Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Meadow Manor during CMS and state inspections, most recent first.
Incomplete and inaccurate PBJ staffing submission: The facility failed to submit complete and accurate PBJ staffing data to CMS for the reviewed quarter. The PBJ report showed excessively low weekend staffing, a one-star staffing rating, no RN hours for 11 days, and no licensed nursing coverage for 24 hours/day for 65 days. During interview, leadership stated the prior administrator had been submitting PBJ data before leaving, current leadership lacked access to the submission system, and contract nursing staff had been entered incorrectly as nursing assistants.
A resident with mild cognitive impairment experienced a lack of privacy due to broken blinds in her room, which had been an issue for seven months. Despite the resident's complaints, the facility failed to document and address the problem in a timely manner, as required by their policy. Observations confirmed the blinds were missing slats, and the nurse manager acknowledged the oversight.
The facility failed to appoint a grievance official after the social services director left, leaving residents without a clear process to report grievances. A resident council president and staff confirmed the absence of grievance forms and policies in the front lobby, contrary to facility policy.
A medication aide left dispensed medications unattended on a medication cart, within reach of a cognitively impaired resident with a history of wandering. The facility's policy requires medications to be locked in the cart when not in sight, which was not followed, posing a risk of unauthorized access.
A facility failed to ensure proper PPE use during catheter care for a resident with an indwelling urinary catheter. A nursing assistant did not don a gown while emptying the catheter bag, despite the facility's policy requiring enhanced barrier precautions (EBP) for residents with medical devices. The infection preventionist and DON confirmed EBP implementation, but there was a lack of communication and adherence to the policy, as staff were unaware of the significance of the star symbol indicating EBP on the resident's nameplate.
The facility failed to ensure that three years of survey results were readily accessible for residents or visitors without having to ask. A resident with mild cognitive impairment, who is the resident council president, noted the survey binder was removed from the common area. The DON and activities director confirmed the binder was only available upon request, and no policy on posting survey results was provided.
The facility failed to prevent falls and implement care plans for two residents with a history of falls, resulting in significant injuries. Despite being identified as high fall risks, the care plans were not adequately updated, and comprehensive fall analyses were not conducted. Staff inconsistencies and lack of adherence to the facility's fall prevention policy contributed to the deficiencies.
The facility failed to develop and implement a comprehensive falls quality improvement project, resulting in significant injuries to two residents. Despite identifying falls as a problem area, the facility did not conduct comprehensive causal analyses for 29 fall incidents or create effective action plans. The quality assurance documentation lacked detailed analysis and action plans, and the administrator and medical director were unaware of the deficiencies in the falls policy implementation.
The facility failed to report falls with serious injuries for two residents to the State Agency and did not conduct thorough investigations. One resident fell twice, resulting in a broken finger and subsequent death, while another fell due to insufficient staff assistance, leading to a head injury. The facility's policy requires reporting such incidents, but the administrator only considered reporting if the facility was at fault. Investigations were found to be incomplete, lacking necessary details to determine adherence to care plans.
A long-term care facility failed to conduct thorough investigations of falls for three residents, leading to deficiencies in determining the root cause and adherence to care plans. One resident with severe cognitive impairment experienced multiple falls without proper analysis, while another with moderately impaired cognition had falls without confirming if care plans were followed. A third resident, with a history of repeated falls, experienced 20 falls without comprehensive investigations. The facility's fall prevention policy was not consistently implemented, resulting in incomplete documentation and analysis.
The facility failed to update care plans for three residents reviewed for falls, leading to deficiencies in care. One resident with severe cognitive impairment experienced multiple falls without timely updates to their care plan. Another resident with moderately impaired cognition had falls and injuries without care plan revisions. A third resident, at high risk for falls, experienced numerous falls without care plan updates. Staff interviews revealed a lack of clarity on responsibility for updating care plans, contributing to the deficiency.
