Glenwood Village Care Center: Fall Safety Failures - MN
The resident, identified in inspection records only as R1, had been telling staff she was falling. Nobody could confirm it. A nursing assistant told inspectors she had heard noises coming from R1's room, but when she got there, R1 was not on the floor and denied falling. Staff assumed she was falling without reporting it. R1 had sundowning behaviors, wanted to leave the facility, and was difficult to redirect.
On September 26, a progress note documented increased rib pain. Three days later, the Director of Nursing learned R1 had rib fractures. The DON told inspectors she assumed R1 had fallen against something, interviewed a couple of nurses who weren't aware of any falls, and moved on. She acknowledged she should have investigated further. X-rays also revealed an elbow fracture. No RN follow-up note was completed for the two falls on September 26. No new interventions were put in place.
R1 fell again on October 5. She was agitated, refusing care. She was sent to the hospital and returned on palliative care. That fall also had no RN follow-up, no root cause analysis, no updated care plan.
The facility's own protocol required a nurse manager to review each fall, document a root cause analysis, determine an appropriate intervention, update the care plan, and communicate changes to staff. The charge nurse who had identified a short-term intervention — keeping R1 in a recliner in the commons area within view — never had that intervention formalized or communicated. The care plan was never revised.
After inspectors arrived in October, the DON sent an email saying the facility would pursue "progressive counseling" for the nurse involved in the September 26 falls and would provide staff education at a team meeting on October 29.
R1 was on hospice by the time inspectors completed their review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenwood Village Care Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GLENWOOD VILLAGE CARE CENTER in GLENWOOD, MN was cited for violations during a health inspection on October 22, 2025.
The resident, identified in inspection records only as R1, had been telling staff she was falling.
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.