Grundy Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 17, 2023

  Based on observations, interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136 and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touching Resident #136 and Resident #187. All 3 of these residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 psychosocial harm. These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 32. […]

• Immediate jeopardy, patternF689Aug 17, 2023

  Based on observations, interviews and record review, the facility failed to provide adequate supervision for all residents resulting in exploitation for 4 out of 4 residents reviewed (Resident #17, #20, #136, and #187). The facility must not allow verbal, mental, physical or sexual abuse. Resident #18 was found kissing resident #20 and inappropriately touched Residents #136 & #187. These residents had diminished cognitive functioning. Resident #18 was found sitting in Resident #17's doorway and would not leave when she asked him to, causing Resident #17 fear. The facility was aware of these and other incidents but failed to put interventions into place that would prevent Resident #18 from further exploiting female residents. […]

• Immediate jeopardy, isolatedF600Jan 7, 2025

  Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to protect a resident from physical and mental abuse for 1 of 3 residents reviewed (Resident #1). Staff A, Certified Nurse Aide (CNA), accepted money, kissed, sent inappropriate pictures via text, and exchanged inappropriate touch with Resident #1. The inappropriate interactions continued until Staff A resigned from the facility. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/16/24 on 1/6/25 at 2:55 PM The facility staff removed the Immediate Jeopardy on 1/7/25 by implementing the following actions: a. […]

• No harm, potential for more than minimal, widespreadF851Jan 8, 2026

  Based on interviews, schedule review and CMS (Centers for Medicare and Medicaid Services) document submission review, the facility failed to submit accurate licensed nurse coverage hours into the CMS system, resulting in the appearance of low weekend staffing and lack of 24 hour licensed coverage. The facility reported a census of 30 residents. Findings include:Review of the facility's licensed coverage submission for the 4th quarter of July 1, 2025 - September 30, 2025, listed the facility short of the 24 hours requirements:7/5/25 (Saturday); 12.97 hours7/6/25 (Sunday): 18.92 hours7/12/25 (Saturday): 18.31 hours7/13/25 (Sunday): 17.86 hours9/20/25 (Saturday): 17.48 hoursAn email sent by the Administrator on 1/6/26 at 12:24 PM, documented she looked at the facility's payroll system to see… […]

• No harm, potential for more than minimal, widespreadF725Aug 1, 2024

  Based on observation, document review and staff interview, the facility failed to ensure licensed nurse coverage 24 hours a day. On 6/15/24 the night nurse clocked out at 6:45 AM and the day nurse clocked in at 8:41 AM The facility did not have a licensed nurse on duty, in house during that time frame. The facility staff contacted the Director of Nursing (DON) and the Administrator who failed to act to immediately to provide licensed coverage. The facility identified 15 diabetic residents, 8 of whom are insulin dependent with one resident (Resident #7) who had a blood glucose reading of 65, during the time the facility didn't have no licensed nurse coverage. […]