Incomplete and inaccurate PBJ staffing submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for 1 of 1 quarters reviewed, Quarter 4 (July 1-September 30, 2025), based on payroll and other verifiable and auditable data. Review of the PBJ Report 1705 D showed excessively low weekend staffing, a one-star staffing rating, no RN hours for 11 days in Quarter 4, and no licensed nursing coverage for 24 hours per day for 65 days in Quarter 4. During interview, the administrator stated the previous administrator had been submitting the PBJ information until employment ended in October 2025. The CRD stated the previous administrator had access to the PBJ submission program, but the current administrator and CRD did not, and that a ticket had been created to gain access. The CRD also stated there had been issues with contract staff being entered correctly and that, during PBJ submission to CMS, contract nursing staff had consistently been changed to nursing assistants. A request for tickets, CMS communications, submission reports, and CMS confirmation reports was made, but this information was not received. The facility policy stated that staffing data submitted to CMS must be complete, accurate, timely, and auditable, and that the administrator, HR director, DON, and corporate CFO were responsible for verifying and submitting the data and reviewing validation reports.
Failure to Ensure Resident Privacy Due to Broken Blinds
Penalty
Summary
The facility failed to ensure personal privacy for a resident who had been at the facility for seven months. The resident, who had mild cognitive impairment and required substantial assistance for activities of daily living, including bed baths, reported that the blinds in her room had been broken since her arrival. This lack of privacy was a concern for the resident, especially during personal care activities. Despite the resident voicing her concerns about the broken blinds, the issue remained unresolved for an extended period. Observations confirmed that the vertical blinds in the resident's room were missing slats and the remaining slats were broken. The nurse manager, upon being informed, acknowledged the importance of resident privacy and the need for repair. However, the maintenance staff admitted to knowing about the issue weeks prior but failed to document it in the work order report, resulting in a delay in addressing the problem. The facility's policy required all repair and maintenance requests to be documented to ensure timely resolution, which was not followed in this case.
Facility Lacks Designated Grievance Official and Accessible Grievance Forms
Penalty
Summary
The facility failed to identify a grievance official to oversee, process, and track grievances presented by residents, resident representatives, and visitors. This deficiency was observed during an interview with a resident council president who reported that the social services director, who previously served as the grievance official, left in November 2024. Since then, no new grievance official has been designated, and residents are unaware of whom to report grievances to. The resident council president noted that grievances were frequently followed up on before the departure of the social services director, but since then, it has been difficult to report and follow up on grievances. Further observations and interviews confirmed the absence of a grievance official and the unavailability of grievance forms or policies in the facility's front lobby. The nurse manager, director of nursing, and activities director all confirmed the lack of a designated grievance official and the absence of grievance forms and policies accessible to residents, resident representatives, or visitors. An undated facility policy indicated that grievance forms and policies should be available in the front lobby, but this was not the case at the time of the survey.
Failure to Secure Medications on Medication Cart
Penalty
Summary
The facility failed to secure dispensed medications properly, leading to a potential risk of diversion or consumption by unauthorized individuals. During a medication administration observation, a trained medication aide (TMA-A) dispensed medications for a resident with intact cognition, who was prescribed ondasetron and Slo-mag tablets, and left them unattended on top of a medication cart. This occurred while the TMA-A went to retrieve a nutritional supplement from the kitchen, leaving the medications within reach of another resident with severe cognitive impairment and a history of wandering. The cognitively impaired resident, who was identified as having dementia and wandering tendencies, approached the medication cart and was observed fidgeting with a pen near the unattended medication cup. Although the resident did not consume the medications, the situation highlighted a lapse in protocol, as confirmed by interviews with the TMA-A, a registered nurse, and the director of nursing. The facility's policy mandates that medications should be locked in the cart when out of sight of the administering nurse or aide to prevent unauthorized access.
