Glenwood Village Care Center

Penalties

• Aug 25, 2023 — Fine ($15,592)

Inspection findings

1. Jul 1, 2026 Fire Safety · 5 findings
   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jul 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jul 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 31, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jul 1, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 9, 2026 · CMS fire safety

2. Dec 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 19, 2025 · CMS health inspection

3. Nov 10, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H54025822C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

4. Oct 22, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 26, 2025 · CMS health inspection

5. May 21, 2025 Health · 20 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Jun 23, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 17, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jun 17, 2025 · CMS fire safety

6. Jan 27, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H54024481C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Jan 10, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 28, 2025 · CMS health inspection

8. Aug 15, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Sep 9, 2024 · CMS health inspection

9. Mar 13, 2024 Fire Safety · 15 findings
   • Not serious Scope/severity C Complaint

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Apr 6, 2024 · CMS fire safety

   • Not serious Scope/severity C Complaint

     E0009 Emergency Preparedness Deficiencies

     Include a process for Emergency Preparedness collaboration.

     Corrected Apr 6, 2024 · CMS fire safety

   • Not serious Scope/severity C Complaint

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Apr 6, 2024 · CMS fire safety

   • Not serious Scope/severity C Complaint

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Apr 13, 2024 · CMS fire safety

   • Not serious Scope/severity C Complaint

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Apr 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Apr 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0661 Resident Assessment and Care Planning Deficiencies

     Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Apr 12, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 12, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Apr 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 5, 2024 · CMS fire safety

10. Sep 6, 2023 MDH complaint investigation · 1 finding
    • Severity not stated

      H54024742C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

11. Aug 25, 2023 Health · 2 findings
    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Aug 22, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Sep 21, 2023 · CMS health inspection

12. Feb 8, 2023 MDH complaint investigation · 1 finding
    • Severity not stated

      H54027858C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

13. Mar 16, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H5402028C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

14. Jan 10, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H5402027C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

15. Nov 30, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5402025C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• BOGIE, DOUGLAS — corporate director, NOT APPLICABLE, since 03/05/2017
• BRAATEN, SHARON — corporate director, NOT APPLICABLE, since 03/01/2022
• DAHLSENG, ALLEN — corporate director, NOT APPLICABLE, since 03/01/2022
• GARCIA, BILL — operational/managerial control, NOT APPLICABLE, since 01/23/2023
• GUGISBERG, MARNIE — operational/managerial control, NOT APPLICABLE, since 10/10/2022
• GUGISBERG, MARNIE — corporate officer, NOT APPLICABLE, since 10/10/2022
• ISDAHL, SHARON — corporate director, NOT APPLICABLE, since 03/04/2012
• JERGENSON, LAURA — corporate director, NOT APPLICABLE, since 10/29/2015
• MCGINTY, JODI — corporate director, NOT APPLICABLE, since 03/01/2021
• TALLE, THOMAS — corporate director, NOT APPLICABLE, since 03/03/2013
• URMAN, ANGELA — operational/managerial control, NOT APPLICABLE, since 10/10/2022
• KNUTE NELSON — operational/managerial control, NOT APPLICABLE, since 10/10/2022