Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grundy Care Center during CMS and state inspections, most recent first.
Inaccurate PBJ Licensed Nurse Coverage Submission: The facility failed to submit accurate direct care staffing data to CMS, resulting in PBJ records showing several weekend days with less than 24 hours of licensed nurse coverage. The Administrator stated the payroll system did not transfer daily sheet hours correctly, some hours had to be entered manually, and the submission was not accurate even though the facility had the weekend and licensed coverage needed.
Unsafe Glove Use During Food Prep: A cook wore gloves while passing meals and then used the same gloves to touch potholders, a microwave, a bag of buns, and a resident’s hamburger and bun while assembling a sandwich. The Administrator and Dietary Mgr acknowledged the glove use and hand hygiene issue, and the facility policy required safe hygienic practices and prevention of cross-contamination.
A resident with dementia and severe cognitive impairment, identified in the care plan as high risk for wandering and elopement, exited the building without staff knowledge or supervision and was found in the hospital parking lot across the street. Video review showed the resident outside the facility and crossing the street, and the Administrator stated the resident likely followed a subcontractor out a back door after the alarm was deactivated; no door alarm sounded before the resident was found.
A resident with a history of neurogenic bladder, anxiety, bipolar disorder, depression, PTSD, and paraplegia was subjected to physical and mental abuse by a CNA. The CNA engaged in inappropriate interactions, including kissing and sending inappropriate pictures, which continued until the CNA resigned. The resident experienced increased isolation and depression due to the relationship, and the facility failed to implement its abuse prevention and reporting policy effectively.
The facility failed to ensure 24/7 licensed nurse coverage as required by policy. The PBJ Staffing Data Report indicated missing coverage on specific dates, and the facility could not immediately verify shifts due to reliance on an external company for time card management. Staff provided a list of scheduled nurses, but verification was pending. The policy mandates continuous licensed nurse presence for supervision and care.
The facility failed to maintain appropriate staffing levels, lacking RN coverage and a DON on several occasions. The DON left without notice, and the facility relied on temporary staff. The PBJ report showed missing RN coverage on multiple dates, and the facility's policy of having an RN for at least eight hours daily was not met.
The facility failed to notify a resident's representative and the LTC Ombudsman of transfers to the hospital for two residents, as required by federal regulation. One resident's guardian was not informed of the hospital admission, and the facility's administrator acknowledged the oversight in notifications.
A facility failed to update the PASRR evaluation for a resident diagnosed with a new mental health condition, delusional disorder. Despite the resident's intact cognition and initial diagnoses of anxiety and depressive disorders, the facility did not request an updated PASRR following the new diagnosis. Interviews with the ADON and DON confirmed the oversight, acknowledging the requirement for a new screening per facility policy.
The facility failed to supervise a resident during medication administration and did not accurately process physician orders, leading to continued administration of a discontinued medication. Additionally, the facility did not notify a physician about a resident's high blood glucose level as required, lacking documentation of such notification.
A resident with moderate cognitive impairment and multiple diagnoses developed a UTI associated with an indwelling catheter. The facility failed to prevent the catheter tubing from dragging on the floor, as observed during a walk with a CNA. The DON and ADON acknowledged the infection control lapse, which contradicted the facility's catheter care policy.
The facility failed to keep medication and treatment carts locked when not supervised, as observed during a survey. On several occasions, the carts were found unlocked and unattended in the hallway, with staff and residents passing by. Despite the facility's policy requiring locked compartments for medications, the carts were repeatedly left unsecured, indicating a lack of adherence to the policy.
The facility failed to store food safely, as observed in the kitchen's refrigerators and freezers where opened items were unsealed and lacked proper labeling. The Dietary Manager acknowledged the oversight, and the Administrator confirmed the expectation for labeling. The facility's policy requires all stored foods to be covered, labeled, and dated.
The facility failed to maintain the highest well-being of residents by not sustaining their Plan of Correction to ensure required members attended quarterly QAPI meetings. Despite a POC, the DON and IP were frequently absent from these meetings, as shown by attendance records. The Interim Administrator confirmed the expectation for all department heads and the Medical Director to attend.
The facility failed to ensure the required members, including the DON and IP, were present at QAPI meetings. Attendance records showed the DON was absent from several meetings, and the IP was also missing from multiple sessions. The Interim Administrator confirmed the expectation for quarterly meetings with all key members present, as per facility policy.
