Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Stanton during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of elopement risk, despite wearing a wander guard and having a care plan with specific interventions, was able to leave an outdoor group activity unsupervised. Staff interviews confirmed that no CNA was assigned to supervise residents with wander guards during the event, and the resident was not noticed missing until alerted by another resident. The resident was found at a nearby family home and returned without injury, highlighting a lapse in required supervision.
A resident with an initial negative Level I PASRR screening was later diagnosed with anorexia and unspecified psychosis, but the facility did not update or resubmit the PASRR referral as required. The DON, responsible for PASRR submissions, acknowledged the oversight and the lack of a formal policy contributed to the failure to refer the resident for a Level II PASRR evaluation.
A resident with a history of multiple medical conditions experienced several days of nausea and vomiting without documented vital signs or bowel assessments, despite ongoing symptoms and a care plan requiring such monitoring. Staff did not consistently assess or document the resident's condition, and there was no clear policy guiding response to changes in status. The resident was eventually hospitalized with a bowel obstruction and septic shock, and later died after returning to the facility.
A resident with multiple cardiac and respiratory diagnoses, who was ordered continuous oxygen therapy, was observed on two occasions with an empty oxygen tank while in the dining room. Staff interviews revealed that the LPN did not check the oxygen tank before transport and that staff relied on CNAs to report empty tanks. The DON confirmed that tanks could empty quickly at the prescribed flow rate and acknowledged that staff should have monitored them more closely. The facility lacked a policy and documentation of staff education on oxygen therapy standards.
The facility failed to personalize care plans for several residents, leading to deficiencies in meeting their needs. A resident's care plan for anticoagulant therapy lacked details on medication reasons and side effects, while another's antipsychotic medication plan was missing key information. A hospice care plan was not individualized, and other residents' plans lacked targeted interventions for cognitive and mood disorders. The MDS Coordinator was still learning the process, and the facility lacked specific policies for care plan updates.
The facility failed to employ a certified dietary manager, as the Dietary Manager had not purchased the necessary license despite passing the certification test. The facility's policy required sufficient and competent staffing, but the Administrator confirmed the DM lacked the correct certification.
The facility failed to properly prepare pureed diets for two residents and did not serve appropriate portions for others. Observations showed that the cook did not measure ingredients or final volumes, leading to improper preparation of pureed diets. Additionally, incorrect portion sizes were served for regular and carbohydrate-controlled diets, as the first 11 plates had partially full servings, contrary to menu specifications.
The facility failed to maintain sanitary practices in food storage and handling, with observations of unlabeled and undated food items, improper hand hygiene, and unsanitary kitchen conditions. Staff did not follow facility policies on food safety, leading to potential cross-contamination.
The facility failed to implement its Infection Prevention and Control Program, with staff not discarding PPE immediately and not performing hand hygiene. Additionally, the facility lacked a comprehensive water management plan to address Legionella risk, with the Maintenance Director unfamiliar with the water flow system and lacking necessary documentation.
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) within 2 days for two residents receiving skilled care under Medicare A. The Social Services Director was initially unaware of the NOMNC requirement, leading to residents not being informed about their right to appeal for continued Medicare coverage.
The facility did not ensure that two staff members completed the required Dependent Adult Abuse training within six months of hire. Despite attempts to locate the training certificates, documentation was not found, violating the facility's policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented care needs. One resident's MDS inaccurately recorded cognitive status and medication use, while another's incorrectly noted bed rail use as a restraint. A third resident's MDS failed to document an unstageable pressure ulcer. The MDS Coordinator admitted to errors due to a lack of tracking systems and training, and the DON confirmed the absence of policies for MDS and care plan updates.
The facility failed to update care plans for two residents, one with a pressure ulcer and another with significant pain from a previous fall. Despite physician orders and ongoing treatment, the care plans were not revised to reflect these conditions. The MDS Coordinator was still learning the process, and the DON acknowledged the absence of a specific care plan policy.
A resident with functional limitations and dependency on staff for daily activities did not receive restorative activities to maintain range of motion, despite having a care plan and a Restorative Nursing Program. Staff were unaware of the program, and the resident had not been screened for therapy, leading to a deficiency in care.
The facility did not complete and post nurse staffing information at the beginning of each shift. A review on July 19, 2024, showed incomplete staffing data for the day and evening shifts, and all 17 staffing sheets for July 2024 were incomplete, with no sheet for July 17, 2024. The DON stated that the staffing sheet is initiated during the night shift, but there was no policy for posting staffing data.
