Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glenwood Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Improper Food Storage and Wet Dish Stacking: Surveyors found uncovered cake, unlabeled meat mixture, an unidentifiable food item, and opened hamburger and chicken patties in the refrigerator and freezer without required labels or dates. Staff and leadership stated opened items must be labeled and dated, but a Dietary Aide could not identify one bagged item. Surveyors also observed cups, trays, and steam table pans stacked while still wet, and staff acknowledged dishes should be air dried before being put away.
Accessible bathroom sink water in multiple resident rooms measured above the facility’s expected safe range, with readings of 122.8 to 124.7 degrees F. Residents affected included individuals with dementia, Parkinson’s disease, diabetes with neuropathy, reduced mobility, and dependence on staff for bathing and other ADLs. Staff and leadership stated water should be kept between 105 and 120 degrees F, but the facility had no hot water temperature monitoring policy.
Staff failed to follow EBP and hand hygiene during incontinent care for two residents, including a resident with a wound and another resident dependent on staff for total hygiene care. CNAs and an aide entered rooms without hand hygiene, did not consistently change gloves between dirty and clean tasks, and did not wear gowns for EBP when providing direct care. The facility also failed to complete TB screening timely for an RN, as the step-one TST was read outside the required 48 to 72 hour window.
Failure to Document Reapproaches After Bathing Refusals: Two residents with significant cognitive and physical impairments repeatedly refused showers, but staff did not document the refusals or any reapproaches in the progress notes. One resident with dementia and severe cognitive impairment had multiple shower refusals and was observed several times with disheveled, unwashed hair. Another resident with stroke-related deficits and severe cognitive impairment also refused multiple showers and was observed with dirty, uncombed hair. Interviews confirmed staff expected reapproaches and documentation, but these were not recorded.
Medication error rate exceeded the 5% limit after two errors were found in 25 opportunities. An LPN crushed potassium chloride ER that was ordered not to be crushed for a resident with hypokalemia, and an RN administered insulin lispro to a resident with diabetes without priming the pen as required by the order and FDA instructions.
Missed Dialysis-Day Insulin and Failure to Prime Insulin Pen: A resident with CKD, DM, and renal dialysis dependence repeatedly missed noon BG checks and sliding scale insulin on dialysis days because staff held the medications without a specific hold order, even after the NP said to give them as prescribed. In addition, an RN administered insulin lispro to the resident without priming the pen, despite the FDA insert and facility staff stating the pen should be primed before each dose.
The facility failed to maintain a complete infection prevention and control program by not ensuring Tuberculin Skin Tests (TST) were completed for the DON, AD, and Laundry E. The required TB testing documentation was missing or incomplete, and interviews revealed inconsistencies in the administration and tracking of TB tests.
The facility failed to notify and coordinate with the State-designated authority for a resident with schizophrenia, intellectual disabilities, and anxiety disorder, who had a temporary approved level two PASARR. The necessary DA-124 forms were not completed or submitted, and staff interviews revealed a lack of knowledge and responsibility regarding the PASARR process.
The facility failed to retain a PASARR level one in the medical record for a resident with significant mental health issues, including schizophrenia and psychotic disorder. Incomplete documentation and unclear staff responsibilities contributed to the deficiency.
The facility failed to provide proper pressure ulcer care for a resident by not documenting a complete assessment of a new pressure ulcer and not updating the care plan timely. The resident's new pressure ulcer was not properly documented or communicated to the necessary parties, leading to inadequate care.
The facility failed to provide appropriate respiratory care for a resident using a CPAP machine by not obtaining a physician's order or including the CPAP use in the care plan and MDS. Staff interviews confirmed the oversight, and the resident's diagnoses included COPD, heart failure, and obstructive sleep apnea.
The facility failed to document an assessment of risk versus benefits of side rail use, obtain informed consent, address side rail use in the care plan, obtain physician orders, and complete ongoing assessments for two residents. The side rails were installed by hospice without proper follow-up or documentation.
The facility failed to accurately document a resident's ostomy on the MDS, despite the resident having a colostomy and physician orders for colostomy care every shift. Multiple MDS assessments did not reflect the presence of the ostomy, and interviews with staff confirmed that it should have been documented. The facility also lacked a policy on MDS documentation.
