F 0609 During an interview on 5/21/25 at 2:27 p.m., CTC confirmed Resident R15 had talked to the CTC about the incident that took place on 11/5/24. CTC did not remember the exact date and time Resident R15 talked with the CTC. CTC Level of Harm - Minimal harm or stated Resident R15 did not appear to have any bruising and a full investigation was completed. CTC further stated potential for actual harm CTC did not feel it needed to be reported to the SA.

Residents Affected - Few During an interview on 5/21/25 at 2:34 p.m., administrator indicated if a resident had any abuse allegations

the administrator would work with the director of nursing (DON) and social services to complete a through investigation. Administrator stated the staff member would be placed on a leave while the investigation was being completed. Administrator further stated she did not remember receiving a call from C-A and she would look for any information regarding this incident. Administrator indicated if abuse was suspected there should have been a report sent to the SA within two hours of the allegations being discovered.

During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware Resident R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to look into Resident R15's allegations and attempt to find documentation regarding the allegations.

Requested a copy of the investigation report, however one was not provided.

Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, the plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, has been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. If the events did not result in serious bodily injury, the individual should report the suspicion immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware Resident R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to Level of Harm - Minimal harm or look into Resident R15's allegations and attempt to find documentation regarding the allegation. potential for actual harm Requested a copy of the investigation report, however one was not provided. Residents Affected - Few

Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, The plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, had been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. The notice to the SA should include the occurrence of such incident, type of abuse that was committed, date/time the alleged incident occurred, name (s) of all persons involved in the alleged incident and what immediate action was taken by the facility. The administrator, or a designee, would provide

the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 During a follow-up interview on 5/21/25 at 3:18 p.m., DON was not aware Resident R34 did not have oral cares completed. DON stated oral care audits were being completed and CM-A should have removed the audit Level of Harm - Minimal harm or card within 12 hours of placing it to ensure Resident R34 had oral cares completed that day. DON indicated oral cares potential for actual harm should have been completed two times a day and staff should have returned the card to the CM. DON stated her expectations were residents received oral cares two times daily. Residents Affected - Few

Review of a facility policy titled Activities of Daily Living (ADLs), Supporting revised 3/20/25, identified residents would be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Identified, appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, shaving, grooming, and oral care).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 - 4:29 p.m., Resident R47 remained in the same position.

Level of Harm - Minimal harm or - 4:51 p.m., Resident R47 into the dining room and placed Resident R47 at the table to be fed supper. potential for actual harm - 5:55 p.m., Resident R47 was being fed by staff in the dining room. Residents Affected - Few - 6:15 p.m., Resident R47 nursing assistant (NA)-B pushed Resident R47 out of the dining room and to the dayroom.

During an observation on 5/20/25 at 6:20 p.m., NA-B wheeled Resident R47 to her room. NA-B, NA-C, and registered nurse (RN)-A sanitized hands, and hooked Resident R47 up to the mechanical lift, placed Resident R47 onto the bed, changed Resident R47's incontinent product and repositioned Resident R47.

During an interview on 5/20/25 at 6:38 p.m., NA-B stated Resident R47 required staff assistance to reposition and change incontinent products. NA-B stated she was unsure of the last time Resident R47 had been repositioned because when she arrived to work at 4:00 p.m., Resident R47 had already been sitting in her wheelchair. NA-B stated staff had not documented the time that Resident R47 had been repositioned but stated Resident R47 should have been repositioned every two hours to prevent skin breakdown.

During an interview on 5/20/25 at 5:57 p.m. director of nursing (DON) stated the usual facility procedure for pressure ulcer repositioning depended on a resident's Braden assessment, location of the resident's pressure ulcer, and repositioning could have been completed between one to three hours. DON stated if it was care planned for every two hours repositioning, it was expected to be done, unless the resident or family refused. DON stated repositioning was important to reduce risk for further skin breakdown. DON stated Resident R27's pressure ulcer was first assessed as a Kennedy ulcer however, was then changed to a stage three pressure ulcer after the clinic wound nurse assessed it.

During a follow-up interview on 5/20/25 at 7:02 p.m., DON confirmed the above findings and stated the clinical managers set up the turning and reposition programs. DON indicated the facility did complete tissue tolerance tests and each resident was monitored through the Braden scale. DON stated she was not aware Resident R21 was not wearing her blue boots. DON said her expectations were for staff to follow the care plan for each resident and reposition them as indicated.

