GLENWOOD, MN - State health inspectors identified critical lapses in fall prevention protocols at Glenwood Village Care Center, including failures to update care plans with new safety interventions and improper equipment storage that created ongoing fall risks for vulnerable residents.
Fall Prevention Protocols Not Communicated to Staff
During a May 21, 2025 inspection, investigators discovered that staff members were unaware of critical fall prevention measures that had been implemented for a resident identified as R15. The resident had experienced a fall that prompted new safety interventions, but these crucial changes were never incorporated into the formal care plan that guides daily staff actions.
A non-mechanical lift device, specifically designated to assist R15 with mobility, was supposed to be removed from the resident's room after each use to prevent unauthorized attempts at self-transfer. However, inspectors found the equipment remained in R15's bathroom even after the resident had been assisted to the dining room.
When questioned, a nursing assistant confirmed placing the standaid back in R15's bathroom after helping the resident to bed on May 20, stating she "was unaware the non mechanical lift was not supposed to be stored in R15's bathroom." A trained medical aid interviewed the following morning similarly reported having no knowledge that the equipment needed to be removed after assisting the resident.
Management Unaware of Safety Changes
The breakdown in communication extended to supervisory levels. The facility's clinical manager acknowledged during the inspection that she had not been informed about the new intervention for R15. "CM stated that was implemented by another staff," according to the inspection report, and confirmed the critical safety measure had not been updated in the resident's care plan.
This oversight violates fundamental nursing home safety protocols. Care plans serve as the primary reference document for all staff members providing direct resident care. When fall prevention strategies are modified but not documented, staff cannot consistently implement protective measures, leaving residents vulnerable to preventable injuries.
Falls represent one of the most serious risks in long-term care facilities. For elderly residents, a single fall can result in hip fractures, head injuries, or other trauma that dramatically reduces quality of life and independence. Studies show that residents who fall once face significantly increased risk of subsequent falls, making proper prevention protocols essential.
Facility Policy Violations Documented
The inspection findings revealed clear violations of the facility's own Fall Prevention and Management policy dated December 10, 2024. According to this policy, staff nurses are required to assess all factors contributing to fall events, recommend interventions and changes to the plan of care to prevent repeat falls, and communicate and document results in the medical record.
The policy specifically mandates that nurses review occurrence reports, analyze environmental and equipment factors, and ensure all recommended interventions are properly documented and communicated to staff. These steps are designed to create a comprehensive safety net around residents identified as fall risks.
Standard medical practice in long-term care requires immediate care plan updates whenever new safety interventions are implemented. This ensures continuity of care across all shifts and prevents dangerous gaps in resident protection. The failure to update R15's care plan meant that multiple staff members were operating without critical safety information.
Director of Nursing Acknowledges Failures
The facility's director of nursing confirmed the inspection findings and acknowledged that the new intervention "should have been added to R15's care plan." The DON stated expectations were clear: "if a new intervention was put in place that it was added to the care plan and staff were to follow it."
By the afternoon of the inspection, the clinical manager reported that R15's care plan had been updated to reflect the fall intervention and the non-mechanical lift had been moved out of the resident's bathroom. However, this corrective action came only after state inspectors identified the violation.
Additional Issues Identified
The inspection also noted problems with follow-up documentation requirements. The facility's policy requires specific timelines for completing fall follow-up documentation in medical records, but the inspection suggests these protocols were not being consistently followed.
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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