Glenwood Village Care Center: Pressure Ulcer Failures - MN
The finding came out of a May 2025 inspection at the facility on Southeast 2nd Street. Inspectors spent part of the evening of May 20 watching a resident identified in the report as R47, a woman who required staff assistance to reposition and who had a pressure ulcer serious enough to be classified as stage three.
At 4:29 p.m., R47 was still in the same position she had been in when inspectors first observed her. At 4:51 p.m., staff wheeled her into the dining room for supper. She was being fed there at 5:55 p.m. At 6:15 p.m., a nursing assistant pushed her out of the dining room to the dayroom. At 6:20 p.m., she was finally wheeled to her room, lifted by mechanical lift onto her bed, and repositioned — more than an hour and a half after inspectors first noted she hadn't moved.
When inspectors spoke with the nursing assistant, identified as NA-B, at 6:38 p.m., she said she had arrived for her shift at 4:00 p.m. and R47 was already sitting in her wheelchair when she got there. She said she didn't know the last time R47 had been repositioned. She acknowledged that staff hadn't documented a repositioning time. She knew R47 should have been turned every two hours to prevent skin breakdown. She just didn't know whether it had happened.
The gap between knowing what should be done and knowing whether it was done is precisely what the inspection exposed.
The facility's director of nursing, interviewed at 5:57 p.m. the same evening, said repositioning frequency depended on a resident's Braden scale assessment and the location of the pressure ulcer, and could fall anywhere between one and three hours. If a care plan called for every-two-hour repositioning, she said, staff were expected to follow it unless a resident or family refused. She described repositioning as important to reduce the risk of further skin breakdown.
She also disclosed something significant: R47's wound had originally been assessed as a Kennedy ulcer, a type of skin breakdown sometimes associated with the dying process and considered potentially unavoidable. But after a clinic wound nurse evaluated it, the classification changed to a stage three pressure ulcer, a wound that has broken through the skin into the tissue beneath.
The distinction matters. A Kennedy ulcer classification can, in some circumstances, suggest a wound was unavoidable. A stage three pressure ulcer, particularly one in a resident whose care plan called for regular repositioning, raises different questions about whether the wound was adequately managed.
In a follow-up interview at 7:02 p.m., the director of nursing confirmed what inspectors had found and said clinical managers were responsible for setting up turning and repositioning programs. She said she had not been aware that another resident, R21, was not wearing her blue boots, a detail that suggests the repositioning and pressure injury prevention failures extended beyond R47 alone. She said her expectation was that staff follow each resident's care plan.
Expectations and execution were not matching.
The facility's own policy on preventing and managing pressure ulcers, last revised in March 2025, two months before the inspection, stated that residents admitted without pressure ulcers should not develop them unless clinically unavoidable, and that residents who already had ulcers should receive care to promote healing and prevent additional wounds. The policy laid out a system of Braden scale assessments, individualized care plans specifying repositioning frequency, and weekly wound documentation by a registered nurse.
A separate repositioning policy, revised in March 2024, said repositioning schedules would be identified in the care plan.
The policies existed. The care plan existed. The two-hour repositioning requirement existed. What didn't exist, on the evening inspectors watched R47 sit motionless in her wheelchair, was any record that anyone had turned her.
Pressure ulcers are graded on a scale from stage one, which involves reddened but intact skin, to stage four, which reaches bone, tendon, or muscle. A stage three wound has an open crater where the skin has been lost and subcutaneous tissue is visible. They are painful, prone to infection, and can deteriorate quickly without consistent offloading of pressure.
For a resident who cannot reposition herself, the people around her are her only protection against that progression.
NA-B said she didn't know when R47 had last been moved. The documentation said nothing. And R47 sat in her chair.
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.
The finding came out of a May 2025 inspection at the facility on Southeast 2nd Street.
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.