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Complaint Investigation

Grand Meadows Senior Living & Health Care

March 26, 2026 · Asbury, IA · 5300 Grand Meadow Drive
Citations 7
CMS Rating 1/5
Beds 32
Provider ID 165618
Healthcare Facility
Grand Meadows Senior Living & Health Care
Asbury, IA  ·  View full profile →
Inspection Summary

Grand Meadows Senior Living & Health Care in Asbury, IA — inspection on March 26, 2026.

Found 7 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited Grand Meadows Senior Living & Health Care in Asbury, IA for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2026-03-26.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of Grand Meadows Senior Living & Health Care.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-04-16.

bathroom and Resident #25 said she could not put any weight on her leg, so had to get a second

she had to help with transfers that night and Resident #25 wasn't able to bear weight. On 3/26/26 at

complaints of pain staff should notify the physician and potentially have evaluation at the emergency room or attempt to get a physician appointment. On 3/26/26 at 1:33 PM the Director of Nursing (DON) reported with condition changes for residents, staff should notify the on-call nurse, DON, and the on-call physician.

The DON revealed Resident #25 was alert and oriented, and the resident should have been talked to about if she wanted follow up and staff should have offered her choices.

The facility provided a policy dated 12/2024 titled Significant Condition Change and Notification which stated the purpose was to ensure the resident's family and/or representative and medical practitioner were notified of resident changes such as those listed below: -An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention. -A significant change in the resident's physical, mental or psychosocial status.

Sudden onset of shortness of breathMobility changesAbnormal, unusual or new complaints of pain

165618 03/26/2026

Grand Meadows Senior Living & Health Care 5300 Grand Meadow Drive Asbury, IA 52002

Federal health inspectors cited Grand Meadows Senior Living & Health Care in Asbury, IA for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2026-03-26.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of Grand Meadows Senior Living & Health Care.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-04-15.

Federal health inspectors cited Grand Meadows Senior Living & Health Care in Asbury, IA for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2026-03-26.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of Grand Meadows Senior Living & Health Care.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-04-16.

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the resident could stand up.

Staff A said Resident #1 stood fine, said she was ready, and then her

broken.

Staff A confirmed the resident said she hit her head but Staff A didn't see that happen.

The

full body lift, and they got Resident #1 into bed.

She saw the nurse complete the neurological assessment and vitals, but it was after they put the resident in bed.

She did not see her assess for range of motion.

Staff A stated the resident still complained of pain when she was in bed.

At 1:10 PM on 03/26/26 the Director of Nursing (DON) stated the nurse completing the initial assessment on Resident #1 was an agency nurse and she was not sure what her assessment entailed.

The nurse texted the DON at midnight even though it was facility policy to call, so she wasn't aware of the fall until morning when she arrived at 6:00 AM to cover a shift. It was at that time she was notified of the resident's complaints of pain.

The DON was not sure what information was provided to the nurse practitioner because it was not documented.

She stated the resident was tearful when she saw her that morning, complained of pain that was at a 10, and took pain medication.

She was not sure if the medication was effective because the resident went to dialysis.

The resident reported to the DON that her leg gave out, and the DON believed that the CNA didn't let go too fast but rather the resident was already falling because her leg gave out.

The DON reported she offered to send the resident to the ER twice because she was not her normal self, but the resident wanted to go to dialysis.

She reported that she called dialysis who said they would provide her treatment and then send her to the ER.

The facility provided a policy titled Significant Condition Change and Notification dated 12/2024.

The policy directed documentation will include an assessment of the resident's current status as it related to the change in condition.

Charting will be done each shift for 72 hours for residents with a change of condition. A change of condition is reviewed by DON or designee for the continued need for additional documentation.

Federal health inspectors cited Grand Meadows Senior Living & Health Care in Asbury, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2026-03-26.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of Grand Meadows Senior Living & Health Care.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-04-16.

Federal health inspectors cited Grand Meadows Senior Living & Health Care in Asbury, IA for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2026-03-26.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of Grand Meadows Senior Living & Health Care.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-04-15.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Asbury, IA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Grand Meadows Senior Living & Health Care or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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