Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Glen Oaks Health Campus during CMS and state inspections, most recent first.
A resident with a history of pulmonary embolism, prosthetic heart valve, and hyperlipidemia, who was cognitively intact and at risk for falls, was found on the bathroom floor without a pulse and with blood under the head. Facility staff documented only a small forehead laceration and, after the medical director attributed the event to a cardiac cause, the DHS and ED did not report the fall with injury to the health department. Later, a coroner and funeral home staff identified a large, deep laceration on the resident’s forehead, with photos and a written report describing an open wound exposing the skull, indicating a significant head injury of unknown source that had not been reported as required.
A resident with CHF, atherosclerotic heart disease, type 2 DM, and documented fall risk who used a walker/wheelchair and required partial/moderate assistance with toileting was assisted to the toilet by an LPN and then left alone with instructions to use the call light when finished. Despite a care plan identifying fall risk related to weakness and a facility fall management policy intended to mitigate fall risks, the resident was not continuously supervised in the bathroom. A CRCA later found the resident unresponsive on the bathroom floor with no call light activated, and an RN confirmed the resident was on the bathroom floor without a pulse.
Improper Food Storage and Outdated Food: The facility failed to dispose of outdated ground beef and left multiple refrigerated food items, including bacon, cake, and cherry pie, uncovered and open to air. The DM acknowledged the ground beef was past its use or freeze date and stated it would be discarded, while the other items were observed unwrapped in the walk-in refrigerator.
Hand hygiene and medication handling lapses were observed during multiple med passes. An RN administered oral meds, eye drops, blood sugar checks, and a nebulizer treatment while donning gloves without first performing hand hygiene, and another RN picked up a dropped pill from the med cart with bare hands before giving it to a resident. The nurse consultant stated staff should use hand hygiene prior to donning gloves, and the facility policy required hand hygiene before and after direct resident contact and after glove removal.
A nurse administered sliding-scale insulin to two residents without observing the required 2-unit priming of the insulin flex pen before dosing. The facility also failed to document wound measurements and wound characteristics for a resident with a left lower leg wound, despite orders for daily wound care and a policy requiring weekly wound documentation.
A resident with spinal stenosis and heart disease, who needed substantial help with bathing and toileting and was identified as a fall risk, fell in the bathroom during a shower transfer. She was barefoot on the commode while shower water was running and the floor was wet, and she fell as she stood to transfer toward the wheelchair, sustaining a right buttock laceration/abrasion after striking a plastic shelf. The CRCA student involved said this was her first time assisting the resident and that the resident was not wearing non-skid footwear at the time of the fall.
Failure to Develop and Track Behavior Plan for Verbal Aggression: A resident with major depressive disorder with psychotic symptoms had repeated episodes of verbal agitation, cursing, and yelling at staff and a roommate, but the record did not contain a physician order or order set to track the behaviors and did not include a care plan addressing the aggression. Notes documented multiple incidents of yelling, berating, and disruptive behavior, and the resident was later sent for inpatient psych evaluation.
A resident with heart failure and cognitive impairment did not have fresh ice water available at the bedside, as staff failed to pass ice water every shift due to time constraints. The facility lacked a specific policy for passing ice water, contributing to the deficiency.
A resident reported missing clothing items to staff, but the facility failed to document and address the grievance according to its policy. Despite informing CNAs and laundry staff, no formal grievance was filed, and the missing items were not located. The facility's grievance policy requires concerns to be documented and resolved, but this process was not followed, leading to a deficiency.
A facility failed to consistently implement a sling for a resident with impaired ROM due to hemiplegia and hemiparesis from a CVA. Despite the resident's need and preference for the sling, observations showed the resident without it on multiple occasions. The facility lacked a policy for ROM, splints, or contractures, contributing to the oversight.
A resident with significant weight loss did not receive fortified food and shakes as recommended by the RD and ordered by the physician. Despite a severe impairment in decision-making, the resident was observed without the necessary nutritional supplements. The Dietary Manager was unaware of the order, and the DHS indicated a failure in communication and adherence to the facility's weight monitoring policy.
