Glenwood Village Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated the floor staff would be expected to implement an immediate intervention until the nurse manager reviewed the fall and determines an appropriate intervention and then updates the resident's care plan and communicates revisions in the nurses' report.On 10/16/25 at 5:29 p.m., surveyor receive email from DON which revealed: After reviewing the fall that occurred on 9/26, it was noted that the nurse on duty implemented an intervention to keep the resident within view in the common area. However, upon further
review with the nurse manager responsible for the resident at the time, it was identified that an RN fall follow-up was not completed. We will be proceeding with progressive counseling for the RN regarding this incident and will provide education to all staff on appropriate fall interventions during our next team meeting
on 10/29. On 10/17/25 at 9:48 a.m., DON stated prior to Resident R1's fall on 9/26/25, Resident R1 had been reporting she fell but there was no bruising noted to the area. On 9/26/25, there was a progress note regarding increased rib pain. DON stated she was made aware of Resident R1's rib fractures on 9/29/25, and DON stated she was assuming Resident R1 had fallen against something because there was no evidence of other falls. DON stated she interviewed
a couple of the nurses who were not aware of any additional falls, and DON stated she should have investigated the fractures more following that. Further, DON confirmed Resident R1's two falls on 9/26/25, did not have evidence of a RN follow-up note or new interventions implemented to prevent future falls. DON stated Resident R1 had an x-ray of her arm following the fall on 9/26/25, and DON reviewed the radiology report and interpreted as not being a definite fracture but more than likely the fracture would have been associated with Resident R1's fall. DON confirmed Resident R1's fall that occurred on 10/5/25, did not have an RN follow-up completed either with a root cause analysis or new intervention. On 10/16/25 at 11;06 a.m., LPN-C stated Resident R1 would exhibit sundowning behaviors and want to leave the facility and Resident R1 would be challenging to redirect. LPN-C recalls Resident R1 reporting she had fallen but there was no documentation by staff of any other falls because no staff had found her, Resident R1 just kept reporting she fell. On 10/16/25 at 11:19 a.m., NA-G stated Resident R1 had impaired cognition and was at risk for falls. NA-G stated staff were assuming Resident R1 was falling and not reporting the falls to staff. NA-G stated she had heard noises coming from Resident R1's room but upon arrival Resident R1 was not on the floor and Resident R1 would deny a fall. On 10/21/25 at 10:42 a.m., attempted interview with Resident R1's physician unsuccessful. Review of facility policy titled Fall Prevention and Management revised 6/11/25, defined an intercepted fall as when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another p
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GLENWOOD VILLAGE CARE CENTER in GLENWOOD, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENWOOD, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GLENWOOD VILLAGE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.