Improper Food Storage and Wet Dish Stacking
Penalty
Summary
Food was not protected from possible contamination because staff failed to properly store and label items in the kitchen. During observation, surveyors found seven pieces of cake on small white foam plates uncovered in the refrigerator, a large zipped bag of meat mixture that was not labeled, and a small red plastic bowl containing an unidentifiable orange item. In the freezer, six hamburger patties and six chicken patties were found with packages opened, exposed to air, and with no date or label. During interview, a Dietary Aide could not identify the unlabeled bag and thought it may have been chicken alfredo or tuna noodle casserole but was unsure. Facility staff, including the Dietary Manager, DON, and Administrator, stated that opened items should be labeled and dated before storage and that all items should be identifiable. The facility also failed to ensure dishes were properly dried before being stacked or stored. The facility did not have a policy regarding dish washing and drying, and surveyors observed multiple items stacked while still wet, including clear drinking cups, plastic trays, and steam table pans with no air flow. On a later observation, additional plastic trays and drinking cups were again found stacked wet with no air flow. A staff member said he/she did not realize dishes had to be air dried, while other staff stated dishes should be air dried completely before being put away and that dishes should not be stacked wet. The DON and Administrator also acknowledged that dishes should be air dried and not stacked wet.
Accessible Hot Water Exceeded Safe Temperature Range
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards when accessible hot water in resident bathrooms measured above 120 degrees Fahrenheit in multiple rooms. Survey observations on the evening of 04/29/26 found bathroom sink water temperatures of 124.1 degrees F and 124.7 degrees F in the rooms of four residents, and another observation found sink water temperatures of 122.8 degrees F in the rooms of four additional residents. The facility did not have a policy for hot water temperature monitoring, and the Maintenance Director, Dietary Manager, DON, and Administrator each described an expected safe range of 105 to 120 degrees F. The affected residents had diagnoses and care needs that included dementia, altered mental status, Parkinson's disease, Alzheimer's disease, vascular dementia, Huntington's disease, diabetes with neuropathy, generalized weakness, reduced mobility, and need for assistance with bathing, toileting, transfers, and personal hygiene. Several residents were documented as cognitively impaired or dependent on staff for bathing and other activities of daily living, while others were described as cognitively intact but still required varying levels of assistance. The observations showed that the hot water in the resident-accessible sinks exceeded the range staff identified as safe. The report also cited the American Burn Association information stating that hot water can cause third-degree burns at temperatures as low as 127 degrees F in one minute and 124 degrees F in three minutes, and that older adults may have thinner skin and decreased ability to feel heat. During interviews, the Maintenance Director said water temperatures in resident rooms were expected to be between 105 and 120 degrees F, the Dietary Manager said weekly monitoring was done during day shift in two rooms per hallway, the DON said staff were expected to check water temperatures at different times and shifts, and the Administrator said staff should notify maintenance and administration if water temperatures were too hot.
Infection Control and TB Screening Failures
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements during resident care. Resident #3 had diagnoses including vascular dementia with agitation, delusional disorders, chronic atrial fibrillation, and depression, and the care plan identified the resident as at risk for skin breakdown related to incontinence, dependent on staff for positioning, and having skin breakdown to the coccyx and heel. The care plan did not address the need for EBP, even though an EBP sign was posted on the resident’s door. During observation of incontinent care for Resident #3, two CNAs entered the room without performing hand hygiene and without donning gowns. The CNAs provided perineal and buttock care, changed the resident’s brief, and continued care without changing gloves or performing hand hygiene between dirty and clean tasks. One CNA later removed gloves, washed hands, put on new gloves, and wiped the resident’s face, then removed gloves and exited the room without performing hand hygiene. The other CNA removed gloves, discarded them, exited the room with trash, and did perform hand hygiene. Staff interviews stated that hand hygiene should be performed before and after resident care, gloves should be changed between dirty and clean tasks, and gowns and gloves should be worn for residents on EBP, including residents with wounds. A similar failure was observed during incontinent care for another resident who had hemiplegia and hemiparesis, cerebral infarction, major depressive disorder, convulsions, and generalized muscle weakness, and whose care plan required total assistance with hygiene and incontinence care. One aide entered the room and donned gloves without hand hygiene, another aide entered with the Hoyer lift and also did not perform hand hygiene, and both aides provided incontinent care. The aides washed the resident’s front genital area, turned the resident, cleaned the buttocks, and placed a clean brief without performing hand hygiene or changing gloves before moving on to other care and transfer activities. The facility also failed to ensure tuberculosis screening was completed according to policy and state requirements for one RN. The employee’s TB screening record showed step one was administered on hire, but the result was read five days later rather than within 48 to 72 hours, and facility staff stated the test would need to be restarted because it was not read timely.
