Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Forest Glenn during CMS and state inspections, most recent first.
A COTA allowed a resident, previously assessed as unsafe to use a rollator, to demonstrate its use during a therapy session. Despite prior education and warnings, the resident fell while using the rollator, resulting in a hip fracture and hospitalization. The COTA did not consult with supervising therapy staff, and the use of the rollator was not part of the resident's care plan.
Two residents receiving hospice care were not accurately coded as such on their MDS assessments, despite care plans and physician orders indicating hospice services. Staff interviews confirmed these omissions were oversights and that the MDS should have reflected the residents' hospice status.
Surveyors found that staff failed to label, date, and properly store food and drink items in two nourishment room refrigerators. An open energy drink can and leftover pizza were observed without required labeling or dating, and both the DM and DON confirmed that staff were responsible for ensuring proper food storage procedures.
A resident with severe cognitive impairment and multiple medical conditions was improperly restrained by moving her bed against the wall to prevent her from getting out. This action was not recognized as a restraint, and necessary procedures such as obtaining a physician order and consent were not followed. The resident was found wedged between the bed and the wall, leading to her death. Staff interviews revealed a lack of understanding and training regarding restraint management.
A resident with severe cognitive impairment and a history of attempting to get out of bed unassisted was found wedged between her bed and the wall, leading to her death. The bed had been moved against the wall by staff to prevent her from getting out, without considering it a potential accident hazard. The staff failed to recognize the safety risk and did not implement alternative interventions for the resident's behavior.
A facility failed to recognize that positioning a bed against the wall for a cognitively impaired resident constituted a restraint and accident hazard. This led to the resident falling and becoming wedged between the bed and the wall, resulting in her death. The staff did not complete a restraint assessment or obtain necessary consents, and training records indicated a lack of specific training on restraints for new employees.
The facility failed to ensure medications were not left unattended on top of the medication cart and failed to dispose or discard out-of-date medications stored in two of five medication carts. A nurse left prepared medication cups unattended on top of the 100-hall medication cart on two separate occasions, and an observation of the middle A/B medication cart revealed improperly stored and undated medications.
The facility's QAA Committee failed to maintain procedures and monitor interventions, leading to unsecured medications in a medication cart and failure to discard out-of-date medications in 2 of 5 medication carts. Specifically, insulin medications were not discarded according to the manufacturer's instructions in one observed cart.
Failure to Prevent Accident Hazard During Therapy Session
Penalty
Summary
A deficiency occurred when a Certified Occupational Therapy Assistant (COTA) used a rollator, a four-wheeled walker with a seat, during a therapy session with a resident who had previously been assessed as unsafe to use this device. The resident, who had diagnoses including diabetes, chronic obstructive pulmonary disease, and generalized muscle weakness, had been evaluated by physical and occupational therapy, both of which determined that her safest mobility aids were a front wheel walker and a wheelchair. Despite this, the COTA allowed the resident to demonstrate how she intended to use a rollator at home, even though the resident had been educated multiple times about the safety risks associated with the rollator and had previously lost balance while using it during therapy sessions. During the therapy session, the resident stood up from the locked rollator, unlocked the brakes, and while turning to walk forward, fell against the counter and slid to the floor. The COTA had not consulted with the occupational therapist or other supervisors before allowing the resident to use the rollator, and the session was not part of the established treatment plan. The COTA stated that her intention was to show the resident the risks of using the rollator, but she did not anticipate the resident would use it as a wheelchair or that a fall would occur. The occupational therapist and Director of Rehabilitation both confirmed that the rollator was not safe for the resident and that its use was not authorized in the care plan. As a result of the fall, the resident sustained a nondisplaced left greater trochanter fracture and was sent to the emergency department for evaluation and pain management. The incident was witnessed by therapy staff, and subsequent interviews with facility staff, including the Medical Director, Director of Nursing, and Administrator, confirmed that the use of the rollator was not appropriate for the resident and that proper supervision and adherence to the care plan were not maintained during the therapy session.
Failure to Accurately Code Hospice Status on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of hospice care for two residents. For the first resident, who had diagnoses including senile degeneration of the brain, chronic diastolic heart failure, and chronic respiratory failure with hypoxia, the care plan and physician orders indicated she was receiving hospice services. However, her quarterly MDS did not reflect her hospice status. Interviews with the MDS Nurse, Director of Nursing (DON), and Administrator confirmed that this was an oversight and that the MDS should have indicated hospice care. Similarly, the second resident, diagnosed with dementia and hypertensive heart disease, was also receiving hospice services as documented in her care plan and physician orders. Despite this, her quarterly MDS did not indicate she was on hospice care. Staff interviews again confirmed that this was an oversight and that the MDS should have been coded to reflect the resident's hospice status.
Failure to Label, Date, and Properly Store Food and Drink in Nourishment Room Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to properly label, date, and discard food and drink items in two nourishment room refrigerators. In the 100-hall nourishment refrigerator, an open energy drink can with a straw and some liquid inside was found without a label or date. In the 200-hall nourishment refrigerator, two pizza boxes containing leftover pizza were also found without labels or dates. The Dietary Manager confirmed that nursing staff were responsible for labeling and dating food items before placing them in the refrigerators. The Director of Nursing and the facility Administrator both stated that staff should have labeled and dated the food items and that opened drinks should not have been stored in the refrigerator. These observations indicate that the facility did not follow its own procedures or professional standards for food storage, as required, leading to the cited deficiency.
