Glenwood Village Care Center: Call Light Left Out of Reach - MN
Inspectors visiting Glenwood Village Care Center found her that way three times.
The resident, identified in inspection records only as R23, had moderate cognitive impairment and dementia, along with hypertension. She depended entirely on staff for mobility and daily care. Her own care plan flagged her as a fall risk and listed a specific intervention: keep the call light within reach, and encourage her to use it.
The call light cord was attached to the wall.
On May 19, 2025, at 11:26 in the morning, inspectors found R23 seated in her reclining wheelchair. The cord was clipped to the wall, nowhere near her hands. That afternoon at 3:09, she was lying in bed. Still attached to the wall. The next morning, May 20, at 9:58 a.m., she was in bed again. The cord had not moved.
At 10:15 that same morning, inspectors sat down with a nursing assistant and a licensed practical nurse. Both said R23 was capable of using the call light. The nursing assistant looked at the cord, confirmed it wasn't within reach, pulled it off the wall, and placed it on the siderail next to R23. The LPN said her expectation was that the call light would have been within reach.
Nobody explained why it hadn't been.
The director of nursing, interviewed the following morning, said the same thing: R23 could use the call light, and her expectation was that it would have been placed where R23 could reach it.
What the care plan required, what the staff expected, and what actually happened in that room were three different things, and no one interviewed by inspectors offered an explanation for the gap.
The facility's own call light policy, last revised in January 2024, was explicit: when a resident is in bed or confined to a chair, the call light must be within easy reach.
R23 was confined to a chair. Then a bed. Then a chair again. Over the course of nearly 47 hours across two days of observation, the cord stayed on the wall.
For a resident who cannot stand, cannot walk, and cannot summon help any other way, a call light out of reach is not a paperwork problem. A fall in that room, unwitnessed, with no way to signal anyone, is the scenario the care plan was written to prevent.
The inspection, completed May 21, 2025, cited the facility for failing to ensure the call light was accessible. The violation was rated at the level of minimal harm or potential for actual harm.
R23 was still in her room when inspectors left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenwood Village Care Center from 2025-05-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
GLENWOOD VILLAGE CARE CENTER in GLENWOOD, MN was cited for violations during a health inspection on May 21, 2025.
Inspectors visiting Glenwood Village Care Center found her that way three times.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.