Failure to Document Reapproaches After Bathing Refusals
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain good personal hygiene when staff did not document reapproaches after bathing refusals for two residents. The deficiency was identified through observation, interview, and record review involving 19 residents reviewed in a facility with a census of 54. The facility policy titled Activities of Daily Living stated that residents would receive care according to their individualized care plan and that staff would ensure a resident’s ability to perform ADLs did not decline unless unavoidable, but the facility did not provide a policy related to showers. One resident had diagnoses including dementia with behavioral disturbances, Alzheimer’s disease, hypertension, and dizziness, and the quarterly MDS showed severe cognitive impairment, dependence on staff for bathing, and supervision needed for dressing. The care plan stated the resident was dependent on staff for bathing, often refused bathing, and required staff to reapproach as needed. In April 2026, the resident received one shower and then repeatedly refused showers on multiple dates. Progress notes for those refusals did not document the refusals or any attempts to reapproach the resident. A later progress note documented staff escorting the resident to the shower room, the resident trying to leave, staff speaking in a soothing tone, and staff being unable to bathe the resident, but no new interventions, second attempt, or reschedule were documented. Additional bathing assessments showed another shower refusal and the progress note again lacked documentation of the refusal. Observations showed the resident’s hair appeared disheveled and unwashed on multiple occasions, with uncombed hair and an oily substance throughout the roots to the ends. During interviews, an LPN stated the resident was non-compliant with cares and that staff would need to reapproach at different times of day, while an RN stated the resident was very confused, difficult to assist with bathing, and that staff tried to reapproach and redirect but were unsure what else could be implemented. For the second resident, the face sheet showed diagnoses including stroke, brain changes, right-sided weakness/immobility, speech difficulty, arthritis, muscle wasting, swallowing difficulty, difficulty walking, cognitive communication deficit, pain, and a history of falling. The MDS showed severe cognitive impairment and dependence on staff for oral care, toileting, personal hygiene, showers/bathing, dressing, bed mobility, and transfers. The care plan stated the resident was totally dependent on staff for bathing and should receive a sponge bath when a full bath or shower could not be tolerated. The resident refused multiple showers in April 2026, but the progress notes did not document the refusals or staff reapproaches. An observation showed the resident’s hair was uncombed and dirty. Staff interviews stated residents should be reapproached later in the day, refusals should be documented in progress notes, and family should be notified if bathing refusals continued for an extended period.
Medication Error Rate Exceeded Limit
Penalty
Summary
The facility failed to ensure medication error rates did not exceed five percent after surveyors identified two medication errors out of 25 opportunities, resulting in an 8% error rate and affecting two residents. The facility procedure titled Medication Pass Tips required staff to verify the resident’s identity, check each drug against the eMAR, confirm whether a medication could be crushed before preparing it, verify the route, administer medications as ordered, and prime insulin pens with two units before each use. For one resident with hypokalemia, the physician order directed staff to give potassium chloride 20 meq ER by mouth twice daily and not crush it, with an option to dissolve it in water if needed. During observation, an LPN prepared the evening medications, placed the potassium chloride tablet with the other medications in a plastic sleeve, crushed the medications, mixed them with applesauce, and administered them to the resident. Multiple staff members, including an RN, CMTs, the DON, and the Administrator, stated that delayed release, extended-release, and enteric-coated medications should not be crushed and that potassium chloride should not be crushed. For another resident with diabetes, the physician order for insulin lispro required sliding-scale dosing and the FDA package insert stated the pen should be primed with two units before each injection. During observation, an RN checked the resident’s blood glucose at 371 mg/dL, prepared 10 units of insulin lispro, and administered the insulin without priming the pen. The RN later stated insulin pens should be primed with two units before each administration, and other staff, including the MDS Nurse, Social Services Director/Infection Preventionist, DON, and Administrator, stated that physician orders should be followed and insulin pens should be primed with two units with every administration.
Missed Dialysis-Day Insulin and Failure to Prime Insulin Pen
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when a resident with chronic kidney disease, diabetes, and dependence on renal dialysis repeatedly did not receive noon blood glucose checks and sliding scale insulin on dialysis days. The resident’s care plan directed staff to monitor blood glucose as ordered and provide insulin as ordered, and the physician order sheet included dialysis every Monday, Wednesday, and Friday along with insulin lispro per sliding scale. The medication administration record showed multiple dates in April 2026 when the noon blood sugar check and insulin dose were not administered, and progress notes repeatedly documented that noon insulin was held because the resident was attending dialysis. On 04/24/26, staff documented that the resident’s noon medications were held due to dialysis, and later that morning staff spoke with the NP about whether medications were to be held before dialysis treatments. The NP advised that the medications were to be administered as prescribed. Despite this, the MAR still showed missed noon blood sugar checks and insulin doses on subsequent dialysis days, and one progress note contained no documentation regarding administration or withholding of the medications. Interviews with RN A, CMTs, the IP/SSD, the DON, and the Administrator confirmed that physician orders should be followed, that medications should be given unless there was a specific hold order in the POS, and that missed medication administrations should be documented and the physician notified. The facility also failed to prime an insulin pen before administration for the same resident. During observation, the resident’s blood glucose was 371 mg/dL, requiring 10 units of insulin lispro per order. RN A obtained the insulin pen, attached the needle, dialed the dose to 10 units, and administered the insulin without priming the needle. The FDA package insert for insulin lispro states that the pen should be primed before each injection, and RN A, the MDS Nurse, the IP/SSD, the DON, and the Administrator all stated that insulin pens should be primed with two units before each administration to ensure the correct dosage.