Resident Death Due to Improper Restraint Management
Penalty
Summary
The deficiency involved a resident who was admitted with multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, anxiety, unspecified psychosis, and dementia. The resident was assessed for severe cognitive impairment and was care planned as a fall risk due to decreased range of motion and pain. Despite this, the facility staff moved the resident's bed against the wall to prevent her from getting out of bed, which was not identified as a restraint. This action was taken without completing a restraint assessment, obtaining a physician order, or obtaining consent from the responsible party. The incident occurred when the resident was found wedged between the bed and the wall after the bed was moved to prevent her from getting out. The staff failed to recognize this as a restraint, and the resident was found without a pulse or respirations, leading to her death. Interviews with various staff members revealed that they did not consider the bed against the wall as a restraint and did not follow the necessary procedures for implementing a restraint. The staff also failed to administer the prescribed medication for anxiety and restlessness, which could have potentially mitigated the resident's behaviors. The facility's failure to properly assess and manage the resident's behaviors and the inappropriate use of the bed against the wall as a restraint led to the resident's death. The staff's lack of understanding and training regarding restraint management and the necessary procedures contributed to the incident. The deficiency highlights the need for proper assessment, documentation, and adherence to policies regarding restraint use in long-term care facilities.
Resident Safety Compromised by Bed Placement
Penalty
Summary
The facility failed to keep a resident free from accident hazards by placing her bed against the wall, which restricted her ability to get out of bed safely. The resident, who had a history of severe cognitive impairment, congestive heart failure, chronic obstructive pulmonary disease, psychosis, and dementia, was known to attempt to get out of bed unassisted. On the night of the incident, the resident was experiencing extreme behaviors, including yelling and attempting to get out of bed. In response, a nurse moved the resident's bed against the wall to prevent her from getting out, not considering it a potential accident hazard. The resident was later found wedged between the bed and the wall, face down, without a pulse or respirations. Despite efforts to resuscitate her, the resident expired. Interviews with staff revealed that the bed was not in the lowest position, and there was a lack of awareness among staff about the potential safety hazard of placing the bed against the wall. The staff did not recognize that this action could create a life-threatening hazard, and there was no consideration of alternative methods to address the resident's behavior of attempting to exit the bed unsafely. The incident report and subsequent interviews highlighted that the staff did not view the bed's position as an accident hazard, and there was a general assumption that the interdisciplinary team had approved the bed's placement. The facility's investigation did not initially consider the bed's position as a contributing factor to the resident's fall and subsequent death. The lack of staff knowledge and failure to implement appropriate interventions for the resident's behavior were identified as key factors leading to the deficiency.
Failure to Recognize Bed Positioning as a Restraint Leads to Resident's Death
Penalty
Summary
The facility failed to demonstrate competency in recognizing that positioning a bed against the wall for a severely cognitively impaired resident with anxiety, agitation, and restlessness constituted a restraint and an accident hazard. Nurse #1 placed the resident's bed against the wall to prevent her from getting out, which was not identified as a restraint by the staff. This action led to the resident falling out of bed and becoming wedged between the bed and the wall, where she was found without a pulse or respirations. Cardiopulmonary resuscitation (CPR) was initiated by facility staff and continued by paramedics, but the resident expired. The deficiency was identified as Immediate Jeopardy when the resident was found in a life-threatening situation due to the bed's positioning. The facility did not complete a restraint assessment, obtain a physician order, or secure consent from the responsible party for the use of a restraint. The incident involved one of three residents reviewed for restraints, highlighting a failure in the facility's processes to ensure resident safety and proper identification of restraints and accident hazards. The facility's training records revealed that the most recent restraint training for staff occurred prior to the incident, and there was a lack of specific training on restraints for new employees. The Director of Nursing acknowledged the need for re-education and clarification on the definition of restraints and accident hazards, as the staff did not recognize the potential risks associated with the bed's positioning. The deficiency was noted to have a potential for minimal harm, but it was not considered immediate jeopardy after corrective actions were initiated.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure medications were not left unattended on top of the medication cart and failed to dispose or discard out-of-date medications stored in two of five medication carts. During a medication pass, a nurse left prepared medication cups unattended on top of the 100-hall medication cart on two separate occasions. The nurse covered the medication cups with plastic cups and left the cart to perform other tasks, leaving the medications unattended for several minutes. During these periods, two residents with cognitive loss were observed self-mobilizing around the hall near the unattended medication cart. The nurse acknowledged leaving the medications unattended and stated she was in a rush. Additionally, an observation of the middle A/B medication cart revealed a vial of multidose lidocaine hydrochloride injection 1% that was open and not dated when opened. The cart also contained vials of Ipratropium-albuterol outside of their foil packaging with no date. Interviews with nursing staff and the Director of Nursing confirmed that these medications should have been dated and stored properly, and that expired or improperly stored medications should be removed and returned to the pharmacy. The facility's procedures for checking and removing expired medications were not followed, leading to these deficiencies.
Failure to Securely Store Medications and Discard Out-of-Date Medications
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions following the 6/21/21 recertification and complaint investigation. This failure was evident in the recertification and complaint survey of 2/23/24, where the facility was cited for not securely storing medications in a locked medication cart and leaving them unattended, making them accessible to residents. Additionally, the facility failed to dispose of or discard out-of-date medications in 2 of 5 medication carts. Specifically, during the 6/21/21 survey, the facility did not discard insulin medications according to the manufacturer's instructions in one of the observed medication carts (100 hall).
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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 Garner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bellarose Nursing And Rehab | 2.8 mi | — | 0 | 0 |
| Pruitthealth-raleigh | 3.9 mi | — | 3 | 0 |
| Sunnybrook Rehabilitation Center | 5.9 mi | — | 0 | 0 |
| Capital Nursing And Rehabilitation Center | 5.9 mi | — | 0 | 0 |
| Raleigh Rehabilitation Center | 6.3 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.