Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Meadows during CMS and state inspections, most recent first.
Delayed Significant Change MDS Assessments After Hospice Admission: The facility failed to complete timely significant change MDS assessments for two residents after hospice enrollment. One resident had severe cognitive impairment and Alzheimer's disease, and another had respiratory failure with multiple comorbidities; both were admitted to hospice, but the required assessments were not completed within the expected 14-day timeframe, as confirmed by the MDS LPN.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required 14-day window for three residents. One resident had dementia, schizophrenia, and major depressive disorder with severe cognitive impairment and extensive ADL assistance needs; another had MS, COPD, CHF, and atrial fibrillation with incontinence and significant assistance needs; and a third had AV block, prostate and bone cancer, and HTN with assistance needs and a refused bathing assessment. An MDS LPN verified the assessments were completed after the ARD deadline.
The facility failed to maintain resident dignity during meals, affecting two residents with cognitive impairments. Staff members were observed standing while assisting residents with eating, contrary to the facility's policy of being at eye level. Interviews revealed a lack of awareness among staff about the dignity issue, despite prior education. The DON and Administrator confirmed the expectation for staff to be seated at eye level during meal assistance.
The facility failed to thoroughly investigate allegations of resident-to-resident abuse and staff distribution of illegal substances. In one case, a resident with cognitive impairment was assaulted by another resident, but the investigation lacked comprehensive witness interviews. In another case, a resident alleged an LPN provided THC edibles, but the investigation was limited to interviews with the resident and the accused LPN, contrary to facility policy.
A resident with moderate cognitive impairment and dependency on staff for personal hygiene did not receive proper fingernail care, resulting in cracked and sharp nails. Despite the care plan requiring total assistance with grooming, staff interviews revealed a lack of communication and follow-through on nail care responsibilities. The facility's policy mandates daily cleaning and regular trimming of nails.
A resident with severe cognitive impairment experienced an unwitnessed fall in a common area, resulting in a head injury. The investigation, conducted by an LPN who was not present at the time, lacked comprehensive staff interviews and relied on assumptions. Key staff members who witnessed the aftermath were not interviewed, and the facility's policy for thorough fall investigations was not followed.
A resident with COPD required supplemental oxygen therapy, but the facility failed to maintain the oxygen concentrator filters properly. Observations showed the filter was covered with thick fuzz, and staff interviews revealed confusion about cleaning responsibilities. The facility's policy required weekly cleaning or as needed, but this was not adhered to.
A facility failed to ensure proper hand hygiene during wound care for a resident with severe cognitive impairment and multiple medical conditions. An LPN did not change gloves or sanitize hands between cleaning two separate wounds, contrary to facility policy. Additionally, biohazardous waste receptacles for a resident on COVID-19 precautions were placed in the hallway instead of inside the room, due to space constraints and the resident's behavior, which was against the facility's usual practice.
Delayed Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to ensure significant change assessments were completed in a timely manner after two residents were admitted to hospice services. Resident #27 had diagnoses including localization-related symptomatic epilepsy, COPD, and Alzheimer's disease, and was admitted to hospice with a diagnosis of Alzheimer's disease. The record showed hospice enrollment effective 12/22/25, but no significant change MDS assessment was completed after that enrollment. During interview, the MDS LPN verified that no significant change MDS had been completed after the resident entered hospice and stated that such an assessment should be completed within 14 days of hospice admission. Resident #04 was admitted with acute and chronic respiratory failure with hypercapnia requiring non-invasive ventilation, schizoaffective disorder, diabetes mellitus type II, and morbid obesity. The physician ordered hospice evaluation and admission with a terminal diagnosis of acute and chronic respiratory failure with hypercapnia, and the resident transitioned to hospice on 01/07/26. The significant change MDS assessment was not completed until 02/10/26. During interview, the MDS LPN verified the hospice admission date and the delayed significant change assessment, and stated that the assessment should be completed within 14 days of hospice admission.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed within the required 14-day timeframe for three residents reviewed. Resident #17 was admitted with diagnoses of unspecified dementia, schizophrenia, and major depressive disorder. The quarterly MDS showed severe cognitive deficit, frequent bowel and bladder incontinence, and need for varying levels of assistance with eating, oral hygiene, dressing, bed mobility, transfers, toileting, bathing, and personal hygiene. The assessment had an ARD of 02/18/26 but was not completed until 03/09/26. Resident #20 was admitted with multiple sclerosis, COPD, CHF, and atrial fibrillation. The quarterly MDS showed intact cognition, frequent bowel and bladder incontinence, and assistance needs ranging from set-up for eating and oral hygiene to moderate assistance for transfers and maximal assistance for personal hygiene, toileting, bathing, and dressing. The assessment had an ARD of 02/19/26 and was completed on 03/09/26. Resident #21 was admitted with atrioventricular block, malignant neoplasm of the prostate and bone, and hypertension. The quarterly MDS showed intact cognition, continence of bowel and bladder, and assistance needs including set-up for eating and oral hygiene, supervision for toileting, dressing, bed mobility, and transfers, and maximal assistance for personal hygiene; the resident refused the bathing assessment. This assessment had an ARD of 02/20/26 and was completed on 03/09/26. During interview, the MDS LPN verified each quarterly assessment was completed on 03/09/26 and stated quarterly MDS assessments must be completed within 14 days of the ARD.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during meal times, specifically affecting two residents with cognitive impairments. Resident #22, who had severe cognitive impairment and required substantial assistance for eating, was observed being fed by a standing State Tested Nursing Assistant (STNA) #14. Similarly, Resident #37, with moderate cognitive impairment and also requiring substantial assistance, was assisted by a standing Licensed Practical Nurse (LPN) #5. Both staff members were observed standing over the residents while feeding them, which is contrary to the facility's policy of being at eye level with the residents during meals. Interviews with the staff involved revealed a lack of awareness regarding the dignity issue associated with standing while feeding residents. STNA #14 admitted to not liking to sit and was unaware that standing was a dignity issue, despite having been educated on proper feeding techniques during orientation. LPN #5 stated she stood because of her height. The Director of Nursing (DON) and the Administrator confirmed that the expectation was for staff to be seated at the resident's eye level when providing meal assistance, highlighting a failure in adherence to the facility's dignity protocols.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. One resident, with a history of alcohol dependence and cognitive impairment, was physically assaulted by another resident with a history of schizophrenia and behavioral disturbances. The incident occurred in a common area, and although staff intervened and separated the residents, the investigation did not include interviews with all potential witnesses present at the time of the incident. The Director of Nursing (DON) and the Administrator both confirmed that the investigation should have included interviews with all staff and resident witnesses. Additionally, the facility did not adequately investigate an allegation of a staff member distributing illegal substances to a resident. The resident, who had a history of psychoactive substance abuse, alleged that an LPN provided them with THC edibles. The investigation was limited to interviews with the resident and the accused LPN, who denied the allegations. No other staff or residents were interviewed, despite the facility's policy requiring a thorough investigation of all abuse allegations. The facility's policies on investigating incidents and allegations of abuse were not followed, as evidenced by the lack of comprehensive interviews and witness statements. The facility's policy required the removal of the accused staff member pending the investigation's outcome, but the investigation documents did not reflect adherence to this policy. The failure to conduct thorough investigations compromised the facility's ability to address and prevent future occurrences of abuse.