Failure to Maintain Complete Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not ensuring Tuberculin Skin Tests (TST) were completed in accordance with tuberculosis (TB) testing requirements for long-term care employees. Specifically, the Director of Nursing (DON), Activity Director (AD), and Laundry E did not have the required TB testing documentation. The DON had an annual TB test from another facility but lacked documentation of a second step test or evidence of a Mantoux PPD test in the past two years. The AD and Laundry E had no documentation of step 1 or step 2 TB tests administered. The Business Office Manager (BOM) confirmed the absence of these records during interviews. The facility's policy and state regulations require a two-step PPD test within one month prior to employment, with documentation maintained for each employee's tuberculin status. Interviews with the BOM, DON, and Administrator revealed inconsistencies in the administration and tracking of TB tests. The social worker, who also serves as the infection control nurse, was responsible for tracking staff TB testing but was out of the office at the time. The DON and Administrator described the process for TB testing but acknowledged that it was not consistently followed, leading to the identified deficiencies.
Failure to Coordinate PASARR Requirements for Resident with Mental Illness
Penalty
Summary
The facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for a resident who had a temporary approved level two Preadmission Screening and Resident Review (PASARR). The resident, who was admitted with diagnoses including schizophrenia, intellectual disabilities, and anxiety disorder, had a Level 1 PASARR indicating no signs of major mental disorder but noted severe developmental disorder and cognitive delay. The resident's PASARR evaluation recommended short-term nursing facility placement with a transition to community living and required a new DA-124 form by a specified date, which was not completed by the facility. The resident's Conditional Temporary Approval letter from the Department of Health and Senior Services indicated the need for a new DA-124 form by a specific date, which the facility failed to submit. Interviews with facility staff, including the Business Office Manager, Director of Nursing, and Licensed Practical Nurse, revealed a lack of knowledge and responsibility regarding the PASARR process and the completion of the DA-124 forms. The Administrator confirmed that the DA-124 should be completed by the social worker and sent to the Medical Director for signature, but this process was not followed. The deficiency was identified during a review of the resident's records, which showed no additional DA-124 or Level 1 forms were submitted. The Administrator admitted to being unaware of the temporary approval status and the requirement for a new DA-124 form. The failure to complete and submit the necessary forms resulted in non-compliance with PASARR requirements, as the facility did not ensure proper coordination with the State-designated authority for the resident's mental health needs.
Failure to Retain PASARR Level One Documentation
Penalty
Summary
The facility failed to ensure a PASARR (Preadmission Screening and Resident Review) level one was retained in the medical record and accessible for one resident. The resident, who had diagnoses including schizophrenia, anxiety disorder, psychotic disorder with delusions, and encephalopathy, was admitted on an unspecified date. The resident's care plan indicated a history of significant mental health issues, including hollering, cursing, and talking to voices, as well as experiencing trauma. A review of the resident's electronic submission for the Level One Nursing Facility Pre-Admission Screening showed incomplete documentation, including an unsigned physician's authorization and an incomplete level of care determination by the Division of Regulation and Licensure (DRL) Central Office Medical Review Unit (COMRU). No additional screening forms or Level 1 forms were found in the resident's record, and an email exchange with Missouri COMRU confirmed that a new application was needed as the previous Level 2 was outdated. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. The Business Office Manager, who was the previous social worker, described a process where the Director of Nursing (DON) completed the medical information on the DA-124 form, which was then sent to the state's COMRU. However, the current DON and Licensed Practical Nurse (LPN) indicated that the social worker was responsible for the PASARR process. The social worker was unavailable for an interview, and the Administrator confirmed that the facility did not have a record showing submission, completion, and level of care determination for the resident. Additionally, the facility did not provide a policy regarding PASARR requirements.
