Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Glenfields Living With Care during CMS and state inspections, most recent first.
Nursing staff did not consistently perform hand hygiene between glove changes during wound care for two residents, and Enhanced Barrier Precautions were not properly implemented for four residents requiring contact precautions. Rooms lacked appropriate signage and PPE storage, and residents or their representatives often did not recall being educated about or consenting to opt out of EBP, despite facility documentation indicating signed agreements.
Two residents receiving anticoagulant therapy did not have care plans that included management or monitoring for side effects such as bleeding. Despite staff expectations to monitor for bruising and bleeding, care plans and orders lacked documentation of these interventions, and facility policy did not address monitoring for anticoagulant use.
A resident with severe cognitive impairment and multiple chronic conditions experienced a significant weight gain over several months. The RD identified the gain as likely not nutrition-related and communicated concerns to nursing staff, who performed assessments but did not notify the PCP as required by facility policy. Staff interviews confirmed the expectation to update the PCP in such cases, but documentation showed this did not occur.
A resident with multiple sclerosis, a stage 4 pressure ulcer, and malnutrition was not consistently offered range of motion (ROM) exercises as ordered in her restorative nursing program. Documentation and staff interviews confirmed that ROM activities were frequently not provided or completed, with staff citing lack of time and marking tasks as 'not applicable' when not offered. The resident expressed awareness of the importance of these exercises, but the facility failed to ensure consistent delivery of the restorative program.
A facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including dysphagia, leading to inadequate management of choking risks and refusal of care. The resident's care plan lacked specific interventions for when he refused to sit upright during meals or eat in a supervised location. Despite being identified as a choking risk, the resident was allowed to eat unsupervised in his room, resulting in his death. Staff interviews revealed a lack of communication and awareness regarding the resident's choking risk and supervision needs.
Failure to Ensure Proper Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for two residents. Observations revealed that registered nurses did not consistently perform hand hygiene when changing gloves between wound care tasks. Specifically, one nurse washed hands before starting wound care and after completion, but did not perform hand hygiene each time gloves were changed, despite changing gloves multiple times during the procedure. Another nurse also failed to perform hand hygiene between glove changes, only doing so at the beginning and end of the wound care process. Interviews with the nurses and the director of nursing confirmed inconsistent understanding and implementation of hand hygiene protocols, with some staff believing that changing gloves was sufficient without hand hygiene unless hands were visibly soiled. The facility also failed to properly implement Enhanced Barrier Precautions (EBP) for four residents who required contact precautions due to conditions such as stage 4 pressure ulcers, indwelling catheters, diabetic foot wounds, and gastrostomy tubes. Observations showed that rooms for these residents lacked signage indicating the need for precautions and did not have visible storage for personal protective equipment (PPE). Interviews with residents and family members indicated a lack of awareness or recall regarding the negotiated risk agreements that were signed to opt out of EBP, and some did not remember being educated about the risks or the precautions required for their conditions. Facility documentation indicated that all residents who qualified for EBP had signed negotiated risk agreements to opt out of these precautions, as confirmed by the director of nursing. However, interviews revealed that the process for presenting and explaining these agreements was unclear, and residents or their representatives often did not recall the information being reviewed with them. The facility's policy required a risk assessment for EBP on all new admissions, but the observed lack of signage, PPE availability, and inconsistent education contributed to the failure to implement EBP as recommended.
Failure to Include Anticoagulant Monitoring in Care Plans
Penalty
Summary
The facility failed to ensure that care plans for two residents receiving anticoagulant therapy included management and monitoring for potential side effects, specifically signs of bleeding. One resident, who was cognitively intact and had diagnoses including atrial fibrillation, hypertension, and a history of stroke, was prescribed Eliquis but did not have corresponding care plan interventions or monitoring orders for side effects related to anticoagulant use. Similarly, another resident with severe cognitive impairment, hypertension, diabetes, Alzheimer's disease, and a history of stroke was prescribed warfarin, but their care plan also lacked documentation of anticoagulant use and monitoring for adverse effects. Interviews with facility staff, including a registered nurse case manager, consultant pharmacist, and the director of nursing, confirmed that there was an expectation for monitoring for bruising and bleeding in residents on anticoagulants. However, the care plans and order summaries reviewed did not reflect these practices. Additionally, the facility's policy on anticoagulant use did not address monitoring requirements, contributing to the deficiency.
