Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Glenaire during CMS and state inspections, most recent first.
The facility failed to include bed rail use in the comprehensive care plans for four residents who were actively using various types of bed rails as enablers to assist with rolling in bed and moving from lying to sitting. Assessments documented that these residents were cognitively intact or severely impaired, with some having lower extremity impairments, and observations confirmed that unilateral or bilateral bed rails were in the raised position on their beds. Despite this, their most recently reviewed care plans contained no problems, goals, or interventions related to bed rails. Staff interviews, including with an RN, the DON, the MDS nurse, and the Administrator, showed that the MDS nurse was responsible for updating care plans and that leadership and the MDS nurse were unaware that the grab bars in use were considered bed rails requiring care plan inclusion.
Surveyors found that the facility failed to complete and document required bed rail assessments, informed consent, and entrapment risk evaluations for four residents using various types of bed rails. Residents with conditions such as CHF, chronic respiratory failure, anxiety disorder, and severe cognitive impairment were observed with raised bed rails that were not addressed in their care plans, and documentation lacked evidence of alternatives attempted prior to bed rail use. Staff interviews showed confusion between therapy, nursing, the DON, and the Administrator about who was responsible for bed rail risk assessments, entrapment evaluations, and consent, and leadership was unaware that the grab bars in use were considered bed rails.
The facility failed to report an allegation of misappropriation of property to law enforcement after a resident with a femur fracture reported $100 missing from a wallet. The DON documented the allegation, notified APS, and recorded that law enforcement was not contacted because the resident declined to make a police report. The investigation report repeated that law enforcement was not notified for the same reason. In subsequent interviews, the Social Worker, DON, and Administrator each confirmed they did not contact law enforcement, stating they relied on the resident’s wish not to report the incident to police.
A resident with moderate cognitive impairment signed a consent form to receive influenza and pneumococcal vaccines at admission but never received them. The MDS showed the vaccines had not been offered, and the medical record lacked documentation of vaccine administration or consent, even though the IP later produced the signed consent form. Interviews with the IP, DON, Admissions Coordinator, NP, and Administrator revealed unclear, inconsistent processes and communication gaps regarding how vaccination consents obtained at admission—especially for residents admitted between twice-yearly vaccination clinics—were communicated to clinical staff and acted upon, resulting in the resident not receiving the requested vaccinations.
Failure to Include Bed Rail Use in Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to update and include the use of bed rails in the comprehensive care plans for four residents who were using them. For each of these residents, bed rail assessments and MDS assessments documented the presence and use of bed rails as enablers to promote independence, and residents reported using the rails to assist with rolling in bed and moving from lying to sitting. Observations on multiple dates showed various types of bed rails (half-circle and rectangular, unilateral and bilateral) in the raised position on the residents’ beds. Despite this, the most recently reviewed care plans for these residents did not contain any care plan problem, goal, or interventions addressing bed rail use. Resident #1 was cognitively intact with lower extremity impairment and used a left-side half-circle bed rail to assist with rolling and sitting up, but his care plan lacked any bed rail interventions. Resident #6 was severely cognitively impaired with lower extremity impairment and used a left-side rectangular bed rail as an enabler, yet his care plan also did not address bed rails. Resident #41, cognitively intact with no extremity impairment, had bilateral rectangular bed rails raised and used them for repositioning and moving to sitting, but her care plan contained no bed rail information. Resident #49, cognitively intact with no extremity impairment, had bilateral half-circle bed rails raised and used them for rolling and sitting up, with no corresponding care plan entry. Interviews with Nurse #1, the DON, the MDS Nurse, and the Administrator revealed that the MDS Nurse was responsible for updating care plans and that facility leadership and the MDS Nurse were unaware that the “grab bars” in use were considered bed rails that needed to be included in the comprehensive care plans.