Two residents with severe cognitive impairments and mobility issues were not repositioned according to the facility's policy, leading to skin care deficiencies. One resident was left in a recliner for hours, resulting in severe excoriation and bleeding, while another was observed in the same position for extended periods, contrary to the required repositioning schedule. Staff acknowledged the lack of repositioning, which was inconsistent with the facility's policy for preventing skin breakdown.
A resident was transferred to the hospital without the facility providing the Bed Hold policy to the resident or their representative. The facility's records lacked documentation of notification, and the resident's guardian was not informed of the hospital admission. The facility's policy requires notification of Bed Hold policies at least twice, but this was not adhered to in this instance.
A facility failed to accurately document and manage a resident's pressure ulcers, leading to inconsistent wound assessments. The resident's records showed discrepancies in the measurement and staging of a wound on their right buttock, with different nurses documenting varying details each week. Staff interviews revealed a lack of specialized training in skin assessments, contributing to the inconsistency in documentation.
A long-term care facility failed to maintain licensed nurse coverage 24/7, leaving a gap from 6:45 AM to 8:41 AM. During this time, a resident with a tracheostomy and another with diabetes requiring insulin were at risk due to the absence of a licensed nurse. Staff were aware of the situation but unable to perform necessary medical interventions, highlighting a significant lapse in care and oversight.
The facility failed to follow the planned menu for residents, serving a different meal than listed without obtaining dietitian approval. The Dietary Manager made last-minute changes without informing the dietitian, and the cook improvised due to unavailable menu items, leading to unmet nutritional needs.
A cook at the facility was observed handling ready-to-eat food with contaminated gloves during meal service, touching various surfaces before serving the food to residents. The Dietary Supervisor confirmed the expectation to prevent foodborne illness by not using bare hands or contaminated gloves, as per the Food Code.
The facility failed to employ sufficient staff with the necessary competencies in the food and nutrition service. A part-time consultant Dietitian was employed, and the Dietary Supervisor lacked required certification and experience, having only worked at the facility for two weeks and not completed necessary education or certification programs. The facility could not provide documentation of the Dietary Supervisor's certification.
Inaccurate PBJ Licensed Nurse Coverage Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data. Review of the facility’s licensed coverage submission for the 4th quarter of July 1, 2025 through September 30, 2025 showed several days with less than the required 24 hours of licensed nurse coverage, including 7/5/25 with 12.97 hours, 7/6/25 with 18.92 hours, 7/12/25 with 18.31 hours, 7/13/25 with 17.86 hours, and 9/20/25 with 17.48 hours. The facility reported a census of 30 residents. An email from the Administrator stated she reviewed the payroll system to determine why the daily sheet hours did not transfer over. She later reported there was a problem with the system and that corporate had been contacted. She stated that on the listed days, most coverage was provided by nurses who punch a timeclock and those hours should have automatically transferred but did not, and that hours for staff who do not punch a timeclock had to be entered manually. The Administrator stated she was frustrated because she knew the facility had the weekend and licensed coverage needed, but understood the submission had to be accurate.
Unsafe Glove Use During Food Preparation
Penalty
Summary
The facility failed to safely handle food while preparing a hamburger sandwich. During an observation, a cook wore gloves during the meal pass for multiple residents, then touched potholders on the line and placed a hamburger on a plate from behind her in the microwave. Using the same gloves, she reached into a bag of buns, removed one, and placed it on a resident’s tray before opening the bun on the tray. She then took the burger out of the microwave with the same gloves, picked up the burger, placed it on the bun, and added the top bun before smashing it down. She removed her gloves and performed hand hygiene only after finishing the task. During an interview, the Administrator and Dietary Manager acknowledged that the cook could use gloves or tongs to handle the bun or patty, but if she touched the microwave and then the resident’s food with the same gloves, she needed to remove the gloves and perform hand hygiene. The facility’s undated Food Safety Requirements policy stated staff must follow safe hygienic practices to prevent contamination from hands or physical objects, must not touch food with bare hands, and should use gloves, tongs, deli paper, and spatulas appropriately to prevent cross-contamination of foods.