Failure to Report Fall With Significant Head Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to report a fall with injuries of unknown source to the state health department. Resident B, who had diagnoses including pulmonary embolism, a prosthetic heart valve, and hyperlipidemia, was cognitively intact per the admission MDS and used a walker/wheelchair, required partial/moderate assistance with toileting, and was identified as at risk for falls. A progress note documented that on 4/16/26 at 6:15 a.m., Resident B was found on the bathroom floor without a pulse, with a small amount of blood noted under the head. During an interview, the DHS and ED stated that Resident B had a small laceration to the forehead after the fall and, based on the medical director’s indication that the fall was from a cardiac event, they did not report the incident to the department of health. Subsequent information from external parties described a more significant injury than what the facility reported. The Coroner stated that EMS contacted him the morning of 4/16/26 and advised that he did not need to investigate because nothing appeared suspicious or unnatural, but later the family observed what appeared to be a quarter- to half-dollar–sized deep laceration on the left side of the forehead at the funeral home. Photos provided by the funeral director showed a deep cut on the middle left side of the forehead before the hairline, with a quarter-sized area where tissue and blood were visible. The funeral director’s written report noted that a clear shower cap had been placed over the resident’s head and that, upon further examination, a large open wound approximately 2 inches in diameter exposing the skull was found above the left eye. Despite these injury findings, the facility had not reported the fall with injury of unknown source to the department of health.
Failure to Supervise High Fall-Risk Resident in Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to a high fall-risk resident while using the bathroom. The resident had diagnoses including chronic congestive heart failure, atherosclerotic heart disease, and type 2 diabetes mellitus. The admission MDS indicated the resident was cognitively intact, used a walker/wheelchair for ambulation, required partial/moderate assistance with toileting, and was at risk for falls. The care plan, dated 2/23/26, identified the resident as at risk for falls related to weakness, with interventions including staff assistance with transfers as needed. On the morning of 4/16/26, an LPN assisted the resident onto the toilet and then left the resident alone in the bathroom, instructing the resident to use the call light when finished. The LPN’s witness statement indicated the resident was left unattended, and a family member later reported being told by a nurse that the resident had been left alone for only about five minutes. A CRCA doing rounds around 6:15–6:20 a.m. found the resident lying unresponsive on the bathroom floor, with the call light not activated and without prior awareness that the resident was in the bathroom. An RN was called to the room around the same time and found the resident unresponsive on the bathroom floor without a pulse. The facility’s Fall Management Guidelines policy, provided by the Executive Director, stated the purpose was to mitigate fall risk factors and implement preventive measures.
Improper Food Storage and Outdated Food
Penalty
Summary
The facility failed to timely dispose of outdated food and failed to ensure refrigerated items were not open to air. During observation of the kitchen with the Dietary Manager, a large roll of ground beef was found in the walk-in refrigerator with a date received of 10/24/25, while the plastic casing indicated use or freeze by 11/2/25; the Dietary Manager stated the ground beef had not been pulled from the freezer and said it would be thrown away. On a later observation, the walk-in refrigerator contained multiple trays of bacon, a pan of chocolate cake, and trays with slices of cherry pie that were all unwrapped and open to air. The Dietary Manager stated the cherry pie was for dinner that evening, the chocolate cake was from the day before, and the bacon was prepped for the next morning. The facility’s Storage Policy, last revised 7/10/25, stated that food and supplies shall be properly stored and that refrigerated food is covered, dated, and stored loosely to permit air circulation.
Hand Hygiene and Medication Handling Lapses
Penalty
Summary
The facility failed to maintain infection control practices during multiple medication administrations by not ensuring hand hygiene was performed before staff donned gloves and by handling a dropped pill with bare hands. During observations of medication passes for several residents, RN 10 and RN 28 were seen preparing oral medications, eye drops, blood sugar checks, and nebulizer treatments while wearing gloves without first performing hand hygiene. In one observation, RN 10 also touched her hair with gloved hands and knocked on a resident’s door with the same gloves before administering medications and eye drops. Resident 65 had diagnoses including heart failure. During an observed medication pass, RN 28 performed hand hygiene, administered oral medications, and assessed lung sounds. RN 28 then handled a nebulizer set, went to the bathroom to don gloves without performing hand hygiene first, and administered the nebulizer medication. In another observation with the same nurse, RN 28 obtained gloves and a paper towel from the bathroom, placed the paper towel on the bedside table, donned gloves, and performed a blood sugar check without hand hygiene before putting on the gloves. Resident 56 had diagnoses including cerebral palsy. During medication preparation at the cart, RN 10 dropped a pill medication on top of the medication cart, picked it up with bare hands, placed it in the medication cup, and then entered the resident’s room to administer it. Similar observations were made for residents with diabetes, hypertension, epilepsy, and morbid obesity, where staff donned gloves without hand hygiene before obtaining blood sugars or administering medications. The nurse consultant stated staff should be utilizing hand hygiene prior to donning gloves, and the facility’s hand hygiene policy stated health care workers shall use hand hygiene before and after direct physical contact with residents and after removing gloves.