Review of facility policy titled Preventing & Managing Pressure Ulcers And Wound revised 3/5/25, identified that a resident who was admitted to this facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable, and that a resident who had an ulcer received cares and services to promote healing and to prevent additional ulcers. The policy included instructions for a body audit to be completed with the first 24 hours of admission, a Braden scale be completed on admission then weekly times four, quarterly, and with any significant change and annually. The individualized resident care plan would indicate the frequency of repositioning and/or off loading, special cushions or devises to be used in the bed or chair, and special nourishments. With the guidance of the registered nurse, wound care nurse, or physician, staff would follow the treatment orders to care for the wound, and weekly wound documentation would be completed by a registered nurse.

Review of a facility policy titled Repositioning Policy revised 3/24, identified a resident's repositioning schedule would be identified in the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an observation on 5/21/25 at 7:16 a.m., Resident R15 was in the dining room. The standaid remained in Resident R15's room. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/20/25 at 4:30 p.m., NA-E confirmed NA-E assisted Resident R15 to bed on 5/20/25, and placed the non mechanical standaid back in the bathroom. NA-E stated she was unaware the non Residents Affected - Few mechanical lift was not supposed to be stored in Resident R15's bathroom.

During an interview on 5/21/25 at 9:41 a.m., trained medical aid (TMA)-A stated TMA-A was not aware the non mechanical lift was to be removed from Resident R15's room after staff assisted Resident R15.

During an interview on 5/21/25 at 9:43 a.m., clinical manager (CM) indicated she was not aware of the new intervention for Resident R15. CM stated that was implemented by another staff. CM confirmed it was not updated in Resident R15's care plan.

During a follow-up interview on 5/21/25 at 12:30 p.m., CM stated Resident R15's care plan had been updated to reflect

the fall intervention and the non mechanical lift had been moved out of Resident R15's bathroom.

During an interview on 5/21/25 at 3:10 p.m., director of nursing (DON) confirmed the above findings and stated it should have been added to Resident R15's care plan. DON stated her expectations were if a new intervention was put in place that it was added to the care plan and staff were to follow it.

Facility policy titled Fall Prevention and Management dated 12/10/24, the staff nurse will review the occurrence report and will:

- Assess all factors contributing to the fall event such as environment, equipment, medication factors and which interventions were in place at the time of the fall using Fall follow up form as a guideline.

- Recommend interventions and changes to plan of care to prevent repeat fall.

- Communicate and document results.

- The staff nurse will complete the follow up documentation in the medical record by the following schedule.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a resident council meeting on 5/20/25 at 1:00 p.m., Resident R22 stated she had brought up concerns about

the food being cold at resident council meeting however, nothing had ever been done about it. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/19/25 at 1:05 p.m., DM stated the holding temperature for hot food should be at least 135 degrees Fahrenheit (F). and the temperature of cold food should be at 41 degrees Fahrenheit (F). Residents Affected - Some or lower. DM stated her expectation was that all food would have been at the proper holding temperatures.

During an interview on 5/19/25 at 1:39 p.m., Resident R62 stated the meat and potatoes were cold and the potato salad was lukewarm.

Review of a facility policy titled Food Service Policy revised 5/20/25 identified hot foods were to be served hot and cold food was served cold. Identified hot food must reach a holding temperature of 135 degrees Fahrenheit (F).and cold foods must be maintained at 41 degrees Fahrenheit (F).or below until served.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 245402 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245402 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Glenwood Village Care Center 719 Southeast 2nd Street Glenwood, MN 56334

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -ketchup opened, undated.

Level of Harm - Minimal harm or Sunrise Cove kitchenette refrigerator: potential for actual harm -cocktail sauce opened, dated 1/31/25. Residents Affected - Many -french dressing opened, dated 1/13/25.

-ranch dressing opened, dated 2/11/25.

-soy sauce opened, undated.

-ketchup opened, undated.

Sunrise Cove resident refrigerator:

-Chinese dish of food, not labeled, undated.

-small cardboard container, initialed, undated.

During an interview and initial tour on 5/19/25 from 11:22 a.m. to 11:55 a.m., DM-A confirmed the above findings and confirmed expectations of all foods to be covered, labeled and dated. DM-A stated the dietary aides were responsible for dating items and removing items out of date. DM-A indicated was unsure how long dressings and sauces should have been kept in the refrigerator once opened, and then disposed of dressings and sauces identified and listed above.

Review of facility policy titled Food Storage, revised 5/20/25, identified purpose to store food in it's appropriate place and within it's appropriate expiration date to ensure foods were consumed by the safe used by date or discarded. Foods would be stored to prevent contamination and cross contamination. All food containers would be legible and accurately labeled.

Review of facility policy titled Food Brought In By Family/Visitors Policy revised 2/18/24, identified food brought into the facility by visitors and family was permitted. The policy identified family was instructed that any food kept in facility coolers was to have resident name and date on the container. Any food not labeled or dated was to be discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 245402