Failure to Supervise High-Risk Resident During Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as high risk for wandering and elopement when the resident exited the building without staff knowledge or supervision. The resident had diagnoses of non-Alzheimer's dementia and memory deficit following a cerebral infarction, and the MDS showed a BIMS score of 5, indicating severe cognitive impairment. The care plan identified a risk for injury due to wandering and attempting to elope and directed staff to supervise the resident when outside the facility. On the day of the incident, the resident was found walking in the hospital parking lot across the street from the facility and was returned without incident. Review of the event and video footage showed the resident was first seen outside the facility at 3:32 PM and was observed crossing the street toward the parking lot. The facility reported no door alarm had sounded before the resident was found outside, and the Administrator stated the resident likely exited through the back door after following a subcontractor who entered the code to deactivate the alarm. The Administrator also stated the back door signage warning visitors not to let residents out had been removed.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse by a Certified Nurse Aide (CNA), identified as Staff A. The CNA engaged in inappropriate interactions with a resident, including accepting money, kissing, sending inappropriate pictures via text, and exchanging inappropriate touch. These interactions continued until the CNA resigned from the facility. The resident involved had a history of neurogenic bladder, anxiety, bipolar disorder, depression, PTSD, and paraplegia, and was reported to have almost constant pain and multiple pressure injuries. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and required assistance with activities of daily living due to paraplegia. The resident was described as pleasant and cooperative, with a good appetite and fluid intake. However, there were fluctuations in the resident's mood, with periods of isolation and depression noted in the health status notes. The resident reported feeling uncomfortable with a young CNA and expressed embarrassment due to the colostomy bag smell, which contributed to his isolation. The inappropriate relationship between the CNA and the resident was discovered after the CNA resigned. The resident reported that the CNA initiated contact and that the relationship included sexual conversations and physical interactions. The resident felt guilty, judged, and taken advantage of, leading to increased isolation and depression. The facility's investigation revealed that the CNA had spent excessive time with the resident, and other staff members were aware of the relationship but did not report it. The facility's policy on abuse prevention and reporting was not effectively implemented, leading to the deficiency.
Removal Plan
- Resident #1 will receive on-going psychiatry services as indicated by the provider and as needed (PRN).
- The facility interviewed all interviewable residents to determine no additional concerns.
- The facility interviewed all staff, and concerns raised about Resident #1 isolating himself. The administrator interviewed Resident #1 about these concerns and addressed the concerns.
- The facility educated all staff. The facility provided and reviewed a copy of the abuse policy and procedure for reporting, trauma informed care, and education regarding psychosocial well-being of the residents.
- All newly hired staff and agency staff will complete annual training for trauma-informed care upon hire and be provided with the policy for abuse and abuse reporting.
- Quality Assurance and Performance Improvement (QAPI review), with on-going audits that include interviews with residents and staff.
Failure to Provide 24/7 Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide licensed nurse coverage 24 hours a day, 7 days a week, as required by their policy. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 revealed that the facility did not have licensed nurse coverage on several specific dates. Interviews with the Interim Administrator indicated that the facility was unable to provide immediate verification of licensed nurse coverage for these dates, as they were waiting for information from an external company that managed their time cards. Staff C, a Certified Medical Assistant and Scheduler, provided a list of licensed nurse coverage for the dates in question, indicating that both agency and facility nurses were scheduled. However, there was a lack of immediate verification of these shifts. The facility's policy, revised in August 2022, mandates that a licensed nurse must be on duty at all times to supervise nursing services and provide resident care. Despite this policy, the facility was unable to demonstrate compliance for the specified dates, leading to the deficiency finding.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to ensure appropriate staffing, specifically lacking Registered Nursing (RN) coverage and a Director of Nursing (DON) on multiple occasions. The Assistant Director of Nursing (ADON) reported that the DON left without notice, and there was no replacement at the time of the survey. Interviews with staff indicated a need for more staff, as the DON and Administrator had both quit, leading to reliance on temporary staff. The Facility Assessment highlighted the necessity of having a DON and RN full-time to meet resident needs, but this was not adhered to. The Payroll Based Journal (PBJ) Staffing Data Report revealed the facility lacked 8 hours of RN coverage on several dates, and the Interim Administrator was unable to provide verification of RN coverage for those dates. Additionally, the facility's nursing schedules showed that the contracted DON did not provide the required 8 hours of RN coverage on several days in October. The facility's policy stated that a registered nurse should provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met, leading to the deficiency.
Failure to Notify Resident Representatives and Ombudsman of Transfers
Penalty
Summary
The facility failed to notify a resident's representative and the Long Term Care Ombudsman of the discharge or transfer of residents as required by federal regulation. Specifically, Resident #3 was transferred to a hospital and reentered the facility without documentation of notification to the resident's representative or the Ombudsman. The resident's guardian expressed concern about not being informed of the hospital admission, highlighting the lack of communication from the facility. Similarly, Resident #20 was transferred to a hospital and later reentered the facility without the required notification to the Ombudsman. The facility's administrator acknowledged the failure to notify both the Ombudsman and Resident #3's guardian, despite the expectation of accurate and timely notifications. This deficiency was identified through record reviews, staff interviews, and policy reviews, affecting two out of four residents reviewed for discharge or transfer.
