Grand Meadows Senior Living & Health Care

Inspectors wroteBased 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. Several residents including Resident #13 were heard repeatedly asking for something to drink. [...]

Inspectors wroteBased on record review, staff interviews and facility policy review the facility failed to notify the physician of change in resident transfer status and pain in left ankle for 1 out of 1 resident reviewed with injury of unknown origin (Resident #25). The facility identified a census of 29 residents.

Inspectors wroteBased on record review, interviews, and the Medicare Claims Processing Manual the facility failed to provide a resident with form CMS-10055 (Centers for Medicare & Medicaid Services) at the end of therapy services when the resident planned to remain in the building for one of three residents reviewed for Beneficiary Notice (Resident #20). The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to document targeted behaviors and provide non-pharmacological interventions prior to the use of an as needed antianxiety medication for 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, record review, staff interviews, and facility policy review the facility failed to assess and intervene for a resident with a fall which resulted in a fracture (Resident #1) and for a major injury of unknown origin (Resident #25) for 2 out of 2 residents reviewed with injuries. The facility reported a census of 29 residents.

Inspectors wroteBased on observation, record review and staff interviews the facility failed to provide enhanced barrier precautions to prevent the spread of infections for 2 out of 4 residents ( Resident # 7) with a catheter and (Resident # 11) with an open wound. The facility identified a census of 29 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the pneumococcal vaccine for 2 of 5 residents reviewed (Resident #7 and Resident #13). The facility reported a census of 29 residents. Findings Include: 1. The admission Minimum Data Set (MDS) assessment tool, dated 3/2/26 revealed Resident #7 admitted to the facility on [DATE]. The MDS revealed the resident had severely impaired cognition for daily decision making. The admission MDS documented the resident received a Influenza vaccine outside the facility, was not up to date with pneumococcal vaccination, and was not offered a pneumococcal vaccine. The Immunization Consent Form for Resident #7 dated 10/24/24 documented the resident received a Covid vaccine and Influenza vaccine. There was no documentation of a pneumococcal vaccine. [...]

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview, and review of the facilities Resident's Rights form revealed staff failed to treat 1 of 3 residents with dignity and respect during cares as a means to maintain their individual resident rights (Resident #3).

Inspectors wroteBased on observation, kitchen record review, interview, and policy review the facility failed to store food according to professional guidelines and to clean dishes under sanitary conditions during 1 of 2 kitchen observations. Dry storage and the refrigerator contained expired, unlabeled, and undated items. Dishwasher sanitizer logs were not maintained and the sanitizer sink did not register chemical content. The facility reported a census of 29 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to provide range of motion services to improve or maintain functioning in all extremities for 1 out of 1 residents reviewed (Resident #11). The facility reported a census of 29 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and record review the facility failed to provide trauma informed care for 1 of 5 residents reviewed (Resident #15). The resident arrived at the facility on 2/17/25 with diagnoses of PTSD (Post Traumatic Stress Disorder), anxiety, adjustment disorder, and depression and was not assessed for potential triggers that could cause re-traumatization. The facility reported a census of 29 residents.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to ensure psychotropic medications were used only to treat documented conditions for 1 of 5 residents reviewed for unnecessary medications (Resident #25). The facility did not respond to the pharmacist's request to document resident behaviors or implement non-pharmacological interventions to help reduce anxiety. The facility reported a census of 29 residents.

Inspectors wroteBased 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. All meals will be served in this location until the barriers can be placed between resident care areas and the kitchen serving area where the steam tables are located. c. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to keep garbage cans covered near food preparation surfaces to provide a sanitary cooking environment. The facility reported a census of 30 residents.

Inspectors wroteBased on record review, resident and staff interview and policy review the facility failed to prevent a resident from neglect for 1 out of 1 residents who reported abuse (Resident #35). The facility reported a census of 30 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to complete a thorough investigation of allegation of abuse to prevent further abuse. The facility reported a census of 30 residents.

Inspectors wroteBased on staff interviews, facility record review, and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to provide appropriate assessment and interventions for one of three residents reviewed. (Resident #1). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to appropriately supervise one of three residents to ensure their safety. (Resident #1). The facility reported a census of 26 residents.