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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
26D
7E
3F
Potential for minimal harm
0A
0B
2C
December 10, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, clinical record review and staff interviews, the facility failed to provide care that promotion each resident's dignity, demonstrated when staff failed to assist a dependent resident change out of a heavily soiled shirt that the resident continued to wear throughout the day, in front of other residents and facility visitors, for 1 of 7 residents in the open sample (Resident #7). The facility reported a census of 55 residents.
October 2, 2025Standard inspection, Complaint inspection · 6 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, resident and staff interviews, provider interview and facility policy review, the facility failed to provide a safe environment free from physical abuse for 1 resident (Resident #64). This resulted in harm to the resident in the form of a displaced fracture to the lower end of the right humerus and a non-displaced fracture to the head of the right radius. The facility reported a census of 55.
- 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, record review and staff interviews the facility failed to store food properly, handle food correctly for 3 out of 3 meals observed and maintain clean refrigerator and microwave to prevent food borne illnesses. The facility identified a census of 55 residents.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on the previous Center for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, staff interview, current CMS Statement of Deficiencies form and facility policy review the facility failed to carryout Quality Assurance (QA) activities to prevent reoccurrence of deficiencies. The facility reported a census of 55 residents.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interviews, facility sign-in sheets and facility policy, the facility lacked the required Infection Preventionist (IP) at 3 of the 4 quarterly meetings. The facility reported a census of 55 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff and resident interviews and facility policy review the facility failed to complete dialysis site assessments before and after dialysis for 1 of 1 residents reviewed (Resident#11). The facility reported a census of 55 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff and resident interviews and facility policy review the facility failed to implement Enhanced Barrier Precaution (EBP) for 2 out of 6 residents reviewed (Resident #2 and 11). The facility reported a census of 55 residents.
March 19, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure staff assisted 3 of 6 residents (Resident #5, #6, and #8) to eat in a dignified manner, and promoted their individuality while during a meal service. The facility reported a census of 61 residents.
September 26, 2024Standard inspection · 15 citations
- J
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review the facility failed to hold warfarin, an anticoagulant medication (Coumadin, brand name for warfarin) following a documented International Normalized Ratio (INR) documented as 7.8 on 4/8/24 for one of one resident reviewed for warfarin administration (Resident #19). The resident received doses of warfarin on 4/8/24 and 4/9/24 when the medication was to be held. The resident's INR was documented as 9.3 on 4/10/24. The resident was found with blood on their arms and legs on 4/13/24. Resident sent to the hospital and admitted for INR of 8.2, Hemoglobin (Hgb) of 8.6, and treated with Vitamin K (antidote). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 51 residents.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, facility policy review, and staff interviews, the facility failed to serve food that maintained a safe and appetizing temperature. The facility reported a census of 51 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, facility policy review and staff interviews, the facility failed to use standard food handling practices of washing hands and glove changes between tasks to prevent the potential for cross contamination during meal service. The facility reported a census of 51 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents treated in a dignified manner for one of three residents reviewed for dignity (Resident #5). The facility reported a census of 51 residents.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview, clinical record review, and facility policy review the facility failed to ensure timely completion of an admission Minimum Data Set (MDS) assessments for one of two residents reviewed for Resident Assessment Task (Resident #38). The facility reported a census of 51 residents.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record review and staff interview the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for two of two residents reviewed for Resident Assessment Task (Resident #13, Resident #38). The facility reported a census of 51 residents.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review and staff interview the facility failed to ensure Minimum Data Set assessments submitted timely for one of two residents reviewed for Resident Assessment Task (Resident #13). The facility reported a census of 51 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) assessment for one of five residents reviewed for unnecessary medications (Resident #23). The facility reported a census of 51 residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on clinical record review, resident and staff interview, the facility failed to complete a Baseline Care Plan within 48 hours of admission for 2 of 2 newly admitted residents reviewed (Resident #32 and Resident #53). The facility reported a census of 51 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 interview and record review the facility failed to update the resident's Care Plan following discontinuation of anticoagulant medication for one of seventeen residents reviewed for care plans (Resident #19). The facility reported a census of 51 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interviews, and clinical record review the facility failed to ensure ongoing coordination of care between facility staff and hospice staff for one of one resident reviewed for hospice (Resident #19). The facility reported a census of 51 residents.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to prevent reoccurrence of deficiencies. The facility reported a census of 51 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and policy review the facility failed to wear appropriate Personal Protective Equipment (PPE) when providing care for residents with COVID-19, a tracheostomy and when performing wound care for 3 of 3 residents reviewed (Residents #257, #15 and #53). The facility reported a census of 51 residents.
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on clinical record review, and policy review, and staff interview the facility failed to have the minimum required members participate in the facility Quality Assessment and Assurance (QAA) committee meetings. The facility reported a census of 51.
- C
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on record review, staff interview and policy review the facility failed to document nursing education on the QAPI (Quality Assurance Performance Improvement) program for 4 out of 4 staff members reviewed. The facility reported a census of 51 residents.
