Grand Meadows Senior Living & Health Care

In the surveyor’s words

From the most serious findings on record at Grand Meadows Senior Living & Health Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 23, 2024

  Based on observations, staff interviews and facility policy review the facility failed to secure and supervise access to 2 out of 2 hot steam table surfaces. This failure resulted in the ability of eight cognitively impaired and independently mobile residents to access the areas that held the steam tables, therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of February 15, 2024 on April 17, 2024 at 3:10 p.m. Facility staff removed the Immediate Jeopardy on April 17, 2024 through the following actions: a. The meals will be served in the Bistro common dining room. b. […]

• Immediate jeopardy, isolatedF689Feb 25, 2021

  Based on clinical record review, observation and staff interviews the facility failed to provide assessment/intervention and supervision for one of five residents when the resident exhibited increased confusion and verbalized a desire to exit the facility. (Resident #1). Facility front entrance/exit door not alarmed allowing Resident #1 to exit the facility without staff knowledge, resulting in immediate jeopardy to health and safety.The facility reported a census of 27 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had severe cognitive impairment, no wandering behaviors exhibited, transferred from one surface to another with extensive assistance of two staff, and had [DIAGNOSES REDACTED]. […]

• Actual harm, isolatedF689Sep 13, 2022

  Based on observation, record review, and staff interview the facility failed to provide adequate supervision for one of three residents reviewed (Resident #1) to prevent a fall with injury. Resident #1 fell and sustained multiple facial fractures. The facility reported a census of 28 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had diagnoses that included [CONDITION(S)], [CONDITION(S)] and anxiety. Resident #1 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognitive status. The resident needed extensive assist of 1 staff with transfers and ambulation. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2024

  Based on observation, policy review, and staff interview the facility failed to date opened foods, use gloves appropriately for serving meals, keep hands off the drinking surfaces of drinking glasses, keep the ice machine clean, and keep the kitchen and household kitchenettes clean in order to serve meals under sanitary conditions. The facility reported a census of 30 residents. Findings include: During a continuous observation of the kitchen on 4/15/24 from 10:00 AM to 10:28 AM the following was revealed: A. [NAME] streaks running down the lip of the ice chute in the ice machine B. Egg noodles opened and undated C. Mandarin oranges in a Styrofoam cup covered in plastic wrap undated in the refrigerator D. […]

• No harm, potential for more than minimal, patternF550Mar 26, 2026

  Based on observation, resident and staff interview, and facility policy review the facility failed to ensure residents had a dignified dining experience for Resident #13 and four additional residents. The facility reported a census of 29 residents.Findings Include: Review of Resident #13's Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. The MDS further revealed diagnosis of unspecified dementia without behavioral disturbance and Diabetes Mellitus. On 3/26/26 at approximately 6:45 AM, an observation was made of residents brought to the dining table by Staff K Certified Nursing Assistant (CNA). Five residents were observed at the table by 7:00 AM. […]