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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
1E
1F
Potential for minimal harm
0A
0B
0C
May 27, 2026Standard inspection · 4 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record reviews staff interview, and facility policy review, the facility failed to ensure that 1 out of 5 residents reviewed (Resident #36) for medications were provided with information, education regarding the risks and benefits of psychotropic medications or choice of alternatives and options. The facility reported a census of 45 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 interviews, observation, clinical record review, and Iowa Physician Orders for Scope of Treatment, (I-POST) documents the facility failed to ensure consistency with process's to ensure clear direction with Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) code status for 3 of 16 reviewed for Advance Directives (Resident #4, #36, #40) . The facility reported a census of 45 residents.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on clinical health record review, facilty document review, resident interviews, staff interviews, and policy review, the facilty failed to ensure residents were free from exploitation for 2 of 45 residents reviewed for abuse (Residents #10 and #18). Staff E, Licensed Practical Nurse (LPN), stole resident pain medications and documented the medications were administered to the residents. These actions continued until Staff E was suspended and terminated. The facility reported a census of 45.
- 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, facility record review, family interview, staff interviews, and policy review, the facility failed to provide services to protect the resident from accidents or hazards by not ensuring the correct mechanical lift sling was used resulting in the resident sliding out from the sling (Resident #7). The facility reported a census of 45.
May 22, 2025Standard inspection · 1 citation
- 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, policy review, and staff interview the facility failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness during one of one meals observed. Facility staff also failed to cover facial hair (beard) while preparing food. The facility reported a census of 43 residents.
May 16, 2024Standard inspection · 2 citations
- F
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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 39.
- 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 staff failed to follow the Care Plan to properly transfer a resident as directed in the resident's care plan for 1 of 4 residents sampled for transfers and falls (Resident #22). The facility reported a census of 39 residents.
Fire safety inspections
20 fire safety citations on file: 5 on May 27, 2026, 11 on May 22, 2025, 4 on May 16, 2024.
Every fire safety citation20 citations
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 27, 2026 · 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 · May 27, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 27, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 27, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 27, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 22, 2025 · 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 22, 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 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 22, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · May 22, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 22, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 22, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 22, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 22, 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 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 16, 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 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 16, 2024 · Corrected (the home has a date of correction)