Grand Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 28, 2023

  Based on interview and document review, the facility failed to provide adequate supervision when staff did not appropriately respond to a sounding exit door alarm for 1 of 3 residents (R1) identified at risk for elopement, who was able to exit the building, despite WanderGuard alarming, resulting in R1 being outside the facility without staff knowledge. This resulted in an immediate jeopardy (IJ). The immediate jeopardy began on 4/16/23, at approximately 3:00 a.m. when R1 was found outside the facility banging on the entrance door near the unit he resided on. The IJ was identified on 4/28/23, and the administrator was notified of the IJ on 4/28/23, at 5:45 p.m. […]

• Immediate jeopardy, isolatedF600Oct 13, 2021

  Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R2) with sexual behaviors, was comprehensively assessed and interventions implemented to mitigate risk to others and prevent subsequent sexual abuse of 1 of 1 resident (R1) reviewed whom was dependent on staff for their care. These findings resulted in an immediate jeopardy (IJ) situation for R1 when she was sexually abused by R2 while at the nursing home. The IJ began on 10/1/21, when the facility failed to implement appropriate interventions to protect a resident (R1) from sexual abuse after they became aware R2 was exhibiting inappropriate sexual behaviors toward staff, residents and R1. […]

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

  Based on observation, interview and document review, the facility failed ensure beard coverings were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 68 out of 68 residents that received food out of the kitchen or kitchenette. Findings included: During initial kitchen tour on 5/19/25 at 11:19 a.m., cook-A was observed in the kitchen not wearing a beard covering. Cook-A stated he had just finished making lunch. On 5/20/25 at 8:27 a.m., cook-B was observed in a unit kitchenette serving food to residents without a beard net. Cook-B's facial hair went from below the ears to the top of the neck and under the chin, and was approximately 1.5 inches long and shaggy in areas. […]

• No harm, potential for more than minimal, widespreadF880Sep 27, 2023

  Based on observation, interview and document review, failed to implement timely transmission-based precautions (TBP) and testing according to the Centers for Disease Control (CDC) for 1 of 1 residents (R10) who were displaying COVID-19 symptoms; and the facility failed to conduct COVID-19 outbreak testing was conducted according to CDC guidance for 4 of 4 residents (R21, R26, R21, R41) who were exposed to COVID-19 and 1 of 1 staff ( NA-D) who worked without participating in outbreak testing; and failed to ensure surveillance tracking of infections was completed for 6 of 6 residents (R118, R1, R14, R49, R15, R45) who displayed signs and symptoms of potential infection. This had the potential to affect all residents and staff. […]

• No harm, potential for more than minimal, patternF883Sep 27, 2023

  Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R5, R26, R19, R58, R61) reviewed for immunizations. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 admitted to the facility on [DATE], was [AGE] years old, at had diagnoses including hypertension, atrial fibrillation, and history of pancreatic cancer. The facility Immunization Report dated 9/27/23, identified R5 received the pneumococcal polysaccharide vaccine (PPSV23) on 12/2/08 and the pneumococcal conjugate vaccine (PCV13) on 10/30/15. […]