Failure to Update PASRR Evaluation for New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was diagnosed with a new mental health condition. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was initially admitted with diagnoses of anxiety disorder and depressive disorder. However, on March 9, 2023, the resident received a new diagnosis of delusional disorder, which was not followed by a request for an updated PASRR evaluation as required. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) confirmed their awareness of the PASRR requirements, which mandate a new screening when there is a change in mental health diagnosis. Both acknowledged that an updated PASRR should have been requested following the resident's new diagnosis. The facility's policy, dated 2001, also directed that new or changed behaviors indicating a serious mental disorder should be referred for a Level II PASRR evaluation, which was not done in this case.
Failure to Supervise Medication Administration and Notify Physician
Penalty
Summary
The facility failed to adhere to professional standards by not supervising a resident during medication administration and not accurately processing physician orders. During an observation, a resident was seen taking medication unsupervised, which was against the facility's policy that requires nurses or certified medication aides to be present until medications are administered. Additionally, a review of Resident #3's records revealed that despite a physician's order to discontinue a specific dosage of Oxybutynin, the medication was still administered throughout September and part of October, indicating a failure to accurately follow and process physician orders. Furthermore, the facility did not notify a physician as required for a resident with high blood glucose levels. Resident #23, who had a history of diabetes mellitus, coronary artery disease, heart failure, and peripheral vascular disease, had a blood sugar reading of 461, which necessitated physician notification according to the sliding scale insulin order. However, there was no documentation of such notification, which was confirmed by the interim administrator who could not locate any record of provider notification. This oversight was contrary to the facility's policy on notifying physicians of acute changes in a resident's condition.
Inadequate Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate interventions to minimize or prevent complications of infections for a resident with urinary conditions. Resident #10, who has moderate cognitive impairment and diagnoses including diabetes, anxiety, depression, lung disease, and renal insufficiency, had an indwelling catheter due to obstructive uropathy and urinary retention. The care plan for Resident #10 included monitoring for signs and symptoms of urinary tract infections (UTIs). However, an Emergency Department report documented that Resident #10 developed a UTI associated with the indwelling catheter, requiring antibiotic treatment. During an observation, it was noted that Resident #10's catheter tubing dragged on the floor while walking with a CNA. The CNA acknowledged the issue, stating that the resident previously had a shorter tube and was unaware of the current tubing dragging. Interviews with the DON and ADON confirmed that for infection control purposes and to prevent falls, the catheter tubing should not have been allowed to drag on the floor. The facility's catheter care policy from 2009 also emphasized keeping catheter tubing and drainage bags off the floor to prevent catheter-associated UTIs.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication and treatment carts remained locked when not under staff supervision, as observed during a survey. On multiple occasions, the medication cart and treatment cart were found unlocked and unattended in the central hallway next to the nurses' station. This occurred despite the facility's policy requiring that compartments containing medications and biologicals be locked when not in use. During the observations, various staff members and residents passed by the unlocked carts, indicating a lack of adherence to the facility's medication labeling and storage policy. Specifically, on one occasion, a staff member, identified as Staff D, RN, was observed removing supplies from the treatment cart, locking it, and then leaving it unattended again shortly after. Additionally, Staff D placed insulin pens on top of the medication cart and left them unattended while entering a resident's room. The facility administrator confirmed that the expectation is for medication and treatment carts to remain locked when not in use or supervised, aligning with the facility's policy. However, the repeated observations of unlocked carts suggest a failure to consistently implement this policy.
Failure to Store Food Safely
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an initial observation of the kitchen's refrigerators and freezers, it was found that there were opened items that were unsealed and lacked labeling to identify the product, open date, and use-by date. This observation was made with a reported census of 26 residents in the facility. In an interview, the Dietary Manager acknowledged that these items should have been sealed, labeled, and dated when opened. Additionally, the facility's Administrator stated that the expectation is for all opened and stored foods to be labeled with identification of the product, open date, and expiration date. A review of the facility's policy titled 'Food Receiving and Storage,' revised in November 2022, indicated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated.
