Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 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.
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.
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 | — | 0 | 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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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.