Failure to Provide Proper Fingernail Care for a Resident
Penalty
Summary
The facility failed to ensure proper fingernail care for a dependent resident, identified as Resident #37, who was unable to perform activities of daily living independently. Resident #37 had a history of cerebral infarction, abnormal posture, contractures, and vascular dementia, with a BIMS score indicating moderate cognitive impairment. The resident's care plan required total assistance with grooming, including nail care. However, observations revealed that the resident's fingernails were cracked, had sharp edges, and extended significantly past the fingertips. Interviews with staff, including an STNA and an LPN, indicated that nail care was supposed to be performed during shower days. The STNA reported being unable to provide nail care due to the resident's discomfort and claimed to have informed the nurse, but the LPN denied receiving any notification about the issue. Further interviews with the Unit Manager and the Director of Nursing confirmed that nail care should be conducted on shower days, and the Administrator acknowledged that residents' nails should be clean and neat. The facility's policy on nail care emphasized daily cleaning and regular trimming to prevent skin problems and injuries.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation of an unwitnessed fall involving Resident #18, who was severely cognitively impaired and at risk for falls due to poor judgment, safety awareness, and impaired balance and gait. The resident was found face down on the floor in front of a chair in the common area with a bump on her head. The fall investigation, completed by LPN #18, lacked comprehensive staff interviews and relied on assumptions about the resident's condition at the time of the fall. LPN #18, who was not present at the time of the fall, completed the investigation report based on limited information and did not interview other staff members who were present. STNA #20 and RN #19, who were on duty, were not interviewed by LPN #18, and their observations were not included in the investigation. LPN/UM #7, responsible for tracking falls, did not verify the accuracy of the report or conduct additional interviews to gather more information about the incident. The Director of Nursing and the Administrator expected thorough investigations involving the interdisciplinary team, but this expectation was not met. The facility's policy required all falls to be investigated and documented, but the investigation into Resident #18's fall was incomplete, lacking input from key staff members and failing to provide a clear understanding of the circumstances leading to the fall.
Inadequate Maintenance of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure proper maintenance of oxygen concentrator filters for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who had moderate cognitive impairment, required supplemental oxygen therapy as part of their care plan. Observations on two consecutive days revealed that the oxygen concentrator's filter was covered with a thick, white/gray fuzz, indicating inadequate cleaning and maintenance. Interviews with staff members, including a State tested Nursing Assistant (STNA), a Registered Nurse (RN), a Licensed Practical Nurse/Unit Manager (LPN/UM), and the Director of Nursing (DON), revealed a lack of clarity and responsibility regarding the cleaning schedule for the oxygen concentrator filters. The facility's policy stated that filters should be cleaned weekly or as needed, but staff were uncertain about the frequency and responsibility for this task, leading to the deficiency in care for the resident.
Infection Control Deficiencies in Wound Care and Biohazard Waste Management
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during wound care for a resident with severe cognitive impairment and multiple medical conditions, including pressure ulcers and chronic multifocal osteomyelitis. During an observation, an LPN/Unit Manager did not change gloves or sanitize hands between cleaning two separate wounds on the resident, despite facility policy requiring proper hand hygiene and glove changes during wound assessments. The LPN/UM acknowledged the oversight, and the Director of Nursing confirmed that pressure ulcer care should be performed separately for each wound. Additionally, the facility did not ensure the appropriate placement of biohazardous receptacles for a resident on contact and droplet precautions due to a COVID-19 diagnosis. The biohazard trash cans, intended for waste from the resident's room, were consistently observed in the hallway outside the room, contrary to the facility's usual practice of keeping them inside. The Infection Preventionist and Director of Nursing noted the lack of space inside the room and the resident's tendency to access the trash as reasons for the hallway placement. The facility's policy emphasized implementing appropriate interventions to prevent the spread of COVID-19.
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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 Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hamilton Respiratory And Nursing Center | 0.9 mi | ★★★★★ | 14 | 0 |
| Birchwood Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Doverwood Village | 1.2 mi | ★★★★★ | 0 | 0 |
| Liberty Station Health Campus | 2 mi | — | 0 | 0 |
| Residence At Huntington Court | 2.3 mi | ★★★★★ | 2 | 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.