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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
34D
10E
2F
Potential for minimal harm
0A
0B
0C
May 21, 2026Complaint inspection · 11 citations
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on the Provider History Report, State Agency Website, Quality Assurance and Performance Improvement Plan (QAPI), staff interview, and facility policy review, the facility failed to adequately address repeat regulatory violations in the following regulatory categories: F812, F880, F725, and F684. The facility reported a census of 86.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on clinical record review, facility policy review, resident and staff interview, the facility failed to uphold the established grievance process when staff members failed to report repeated resident grievances to management. The facility reported a census of 86.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on direct observation, clinical record review, staff and resident interview, and facility policy review the facility failed to maintain adequate staffing to ensure residents had access to timely requests for help, as noted by excessively long call light times. The facility reported a census of 86.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on direct observation, clinical record review, facility policy review, resident and staff interview, the facility failed to treat residents with dignity and respect. An observation revealed a member of the therapy team ignored the wishes of the resident for 2 of 7 residents screened for dignity related concerns (Residents #13 and #14). The facility reported a census of 86.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, clinical record reviews, and facility policy review, the facility failed to have an order for a resident to self-administer their own medications before leaving them unattended with Miralax for 2 of 2 residents observed (Residents #10 and #16). The facility reported a census of 86.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, resident interviews, staff interviews, and policy review, the facility failed to complete resident assessments for 2 of 2 residents reviewed for assessment and interventions (Residents #3 and #4). Resident #3 lacked the completion of neurological checks (neuros) after an unwitnessed fall. Resident #4 lacked nursing assessment and follow-up post same-day surgery. The facility reported a census of 86.
- 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, resident interviews, staff interviews, and policy review, the facility failed to provide adequate resident supervision during severe weather warning as well implement Care Plan interventions after a series of falls (Resident #16) for 1 of 9 residents reviewed for supervision. The facility reported a census of 86.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, facility policy review, clinical record review, staff, and Resident Representative interviews, the facility failed to follow-up after a significant change in weight in short period of time for 2 of 2 residents reviewed (Residents #2 and #11). Both residents had significant changes in weight in less than a month. The facility reported a census of 86 residents.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy review, the facility failed to administer significant medications correctly when a nurse failed to correctly prime an insulin pen before administration, risking the resident not receiving a sufficient dose of the medication for 1 of 8 residents sampled for medication administration (Resident #15). The facility reported a census of 86.
- D
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 interview, and policy review, the facility failed to ensure appropriate food handling practices were followed for 2 of 2 dining rooms observed. The facility reported a census of 86.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interview, and policy review, the facilty failed to complete glove change and hand hygiene during personal cares, implement Enhanced Barrier Precautions (EBP) as indicated, and proper glucometer cleaning for 3 of 7 residents reviewed for infection control (Resident #8, #11, and #15). The facility reported a census of 86.
January 7, 2026Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to treat 1 of 7 residents (Resident #1) reviewed for dignity with respect by applying multiple incontinent briefs during personal hygiene care. The facility reported a census of 38 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out assessments for 1 of 3 residents reviewed for a change in condition(Resident #1) by failing to carry out timely skin assessments after a hospitalization. The facility reported a census of 38 residents.
October 7, 2025Standard inspection, Complaint inspection · 3 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 document review, observations, staff interview, and policy review, the facility failed to ensure food served and prepared in accordance with professional standards for food service safety. The facility reported a census of 88.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, staff failed to transfer a resident using a technique which would not place pressure on the resident's compromised left foot and failed to notify the podiatrist in a timely manner of an open area for 1 of 3 residents reviewed for skin ulcers(Resident #6). The facility reported a census of 88 residents.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on electronic health record (EHR) review, observations, resident and staff interviews, the facility failed to ensure residents were aware of and offered alternative menu options for 2 of 3 residents reviewed for food (Residents #4 and #79). The facility reported a census of 88.
