holding two foam toy guns. On one occasion, the resident fired a foam bullet that struck a passerby and then quickly propelled the wheelchair away; on another, the resident stood briefly and pointed the toy guns at a passerby while two staff members were present but did not intervene. Other residents reported being afraid of the resident, said the resident did whatever they wanted and staff would not intervene, and described vaping, screaming in the hallways, and blaring loud music. The Administrator stated the resident had been asked to put away the foam guns on admission and not to vape in the hallways, and the Social Services Director stated there was no identification and no tracking unless it was on the MAR.
Refrigerated Medication Temperatures Not Properly Monitored
Penalty
Summary
The facility failed to ensure refrigerated medications were monitored in accordance with manufacturer guidelines in one of one refrigerated storage units reviewed. During an observation in the medication storage room, the freezer and refrigerator log was missing internal temperature measurements for 9/17/25, 9/18/25, and 9/19/25. The last recorded refrigerator temperature on 9/16/25 was 37 degrees Fahrenheit, while the thermometer inside the refrigerator measured 20 degrees Fahrenheit and felt cold. An LPN observed the thermometer and confirmed it read 20 degrees, and also stated the thermometer should be exchanged and that the DON was notified the refrigerator temperatures were out of range. Medications stored in the refrigerator included an Ozempic pen and four Degludec insulin pens for Resident 4, a Rezvoglar pen for Resident 50, a Lispro insulin pen for Resident 23, and a vial of Aplisol tuberculin labeled house stock. Manufacturer instructions reviewed indicated Degludec, Ozempic, Rezvoglar, Lispro, and Aplisol should be refrigerated between 36 and 46 degrees Fahrenheit. A later observation showed a different thermometer reading 40 degrees Fahrenheit. The facility policy dated 11/2024 stated medications would be stored between 36 and 46 degrees Fahrenheit and that the refrigerator should be monitored at least once daily.
Misappropriation of Resident Property by CNA
Penalty
Summary
A Certified Nurse Aide (CNA) was observed by a Housekeeping Aide searching the pockets of a resident's clothing, locating the resident's wallet, and removing $27 in cash. The Housekeeping Aide reported that the CNA questioned whether there were cameras in the laundry room and then stated she could use the money for gas before placing the cash in her own pocket. The incident was reported to the Housekeeping Supervisor, who documented the allegation and the sequence of events. The CNA was later interviewed by the Administrator and Housekeeping Supervisor, during which she admitted to searching the resident's clothing but denied taking any money. The facility's policy, titled "Abuse: Zero Tolerance," explicitly prohibits taking or borrowing money from residents, classifying such actions as a form of abuse. Staff interviews confirmed that personal items, including money, should not be taken from residents and that any observed theft should be reported to supervisory staff. The incident involved a resident who no longer resided in the facility at the time of the review. The deficiency was identified during a complaint investigation.
Failure to Ensure Safe Self-Catheterization Practices
Penalty
Summary
The facility failed to ensure the safety of intermittent self-catheterization for a resident, identified as Resident 31, who had difficulty obtaining necessary supplies. Resident 31 reported challenges in acquiring catheters, leading her to reuse them multiple times a day after cleaning them with bleach or vinegar. This practice had been ongoing since March 2024, following the removal of her indwelling Foley catheter. Despite the facility's awareness of her situation, there were no documented orders for intermittent self-catheterization, nor was there any teaching or assessment of her ability to perform the procedure safely. Resident 31's medical records revealed a lack of documentation regarding her self-catheterization needs and practices. Her Minimum Data Set (MDS) assessment did not reflect her use of intermittent self-catheterization, and there were no physician orders or care plans addressing this need. Additionally, grievances filed by Resident 31 highlighted her ongoing issues with obtaining the correct size of briefs and catheters, yet these concerns were not adequately resolved, as evidenced by the absence of follow-up orders or notes in her medical record. Interviews with the Director of Nursing (DON) confirmed that the facility was aware of Resident 31's self-catheterization since the discontinuation of her indwelling catheter. However, the DON was unaware of the resident's unsafe practice of cleaning and reusing catheters. The facility lacked a policy on intermittent self-catheterization, reusing catheters, or cleaning them between uses, further contributing to the deficiency in care provided to Resident 31.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper assessments and maintain consistent communication with the dialysis team for a resident with end-stage kidney disease, diabetes, and heart failure. The resident required dialysis treatments three times a week, with specific physician orders to document their weight and blood pressure upon return from dialysis. However, the facility did not consistently document the resident's pre and post-dialysis weights, and there were multiple instances where the Dialysis Center Communication Tool was incomplete or missing. Additionally, the facility did not review return paperwork from the dialysis center on several occasions. The resident's care plan highlighted the risk of fluid overload, bleeding, and infection due to hemodialysis, with interventions to monitor fluid intake, blood pressure, and symptoms of excess fluid volume. Despite these interventions, the facility's records showed gaps in documentation and communication with the dialysis center. On several dates, there were no progress notes or assessments recorded, and the facility failed to obtain necessary documentation from the dialysis center. The deficiency was further highlighted when the resident experienced a decline in their condition, reporting a productive cough and decreased oxygen levels, leading to their transfer to the emergency department. The resident was later admitted to the hospital due to fluid overload and was intubated. The Regional Nurse Consultant confirmed that pre and post-dialysis assessments should have been conducted, and the facility was responsible for maintaining communication with the dialysis center. The facility's policy emphasized ongoing assessment and monitoring for complications, which was not adhered to in this case.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide effective pressure ulcer care and prevention for a resident, resulting in the development and deterioration of multiple pressure injuries. The resident, who was initially admitted without pressure-related skin impairments, developed a stage two pressure injury on the left buttock, which worsened to an unstageable pressure injury with infection requiring debridement. Additional pressure injuries developed on the coccyx, right buttock, and right hip. The resident's medical history included hemiplegia, memory deficits, COPD, dementia, and chronic smoking. The facility did not revise the care plan or reassess the resident's pressure risk after changes in mobility and positioning were noted. Despite obtaining a physician order for a Broda Chair to prevent slouching, there was no documentation of monitoring for pressure injury risk or interventions initiated. The resident's refusal of wound care was not adequately documented or addressed, and there were no attempts to reapproach the resident or adjust care times according to his preferences. The facility also failed to notify the resident's POA of new wounds and did not document the resident's refusals or the consequences of such refusals. Throughout the period, there were multiple instances where wound care was not administered as ordered, and the facility did not document attempts to complete treatments at different times. The resident's care plan did not address noncompliance or provide interventions to prevent further pressure ulcer development. The facility's lack of documentation and failure to implement timely interventions contributed to the resident's condition worsening, leading to hospitalization for treatment of the pressure ulcers.
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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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit City Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 9 | 0 |
| University Park Rehabilitation And Healthcare | 0.9 mi | ★★★★★ | 4 | 0 |
| Saint Anne Home | 1.3 mi | ★★★★★ | 4 | 0 |
| Life Care Center Of Fort Wayne | 1.6 mi | ★★★★★ | 9 | 0 |
| Canterbury Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.