Failure to Assess, Document Consent, and Evaluate Entrapment Risk for Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required processes before implementing and using bed rails for four residents. The facility did not complete bed rail assessments that documented alternatives tried prior to bed rail use, did not assess for entrapment risk, and did not consistently obtain and document informed consent. Surveyors found that for all four residents reviewed for side rails, there were missing or incomplete assessments, absent documentation of alternatives, and no recorded entrapment risk evaluations, despite bed rails being in use. For one resident with congestive heart failure and a below-the-knee amputation, the MDS showed the resident was cognitively intact, independent with rolling in bed, and required supervision to move from lying to sitting. The care plan did not address bed rail use. A bed rail assessment signed by a nurse lacked documentation of alternatives considered and did not include an entrapment risk assessment. During observation, a half-circle bed rail was raised on the bed, and the resident reported using it to roll and sit up, was unsure if it could be lowered, and stated it had always been present. Interviews with nursing, therapy, the DON, and the Administrator revealed that therapy was believed to be responsible for assessments and entrapment evaluations, but the Therapy Manager stated she had never heard of a bed rail risk assessment and that any attempts at alternatives were only scattered in therapy notes. For a second resident with heart failure and severe cognitive impairment, the MDS indicated no upper extremity impairment, lower extremity impairment, and a need for supervision or partial/moderate assistance for bed mobility. The bed rail assessment did not document alternatives, lacked an RN signature to indicate risk/benefit education and consent, and did not include an entrapment risk assessment. The care plan did not address bed rails, yet a rectangular bed rail was observed in the raised position, and the resident reported using it to roll and sit up, also unsure if it could be lowered. Similar interview findings showed that nursing believed therapy completed assessments and entrapment evaluations, while therapy reported no formal bed rail risk assessment process and inconsistent handling of education and consent. For a third resident with chronic respiratory failure who was cognitively intact and independent with bed mobility, the care plan did not address bed rail use. A bed rail assessment signed by a nurse did not document alternatives to bed rails and did not include an entrapment risk assessment. Observations showed bilateral rectangular bed rails in the raised position while the resident was in bed and later sitting in a chair next to the bed. Staff interviews again reflected that therapy was thought to be responsible for assessments and entrapment evaluations, but the Therapy Manager denied knowledge of a formal bed rail risk assessment and stated that any alternatives tried were only reflected in scattered therapy notes. For a fourth resident with an anxiety disorder who was cognitively intact and required supervision or partial/moderate assistance for bed mobility, the care plan did not address bed rail use. The medical record contained no bed rail assessment, no consent for bed rail use, and no entrapment risk evaluation, despite bilateral half-circle bed rails being observed in the raised position. The resident reported using the bed rails to roll and sit up and stated they had been present since admission. Interviews revealed that nursing believed therapy completed assessments and that an RN would sign after consent, while the Therapy Manager believed this resident had not been assessed because the bed rails may have been present when the resident transferred from assisted living. The DON and Administrator both indicated they believed therapy completed entrapment risk evaluations and attempted alternatives, but they did not know where such documentation could be found, and the Administrator was unaware that the grab bars in use were considered bed rails.
Failure to Report Alleged Misappropriation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to law enforcement after a resident reported missing money. Resident #78, admitted with a diagnosis of fracture of an unspecified part of the left femur, told a therapist that $100 was missing from her wallet. The DON completed a 24-hour initial allegation report documenting the resident’s statement and notification of Adult Protective Services (APS), and recorded that law enforcement was not contacted because the resident declined to make a police report. The facility’s investigation report, also completed by the DON, reiterated that law enforcement was not contacted due to the resident’s refusal. In interviews, the Social Worker, DON, and Administrator each stated that they did not report the alleged misappropriation to law enforcement because the resident did not want the incident reported to police, confirming that only APS was notified and that no law enforcement report was made.
Failure to Administer Flu and Pneumonia Vaccines After Resident Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide pneumococcal and influenza vaccinations to a resident who had consented to receive them. Resident #4, admitted on an unspecified date, had a comprehensive MDS assessment indicating moderate cognitive impairment and showing that influenza and pneumococcal vaccines had not been offered. The medical record contained no documentation of vaccine administration or any consent forms indicating acceptance or refusal of these vaccinations. However, the Infection Preventionist (IP) later produced a pneumococcal and influenza vaccination consent form signed by Resident #4, dated 11/21/25, in which he consented to receiving both vaccinations. In an interview, Resident #4 recalled signing the consent form upon admission and confirmed that he wanted to receive the vaccinations. Multiple staff interviews revealed inconsistent and unclear processes for obtaining, communicating, and acting on vaccination consents, particularly for residents admitted between the facility’s twice-yearly vaccination clinics. The IP stated she was not involved in obtaining consents, administering, or tracking vaccinations beyond receiving lists from the Nurse Practitioner (NP) after clinics, and she was unsure how residents admitted between clinics were offered or administered vaccines. The DON acknowledged there was no established process to ensure such residents received vaccinations if desired and attributed Resident #4’s missed vaccinations to a communication breakdown. The Admissions Coordinator reported obtaining and uploading consents at admission but did not notify the NP or nursing staff when consents were signed and could not explain why Resident #4’s consent was missing from the medical record. The NP indicated she relied on nursing staff to provide consents before clinics and received only inconsistent notifications about new consents between clinics, and she confirmed there was no system to ensure residents admitted between clinics received vaccinations after consenting. The Administrator’s description of the expected notification process conflicted with staff reports, further demonstrating the lack of a functioning process that led to Resident #4 not receiving the consented vaccinations.
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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 Cary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Swift Creek Health Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Highfield Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 15 | 0 |
| Unc Rex Rehab & Nursing Care Center Of Apex | 5.3 mi | ★★★★★ | 0 | 0 |
| Rex Rehab & Nursing Care Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-raleigh | 6.5 mi | ★★★★★ | 3 | 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 August 2026) and official state health department websites.