July 3, 2025Complaint inspection · 4 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, resident and staff interviews, clinical record review and policy review the facility failed to provide interventions to prevent a deep tissue injury (a type of pressure injury that occurs when underlying soft tissue is damaged due to prolonged pressure, often over bony prominence.) from performing for 1 of 5 residents reviewed (Resident #8) and failed to apply treatment to a Moisture Associated Skin Damage (MASD) area on the coccyx (the final bone at the bottom of the spine) for which resulted in the area had gotten worse and the Advance Registered Nurse Practitioner (ARNP was notified 7 days later. (Resident #9). The facility identified a census of 84 residents.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on a document of call light start and end time, resident interview, staff interview, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time for 4 of 4 residents. (#2, #5, #8 and #11) The facility reported a census of 84 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 observations, clinical record review, resident and staff interview, facility policy review, the facility failed to follow the comprehensive Care Plan for 1 of 3 (Resident #2) reviewed for care plans. The facility reported a census of 84 residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, staff interview and policy review, the facility failed to provide incontinence care appropriately to prevent cross contamination for 1 of 3 residents observed for incontinence care (Resident #3). The facility reported a census of 84 residents.
February 3, 2025Complaint inspection · 5 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to notify the Physician and family when a resident experienced a change in condition for 1 of 3 residents reviewed (Residents #1). The facility reported a census of 75 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff interview, facility investigation review and policy review the facility failed to report an allegation of abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 75 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 3 residents reviewed (Residents #2). The facility failed to implement physician orders in a timely manner. The facility reported a census of 75 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 failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 2 of 3 residents reviewed (Resident #1 and #2). The facility failed to complete and document nursing assessments related to nausea, vomiting and diarrhea for Resident #1. The facility also failed to complete vital signs with neurological assessments and complete a range of motion (ROM) assessment after a fall for Resident #1. The facility also failed to complete and document nursing assessments related diuretic usage for fluid overload and assess/monitor the efficacy and side effects of new medications started for fluid overload, sexual inhibition, anxiety and depression for Resident #2. The facility reported a census of 35 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, family interviews, hospital record review and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed (Resident #1) for falls. Resident #1 was identified as a fall risk prior and upon admission and interventions to prevent falls were not implemented upon admission to the facility. Resident #1 fell two times on the same day within 48 hours of admission. Based on staff interviews and documentation the staff did not provide appropriate level of assistance with transfers and the facility failed to complete a thorough assessment including vital signs and range of motion (ROM) after a fall occurred. The facility reported a census of 75 residents.
August 28, 2024Standard inspection · 6 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, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. The facility reported a census of 87 residents.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record review, staff interview, guidance from the Resident Assessment Instrument (RAI) manual, and facility policy review, the facility failed to complete a quarterly assessment for 1 of 18 (Res #73) residents reviewed. The facility reported a census of 87 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to administer medication in a timely manner for 1 of 18 residents reviewed (Resident #50). The facility reported a census of 87. Findings Include: 1. The Minimum Data Set (MDS) of Resident #50, dated 6/3/24, documented the resident had a Brief Interview of Mental Status (BIMS) identified the presence of short and long-term memory impairment. The MDS documented that the resident had short-term, and long-term memory loss. The MDS documented diagnoses that included: renal insufficiency, hypertension, aphasia, quadriplegia, seizure disorder, anxiety disorder, depression, and respiratory failure. It further documented her gastrostomy status, muscle contractures, and dysphagia. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide routine scheduled baths for 1 of 21 residents reviewed (Resident #35). The facility reported a census of 87 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff interview and resident interview, the facility failed to follow physician orders to obtain a resident's daily weight and twice daily oxygen saturation for 1 of 21 (#35) reviewed. The facility reported a census of 87 residents. Findings Include: On 8/25/24 at 11:42 AM, the resident was observed with bilateral, swollen ankles. The resident stated she had heart problems. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, hypertension, Diabetes Mellitus, cardiogenic shock (lack of blood and oxygen to organs caused by heart failure), prosthetic heart valve, and shortness of breath. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on direct observation, staff interview, record and policy review, the facility failed to perform a gastric tube (G-Tube) feeding in a manner that protects residents from cross-contamination for 2 of 3 residents reviewed (Resident #24, #50). In addition, the facility failed to serve meals in a manner that protects residents from cross-contamination. The facility reported a census of 87.