Failure to Notify PCP of Significant Weight Gain
Penalty
Summary
The facility failed to notify the primary care physician (PCP) of a significant weight gain in a resident with severe cognitive impairment and multiple comorbidities, including hypertension, diabetes, Alzheimer's disease, and obstructive sleep apnea. The resident experienced a weight increase from 252 lbs to 292 lbs, representing a 15.87% gain over several months. Documentation showed that the registered dietitian (RD) identified the weight gain as likely not nutrition-related and communicated concerns to nursing staff via email and progress notes. Nursing staff performed cardiac and fluid status assessments but did not update the PCP regarding the ongoing and significant weight gain. Interviews with facility staff, including the RN case manager and the director of nursing (DON), confirmed that the expectation was for nursing to notify the PCP in cases of significant weight changes. Despite repeated notifications from the RD and internal assessments, there was no evidence that the PCP was informed of the resident's 40 lb weight gain. Facility policy required prompt rechecking and follow-up for notable weight changes, but the lack of communication with the PCP constituted a failure to provide appropriate treatment and care according to orders and the resident's needs.
Failure to Consistently Provide Ordered Range of Motion Exercises
Penalty
Summary
A resident with diagnoses including a stage 4 pressure ulcer, multiple sclerosis, and malnutrition was not consistently offered range of motion (ROM) exercises as part of her restorative nursing program. The resident, who was cognitively intact and able to communicate her needs, reported that staff did not always provide the ROM exercises, which she recognized as important for her condition. Review of task documentation over several weeks showed inconsistent completion of restorative and ROM activities, with numerous entries marked as 'not applicable,' indicating the exercises were not offered or completed during those shifts. Interviews with nursing assistants confirmed that 'not applicable' was used when the task was not offered, often due to lack of time. The director of therapy and the director of nursing both acknowledged the importance of the restorative program and expected staff to follow up when tasks were not completed. Progress notes indicated that the program was not always offered, and the facility's policy stated that restorative programs should be designed according to the resident's goals and abilities. Despite these expectations, the resident did not consistently receive the ordered ROM exercises.
Failure to Address Choking Risks and Refusal of Care
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the choking risks and refusal of care for a resident with multiple medical conditions, including hemiplegia, vascular dementia, chronic kidney disease, heart failure, type II diabetes, reduced mobility, depression, and dysphagia. The resident's care plan did not include specific interventions for when the resident refused to sit upright during meals or eat in a supervised location, despite recommendations from the speech language therapist. The resident's electronic health record and Kardex also lacked documentation related to aspiration or choking risks. The resident frequently refused to leave his room for meals and was noncompliant with sitting upright, which was necessary for his swallowing safety. Despite being identified as a choking risk, the resident was allowed to eat in his room without proper supervision. On one occasion, a nursing assistant left the resident unsupervised during a meal, and the resident was later found unresponsive with food in his mouth, leading to his death. Interviews with staff revealed a lack of communication and awareness regarding the resident's choking risk and the need for supervision during meals. The facility did not provide any formal education or policy updates to staff following the resident's death. Interviews with various staff members, including nursing assistants, registered nurses, and the assistant director of nursing, highlighted inconsistencies in how choking risks were communicated and documented. The resident's guardian was not fully informed about the swallowing concerns, and a negotiated risk form was not signed. The facility's failure to adequately address the resident's choking risk and refusal of care contributed to the deficiency identified in the report.
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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 Glencoe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony River Living Center | 11.9 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society Arlington | 12.2 mi | — | 0 | 0 |
| The Gardens At Winsted Llc | 14 mi | ★★★★★ | 6 | 0 |
| Bayside Manor Llc | 15.8 mi | ★★★★★ | 13 | 1 |
| Auburn Home In Waconia | 17.9 mi | ★★★★★ | 4 | 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.