Insulin Administration and Wound Documentation Deficiencies
Penalty
Summary
The facility failed to follow insulin administration protocol for two residents during observed medication passes. One resident with type 2 diabetes had a physician order for Humalog sliding scale insulin twice daily, and another resident with morbid obesity had a physician order for NovoLog sliding scale insulin before meals. During observation, RN 10 administered 2 units of Humalog to one resident after checking a blood sugar of 164 and administered 8 units of NovoLog to the other resident after checking a blood sugar of 267. In both observations, there was no observation of the insulin flex pen being primed with 2 units before the dose was dialed up and given. The facility also failed to document wound measurements and wound characteristics for a resident with a left lower leg wound. The resident had dementia and was identified as at risk for skin breakdown related to weakness, impaired mobility, and incontinence. After a transfer-related laceration to the left lower leg, the resident was sent to the hospital, later had sutures placed, and then had the stitches removed with drainage noted. A physician order later directed daily cleansing, collagen, and a border dressing for the wound. When the wound nurse changed the dressing, the wound was measured at 3 cm by 1.9 cm and was observed to have 50 percent granulation tissue and 50 percent slough. However, the clinical record did not contain a description or measurements of the wound before that observation. The wound nurse stated there were no measurements of the wound until she measured it during the observed treatment. The facility policy provided by the DNS required weekly documentation of wound type, location, stage if applicable, length, width, depth, base, drainage, periwound tissue, and treatment.
Failure to Maintain Fall Interventions During Shower Transfer
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident before she fell in the bathroom. Resident 53 had diagnoses including spinal stenosis and heart disease, had been admitted after back surgery, and her admission assessment showed she required substantial assistance with bathing, toileting, and taking on and off footwear. Her fall care plan identified her as at risk for falling because of weakness and impaired mobility, with interventions to keep the floor free of liquids and foreign objects and to provide non-skid footwear. On the morning of the incident, Resident 53 was on the commode in the bathroom and was barefoot while a CRCA student was preparing her for a shower. The student was running the shower water to warm it while the resident was still on the commode, and the resident stated there was water running all over the floor and no towel on the floor. The resident stood up holding the grab bar and fell to the floor as she was being transferred toward the wheelchair and shower area. The resident and her family member stated the resident was unstable and questioned why the shower water was running while she was still barefoot and not yet in the shower. The fall event record stated the resident was not wearing footwear at the time of the fall and sustained a laceration to her right buttock after hitting a plastic shelf. The wound record documented an abrasion to the upper right buttock measuring 2.5 x 9 cm with redness, and the resident reported soreness afterward. The CRCA student stated this was her first time assisting the resident and that she was later educated about ensuring a towel was down and the resident was wearing socks during transfers.
Failure to Develop and Track Behavior Plan for Verbal Aggression
Penalty
Summary
The facility failed to timely develop a behavior plan of care and failed to track verbal agitation and aggression for a resident with major depressive disorder with psychotic symptoms. The resident’s care plan, dated 11/15/2022, addressed depression and related symptoms such as verbalizations of distress, refusals of care, tearfulness, self-hate, and poor motivation, and a quarterly MDS dated 8/15/25 indicated he was cognitively intact and displayed no behaviors. Clinical notes documented repeated episodes of verbal aggression and agitation toward staff and his roommate, including cursing at a nurse during medication pass, yelling at and berating staff and his roommate, cursing at his roommate from the hallway, raising his television volume so the roommate could not hear his own television, and becoming angry in the dining room and yelling at kitchen staff. The record showed management, family, and the physician were notified, and the resident’s sister agreed to send him for inpatient psychiatric evaluation, but the clinical record did not contain a physician’s order or order set to track or record the verbal agitation or aggression, and it did not include a care plan addressing those behaviors.
