Glenwood Village Care Center

In the surveyor’s words

From the most serious findings on record at Glenwood Village Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 22, 2025

  Based on observation, interview, and document review, the facility failed to implement immediate interventions to prevent re-occurrence following a fall from a full body (EZ Way) mechanical lift for 1 of 1 residents reviewed (R4) who sustained two brain bleeds and a fracture. This resulted in an immediate jeopardy (IJ). In addition to the resident in immediate jeopardy, the facility failed to implement person centered fall interventions and complete a fall analysis for 1 of 3 residents reviewed (R1) who had multiple falls and fractures identified which resulted in actual harm.The immediate jeopardy began on 10/16/25, when R4 returned to the facility from a hospital stay related to her injuries that were sustained after she fell from the fully body mechanical lift during a transfer and upon… […]

• Immediate jeopardy, isolatedF689Aug 25, 2023

  Based on interview and document review the facility failed to follow care plan fall interventions for 1 of 3 residents (R1) reviewed for falls. This failure resulted in R1 sustaining serious injuries requiring hospitalization and surgery. Due to complication related to the surgery, R1 died . This failure resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on [DATE] at 1:00 p.m., when R1 rolled out of bed, fell on to the floor, and sustained fractures of the hip, pelvis and humerus (long bone in the arm runs from shoulder to the elbow). R1 was hospitalized , underwent surgery to repair her hip fracture and died due to complications from the fractures. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:45 p.m. […]

• Actual harm, isolatedF689Jan 10, 2025

  Based on observation, interview, and document review, the facility failed to follow manufacturer's guidelines for a full body mechanical lift by ensuring the loops were secured to the hook on the lift, prior to lifting the resident for transfer for 1 of 3 residents (R1) reviewed. This resulted in actual harm when the hook came off the lift and R1 fell to the floor sustaining a large hematoma to the side of his head, a skin tear to finger and required an emergency department (ED) visit. Findings include: R1's care plan dated 6/15/23, indicated R1 had impaired functional status related to hemiparesis, history of stroke and had limited ability to complete activities of daily living (ADLs), dependent on staff for assistance, and utilized a wheelchair and mechanical lift. […]

• Actual harm, isolatedF760Mar 7, 2022

  Based on interview and document review, the facility failed to follow physician's orders for 1 of 3 residents (R1), when R1's medication change was omitted for 7 days. This resulted in harm when R1 was hospitalization and had a decline in activities of daily living (ADLs) as a result of the error. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS indicated R1 had no cognitive impairments and required extensive assistance by one staff member for activities of daily living (ADLs) such as bed transfers, ambulation, dressing and toileting. Review of facility report to the State Agency (SA) dated 2/10/22, indicated R1 received an order on 2/3/22, with medication changes. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2025

  Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 63 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date. Findings include: During the initial tour of the main kitchen and kitchenettes on 5/19/25 at 11:22 a.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A: kitchen refrigerator: -Thirteen sandwiches were covered with plastic on a try, undated. -one bag cabbage wrapped, undated. […]