Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Providence Place At Glencroft during CMS and state inspections, most recent first.
Surveyors found that a medicated antifungal powder prescribed for a resident was left unattended on a television counter in the resident’s room instead of being stored in a locked treatment cart, as required by facility policy. The resident had multiple medical conditions and a care plan for pressure-ulcer risk but no assessment or provider order authorizing self-administration of medications. LPNs and the DON confirmed that the powder was an active, physician-prescribed treatment that should have been kept in the treatment cart and that no residents were approved to self-administer medications, while facility documentation showed other cognitively impaired and non-ambulatory residents on the same floor.
Staff were observed transporting uncovered drinks from the kitchen to resident rooms, contrary to facility policy and professional standards. Multiple CNAs and an LPN confirmed that drinks should be covered during delivery, but this was not consistently done, particularly at lunch. The DON stated that covering drinks is the facility's expectation to reduce contamination and spills.
A resident with bipolar disorder, anxiety, and heart failure was re-admitted and did not have an updated Level I PASARR completed, despite residing in the facility for over 30 days and having a care plan indicating consideration for Level II PASARR. Staff interviews revealed inconsistent application of PASARR requirements, and facility policy requiring timely PASARR completion was not followed.
Surveyors identified multiple infection control deficiencies, including a shower room left unsanitary with feces, failure to report a Legionella outbreak to the state agency, improper hand hygiene during meal delivery, and inadequate wound care practices for a resident with pressure ulcers. Staff interviews revealed inconsistent adherence to facility policies on cleaning, reporting, hand hygiene, and Enhanced Barrier Precautions.
Two residents experienced abuse when a nurse verbally berated a resident with dementia, and another resident with psychiatric conditions threw coffee and made verbal accusations against a cognitively intact peer. Staff and documentation confirmed both incidents, which resulted in emotional and psychological harm.
A resident with multiple complex diagnoses did not receive scheduled CBC lab tests as ordered by the physician. Review of records and interviews with LPNs and the DON revealed that lab work was not completed or documented during certain months, despite being marked as done in the MAR. The facility's policy required monitoring of physician's orders for completion, but this was not followed, resulting in missed lab services.
A resident experienced a fall resulting in a fracture, but the facility failed to update the care plan to include necessary interventions such as the use of a mechanical lift for transfers. Despite discussions among staff, the care plan was not revised after the resident's return from the hospital, contrary to the facility's policy on comprehensive care plans.
A resident with a history of falls and cognitive intactness slipped out of bed due to an improperly fitting mattress, resulting in foot fractures. Despite fall risk indicators and staff education, the facility failed to ensure the mattress fit correctly, leading to the incident. The IDT reviewed the situation post-incident.
A resident with a history of depression reported a romantic relationship with a CNA, which violated the facility's policy against staff-resident relationships. The relationship began in the shower room and included plans for marriage, causing emotional distress to the resident. The CNA was suspended and later quit, highlighting a deficiency in the facility's protection against abuse.
Unsecured Topical Medication Left Unattended in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored in locked compartments and not left unattended in a resident’s room, as required by facility policy and professional standards. Resident #10, admitted and later readmitted with diagnoses including polyneuropathy, dorsalgia, and hypertension, had a care plan addressing risk for pressure ulcer development related to immobility, obesity, and incontinence, with an intervention to notify the nurse of any new skin breakdown. The care plan did not include any goal, focus, or interventions related to self-administration of medications. An order for Nystatin external powder, a medicated antifungal treatment, was in place beginning March 24, 2026, and the MAR showed it was applied topically under the breast and to the groin on April 9, 2026, and to the breast on April 10, 2026. On April 10, 2026, at 10:54 AM, surveyors observed a container of Nystatin external powder left on the television counter in Resident #10’s room. At that time, an attempted interview with the resident was limited because the resident was sleepy. Facility documentation for the floor where the resident resided showed that 12 residents had BIMS scores under 8 and 8 residents were non-ambulatory. There was no documentation in Resident #10’s record indicating that the resident had been assessed and approved for self-administration of medication, and no physician order authorizing self-administration was present. During interviews, LPN staff acknowledged that the Nystatin powder was a medicated treatment prescribed by a physician and confirmed that it was an active order. One LPN stated that someone had probably left the Nystatin powder in the room and that it should be stored in the treatment cart, although she initially minimized the risk because most residents on the floor were alert and oriented. Another LPN confirmed that Nystatin powder is a medicated antifungal agent that should be stored in the treatment cart and stated there was no order for the resident to self-administer it. The DON described the facility’s expectations that medications and treatments be stored in treatment carts, that self-administration requires cognitive assessment and a provider order, and that no current residents were authorized to self-administer medications. The DON also acknowledged that Nystatin powder had been found on the resident’s television stand and that leaving treatments unattended in resident rooms can pose a potential risk, while noting that not all residents on the floor were alert and oriented. Facility policies on Medication Access and Storage and Self-Administration of Medications required drugs and biologicals to be stored in locked compartments and specified evaluation and documentation requirements for any resident self-administering medications.