Failure to Use Proper PPE During Catheter Care
Penalty
Summary
The facility failed to ensure the use of proper personal protective equipment (PPE) during catheter care for a resident with an indwelling urinary catheter. The resident, who was cognitively intact, confirmed long-term catheter use due to urinary retention. During an observation, a nursing assistant entered the resident's room without donning the required PPE, specifically a gown, while emptying the urinary catheter bag. The nursing assistant acknowledged that enhanced barrier precautions (EBP) should be used for residents with catheters or wounds and that an EBP sign should have been placed on the door. The infection preventionist and director of nursing confirmed that EBP is implemented for residents with indwelling medical devices, such as urinary catheters, and that staff are expected to wear appropriate PPE during care activities. However, there was a lack of communication and follow-through regarding the implementation of EBP, as evidenced by the absence of a list of residents requiring EBP in the nurses' station and staff's lack of awareness about the significance of the star symbol on the resident's nameplate. The facility's policy indicated that EBP is required during high-contact care activities, but the deficiency in communication and adherence to the policy led to the observed failure in PPE usage.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that three years of survey results were readily accessible for residents or visitors to view without having to ask. This deficiency was identified through observation, interview, and document review. A resident with mild cognitive impairment, who also serves as the resident council president, reported that the survey binder containing previous surveys was removed from the common area a long time ago. During an observation, it was confirmed that the survey binder was not present in the common area at the main entrance. The Director of Nursing (DON) and the activities director confirmed that the survey binder had been removed from all common areas and was only available upon request. Additionally, no policy regarding the posting of survey results was provided.
Failure to Prevent Falls and Implement Care Plans
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and follow the care plan to prevent and/or reduce the risk of falls with major injury for two residents with a history of falls. Resident R3, who had moderately impaired cognition and multiple diagnoses including Alzheimer's and Parkinson's disease, experienced several falls resulting in significant injuries such as a hand fracture and facial lacerations. Despite being identified as a high fall risk, R3's care plan was not adequately updated to address the identified risk factors, such as self-ambulating and furniture hazards, and there was no comprehensive fall analysis conducted. Resident R2, with severe cognitive impairment and a history of falls, also experienced multiple falls resulting in injuries, including a laceration above the eye that required sutures. The care plan for R2 required two staff to assist with transfers, but this was not consistently followed, leading to falls. The facility did not conduct a comprehensive fall analysis to determine the root cause of the falls or to assess whether the care plan was appropriate and followed. Additionally, interventions to prevent recurrent falls were not effectively implemented or documented. Interviews with staff and family members revealed inconsistencies in the care provided to both residents, with staff sometimes unaware of the required level of assistance for transfers. The facility's policy on fall risk and prevention was not adhered to, as evidenced by the lack of thorough investigations and documentation of falls. The administrator acknowledged the deficiencies in the facility's fall management process, including the absence of comprehensive analyses and the failure to define and document interventions such as increased checks.
Failure to Implement Effective Falls Quality Improvement Project
Penalty
Summary
The facility failed to develop, implement, monitor, and evaluate a falls quality improvement project (QIP) despite identifying falls as a problem-prone area. This deficiency was highlighted by the lack of comprehensive causal analysis for 29 fall incidents involving three residents over a period of time. Two residents suffered significant injuries due to falls, with one sustaining a hand fracture and facial lacerations, and another requiring sutures for a laceration above the eye. The facility's quality assurance activities did not include action plans to address these issues, and there was no evidence of completed audits or evaluations of the implemented interventions. The facility's quality assurance documentation revealed that although falls were identified as a problem area, there were no action plans for several months, and the only action plan created was incomplete. The documentation also showed that the facility's quality measures for falls were below the 75th percentile, yet there was no detailed analysis or action plan to address the increasing number of falls. The administrator confirmed that the quality committee met monthly, but the only action plan for falls was implemented late and lacked a comprehensive activity plan. Interviews with the facility's administrator and medical director further highlighted the deficiencies. The administrator admitted to receiving only slides without supporting records or audits, and the medical director, who was new to the facility, was unaware of the lack of action plans for the falls QIP. The medical director also noted that the fall policy was not being implemented correctly, and there was limited documentation in interdisciplinary meeting minutes regarding falls. This lack of comprehensive assessment and intervention contributed to the facility's failure to prevent and reduce the risk of falls with major injuries.
