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 41 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 41 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 0628 During a follow up interview on 5/21/25 at 9:42 a.m., SSD-A indicated Resident R22 went independently to the walk in clinic on 3/5/25, and was then sent to the emergency room , where Resident R22 was admitted and as a result, the Level of Harm - Minimal harm or bed hold was missed. SSD-A stated the facility expectation was to follow up and complete the bed hold in potential for actual harm those situations. SSD-A indicated the facility did not complete written notice of reason for transfers, but after shown the facility Transfer Discharge form indicated often they were only notified verbally. SSD-A indicated Residents Affected - Few the expectation was the Transfer Discharge forms were signed and sent to the ombudsman. At 9:49 a.m. SSD-A confirmed a written notice for transfer form had not been completed and the ombudsman had not been notified of Resident R64's transfer.

During an interview on 5/21/25 at 12:13 p.m., director of nursing (DON) confirmed Resident R22's medical record lacked a bed hold, written notification for transfer and ombudsman notification. DON stated the notifications were important for continuity of care and to update the correct people.

During a follow-up interview on 5/21/25 at 12:17 p.m., DON confirmed a written notice for transfer or ombudsman notification of transfer had not completed for Resident R64's transfer as was the expectation.

Review of facility policy titled Transfer/Discharge Policy revised 1/15/24, identified the resident and representative were notified in writing, which included: the specific reason for the transfer, effective date of

the transfer, specific location and explanation of the resident rights, notice of facility bed-hold policies, and name and address and telephone number of the LTC Ombudsman. A copy of the notice was sent to the LTC Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. When a resident was sent emergently to an acute care setting the notice would be provided as soon as was practicable. Bed-Hold policy would be provided to the resident and resident representative within 24 hours of emergency transfer. Documentation would include basis for transfer, that an appropriate notice was provided to the resident and/or legal representative, date and time of the transfer, new location of

the resident, mode of transportation, summary of resident's condition and other as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 41 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 0657 During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and indicated she was unaware Resident R34's ostomy and seatbelt had not been checked for over two hours. DON Level of Harm - Minimal harm or stated her expectations were staff were to be following each residents care plan. potential for actual harm Facility policy titled Comprehensive Care Plans revised 12/10/24, Each resident would have a Residents Affected - Few person-centered comprehensive care plan developed and implemented to meet their other preferences and goals, and address the residents medical, physical, mental, and psychosocial needs. When developing the comprehensive care plan, facility staff must, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Facility policy titled Restraints revised 7/1/24, It shall be the policy of the [NAME] Village Care Center that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 41 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 14 of 41 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 0679 .

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 41 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 24 of 41 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 26 of 41 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 0756 During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated Resident R34 had a history of Level of Harm - Minimal harm or reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes potential for actual harm were entered into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP Residents Affected - Few indicated the facility should have received a note to review this medication with the provider during last rounds.

During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware Resident R34 was receiving

the prophylaxis antibiotic. CM-B indicated Resident R34 did have a lot of UTI's in the past and thought Resident R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review Resident R34's eMAR and would provide additional documentation if any was found.

During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware Resident R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis and rationales with supporting documentation when receiving medications.

During a follow-up phone interview on 5/22/25 at 10:46 a.m., medical director (MD) indicated he was not Resident R34's primary provider and he was not aware Resident R34 was receiving a prophylaxis antibiotic. MD stated he was aware Resident R34 had experienced a lot of UTIs in the past and was probably on the medication due to Resident R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale

on why the resident was taking the medication.

Review of facility policy titled Antibiotic Stewardship Policy revised 2/21/25, it was the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners had documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 41 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 0757 During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated Resident R34 had a history of Level of Harm - Minimal harm or reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes potential for actual harm were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for

the physician to have additional notes and justification to support the continued antibiotic usage. CP Residents Affected - Few indicated the facility should have received a note to review this medication with the provider during last rounds.

On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD).

During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware Resident R34 was receiving

the prophylaxis antibiotic. CM-B indicated Resident R34 had a lot of UTI's in the past and thought Resident R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review Resident R34's eMAR and would provide additional documention if any was found.

During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware Resident R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis, duration and rationales with supporting documentation when receiving medications.

During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not Resident R34's primary provider and he was not aware Resident R34 was receiving a prophylaxis antibiotic. MD stated he was aware Resident R34 had

a lot of UTIs in the past and was probably on the medication due to Resident R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use.

Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 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 32 of 41 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 34 of 41 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 0865 Review of the facility form titled, quality assurance/assessment an performance plan (QAPI) revised 10/21/2022 , revealed the QAPI Program was to utilize an on-going, data driven, pro-active approach to Level of Harm - Minimal harm or advance the quality of life and quality of care for all residents of [NAME] Village Care Center (GVCC) Quality potential for actual harm Assurance and Performance Improvement principles would drive our decision making to promote excellence

in all resident and staff related areas. All facility staff, families and residents would be encouraged to identify Residents Affected - Many opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. GVCC would review the designated sources of data; identify areas where gaps in performance may negatively affect resident or staff outcomes. Where opportunities for improvement were detected, the QAPI Committee, with input from the leadership team would prioritize focus areas for performance improvement project (PIP) development. In prioritizing activities, the team would consider: high-risk to residents and/or staff, high-volume or problem-prone areas, health outcomes, resident safety and resident autonomy. The team would be interdisciplinary with staff representing each job role affected by the project and may include resident and/or family representation when appropriate. A project lead would be selected and would be responsible for coordinating, organizing and directing the activities of that specific project PIP team. The PIP team would identify the information needed to evaluate the problem at hand, supplies required, staff participation, and any equipment needs. The project lead would communicate any identified resource needs to the QAPI Quality Manager. The team would utilize root cause analysis to identify

the cause of the problem and any contributing factors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 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 0880 Review of a facility policy titled Cleaning of Blood Glucose Meter revised 1/24, identified blood glucose monitors that are shared among residents must be cleaned and disinfected between each use per Level of Harm - Minimal harm or manufactures guidelines to prevent carry-over of blood and infectious agents. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 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 0881 During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed there had been no reevaluation of duration and continued antibiotic use for Resident R34. CM-A indicated Resident R34's primary care provider Level of Harm - Minimal harm or was scheduled to complete rounds on 5/22/25, and the facility was going to has Resident R34's primary provider to potential for actual harm add supporting documentation of the continued use.

Residents Affected - Many During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated Resident R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for

the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have have reevaluated the use of this antibiotic.

On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD).

During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware Resident R34 was receiving

the prophylaxis antibiotic. CM-B indicated Resident R34 had a lot of UTI's in the past and thought Resident R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review Resident R34's eMAR and would provide additional documention if any was found.

During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) who was also known to be the infection preventionist of the facility, confirmed the above findings and stated she was unaware Resident R34 was taking the antibiotic. DON stated her expectations were all medications had proper diagnosis, duration and rationales with supporting documentation when receiving antibiotics. DON stated antibiotic use would have been discussed at QAPI meetings.

During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not Resident R34's primary provider and he was not aware Resident R34 was receiving a prophylaxis antibiotic. MD stated he was aware Resident R34 had

a lot of UTIs in the past and was probably on the medication due to Resident R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use.

Review of facility QAPI minutes dated 2/21/25 to 5/21/25 revealed the current QAPI projects included: hand hygiene, personal protective equipment (PPE), falls, and enhanced barrier precautions (EP). QAPI plan minutes lacked documentation of the antibiotic stewardship program.

Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45844 potential for actual harm Based on observation, interview and document review, the facility failed to ensure call lights were accessible Residents Affected - Few for 1 of 2 residents (Resident R23) reviewed for call light accessibility.

Findings include:

Resident R23's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified moderate cognitive impairment and diagnoses which included hypertension (elevated blood pressure) and dementia. Identified Resident R23 was dependent on staff for activities of daily living (ADLs) and mobility.

Resident R23's care plan dated 3/27/25, identified Resident R23 was at risk for falls, with an intervention to ensure the call light was within reach and to encourage Resident R23 to use the call light.

During an observation on 5/19/25 at 11:26 a.m., Resident R23 was seated in her reclining wheelchair in her room. Call light cord was attached to the wall and not within reach.

During an observation on 5/19/25 at 3:09 p.m., Resident R23 was lying in bed. Call light cord continued to be attached to the wall and was not within reach

During an observation on 5/20/25 at 9:58 a.m., Resident R23 was lying in bed. Call light cord was attached to the wall and not within reach.

During a joint interview on 5/20/25 at 10:15 a.m., NA-A and LPN-A stated Resident R23 was able to use the call light. NA-A verified call light cord was not within reach of Resident R23 and removed the call light cord from the wall and placed the cord on the siderail next to Resident R23. LPN-A stated Resident R23 was able to use the call light and her expectation was that Resident R23's call light would be placed within reach.

During an interview on 5/21/25 at 9:25 a.m., director of nursing (DON) verified Resident R23 was able to use the call light. DON stated her expectation was that Resident R23's call light would have been within reach of Resident R23 in her room.

Review of a facility policy titled Call Light Policy revised 1/2024, identified, when the resident/patient was in bed or confined to a chair to be sure that the call light was within easy reach of the resident/patient, and that

the resident/patient had a pendant on if they chose to do so.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 245402