July 10, 2024Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent a male resident (Resident #1) from inappropriately kissing a female resident (Resident #2). The facility reported a census of 81 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, resident and staff interviews, the facility failed to supervise a male resident (Resident #1) with known sexual behaviors from inappropriately kissing a female resident (Resident #2). The facility reported a census of 81 residents.
May 15, 2024Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility policy review, family, resident interviews, and staff interviews, the facility failed to promptly identify and intervene for an acute change in a resident's condition, chest pain, shortness of breath, cough and urinary incontinence related to fluid volume overload. As a result the family transported the resident to the emergency department. Resident #1 was admitted to the hospital with acute hypoxic (lack of oxygen) respiratory failure due to pulmonary edema (excessive fluid in the lungs), sinus bradycardia (slowing of the heart), acute diastolic heart failure and swelling in the scrotum due to the edema. Concerns were identified for 1 or 3 residents reviewed for assessment and intervention. (Resident#1). The facility reported a census 81 of residents.
February 26, 2024Standard inspection, Complaint inspection · 9 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observation, policy review, document review, and staff interviews, the facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to evaluate where hazardous conditions may occur in the water systems and implement measures to prevent waterborne pathogens for 1 of 78 residents. Need universe The facility reported a census of 78 residents.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on resident interviews, call light log review, and facility policy review, the facility failed to answer the residents' call light in less than 15 minutes for 25% of the reviewed time period. The facility reported a census 78 residents.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 78.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to provide alternative food options for residents who refuse the food served. The facility reported a census of 78.
- 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 wroteBased on resident and staff interviews, facility record review, and the facilities admission Agreement, the facility failed to exercise reasonable care for the protection of the personal property against one resident (Resident #15). The facility also failed to maintain proper maintenance to resident rooms to promote a homelike environment. The facility reported a census of 78 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 observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive Care Plan for 1 of 5 residents reviewed (#58). The facility reported a census of 78 residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive care plan for 2 of 5 residents reviewed (#34 & #58). The facility reported a census of 78.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician's orders for 2 of 26 residents (Resident #34 & #80). The facility failed to document the physician order for oxygen therapy for Resident #34 and later titrated oxygen without a physician's order. The facility reported a census of 78.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident and staff interview, and record review, the facility failed to provide restorative activities in order to maintain a functional range of motion and prevent a decline in activities of daily living for 2 of 2 residents (#48 and #58). The facility reported a census of 78 residents.
September 7, 2023Complaint inspection · 6 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, family interview and staff interviews, the facility failed to promptly assess a resident with a change in condition and provide skin assessments in accordance with professional standards of practice for 3 of 3 residents reviewed (Resident #13, #1 and #11). The facility reported census was 82.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to ensure call lights were responded to in a timely manner at no greater than 15 minutes for 5 of 5 residents reviewed (Residents #6, #7, #8, #9 and #10). The facility reported census was 82.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, resident and staff interviews the facility failed to maintain a clean and comfortable environment for their residents. The facility reported census as 82 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, family interview, and provider interview the facility failed to ensure physician orders are followed in accordance with professional standards of practice for 2 of 4 residents reviewed (Resident #5 #11). The facility reported census was 82.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, staff, family and resident interview, the facility failed to provide perineal cares of incontinent residents unable to carry out the activity independently for 2 of 3 residents reviewed (Resident #10, #11). The facility reported census was 82.
- 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, climatologist review and staff interviews, the facility failed to ensure a resident accessing the courtyard was adequately supervised for 1 of 1 residents reviewed (Resident #1). The facility reported census was 82.
Fire safety inspections
7 fire safety citations on file: 2 on October 7, 2025, 1 on August 28, 2024, 4 on February 26, 2024.
Every fire safety citation7 citations
- D
Have properly located and lighted "Exit" signs.
K 293 · October 7, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 26, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 26, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 26, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 26, 2024 · Corrected (the home has a date of correction)