A facility failed to serve food at safe temperatures, as observed when a cook prepared pureed pork ribs, carrots, and macaroni & cheese without checking their temperatures before placing them on the steam table. The food was later served to a resident with temperatures below the required 135 degrees Fahrenheit, contrary to the facility's policy.
A resident with moderately impaired cognition and multiple diagnoses, including Alzheimer's and COPD, sustained an injury of unknown origin and accused a staff member of causing a fall. The facility delayed reporting the incident to the State Agency, initially advised by corporate administration that it was not reportable. The reporting process began several days later, highlighting a deficiency in timely reporting.
A resident with moderate cognitive impairment and anxiety eloped from the facility due to inadequate supervision and security measures. Despite being identified as an elopement risk, the resident managed to remove his wander guard and exit the facility unnoticed, using a door code observed earlier. Staff were unaware of his absence until he returned with items from his home. Documentation of required checks was incomplete, and staff interviews revealed a lack of seriousness regarding the incident.
Two residents experienced inadequate pain management due to the facility's failure to utilize prescribed treatments and document pain assessments. One resident with a broken tailbone did not receive a lidocaine patch as ordered, and pain levels were not consistently recorded. Another resident under hospice care had pain medication administered late multiple times, despite reporting constant pain. The facility lacked a specific pain management policy, contributing to these deficiencies.
Failure to Provide Adequate Supervision for High Elopement Risk Resident During Outdoor Activity
Penalty
Summary
A deficiency occurred when a resident with a known high risk for elopement was not provided with adequate supervision during an outdoor group activity. The resident, who had a diagnosis of unspecified dementia and a BIMS score indicating moderate cognitive impairment, was assessed as a high elopement risk and wore a wander guard. Despite these precautions, the resident was able to leave the supervised activity area without staff noticing and walked to a nearby family home. The absence of direct supervision was confirmed by multiple staff interviews, with several staff members stating that no CNA was assigned to supervise residents with wander guards outside at the time of the incident. The resident's care plan included specific interventions for elopement risk, such as providing diversions, structured activities, and 1:1 supervision when outside, as well as the use of a wander guard. However, during the outdoor activity, staff were engaged in other tasks such as passing ice cream, providing entertainment, and assisting other residents, which led to a lapse in direct supervision. Staff interviews revealed confusion about who was responsible for supervising residents with wander guards, and it was acknowledged by the DON and other staff that there was a lack of clear assignment for supervision during the event. The resident was ultimately located by family and returned to the facility without injury. Documentation and interviews indicated that the facility's policy required supervision for residents at risk of elopement, but this was not consistently implemented during the incident. The DON and other staff confirmed that the expectation was for nursing staff to supervise residents with wander guards when outside, but this did not occur during the group activity. The deficiency was attributed to a breakdown in communication and assignment of supervision responsibilities, resulting in the resident's unsupervised exit from the facility.
Failure to Refer Resident for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after the resident was identified with new or possible serious mental disorders. The resident initially had a negative Level I PASRR result, with the screening only documenting diagnoses of major depression and anxiety disorder. However, subsequent clinical record reviews revealed new diagnoses of anorexia and unspecified psychosis, which were not included in the original PASRR documentation. The facility did not update or resubmit the PASRR referral upon receiving these new diagnoses. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for PASRR submissions at the time and acknowledged that the new diagnosis of psychosis should have triggered a new PASRR referral. The DON admitted to not considering anorexia as a qualifying diagnosis for PASRR resubmission and recognized the oversight. Additionally, the facility lacked a formal policy for PASRR submissions and relied on general requirements for status changes, contributing to the failure to refer the resident for appropriate evaluation.
Failure to Assess and Intervene for Resident with Persistent Nausea and Vomiting
Penalty
Summary
The facility failed to provide adequate and timely assessment and intervention for a resident who experienced nausea and vomiting over a four-day period. Despite the resident's ongoing symptoms, including repeated vomiting and refusal of food and medications, the clinical record lacked documentation of vital signs or bowel assessments during this time. The care plan for the resident, who had a history of anemia, atrial fibrillation, heart failure, benign prostatic hyperplasia, and constipation, required staff to assess bowel sounds and abdomen and to report abnormalities to the primary care physician, as well as to follow bowel protocols and administer as-needed medication for constipation. Nursing progress notes indicated that the resident was seen by a doctor and treated for a suspected urinary tract infection, with antibiotics and anti-nausea medication prescribed. However, the resident continued to experience nausea, vomiting, and a decline in functional status, including increased lethargy and weakness. Staff interviews revealed that vital signs and bowel assessments were not consistently performed or documented, and staff were uncertain about the expectations for monitoring residents on antibiotics. The Director of Nursing confirmed that there was no policy on resident change in status and that standard of care was to be followed, but could not provide a specific resource for staff guidance. The resident was eventually sent to the emergency department after continued deterioration, where he was found to have a small bowel obstruction with perforation and septic shock. Hospital records documented hypotension, tachycardia, and significant abdominal findings. The resident was transferred for possible surgical intervention and later returned to the facility, where he subsequently passed away. The lack of timely assessment and intervention, including failure to monitor vital signs and bowel status, contributed to the deficiency identified by surveyors.