Uncovered Drinks Transported to Resident Rooms
Penalty
Summary
Staff failed to ensure that drinks delivered to residents' rooms were covered during transport, as required by professional standards and facility policy. Multiple observations showed certified nursing assistants carrying trays with uncovered drinks down hallways and into resident rooms, with some instances involving up to eight uncovered cups of juice being distributed. Interviews with staff, including CNAs and an LPN, confirmed that drinks should have been covered during delivery, but this practice was not consistently followed, particularly during lunch service. Staff acknowledged awareness of the expectation to cover drinks and recognized the risk of contamination when this protocol was not observed. The Director of Nursing also confirmed that the facility's expectation is for drinks to be covered in the kitchen before being transported to residents. The facility's Food Safety and Sanitation policy requires adherence to all local, state, and federal standards to maintain a safe and sanitary food and nutrition service. Despite this, the observed practice did not align with policy or professional standards, as drinks were repeatedly transported uncovered from the kitchen to resident rooms.
Failure to Complete Required PASARR for Resident with Mental Health Diagnosis
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) was completed for one of three sampled residents with a diagnosis of bipolar disorder, anxiety, and heart failure. The resident was re-admitted to the facility and had a care plan indicating consideration for a Level II PASARR, with paperwork submitted for review. However, a review of the medical record revealed no evidence that a Level I PASARR had been updated or completed, despite the resident residing in the facility for over 30 days. The resident's clinical record included a diagnosis of bipolar disorder, a physician's order for Trileptal for bipolar disorder, and a BIMS score indicating moderately impaired cognition. Interviews with the Social Service Director, Social Worker, and DON revealed inconsistent understanding and application of PASARR requirements. The Social Service Director stated that PASARR reviews are conducted upon admission and as needed, but also indicated that, based on the resident's diagnosis and behavior, there was no need for a PASARR to be completed. The DON reported that PASARRs had been completed on several previous dates but did not provide evidence of a current or updated Level I PASARR for the resident. Facility policy requires completion of a Level I PASARR before or at admission and timely requests for Level II PASARR when indicated, which was not followed in this case.
Multiple Infection Control and Reporting Deficiencies Identified
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a shower room, as feces were observed in the shower stall next to the chair and near the drain. Certified Nurse Assistants acknowledged the presence of feces and stated it was not in line with facility expectations, but the area was not cleaned promptly. A resident reported avoiding showers due to repeated observations of feces on the floor, opting for bed baths instead. Facility policy required showers to be cleaned and sanitized up to two times daily, but this was not adhered to during the observed incident. The facility also failed to follow proper reporting guidelines for a Legionella outbreak. After a resident was hospitalized and tested positive for Legionella, the facility communicated with the county health department but did not notify the state agency as required. Interviews with staff, including the DON and Executive Director, revealed a lack of awareness regarding the requirement to report such outbreaks to the state, despite facility policy mandating the reporting, investigation, and documentation of all resident events. The outbreak was resolved, and families, staff, and residents were notified, but there was no evidence of state notification. Additional deficiencies were observed in infection control practices during meal delivery and wound care. CNAs delivering meal trays did not sanitize their hands before or between deliveries, and one CNA donned gloves without prior hand hygiene before assisting a resident with food. During a dressing change for a resident with severe cognitive impairment and pressure ulcers, an RN failed to change gloves or sanitize hands between wound sites, did not use a barrier on the bedside table, and did not wear a gown or implement Enhanced Barrier Precautions (EBP) as required for residents with open wounds. Staff interviews confirmed inconsistent understanding and application of EBP and hand hygiene protocols, despite facility policies outlining these requirements.
Failure to Protect Residents from Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in incidents involving both staff-to-resident and resident-to-resident abuse. One resident with moderate cognitive impairment and a history of dementia, psychosis, and anxiety disorder was verbally abused by a registered nurse, who was overheard loudly telling the resident to "shut up" and that she could not disrespect others. Multiple staff members witnessed the incident, and it was confirmed through interviews and documentation that the nurse raised her voice and used inappropriate language toward the resident, contrary to the facility's expectations and policies regarding resident dignity and respect. Another incident involved resident-to-resident abuse, where a cognitively intact resident was subjected to verbal accusations and had coffee thrown on her by a resident with a history of hallucinations, paranoia, and delusions. The aggressor resident, who was known to display verbal behaviors and make false accusations, asked to be moved closer to the other resident and then threw coffee at her. This event was witnessed by a CNA, and interviews confirmed that the coffee was not hot and did not result in physical injury, but the incident was distressing for the resident who was targeted. The facility's documentation and staff interviews revealed that the resident who threw the coffee had ongoing behavioral issues related to her psychiatric diagnoses and medication adjustments. Despite care plans and interventions in place, the facility did not prevent the abusive interactions between residents or the inappropriate staff response, leading to emotional and psychological harm as described by the Director of Nursing. The facility's policy defines abuse to include both staff-to-resident and resident-to-resident altercations, and the events described were found to be in violation of this policy.
