Glade Avenue Assisted Living

What the state also noted

• — Five of the six surveys in this 24-month window cited deficiencies. This facility does not have a clean inspection history.
• — Two immediate jeopardy findings — the most serious level the state issues — occurred within about three and a half months: substantiated resident-on-resident sexual abuse cited 10-10-2025 (the incident report read 'came to [Resident #2] and touched [their] leg and proceeded to grope [their genitals]'), and the 01-30-2026 elopement in which Resident #16 left out the front door unattended, fell, sustained a head injury with 'fresh blood noted,' and was found by a staff member passing by in a vehicle while direct care staff were unaware the resident was outside.
• — In the October 2025 sexual abuse citation, staff interviews showed the behavior was known beforehand and not acted on: a CNA said the resident was 'touchy touchy with the male residents' and had reported it to the DON; a CMA said the resident 'grabs the men between their legs sometimes. I think [they're] flirting.' Neither could identify any intervention in place.
• — The 01-30-2026 citation covered two failures, not one: inadequate supervision to prevent Resident #16's elopement, AND failure to ensure 'allegations of abuse were thoroughly investigated and all residents were protected during the investigation' for a separate resident (#14).
• — The 11-07-2024 survey substantiated physical abuse by a staff member — an incident report documented a staff member 'was speaking rudely to Resident #1 and grabbed them by the wrist and drug them.' The citation was recorded as isolated to that one resident. The same survey also cited the center for failing to provide a staff member abuse training within 90 days of hire. The facility's plan of correction states it reported the incident to OSDH, suspended, investigated and terminated the employee — that account comes from the facility, not from any OSDH verification, and the plan of correction expressly disclaims being an admission.
• — The 01-30-2026 survey documented that a dependent resident (#10) was found by an outside home health provider soiled in urine and/or feces on 09/11/25, 09/15/25, 09/17/25, 09/23/25, 10/03/25 and 10/07/25 — including 'found in bed soaked in urine and feces soaking through the mattress and several pads' and a note reading '[Resident #10] has been pushing [their] button for assistance for hours and no one is coming.'
• — The 01-30-2026 survey also documented repeated strong urine odors on hall 100 and in the rooms of Residents #11, #12 and #16 across multiple dates; a CNA who smelled urine and stated they did not check whether the resident was incontinent; missed housekeeping and shower assistance; a 10/14/25 fall never documented, never entered on an incident report and never reported to the physician; and five separate hand-hygiene failures by one CNA across four residents' rooms, including handling a catheter bag and then a supplement drink without washing hands.
• — Several October 2025 'in compliance' findings did not hold. Complaints about ADL care for dependent residents, staffing and call-light response were not sustained on 10-10-2025, but the 01-30-2026 survey cited those same failures using evidence from September and October 2025. A complaint about supervision to prevent accidents was not sustained on 10-10-2025, yet a resident fell undetected four days later and the January 2026 immediate jeopardy was itself a supervision failure. Do not read the October clearances as current assurances.
• — Environmental problems (stained and frayed carpet, chipped handrails, damaged laminate, paint splatter on flooring) were cited in October 2025, January 2026, and again in May 2026. OSDH rejected the first May 2026 plan of correction because it did not address replacing the hall 200 and 300 flooring. As of the 06/30/2026 acceptance letter, that flooring was still not installed, with alleged compliance only by 07/07/2026; no revisit result appears in the bundle.
• — The 10-10-2025 survey also cited the center for admitting and retaining a resident it could not communicate with (no Rohingya/Bengali translation available; the administrator said '[Resident #1] don't belong here ... if someone were to pursue [them] or do something to [them] [Resident #1] can't communicate that with us') and for admitting a resident far below the contract's stated age minimum.
• — OCR is incomplete for BOTH immediate-jeopardy surveys. The 01-30-2026 statement of deficiencies ends at page 23 of 35, and the 10-10-2025 statement of deficiencies ends at page 13 of 15. Material from both citations is unavailable for review.
• — The bundle contains OCR pages belonging to a different, unrelated facility (Woodview Home, Inc., Ardmore, provider 375393, complaints #1904253 and #2728934) filed inside the 01-30-2026 section. None of those observations were used in this record.
• — The 'complaints substantiated' count (12 of 20) is approximate: the 01-30-2026 survey investigated four complaints together and the 05-06-2026 survey two, issuing citations without attributing them to individual complaint numbers.