Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Glenwood Village Care Center during CMS and state inspections, most recent first.
A resident with dementia and hemiplegia, who required total assistance, developed two new bruises on the left elbow that were documented by an LPN. The resident's family member, who had requested to be informed of any changes, was not notified about the bruising. The DON confirmed that the family should have been updated, but this did not happen, which was not in line with facility policy.
A resident sustained serious injuries, including brain bleeds and a femur fracture, after falling from a mechanical lift due to improper sling use and lack of immediate intervention or staff education. Another resident experienced multiple falls with fractures, but the facility did not complete root cause analyses or implement new person-centered interventions, resulting in actual harm. Staff concerns about equipment and care planning were not promptly addressed, and care plans were not updated in a timely manner.
A resident with hemiparesis and a history of stroke fell and sustained injuries during a transfer using a mechanical lift due to staff failing to secure the sling properly. The incident occurred when two nursing assistants did not verify the sling's secure attachment, leading to the resident falling approximately three to four feet. The resident suffered a large hematoma and a skin tear, requiring emergency medical attention.
A resident with intact cognition and independent mobility was restricted by a Wander Guard on his wheelchair without a comprehensive assessment or attempt at less restrictive measures. The facility failed to respect the resident's rights and individual needs, leading to increased feelings of restriction and isolation.
Failure to Notify Resident Representative of New Injury
Penalty
Summary
The facility failed to notify a resident's representative of new bruising found on the resident, as required by facility policy. The resident in question had diagnoses including dementia and hemiplegia, and required total assistance with transfers and personal hygiene. On a specific date, an LPN documented the discovery of two new dark purple bruises on the resident's left outer elbow but did not inform the resident's son, who was the responsible party and had previously requested to be notified of any changes in the resident's condition. During interviews, the family member confirmed he was unaware of the bruising and expressed frustration, noting this was not the first time he had not been informed of changes. The DON acknowledged that the family should have been updated about the new injury, in accordance with facility policy, but this did not occur.
Failure to Prevent Recurrent Falls and Implement Person-Centered Interventions
Penalty
Summary
The facility failed to implement immediate interventions to prevent the recurrence of a fall incident involving a resident who sustained two brain bleeds and a femur fracture after falling from a full body mechanical lift. Upon the resident's return from the hospital following the fall, no new interventions were put in place to prevent a similar event, and there was no evidence of staff education or care plan revision until several days later. Multiple nursing assistants expressed concerns about the appropriateness of the sling size used during the transfer, with some stating the large sling was too big for the resident, but these concerns were not promptly addressed or communicated to management. The facility's policy lacked specific guidance on proper sling placement, and staff interviews revealed inconsistent understanding and application of sling sizing and positioning, which contributed to the incident. Additionally, the facility failed to implement person-centered fall interventions and complete a fall analysis for another resident who experienced multiple falls and sustained fractures. Incident reports and progress notes for this resident lacked evidence of a root cause analysis by the interdisciplinary team and did not document the implementation of new interventions to prevent future falls. Staff interviews indicated that while some immediate actions, such as increased monitoring, were taken, there was no systematic approach to updating care plans or communicating new interventions to all staff members. The lack of follow-up and individualized interventions after each fall event resulted in continued risk and actual harm to the resident. Both cases demonstrate that the facility did not ensure areas were free from accident hazards and did not provide adequate supervision or individualized interventions to prevent accidents. The failure to promptly assess, analyze, and address the causes of falls, as well as to communicate and implement appropriate changes in care, led to significant injuries for the residents involved. The documentation and staff responses indicate a lack of timely and effective action to mitigate fall risks and prevent recurrence.
Removal Plan
- Audit R4's lift equipment to ensure the sling is the appropriate size and in good condition
- DON observe a transfer with the staff and R4 to verify the resident is positioned safely and securely in the sling
- Revise R4's care plan and direct staff to remove the lift sheet immediately following each transfer
- Conduct a lift assessment for R4 to ensure type of lift and sling remain appropriate
- Educate all staff on concerns regarding transfers and R4's intervention
- Re-educate all staff per manufacturer's guidelines regarding proper sling application, loop selection, lift safety, and escalation procedures if concerns arise
Failure to Secure Mechanical Lift Sling Results in Resident Injury
Penalty
Summary
The facility failed to adhere to the manufacturer's guidelines for using a full body mechanical lift, resulting in a resident's fall and injury. The incident involved a resident with impaired functional status due to hemiparesis and a history of stroke, who was dependent on staff for transfers using a mechanical lift. During a transfer from a tub chair to a bed, the top right corner of the sling came off the lift, causing the resident to fall to the floor. This resulted in a large hematoma on the side of the resident's head, a skin tear on the finger, and necessitated an emergency department visit. The incident occurred when two nursing assistants were transferring the resident. One assistant hooked the sling to the lift and called for assistance, while the second assistant operated the lift without double-checking the sling's attachment. The failure to ensure the loops were securely attached to the lift led to the resident falling approximately three to four feet. The resident experienced significant pain and was hypertensive at the time of the incident, requiring immediate medical attention. Interviews with staff revealed that the facility's protocol required two staff members to verify the secure attachment of the sling before lifting a resident. However, this protocol was not followed, as the second assistant did not confirm the sling's secure attachment. The facility's policy did not explicitly direct staff to verify the loops were securely hooked prior to lifting, contributing to the oversight that led to the resident's fall and subsequent injuries.
Failure to Respect Resident Rights and Implement Appropriate Interventions
Penalty
Summary
The facility failed to respect and promote the rights of a resident, identified as R1, by placing a Wander Guard on his electric wheelchair without a comprehensive assessment or attempting less restrictive measures. R1, who had intact cognition and was able to operate his motorized wheelchair independently, was restricted from accessing the community despite not being identified as a wander risk. The facility's actions were based on an incident where R1 left the facility grounds to visit a nearby assisted living facility, which resulted in him being found in a ditch and subsequently returned by emergency services. R1's medical history included a stroke, aphasia, hemiplegia, and depression, but he was deemed safe to operate his power scooter and had a BIMS score indicating intact cognition. Despite this, the facility placed a Wander Guard on his wheelchair after the incident, restricting his movement and requiring supervision when outside. The facility did not conduct an assessment for the Wander Guard's application, and no other interventions were attempted before its placement. R1 expressed feeling more restricted and isolated after the Wander Guard was applied, which he believed worsened his depression. Interviews with staff and family members revealed that R1 valued his independence and had no history of elopement. The facility's policy required an elopement risk assessment and preventive interventions for residents identified as high risk, but these were not completed for R1. Staff acknowledged that the Wander Guard restricted R1's mobility and that no assessment was conducted to determine its necessity. The facility's failure to assess and implement appropriate interventions led to the deficiency in respecting R1's rights and individual needs.
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Illustrative
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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 Glenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Minnewaska Community Health Services | 7.3 mi | ★★★★★ | 8 | 0 |
| Knute Nelson Care Center | 16.3 mi | ★★★★★ | 7 | 0 |
| Bethany On The Lake Llc | 16.4 mi | ★★★★★ | 14 | 0 |
| Galeon | 19 mi | ★★★★★ | 7 | 0 |
| Cura Of Sauk Centre | 22 mi | ★★★★★ | 7 | 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.