Failure to Sustain QAPI Meeting Attendance
Penalty
Summary
The facility failed to effectively and efficiently maintain the highest well-being of each resident by not sustaining their Plan of Correction (POC) dated 9/12/23. This POC was intended to ensure that required members were present at the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The facility, which reported a census of 26 residents, was cited during their annual recertification survey on 8/17/23 for not having the required members present at these meetings. Despite implementing a POC, the facility did not maintain compliance, as evidenced by attendance sheets from QAPI meetings on 12/12/23, 4/18/24, 7/29/24, and 10/8/24, which showed the Director of Nursing (DON) was not in attendance. Additionally, the Infection Preventionist (IP) was absent from meetings on 12/12/23, 3/22/24, 4/18/24, and 7/29/24. An interview with the Interim Administrator on 11/7/24 confirmed the expectation that all department heads, the Medical Director, and any other interested staff should attend these meetings.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to have the required members present at their Quality Assurance and Performance Improvement (QAPI) meetings, specifically the Director of Nursing (DON) and the Infection Preventionist (IP). The attendance records showed that while the required members attended the meeting on 9/12/23, the DON was absent from the meetings on 12/12/23, 4/18/24, 7/29/24, and 10/8/24. Similarly, the IP was not present at the meetings on 12/12/23, 3/22/24, 4/18/24, and 7/29/24. The Interim Administrator acknowledged the absence of these key members and stated that the expectation was for the QAPI committee to meet at least quarterly with all department heads, the Medical Director, and any other interested staff present. The facility's policy required the QAPI committee to consist of no less than five members, including the Administrator, DON, IP, Medical Director or Physician designee, and at least two additional facility staff.
Failure to Reposition Residents Leads to Skin Care Deficiencies
Penalty
Summary
The facility failed to ensure proper repositioning and skin care for two residents, leading to deficiencies in their care. Resident #4, with severe cognitive impairment and Moisture Associated Skin Damage (MASD), was observed sitting in a recliner for an extended period without being repositioned. The resident was dependent on staff for transfers and required assistance from two staff members. Observations revealed that the resident had not been repositioned since breakfast, resulting in severe excoriation and bleeding on the buttocks. The Director of Nursing (interim) and Certified Nursing Assistants (CNAs) acknowledged the lack of repositioning and the resident's discomfort. Resident #20, also with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, was observed in a recliner for several hours without repositioning. The resident was dependent on staff for all activities of daily living and required full assistance for repositioning. Observations showed the resident leaning to one side with a mechanical lift sling under them, indicating a lack of movement. The facility's repositioning policy required residents in chairs to be repositioned every hour, but documentation showed repositioning occurred only three times a day. The facility's failure to adhere to its repositioning policy resulted in inadequate care for both residents. The policy, revised in May 2013, emphasized the importance of repositioning to prevent skin breakdown and promote circulation. Despite this, staff interviews revealed that repositioning schedules were not followed, and residents were not moved as frequently as required. This lack of adherence to the policy contributed to the residents' skin issues and discomfort.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide the Bed Hold policy to a resident or their representative during a hospital transfer. Resident #3 was admitted to the hospital on 10/5/24, but the facility did not discuss or provide the Bed Hold policy to the resident or their representative. The clinical record lacked documentation of notification regarding the Bed Hold policy, and the resident's guardian expressed concern about not being informed of the hospital admission. The facility's Administrator acknowledged the failure to notify the resident's representative of the hospital transfer and the Bed Hold policy. The facility's policy, revised in October 2022, requires that residents or their representatives receive written information about Bed Hold policies at least twice: in advance of any transfer and at the time of transfer, or within 24 hours if the transfer was an emergency. However, this procedure was not followed in the case of Resident #3.
Inconsistent Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and manage pressure ulcers for one resident, leading to a deficiency in care. The resident's medical records showed inconsistent documentation regarding a wound on their right buttock. As the wound worsened, the facility did not update the stages of the pressure ulcer to reflect these changes. The assessments showed discrepancies in the measurement and staging of the wound, with different nurses documenting varying details each week. The resident's Minimum Data Set (MDS) assessment initially indicated no pressure ulcers, but subsequent weekly skin assessments revealed the presence of an abscess and skin tear on the right buttock. The measurements and staging of these wounds varied, with some assessments not assigning a stage to the abscesses. The inconsistency in documentation made it difficult for healthcare providers to accurately assess the wound's condition and provide appropriate care. Interviews with staff revealed a lack of specialized training in skin assessments, contributing to the inconsistency in documentation. The Advanced Registered Nurse Practitioner expressed concern over the inconsistent documentation, which hindered the ability to determine the wound's condition until it was observed in person. The facility's Nurse Consultant acknowledged the inconsistency in skin assessments and staging, further highlighting the deficiency in the facility's wound management practices.