Failure to Ensure Supplemental Oxygen Provided as Ordered
Penalty
Summary
Staff failed to provide safe and appropriate respiratory care by not ensuring that a resident on continuous oxygen therapy received supplemental oxygen as ordered. The resident, who had diagnoses including atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, and a cardiac pacemaker, was observed on two separate occasions in the dining room with an oxygen tank that was empty, as indicated by the gauge needle in the red zone. The nasal cannula was attached to the resident but the tank was not supplying oxygen. The resident required minimal assistance with activities of daily living and had intact cognitive ability. Interviews with staff revealed that the LPN who assisted the resident to the dining room did not check the oxygen tank, and staff relied on CNAs to notify them if a tank was empty. The DON acknowledged that at the prescribed flow rate, tanks would empty quickly and staff should have monitored them more closely. The facility did not have a policy for supplemental oxygen use and did not provide documentation of staff education on standards of care for oxygen therapy.
Deficiencies in Personalized Care Plans for Residents
Penalty
Summary
The facility failed to develop and personalize comprehensive care plans for six out of fourteen residents reviewed, leading to deficiencies in meeting the residents' needs. For Resident #6, the care plan for anticoagulant therapy was incomplete, lacking details on the reason for the medication, specific side effects to monitor, and how to assess effectiveness. Similarly, Resident #25's care plan for antipsychotic medication was not personalized, missing the medication name, related diagnosis, and specific behaviors to monitor. Resident #40's care plan under hospice care was not individualized, failing to include interventions for pain management, emotional support, and coordination with hospice services. The Director of Nursing acknowledged the expectation for personalized care plans, particularly for psychotropic medications, but the care plans reviewed did not meet these standards. Resident #29's care plan did not address personalized interventions for dementia, wandering, and anxiety, despite the resident's severe cognitive impairment and mood symptoms. Resident #3's care plan lacked targeted interventions for dementia, personality disorders, and Parkinson's Disease, while Resident #32's care plan did not include personalized interventions for Alzheimer's Disease, cerebrovascular accident, anxiety, and depression. The MDS Coordinator admitted to still learning the process of updating care plans, and the facility lacked specific policies for initiating or revising care plans and MDS assessments, relying instead on general regulations.
Deficiency in Dietary Management Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. Specifically, the Dietary Manager (DM) had passed the certification test but had not purchased the license, and therefore was not certified as an approved nutrition and food service manager. This was confirmed through a course completion certificate and the DM's own admission that she did not have a national certification. The facility's policy titled Personnel - General, dated 2021, indicated that the food and nutrition services department should be staffed with sufficient, competent, and supportive personnel to carry out its functions. However, the Administrator acknowledged that the DM was expected to have the correct dietary management certification, which was not the case.