August 8, 2024Complaint inspection · 3 citations
- J
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 resident and staff interviews the facility failed to identify and respond to an elopement in a timely manner for 1 of 1 residents reviewed for elopement (Resident #1). Resident #1 eloped from the facility on 7/20/24 at approximately 3:00 a.m., was found at 7:20 a.m. by facility staff on a neighboring business property approximately 100 yards from the facility. Facility staff initially identified the resident was missing at 6:50 a.m., notified management staff at 7:08 a.m., and staff went outside and looked for the resident at 7:15 a.m. The facility failed to follow appropriate precautions when a door alarm sounded on 7/20/24, they did not assess the area around the door for residents and did not take action to ensure that all residents were accounted for that resulted in a resident's elopement and fall with injuries. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide appropriate urinary catheter care, and failed to follow standard infection control practices during 2 of 2 observations of urinary catheter care, for 2 of 2 resident's reviewed for catheter care (Resident #5 and Resident #7). The facility reported a census of 51 residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to ensure that residents received medications as ordered and directed by the physician, and resulted in a resident's transfer to a hospital Emergency Department for treatment of symptoms associated to medication withdrawal for 1 of 9 resident's reviewed (Resident #5). The facility reported a census of 51 residents.
January 3, 2024Standard inspection, Complaint inspection · 15 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review, the facility failed to provide residents with an environment that maintains or enhances each resident's dignity by using the term and labeling residents as feeders. The facility failed to ensure residents were treated in a dignified manner for four residents within hearing distance in the dining area. The facility reported a census of 50 residents. Findings Include: 1. On 12/19/23 at 11:30 AM, during an observation of the dining area one of the two Dietary Aides plating the food, Staff Q, Server was heard referring to the resident's who need more assistance as the Feeder's. On 12/20/23 at 11:36 AM, during a dining observation a staff member stated, We need to make sure we get the Feeders. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide residents assistance with dining and/or incontinence care for four of seventeen sampled residents (Residents #9, #25, #40, and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #45 dated 11/16/23 revealed the resident was rarely to never understood. Per this assessment, Resident #45 was dependent for eating. The Care Plan dated 9/19/23 documented, The resident has an Activities of Daily Living (ADL) self-care performance deficit related to (R/T) Dementia. The Intervention dated 9/19/23 revised 10/18/23 documented, Resident #45 needs assist x 1 with dining. On 12/19/23 at 8:27 AM, Resident #45 observed in the dining room. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to ensure fall interventions consistently implemented, determine root cause analysis for falls, ensure residents at risks for falls provided appropriate supervision by staff, and ensure appropriate transport in a shower chair and wheelchair for four of twelve residents reviewed for accidents (Residents #4, #32, #34, and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #45 dated 11/16/23, revealed the resident was rarely to never understood. Per this assessment, the resident had fallen since admit, entry, or reentry, and had two or more falls with no injury. [...]
- E
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 clinical record review, Pharmacy record review, staff interviews, and facility policy review, the facility failed to document a rationale or response to the Consultant Pharmacist's attempts for a Gradual Dose Reduction (GDR) for four of five residents reviewed (Residents #6, #31, #40 and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #6 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and had the following diagnoses: Arthritis, Non-Alzheimer's Dementia and Encephalopathy. [...]
- 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 and staff interviews the facility failed to distribute and serve food under sanitary conditions, when facility staff failed to wear hair restraints (hairnet, hat) that covered all exposed hair including long hair to prevent hair from contacting food, per current Food Code requirements. The facility reported a census of 50 residents. Findings Include: On 12/19/23 at approximately 11:45 AM, Staff R, Server- came into the kitchen to take a food cart to the dining area. Staff R had on a hair net which covered the top and sides of the head but did not cover the long dreadlocks. On 12/20/23 at 11:36 AM, Staff A, Server was observed behind the serving counter with long hair not contained in a hair net. On 12/18/23 11:15 AM, when queried, the Director of Culinary Services advised all staff are required to wear hair nets when in the kitchen or serving food. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on personnel record review, staff interview, and facility policy review, the facility failed to ensure one of three newly hired Nurses completed the Mandatory Reporter Abuse Training within the required timeframe of 6 months within hire (Staff M). The facility reported a census of 50 residents. Findings Include: 1. A review of the Human Resources (HR) file for Staff M, Registered Nurse (RN) revealed the following: a. A hire date of 10/12/22. b. Certificate of completion of Dependent Adult Abuse Mandatory Reporter Training dated 5/14/23 In an interview on 12/28/23 at 10:59 AM, the Director of Nursing (DON) reported Staff M is due to complete the Abuse Training. The DON also reported the HR manager will usually send out e-mails to department heads to inform them of which new employees need to complete the abuse training. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to ensure accurate coding on the Minimum Data Set (MDS) Assessment for catheter use, activities of daily living, and receipt of insulin injections for two of two residents reviewed for MDS accuracy (Residents #36 and #45). The facility reported a census of 50 residents. Findings Include: 1. The MDS Assessment for Resident #45 dated 11/16/23 revealed the resident rarely to never understood. Per this Assessment, the resident had an indwelling and external catheter. The Resident #45's Care Plan in the resident's Electronic Health Record (EHR) did not address presence of a catheter for the resident. The Physician Order dated 10/17/23, documented - Urinary Catheter: [...]