Failure to Document and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for one resident. Staff did not document a complete assessment of a new pressure ulcer and failed to update the care plan timely regarding the skin breakdown and intervention changes. The resident, who had a history of skin breakdown and was at risk for pressure ulcers due to poor nutrition and prolonged time in bed or wheelchair, developed a new pressure ulcer that was not properly documented or communicated to the necessary parties. The resident's Braden Scale Assessment indicated a mild risk for pressure ulcer development, but no new interventions were noted. The resident's care plan, revised in February, did not reflect the new pressure ulcer that was observed in April. Staff failed to document the exact location, measurements, wound bed assessment, peri-wound condition, exudate, pain, or wound approximation. Additionally, there was no documentation of notification to the family, physician, or DON about the new wound. Interviews with staff revealed that the resident had an open area on the coccyx that had worsened due to bowel issues. The DON admitted that measurements were not taken immediately upon discovering the wound and that the initial treatment was calazime cream. The facility's policy required detailed documentation and timely updates to the care plan, which were not followed in this case. The lack of proper documentation and communication led to inadequate pressure ulcer care for the resident.
Failure to Document CPAP Use and Obtain Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with standards of practice for a resident using a CPAP machine. The resident, who had diagnoses including COPD, heart failure, shortness of breath, obstructive sleep apnea, and hypoxemia, did not have a physician's order for the CPAP machine documented. Additionally, the use of the CPAP machine was not included in the resident's care plan or the Minimum Data Set (MDS). Observations confirmed the presence of the CPAP machine on the resident's nightstand, and interviews with staff revealed that the machine was used at night, but no formal orders or care plan documentation existed for its use. Interviews with the CNA, LPN, DON, and QA Nurse indicated that the CPAP machine should have had a physician's order and should have been included in the care plan. The admitting nurse or staff were responsible for obtaining these orders, but this was not done. The QA Nurse confirmed that the CPAP should be listed on the MDS and included in the care plan, but these steps were not taken, leading to the deficiency in providing appropriate respiratory care for the resident.
Failure to Document and Assess Side Rail Use
Penalty
Summary
The facility failed to document an assessment of risk versus benefits of side rail use for one resident and failed to obtain informed consent for the use of side rails prior to installation. Additionally, the facility did not address the use of side rails in the care plan, did not obtain physician orders for the use of side rails, and did not obtain gap measurements for the risk of entrapment. The facility also failed to complete ongoing assessments to ensure the side rails were secure and appropriate for use for two residents. The facility census was 36. Resident #1, who had diagnoses including major depressive disorder, malignant neoplasm of the esophagus, type two diabetes, and chronic obstructive pulmonary disease, was observed with half side rails on both sides of the bed in the upright position. The resident's care plan did not address the use of side rails, and there was no physician's order, side rail assessment, gap measurements, or informed consent documented in the resident's medical record. Interviews with facility staff revealed that the side rails were installed by hospice without proper follow-up or documentation. Resident #20, who had diagnoses including malignant neoplasm of the rectosigmoid junction, chronic kidney disease, type two diabetes, and high blood pressure, was also observed with half side rails on both sides of the bed in the upright position. The resident's care plan did not address the use of side rails, and there was no physician's order, gap measurements, or informed consent documented in the resident's medical record. Interviews with facility staff indicated that the side rails were installed by hospice, and the family requested them to stay in place without proper documentation or follow-up assessments.
Failure to Accurately Document Ostomy on MDS
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Sets (MDS) for a resident with an ostomy. The resident, who had a colostomy, was admitted with a diagnosis that included colostomy status and had physician orders for colostomy care every shift. Despite this, the resident's quarterly and annual MDS assessments repeatedly failed to document the presence of the ostomy under the bladder and bowel appliance care area. This discrepancy was observed in multiple MDS assessments over a period of time, even though the resident's care plan clearly indicated the need for frequent monitoring and care of the colostomy. Interviews with the Director of Nursing (DON), a Licensed Practical Nurse (LPN), and the Administrator confirmed that the ostomy should have been documented on the MDS. The DON and LPN both stated that the MDS should accurately reflect the resident's care needs, and the Administrator emphasized that any applicable appliance or care area should be included in the MDS. The MDS Coordinator, who was responsible for completing the MDS assessments, was unavailable for comment during the survey. The facility also lacked a policy regarding MDS documentation, contributing to the oversight.
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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 Seymour
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshfield Care Center For Rehab And Healthcare | 14.4 mi | ★★★★★ | 7 | 0 |
| Webco Manor | 15.3 mi | ★★★★★ | 4 | 0 |
| Rocky Ridge Manor | 15.7 mi | ★★★★★ | 3 | 0 |
| Heart Of The Ozarks Healthcare Center | 15.9 mi | ★★★★★ | 0 | 0 |
| Hartville Care Center | 16.1 mi | ★★★★★ | 1 | 0 |
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