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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
3E
0F
Potential for minimal harm
0A
1B
0C
April 2, 2026Standard 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, staff interviews, facility record review, and facility policy review, the facility failed to ensure sanitary conditions in the main kitchen and failed to properly sanitize the dining room tables in one of the two facility dining rooms used by the residents for their mealtimes. These failures posed the risk of food borne illness to the residents receiving food from the kitchen and eating in the main dining room. The facility reported a census of 40 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and facility policy review the facility staff failed to perform appropriate hand hygiene with preparation, and administration of medication to four of four residents observed for medication administration (Resident #4, #17, #24, and #27). The facility reported a census of 40 residents.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure code status between the Iowa Physician Orders for Scope of Treatment (IPOST), the electronic health record (EHR) and the Care Plan were congruent for 1 of 1 residents reviewed for advanced directives (Resident #46). The facility reported a census of 40 residents.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment after a resident's hospice level of care was discontinued for 1 of 2 residents reviewed for change of condition (Resident #25). The facility reported a census of 40 residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review, staff interview and Maximus Preadmission Screening and Resident Review (PASRR) policies and procedures, the facility failed to submit a Level II PASRR evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #4). The facility reported a census of 40 residents.
March 13, 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 observation, staff interview, and policy review, the facility failed to ensure proper infection control practices to reduce the risk of contamination and food-borne illness during meal service. The facility reported a census of 40 residents.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 16 residents sampled (Residents #3 and #32). The facility reported a census of 40 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility staff failed to assess and document an injury of unknown origin and perform a skin assessment for 1 of 3 residents reviewed for skin injuries (Resident #33). The facility reported a census of 40 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observation, staff interview, facility policy review, and the Center for Disease Control (CDC) guidelines, the facility failed to follow infection control practices for three of three residents on droplet precautions (Resident # 3, #30, and #32) and prevent the potential spread of infection to other residents and staff. The facility staff also failed to handle soiled linens to prevent the potential spread of infection for 1 of 2 nursing units. The facility reported a census of 40 residents.
- B
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 State Long Term Care (LTC) Ombudsman for 1 of 2 residents reviewed for transfer out of the facility (Resident #19). The facility reported a census of 40 residents.
April 18, 2024Standard inspection, Complaint inspection · 3 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to meet professional standards by not observing a resident take their medications for 1of 8 residents (Resident #18) reviewed. The facility reported a census of 51 residents.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, family and staff interview and policy review, the facility failed to prevent a significant medication error for 1 of 11 residents reviewed (Resident #155). The facility reported a census of 51 residents. Findings Include: The Baseline Care Plan of Resident #155 reflected a date of 4/10/24. The Care Plan documented the resident unable to easily communicate with staff, and to be vision and hearing impaired. The Admit/Readmit Summary, dated 4/10/24 at 7:35 pm, documented the resident admitted to the facility on [DATE], was oriented to self and to place, not to time. The Summary also documented the resident to have moderately impaired vision and moderate difficulty hearing. The Health Status Note, dated 4/13/24 at 7:20 am, documented the resident to be very confused and anxious and not able to follow direction. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, staff interview and policy review, the facility failed to maintain infection control standards due to lack of hand hygiene when providing cares and assisting residents to dine for 2 of 23 residents (Resident #15, and Resident #24). The facility reported a census of 51 residents.
Fire safety inspections
26 fire safety citations on file: 15 on April 2, 2026, 3 on March 13, 2025, 8 on April 18, 2024.
Every fire safety citation26 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · April 2, 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 2, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 2, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 2, 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 · April 2, 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 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 2, 2026 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 13, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 13, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · April 18, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 18, 2024 · Corrected (the home has a date of correction)