Lack of Licensed Nurse Coverage in LTC Facility
Penalty
Summary
The facility failed to ensure licensed nurse coverage 24 hours a day, resulting in a period on 6/15/24 when there was no licensed nurse on duty from 6:45 AM to 8:41 AM. During this time, the night nurse clocked out, and the day nurse had not yet arrived. Despite being informed of the situation, the Director of Nursing (DON) and the Administrator did not act immediately to provide licensed coverage. This lapse in coverage occurred while the facility had 15 diabetic residents, 8 of whom were insulin-dependent, and one resident with a tracheostomy requiring regular care. Resident #2, who had a tracheostomy, required total assistance and had severely impaired cognitive skills. The resident's care plan included specific orders for tracheostomy care, which could only be performed by a licensed nurse. During the time without nurse coverage, there was a risk of the tracheostomy becoming dislodged, which would require immediate intervention. Additionally, Resident #7, who had diabetes and severely impaired cognitive skills, had a blood glucose reading of 65, indicating hypoglycemia, which required assessment and intervention by a licensed nurse. Staff interviews revealed that the facility staff were aware of the absence of a licensed nurse and expressed concerns about the potential risks to residents. Staff D, a Certified Medication Aide, took blood sugar readings but could not administer insulin or assess residents with low blood sugar, as it was outside her scope of practice. The Interim Administrator acknowledged the lack of a formal policy regarding nursing staffing and medication administration, which contributed to the deficiency. The facility's documentation confirmed the absence of a licensed nurse during the specified time, highlighting a significant lapse in care and oversight.
Failure to Follow Planned Menu and Obtain Dietitian Approval
Penalty
Summary
The facility failed to adhere to the planned menu for residents on all diet types, as observed during a lunch meal service. The unsigned dietary menu for the specified day listed a meal of cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo bars, and milk. However, the meal served to residents included a ham salad sandwich, French fries, beets, a cookie, and milk. This discrepancy was noted during an observation of the lunch meal service, and it was found that the menu had not been signed by the dietitian, as required. Interviews with the Dietary Manager and the Corporate Dietitian revealed a lack of communication and protocol adherence. The Dietary Manager admitted to making last-minute changes to the menu without obtaining the necessary approval from the dietitian, who was unaware of the changes. Additionally, the cook reported that they sometimes had to improvise due to the unavailability of menu items, which led to the deviation from the planned menu. This lack of coordination and failure to follow established procedures resulted in the facility not meeting the nutritional needs of the residents as per the planned menu.
Failure to Prevent Food Contamination During Meal Service
Penalty
Summary
The facility failed to protect food from contamination during meal service, as observed during a lunch service. Staff A, a cook, was seen handling ham salad sandwiches and French fries with gloved hands that had touched various surfaces, including the outside of a hamburger bun bag, the counter, a scoop handle, tong handle, serving lids, and her cheek. Despite wearing gloves, Staff A did not change them after touching these surfaces, leading to potential contamination of the ready-to-eat food served directly to residents. During an interview, the Dietary Supervisor acknowledged witnessing Staff A's actions and stated that staff are expected to handle food in a manner that prevents foodborne illness, which includes not touching ready-to-eat food with bare hands or contaminated gloves. The Food Code mandates that food employees must not touch ready-to-eat food with bare hands and should use suitable utensils or clean gloves, emphasizing the need for hand hygiene before food preparation and when changing tasks to prevent cross-contamination.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of the food and nutrition service. The facility employed a corporate Dietitian on a part-time consultant basis and designated a person who lacked the required certification and/or experience to serve as the Dietary Supervisor. The Dietary Supervisor had only worked at the facility for two weeks and had previously worked as a cook at another facility for one year. She had not completed education on safe service or food handling to prevent foodborne illness and had not completed or enrolled in the Certified Dietary Manager certification program. The Corporate Dietitian confirmed that she worked at the facility on a consultant basis and not a full-time basis. The Administrator also confirmed that the Dietary Supervisor did not have her certification and that the facility employed the Dietitian as a part-time consultant. The facility was unable to produce documentation of certification for the Dietary Supervisor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 173 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grundy Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside | 0.4 mi | ★★★★★ | 6 | 0 |
| Parkview Manor Care Center | 8.4 mi | ★★★★★ | 8 | 0 |
| Oakview Nursing Home | 10.7 mi | ★★★★★ | 1 | 0 |
| Westbrook Acres | 12.3 mi | ★★★★★ | 8 | 0 |
| Maple Manor Village | 16.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.