Failure to Provide Fresh Ice Water to Resident
Penalty
Summary
The facility failed to ensure that Resident 9 had fresh ice water available at the bedside, which is a deficiency in meeting the hydration needs of the resident. Resident 9, who has a medical diagnosis of heart failure and is cognitively impaired, was observed to have only room temperature water available, with no ice. The resident reported that ice water was rarely provided, and the available water was either stale or warm, with no fresh water provided outside of meal and medication times. Interviews with staff revealed that ice water was supposed to be passed every shift, but this task was not completed due to time constraints. The Director of Health Services indicated that any staff member could pass ice water, but it was primarily the responsibility of direct care staff. However, the facility lacked a specific policy for passing ice water to residents, as confirmed by the Regional Nurse Consultant.
Failure to Follow Grievance Policy for Missing Clothing
Penalty
Summary
The facility failed to adhere to its grievance policy concerning a resident's missing clothing, resulting in a deficiency. Resident 39, who was cognitively intact and diagnosed with anxiety, reported missing two shirts and a pair of jean pedal pushers. Despite informing several staff members, including CNAs and laundry staff, about the missing items, no formal grievance was filed, and the items were not located. The resident's concerns were not documented in the Resident Concerns Log, and the facility's grievance policy was not followed. Interviews with the Executive Director and Environmental Services Assistant revealed that although the resident's missing clothing was acknowledged by staff, no resident concern form was completed. The facility's policy requires concerns to be documented and addressed promptly, but this process was not followed in this case. The Executive Director was unaware of the issue, and the Environmental Services Assistant did not document the concern, as missing items were a common complaint. This lack of documentation and follow-up led to the deficiency in handling the resident's grievance.
Failure to Implement Sling for Resident with Impaired ROM
Penalty
Summary
The facility failed to implement a sling for a resident with impaired range of motion (ROM), specifically for a resident with hemiplegia and hemiparesis affecting the right side due to a cerebral vascular accident (CVA). Observations over several days revealed that the resident was frequently seen sitting in a wheelchair without the sling, despite the resident's indication that he had a sling in his room and felt better supported when wearing it. The resident's right hand was observed to be curved inward and flaccid, indicating a need for support, which was not consistently provided. The clinical record and plan of care for the resident did not address the utilization of a sling, despite the resident's condition and previous use of a sling as documented by the discharging facility. The facility's Director of Health Services confirmed the presence of the sling in the resident's room and acknowledged the resident's preference for wearing it for comfort. Additionally, the facility lacked a policy for ROM, splints, or contractures, which contributed to the oversight in providing the necessary support for the resident's impaired ROM.
Failure to Provide Fortified Nutrition for Resident with Weight Loss
Penalty
Summary
The facility failed to provide fortified food and fortified shakes as recommended by the Registered Dietician (RD) and as ordered by the physician for a resident who had experienced significant weight loss. Resident 34, who had diagnoses including hemiplegia, hemiparesis, ataxia, polyosteoarthritis, pulmonary fibrosis, and hypothyroidism, was noted to have lost 6.98% of body weight over two months and 5.5% in one month. The resident's Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making. Despite a physician's order for fortified food with puree texture and the RD's recommendation for fortified foods and shakes to promote protein and calorie intake, these were not provided to the resident. Observations on two separate occasions revealed that Resident 34 did not receive a fortified shake with meals, only tea and water. Interviews with the Dietary Manager and the Director of Health Services (DHS) revealed a lack of communication and follow-through on the diet order. The Dietary Manager was unaware of the fortified food and shake order, and the DHS indicated that nursing staff were responsible for providing the diet order to dietary and reweighing the resident as recommended by the RD, which was not completed. The facility's weight policy aimed to monitor resident weight to prevent complications from compromised nutrition, but this was not adhered to in Resident 34's case.
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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 New Castle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At New Castle | 3 mi | ★★★★★ | 9 | 0 |
| Stonebrooke Rehabilitation Center | 3.1 mi | ★★★★★ | 3 | 0 |
| Waters Of New Castle, The | 3.2 mi | ★★★★★ | 8 | 0 |
| Willows Of New Castle | 3.2 mi | ★★★★★ | 10 | 0 |
| Middletown Nursing And Rehabilitation Center | 13 mi | ★★★★★ | 10 | 0 |
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