Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
3E
0F
Potential for minimal harm
0A
0B
0C
May 21, 2026Standard inspection, Complaint inspection · 5 citations
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's policy the facility failed to document 3 non-pharmacological approaches to minimize the need for as needed (PRN) psychotropic medications for 1 out of 5 residents sampled (Resident #30). The facility also failed to limit use of PRN psychotropic medications to 14 days for 2 out of 5 residents sampled (Resident #7 and #9). The facility reported a census of 73 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility investigation review, clinical record review, staff interviews and policy review the facility failed to report an allegation of resident to resident abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 2 residents reviewed (Residents #74 and #80). The facility reported a census of 73 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, facility document review, staff interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice by not following physician orders resulting in medication errors for 2 of 2 residents reviewed (Residents #65 and #6) for medication errors. The facility reported a census of 73 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide adequate nursing supervision to prevent an elopement for 1 of 1 resident reviewed (Resident #7). The facility reported a census of 73 residents.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on personnel file reviews, facility policy review and staff interview, the facility failed to provide dependent adult abuse (DAA) training within 6 months of hire for 1 of 5 employees reviewed. The facility identified a census of 73 residents.
April 24, 2025Standard inspection · 5 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, kitchen record review, and staff interview, the facility failed to ensure food safety was maintained by not obtaining food temperatures and not maintaining temperature logs. The facility also failed to ensure food was properly stored and labeled and all areas of the main kitchen were clean. The facility reported a census of 73.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 1 residents reviewed who transferred to the hospital (Resident #2). The facility reported a census of 73 residents.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on electronic medical record review and staff interview, the facility failed to document the use of non-pharmacological interventions prior to the administration of an as-needed psychotropic drug for 1 of 5 residents reviewed for unnecessary medications (Resident #65). The facility reported a census of 73.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations and staff interview, the facility failed to adequately prepare pureed foods to ensure the appropriate amount of nutrients were provided to residents receiving a pureed diet. The facility reported a census of 73.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, document review and staff interviews the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions (EBP) for 2 out of 2 residents reviewed (Resident #1 and #21). The facility reported a census of 73 residents.
July 18, 2024Standard inspection · 3 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wrote2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #75 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS further documented an admission date to the facility 7/2/24. During an observation on 7/15/24 at 1:18 PM, Resident #75's room temperature was 87.3 degrees Fahrenheit. During an interview on 7/15/24 at 1:20 PM, Resident #75 advised her room temperature is warm, stating it was at 91 degrees Fahrenheit earlier on this date. Resident #75 stated her room temperature has been warm since she admitted to the facility on [DATE], stating she would like for her room temperature to be around 72 degrees Fahrenheit and the room is uncomfortable. 3. The MDS assessment for Resident #4, dated 4/30/24, documented a BIMS score of 15, indicating intact cognition. The MDS further documented an admission date to the facility 9/28/23. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to follow a physician's order for 1 of 1 residents reviewed to notify the physician or complete further assessments of daily weight changes within the established parameters (Resident #37). The facility reported a census of 74 residents. Findings Include: The MDS (Minimal Data Set) assessment dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented the resident had diagnoses to include coronary artery disease, hypertension, diabetes, arthritis, and chronic ischemic heart disease. Review of the Electronic Health Record (EHR) for Resident #37 showed a physician order with a start date 8/16/23 with an order for daily weights. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure safe transport of a resident in a wheelchair for 1 of 1 residents reviewed. (Resident #17). The facility reported a census of 74.
April 9, 2024Complaint inspection · 2 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, clinical record review, facility menus and staff interview the facility failed to follow the menu for 18 of 18 residents in the unit. The facility reported a census of 72 residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, and staff interviews, the facility failed to ensure open items were dated, and labeled in the coolers and walk-in freezer in the kitchen. The facility reported a census of 72 residents.
Fire safety inspections
16 fire safety citations on file: 6 on May 21, 2026, 7 on April 24, 2025, 3 on July 18, 2024.
Every fire safety citation16 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 21, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 21, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 21, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 21, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 18, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 18, 2024 · Corrected (the home has a date of correction)