GLENWOOD, MN - State health inspectors documented multiple violations at Glenwood Village Care Center related to inadequate repositioning of vulnerable residents, with one resident remaining in the same position for over six hours despite having pressure ulcers requiring frequent position changes.
Extended Periods Without Repositioning Documented
During a May 20, 2025 inspection, surveyors observed Resident 47 remaining in a wheelchair from before noon until after 6:00 p.m. without any repositioning. The resident, who required complete staff assistance for movement and changing of incontinence products, was observed at 12:19 p.m., 4:29 p.m., and 4:51 p.m. in the same seated position. Staff finally repositioned the resident at approximately 6:20 p.m. when she was transferred to bed.
A nursing assistant interviewed at 6:38 p.m. acknowledged that "R47 should have been repositioned every two hours to prevent skin breakdown" but admitted being "unsure of the last time R47 had been repositioned." The staff member noted that when she arrived for her 4:00 p.m. shift, the resident had already been sitting in the wheelchair for an unknown period. Documentation of repositioning times was notably absent from the resident's records.
Pressure Ulcer Prevention Protocols Not Followed
The facility's director of nursing confirmed that repositioning schedules typically ranged from one to three hours based on individual resident assessments and the location of any existing pressure ulcers. For residents with care plans specifying two-hour repositioning intervals, the expectation was clear compliance unless the resident or family refused the intervention.
The inspection revealed concerning issues with Resident 27's pressure ulcer management. Initially assessed as a Kennedy ulcer - a type of skin breakdown that can occur at end of life - the wound was later reclassified as a stage three pressure ulcer after evaluation by a wound care nurse. Stage three pressure ulcers involve full-thickness tissue loss where fat may be visible in the wound bed, representing significant skin damage that requires intensive intervention to heal.
Medical Risks of Inadequate Repositioning
Prolonged pressure on bony prominences restricts blood flow to tissues, leading to cellular death and breakdown. For individuals with limited mobility, regular repositioning every two hours is the cornerstone of pressure ulcer prevention. When residents already have existing wounds, the failure to reposition according to prescribed schedules can lead to wound deterioration, delayed healing, and development of additional pressure injuries.
Pressure ulcers progress through stages, with stage three ulcers indicating substantial tissue damage that extends through the epidermis and dermis into subcutaneous tissue. These wounds significantly increase infection risk, can become chronic non-healing wounds, and in severe cases may lead to systemic infections, osteomyelitis, or sepsis. Recovery from stage three pressure ulcers typically requires weeks to months of consistent wound care and pressure relief.
Facility Policies Contradicted by Practice
The facility's own "Preventing & Managing Pressure Ulcers And Wound" policy, revised March 5, 2025, explicitly stated that residents without pressure ulcers should not develop them unless clinically unavoidable, and those with existing ulcers must receive appropriate care to promote healing and prevent additional wounds. The policy required Braden scale assessments - a standardized tool measuring pressure ulcer risk - to be completed on admission, weekly for four weeks, quarterly, and with any significant change in condition.
Furthermore, the facility's Repositioning Policy mandated that each resident's repositioning schedule be clearly identified in their individualized care plan. The director of nursing confirmed that clinical managers were responsible for establishing turning and repositioning programs, with tissue tolerance tests and Braden scale monitoring for all residents.
Additional Issues Identified
The inspection also revealed that Resident 21 was not wearing prescribed blue boots, which are specialized positioning devices designed to prevent foot drop and heel pressure ulcers. The director of nursing stated she was unaware of this omission and emphasized that staff were expected to follow each resident's care plan precisely.
Documentation deficiencies were evident throughout the review, with staff failing to record repositioning times and interventions. The facility's wound care documentation requirements specified that registered nurses should complete weekly wound assessments, yet gaps in this critical documentation were apparent.
The inspection findings demonstrate systemic breakdowns in basic nursing care delivery, particularly for residents at highest risk for skin breakdown. Industry standards recognize frequent repositioning as fundamental to pressure ulcer prevention, with two-hour intervals representing the maximum time immobile residents should remain in one position. The facility's failure to maintain these basic standards placed vulnerable residents at unnecessary risk for painful, debilitating wounds that can significantly impact quality of life and overall health outcomes.
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.
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