GLENWOOD, MN — Federal health inspectors cited Glenwood Village Care Center for failing to implement a resident's individualized care plan, including a gap of more than two hours without monitoring an ostomy appliance and seatbelt restraint, according to a May 2025 survey completed by the Centers for Medicare & Medicaid Services (CMS).
Two-Hour Gap in Ostomy and Restraint Monitoring
During the May 21, 2025 inspection, surveyors identified that staff at the 719 Southeast 2nd Street facility had not checked on a resident identified as R34 for a period exceeding two hours. The resident required regular monitoring of both an ostomy appliance and a seatbelt restraint — two care needs that demand consistent staff attention under federal nursing home regulations.
An ostomy appliance requires routine checks to ensure proper function, skin integrity around the stoma site, and that no leakage has occurred. When ostomy bags are not monitored at appropriate intervals, residents face increased risk of skin breakdown, irritation, and infection at the stoma site. Prolonged contact with ostomy output can cause chemical burns to surrounding skin tissue and lead to painful dermatological complications that may require additional medical intervention.
The restraint component adds another layer of clinical concern. Seatbelt restraints, while sometimes medically necessary, must be monitored at regular intervals to ensure the resident has not shifted into a position that could restrict breathing, impair circulation, or cause nerve compression. A two-hour gap without a restraint check significantly increases the risk of positional injury.
Director of Nursing Confirms Monitoring Lapse
During an interview conducted at 3:18 p.m. on May 21, 2025, the facility's director of nursing (DON) confirmed the inspection findings and acknowledged she had been unaware that R34's ostomy and seatbelt had gone unchecked for the extended period.
The DON stated that "her expectations were staff were to be following each resident's care plan," indicating a disconnect between facility leadership expectations and the care actually delivered on the floor.
This type of gap — where leadership assumes protocols are being followed but has no verification system in place — represents a systemic concern rather than a single isolated incident. Effective care plan implementation requires not only written protocols but also audit mechanisms, staff accountability measures, and consistent supervisory oversight.
Care Plan and Restraint Policies Under Scrutiny
The deficiency was cited under F 0657, which governs the development and implementation of comprehensive, person-centered care plans. Federal regulations require that each nursing home resident have an individualized care plan that addresses their medical, physical, mental, and psychosocial needs, developed using Minimum Data Set (MDS) assessment data.
Glenwood Village's own internal policy on comprehensive care plans, revised as recently as December 10, 2024, states that each resident should have a person-centered plan "developed and implemented to meet their other preferences and goals." The facility's restraint policy, revised July 1, 2024, specifies that restraints should only be used for resident safety after alternatives have been tried, and must never be applied for staff convenience or discipline.
The citation suggests the facility had appropriate written policies in place but failed in the execution of those policies at the bedside level.
Scope and Severity Assessment
Inspectors classified the deficiency at a level indicating minimal harm or potential for actual harm, affecting few residents. While the harm level was assessed as minimal in this instance, the underlying systems failure — staff not following care plans and leadership not monitoring compliance — has the potential to produce more serious outcomes if left unaddressed.
Residents who depend on ostomy care and restraint monitoring are among the most clinically vulnerable individuals in any nursing facility. Their inability to self-manage these medical needs makes them entirely reliant on staff adherence to care protocols.
The full 41-page inspection report contains additional findings from the May 2025 survey. Families and advocates seeking complete details about all cited deficiencies can access the full CMS report through the Medicare Care Compare website or by contacting the Minnesota Department of Health survey agency directly.
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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