Improper Preparation and Portioning of Diets
Penalty
Summary
The facility failed to properly prepare and serve pureed diets for two residents and did not serve appropriate portions for several others. Observations revealed that the cook, Staff A, did not measure the ingredients or the final volume of pureed food, which included carrots, bread, pork ribs, and macaroni. Instead, he used a basting spoon to add unmeasured amounts of food and milk into a blender, divided the mixture into bowls, and placed them on the steam table without ensuring the portions met the required measurements. This lack of measurement and adherence to the menu specifications resulted in improper preparation of pureed diets for the residents. Additionally, the facility did not serve the correct portion sizes for residents on regular and carbohydrate-controlled diets. During lunch service, the first 11 plates were prepared with partially full 4-oz servings of macaroni & cheese, green beans, and mixed vegetables, which did not align with the menu's specified portions. The Dietary Manager acknowledged the absence of a specific policy for the puree process and indicated that staff should follow the designated puree process and diet spreadsheet, which was not adhered to during the observed meal preparation and service.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and service, as observed during a survey. Multiple instances of improper food storage were noted, including unlabeled and undated food items in refrigerators and freezers, and food stored directly on the floor. Additionally, staff were observed handling food without proper hand hygiene or glove changes, contributing to potential cross-contamination. For example, a cook was seen touching a garbage can and then handling food without changing gloves or washing hands. Further observations revealed unsanitary conditions in the kitchen, such as a fan blowing air into a cut-out section of the ceiling above the food serving area, and pieces of ceiling insulation falling onto the serving area. Staff were also seen using inappropriate surfaces for food preparation, such as placing a strainer in a sink designated for dirty dishes and using a piece of sheet metal on a food preparation counter. These actions were contrary to the facility's policies on food storage and handling. The facility's policies, which require food to be dated and stored off the floor, and mandate hand hygiene and prevention of cross-contamination, were not followed. The Dietary Manager confirmed that staff should adhere to these policies, yet multiple violations were observed, indicating a systemic issue with compliance in food safety practices.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to properly implement its Infection Prevention and Control Program (IPCP), as evidenced by several observations and staff interviews. Staff were observed not discarding Personal Protective Equipment (PPE) immediately after use, with isolation gowns hanging out of covered containers and on doors. Additionally, staff did not consistently perform hand hygiene, as seen when a Certified Nurse Aide (CNA) handled a resident's meal ticket and utensils without washing hands. The Infection Preventionist confirmed that PPE should be covered and not reused, aligning with the facility's policy. Furthermore, the facility did not have a comprehensive water management plan to address the risk of Legionella or other waterborne pathogens. The Maintenance Director was unfamiliar with the facility's water flow system and lacked a water management plan or completed water system flow and Legionella risk area documents. The water heater and storage tanks were set at temperatures that may not effectively control pathogen growth. The facility's policy required sound engineering and preventative maintenance to minimize Legionella exposure, but these measures were not in place.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) within the mandated 2 calendar days for two residents receiving skilled care under Medicare A. Resident #43 began receiving skilled care on May 2, 2024, with Medicare coverage continuing until May 20, 2024. Although a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was signed on May 17, 2024, the facility could not produce a signed NOMNC form. Instead, a typed name of the resident representative was noted as a telephone order on the same date. Similarly, Resident #44 received skilled care starting November 1, 2023, with Medicare coverage until January 4, 2024. The SNFABN was signed on December 21, 2023, but again, the facility failed to provide a signed NOMNC form, only noting a telephone order on the same date. The Social Services Director, who assumed the role in March 2023, stated she was initially trained to use only the SNF ABN form and was unaware of the NOMNC requirement. Upon learning about the NOMNC, she contacted residents or their representatives post-discharge to inform them about the form, backdating it to match the SNFABN signing date. Consequently, residents discharged during this period were not informed about their right to appeal to continue their skilled stay under Medicare.
Failure to Complete Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that two of the five staff members reviewed, identified as Staff L and Staff M, completed the mandatory two-hour Dependent Adult Abuse training within six months of their hire date. Staff L was hired on December 8, 2023, and Staff M on January 4, 2024. Upon review of their employee files on July 19, 2024, it was found that there was no documentation of the Iowa Department of Public Health approved Dependent Adult Abuse Mandatory Reporter training being completed by either staff member. The Business Office Manager attempted to locate the certificates on the same day but was unsuccessful by 5:00 pm. The facility's policy, dated January 10, 2022, requires each employee to complete this training within six months of hire and a recertification every three years thereafter.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their documented care needs and conditions. For one resident, the MDS inaccurately recorded a Brief Interview of Mental Status (BIMS) score indicating intact cognition, despite the resident having diagnoses of Alzheimer's disease, anxiety disorder, depression, and bipolar disorder. The MDS also failed to document the use of antidepressant medications and incorrectly noted the use of bed rails as a restraint, despite a side rail assessment indicating they were used to promote independence. Additionally, the facility did not document any gradual dose reduction (GDR) attempts for psychotropic medications, although psychiatric progress notes indicated that GDRs were clinically contraindicated. Another resident's MDS inaccurately documented the use of bed rails as a restraint, which the MDS Coordinator later identified as an error, stating the facility is restraint-free. The MDS Coordinator admitted to a lack of a tracking system for GDRs, leading to incorrect MDS entries. A third resident's MDS inaccurately reported severe cognitive impairment and failed to document an unstageable pressure ulcer, despite physician orders and care plans indicating its presence. The MDS Coordinator acknowledged being in training and unfamiliar with the process of updating care plans, and the Director of Nursing (DON) confirmed the absence of policies for initiating or revising care plans and MDS assessments.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and update the care plan for two residents, leading to deficiencies in their care. Resident #37, who had severe cognitive impairment and multiple medical conditions, was found to have an unstageable pressure ulcer on the right lateral foot. Despite a physician's order for treatment, the care plan was not updated to reflect this condition. The nursing staff completed the treatment as ordered, and the area appeared healed upon assessment. However, the MDS Coordinator, who was still learning the process of updating care plans, did not ensure the care plan was revised to include the pressure ulcer. Resident #16, who had intact cognition, reported significant pain from a previous fall that resulted in a broken tailbone. Although the resident was receiving scheduled pain medication as ordered by the physician, the care plan was not updated to reflect this change in medication regimen. The resident expressed that the pain medication was not effective enough, impacting her ability to sit comfortably. The Director of Nursing acknowledged the lack of a specific policy regarding care plans, stating that the facility follows regulations and standards of care.