Failure to Provide Physician-Ordered Lab Services
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by the physician. The resident, who had diagnoses including dementia, acute kidney failure, encephalopathy, and cerebrovascular disease, had a physician's order for a Complete Blood Count (CBC) with differential and platelet count to be performed on the 1st and 3rd Monday of each month. Review of the clinical record, laboratory results, and the Medication Administration Record (MAR) revealed inconsistencies and missing documentation of completed lab work during certain months, specifically April and the beginning of June. The MAR indicated that labs were marked as completed on scheduled dates, but the actual lab results were not present in the resident's records for those periods. Interviews with nursing staff and the Director of Nursing confirmed that there was no evidence of the required lab work being performed during the specified time frames, and no rationale was documented for the missed labs. The facility's policy required monitoring of physician's orders for completion, but this was not followed in this case. The deficiency was identified through clinical record review, staff interviews, and policy review, which collectively demonstrated that the resident did not receive lab services as ordered by the physician.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall and subsequent change in condition. The resident, who was a low to moderate fall risk due to muscle weakness, experienced a fall while being transferred from the toilet to a shower chair, resulting in a fracture. Despite the fall occurring on January 27, 2025, and the resident being transferred to the hospital, the care plan was not updated to reflect the necessary changes in interventions, such as the use of a mechanical lift for transfers, upon the resident's return to the facility on February 6, 2025. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that although the fall was discussed in meetings, the care plan was not updated with new interventions. The MDS Coordinator acknowledged that the fall should have been added to the care plan, and the Director of Nursing confirmed that the care plan should have been updated to include the use of a lift for transfers. The facility's policy on comprehensive care plans requires that they include measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Improper Mattress Fit Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident did not sustain injuries from falls due to improper fitting of the mattress on the resident's bed. The resident, who was cognitively intact and had a history of repeated falls, slipped out of bed on October 14, 2024, and was assisted to the floor by a CNA. The resident complained of pain in the feet, and an x-ray later revealed fractures in the metatarsal bones. The incident occurred despite the facility's awareness of the resident's fall risk, as indicated by the presence of fall risk indicators such as mats, yellow socks, and labels. Interviews with staff revealed that the mattress was replaced to fit better after the incident, but there was a lack of clarity on what was wrong with the original mattress. The Senior Director of Health Services mentioned that staff receive education to prevent falls, but there was no specific recollection of the mattress issue. The facility's interdisciplinary team (IDT) was involved in reviewing the incident to prevent future occurrences, but the deficiency highlights a lapse in ensuring the resident's environment was free from accident hazards, specifically regarding the fit of the mattress.
Inappropriate Staff-Resident Relationship
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member, specifically a certified nursing assistant (CNA). The resident, who was cognitively intact and had a history of depression, reported having a romantic relationship with the CNA, which began in the shower room with a kiss. This relationship, which included exchanging gifts and plans for marriage, was against the facility's policy prohibiting intimate relationships between staff and residents. The resident expressed that the relationship was consensual and did not want any action taken, despite being emotionally affected by the breakup. The facility's investigation revealed that the relationship had been ongoing for three months, with the resident providing evidence of communication and meetings outside the facility. The CNA was suspended pending investigation but subsequently quit her job. The facility's policy on inappropriate behavior from employees to residents was in place, but there was no specific policy addressing staff and resident relationships. The incident was reported after another staff member overheard the resident discussing the relationship and informed him of the need to report it. The facility's documentation and training materials outlined that inappropriate behavior, including romantic relationships, could lead to disciplinary action or termination. However, the lack of a specific policy on staff-resident relationships may have contributed to the deficiency. The resident's emotional state and the nature of the relationship were documented in psych progress notes, indicating fluctuations in mood and the impact of the relationship on his mental health.
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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 Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Horizon Post Acute And Rehabilitation Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of North Glendale | 3.4 mi | ★★★★★ | 1 | 0 |
| Bella Vita Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 3 | 0 |
| Immanuel Campus Of Care | 4.1 mi | ★★★★★ | 3 | 0 |
| Peoria Post Acute And Rehabilitation | 4.6 mi | ★★★★★ | 5 | 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.