- 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 interviews, and the facility policy the facility failed to Care Plan specialized services for the Preadmission Screening and Resident Review (PASRR) Level II and ensure residents received psychiatric services as recommended by the psychiatric provider for 1 of 1 residents reviewed for PASRR (Resident #25). The facility reported a census of 50 residents. Findings Include: The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #25 scored an 11 out 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderately impaired cognition. The MDS identified diagnoses for anxiety disorder and bipolar disorder. The MDS documented resident received antipsychotic and antidepressant. The PASRR Level II dated [DATE] and expired on [DATE] (short term approval) revealed the following: a. Specialized services for service and support: 1. [...]
- 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, clinical record review, staff interviews, and facility policy review, the facility failed to update Care Plans of two of ten residents reviewed (Residents #20 and #45). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #20 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (kidney failure). The MDS documented Resident #20 required staff supervision or touching assistance with lower body dressing only and independent with the other activities of daily living. An observation of Resident #20 on 12/20/23 at 1:18 PM, revealed she sat in her wheelchair in her room which also had her bed with one ½ side rail up on the right side of the bed. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wrote2. The MDS assessment dated [DATE], revealed Resident #36 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated cognition intact. The MDS identified a diagnosis of diabetes mellitus (DM), and the resident received an injection 7 out of 7 days. The MDS documented the resident received an insulin injection 1 out of the last 7 days since admission/entry or reentry if less than 7 days. The Care Plan documented a focus area dated 11/2/23 for diabetes mellitus. The interventions dated 11/2/23 documented diabetes medication as ordered by doctor and monitored and documented for side effects and effectiveness; and resident took Lispro to assist with managing blood glucose levels. The Electronic Medical Record (EMR) identified a diagnosis of Type II DM without complications. The Physician Orders dated 10/13/23 revealed the following medication: a. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wrote2. The MDS assessment dated [DATE], revealed Resident #25 scored a 11 out 15 on the Brief Interview of Mental Status (BIMS) exam which indicated cognition moderately impaired. The MDS identified the resident dependent with toileting and needed substantial/maximal assistance with upper and lower body dressing and rolling from right to left. The MDS documented an indwelling catheter for the resident. The Care Plan revealed a Focus Area dated 6/10/23 for an indwelling catheter. The interventions dated 6/1/23 to monitor and document intake and output as per facility policy. During an observation on 12/19/23 at 2:00 PM, Resident #25 sat in her recliner with the catheter bag hooked to the trash can with dark yellow urine and the bottom of the catheter bag touched the floor. [...]
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to document an assessment and education provided for one of two residents reviewed with side rails. (Resident #20). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set, dated [DATE] identified Resident #20 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (kidney failure). It also identified Resident #20 required staff supervision or touching assistance with lower body dressing only and independent with the other activities of daily living. [...]
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review, state on-line licensure verification and staff interviews, the facility failed to obtain a current nursing license for one of three nurses reviewed for new hires (Staff L). The facility reported a census of 50 residents. Findings Include: A review of the Human Resources (HR) file for Staff L, Registered Nurse (RN) revealed the following: a. Hire date of 10/17/23. b. New Employee Orientation Checklist (reviewed 12/21/23) did not have documentation to show a copy of the RN license had been obtained. c. Iowa Board of Nursing verification of RN licensure dated as completed 12/27/23. In an interview on 12/28/23 at 10:38 AM , Staff I, Certified Nursing Assistant (CNA) reported she has seen Staff L toilet residents and answer call lights. In an interview on 12/28/23 at 10:59 AM, Staff L, RN reported upon hire, no one made a copy of her nursing license. [...]
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on clinical record review, staff and family interviews, and facility policy review, the facility failed to offer or obtain routine dental services for 3 of 3 residents (Residents #8, #37, and #40) reviewed for dental services. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #8 required set up assistance for oral hygiene and had obvious or likely cavity or broken natural teeth. Resident #8 coded as rarely or never understood, had both short term and long term memory problems, and indicated moderate impairment in ability to make decisions regarding tasks of daily life. Diagnoses included: Leukemia (in relapse), atrial fibrillation, arthritis, asthma, and depression. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to follow the proper transmission based precautions for one of one residents reviewed with contact precautions (Resident #14) and failed to follow the recommendations required for Legionella. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and had the following diagnoses: Pneumonia, Urinary Tract Infection and Respiratory Failure. The MDS also identified Resident #14 required set up or clean up assistance with most activities of daily living and required tracheostomy care with suctioning. The Nurse Practitioner Note dated 12/15/23 documented the following: [...]
Fire safety inspections
10 fire safety citations on file: 5 on October 2, 2025, 2 on September 26, 2024, 3 on January 3, 2024.
Every fire safety citation10 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · October 2, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 2, 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 · October 2, 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 · October 2, 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 · September 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 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 · January 3, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 3, 2024 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · January 3, 2024 · Corrected (the home has a date of correction)