Failure to Report Falls and Conduct Thorough Investigations
Penalty
Summary
The facility failed to report a fall with serious injury and potential neglect to the State Agency for two residents. Resident 3 (R3) experienced two falls, one resulting in a broken finger and the other leading to injuries that contributed to their death. The facility did not report these incidents to the State Agency, and there was no evidence of a thorough investigation or comprehensive fall analysis to determine if R3's care plan was followed at the time of the falls. R3 had multiple diagnoses, including Alzheimer's disease and Parkinson's disease, and required staff assistance for daily activities. Resident 2 (R2) also experienced a fall that was not reported to the State Agency. R2 fell while being transferred to the commode, resulting in a laceration to the left eye. The fall occurred because only one staff member assisted R2, despite the care plan requiring two-person assistance. Interviews with R2, a family member, and staff revealed inconsistencies in the care provided, with R2 frequently receiving only one-person assistance. R2 had severe cognitive impairment and required extensive staff assistance for mobility and transfers. The facility's policy mandates reporting all alleged violations involving abuse, neglect, or mistreatment to the administrator and other agencies as required by state law. However, the administrator indicated that falls would only be reported if the facility was at fault or could have prevented them. Upon review, the administrator acknowledged that the investigations into R2 and R3's falls were incomplete and lacked vital information to determine if the care plans were followed or if neglect occurred.
Inadequate Fall Investigations in LTC Facility
Penalty
Summary
The facility failed to conduct accurate and thorough investigations of falls for three residents, leading to deficiencies in determining the root cause of the falls, whether the care plans were followed, and if the falls were reportable to the State Agency. Resident 2, who had severe cognitive impairment and multiple health issues, experienced several falls. The facility's documentation lacked comprehensive fall analyses and did not verify if the care plan, which required two-person assistance for transfers, was adhered to. Interviews with staff and family members revealed inconsistencies in the care provided, such as transferring the resident with only one staff member, contrary to the care plan. Resident 3, with moderately impaired cognition and a history of falls, also experienced multiple falls without thorough investigations or analyses to determine if the care plan was followed. The resident's care plan required staff assistance with ambulation and transferring, but the fall reports did not provide sufficient information to confirm adherence to these interventions. The lack of detailed investigation and documentation left gaps in understanding the circumstances and potential causes of the falls. Resident 4, who was cognitively intact but had a history of repeated falls, experienced 20 falls over a specified period. The facility did not conduct thorough investigations or comprehensive analyses for these falls, failing to determine if the care plan was followed. Interviews with staff indicated challenges in investigating the falls due to the resident's impulsive behavior. The facility's policy on fall risk and prevention was not consistently implemented, as evidenced by the lack of post-fall huddles and incomplete documentation of fall incidents.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise the care plans for three residents who were reviewed for falls, leading to deficiencies in their care. Resident 2, who had severe cognitive impairment and multiple diagnoses including dementia and a history of falling, experienced several falls without timely updates to their care plan. Despite interventions being identified, such as the use of a reacher and Dycem under the wheelchair cushion, these were not added to the care plan until over two months later. The lack of immediate intervention following falls and the delay in updating the care plan contributed to the deficiency. Resident 3, with moderately impaired cognition and a history of falls, also experienced multiple falls without updates to their care plan. After sustaining injuries from a fall, including a fracture, the care plan was not revised to reflect changes in the resident's activity of daily living status. Interviews with staff revealed a lack of clarity on who was responsible for updating care plans, and it was noted that care plans were not consistently updated following falls. Resident 4, who was cognitively intact but at high risk for falls, experienced twenty falls over a two-month period. Despite the high frequency of falls, the care plan was not updated with fall prevention interventions. Interviews with staff indicated that fall interventions were sometimes communicated informally and not documented in the care plan. The facility's policy required care plans to be updated with changes, but this was not consistently followed, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Meadow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Valley Care Center | 8.9 mi | ★★★★★ | 15 | 0 |
| Ostrander Care And Rehab | 9.5 mi | ★★★★★ | 3 | 0 |
| Stewartville Care Center | 11.3 mi | ★★★★★ | 2 | 0 |
| Field Crest Care Center | 18.7 mi | ★★★★★ | 11 | 0 |
| Good Samaritan Society - Comforcare | 19.1 mi | ★★★★★ | 6 | 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.