Failure to Provide Restorative Activities for Resident
Penalty
Summary
The facility failed to provide restorative activities for a resident, identified as Resident #22, to maintain a functional range of motion and prevent a decline in activities of daily living. The resident was dependent on staff for various activities such as bathing, dressing, bed mobility, transferring, and toileting, and had functional limitations in one upper and one lower extremity. Despite having a care plan that directed staff to perform range of motion exercises and a Restorative Nursing Program, the resident did not receive any Speech, Occupational, or Physical Therapies or Restorative Nursing Programs during the assessment period. Observations noted the resident's right wrist was contracted, and staff interviews revealed a lack of awareness and implementation of the restorative program. The Social Services director was unaware of the resident having a Restorative Program, and the Rehabilitation Director confirmed that the resident had not been screened for therapy during her tenure. The MDS Coordinator could not explain why the resident did not have a restorative program, despite acknowledging the resident's appropriateness for such a program. The facility's policy outlined a process for assessing and developing restorative programs, but it was not followed, leading to the deficiency in care for Resident #22.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to complete and post nurse staffing information at the beginning of each shift, as required. On July 19, 2024, at 12:45 PM, the posted staffing sheet was found to have incomplete data for the day and evening shifts. Further review of the nurse staffing information binder at 2:30 PM revealed that all 17 staffing sheets for July 2024 were incomplete, and there was no staffing sheet available for July 17, 2024. The Director of Nursing (DON) stated that the staffing information sheet is initiated during the night shift, and the nurse for each shift is expected to complete and post the staffing information. However, on July 22, 2024, the DON admitted that the facility did not have a policy regarding the posting of staffing data.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature, as observed during a survey. On July 19, 2024, a cook prepared pureed pork ribs, carrots, and macaroni & cheese for two pureed lunch menus. The cook divided each menu item into separate bowls, heated the pureed carrots, and placed all six bowls in a pan on the steam table without checking the temperatures of the pureed items before placing them in the steam table pan. Later, the cook prepared a plate for a dietary aide to deliver to a resident. A temperature check revealed that the pureed pork ribs were at 129.4 degrees Fahrenheit and the pureed macaroni & cheese was at 80.1 degrees Fahrenheit, both below the required serving temperature of at least 135 degrees Fahrenheit as per the facility's policy. The dietary manager confirmed that staff should adhere to safe food temperature ranges.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of possible abuse or injury of unknown origin in a timely manner for a resident. The resident, who had moderately impaired cognition with a BIMS score of 12 out of 15, was diagnosed with cancer, Alzheimer's disease, COPD, and thoracogenic scoliosis. The resident was dependent on assistance for most activities of daily living. An incident occurred on 6/26/24, where the resident sustained an injury to the left elbow and accused a staff member of causing a fall. The facility's investigation notes indicated that the accused staff member was terminated on 7/01/24 for reasons unrelated to the incident. The Director of Nursing (DON) contacted the facility's corporate office on 7/01/24 regarding the necessity of reporting the incident to the State Agency. Initially, the corporate administration advised that it was not a reportable event. However, the reporting process to the State Agency began on 7/03/24, following further direction. The delay in reporting the incident to the proper authorities constitutes a deficiency in the facility's adherence to reporting requirements. The facility's administrator acknowledged that the facility should comply with the State Agency's reporting requirements.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to adequately supervise and provide a secure environment for a resident identified as an elopement risk. The resident, who had moderate cognitive impairment and a history of anxiety, managed to leave the facility unnoticed. The resident's care plan, which was revised to address elopement risks, included instructions for staff to check the wander guard every shift. However, documentation of these checks was incomplete, and the resident was able to remove the wander guard and exit the facility without triggering an alarm. On the day of the incident, the resident's daughter took him and his wife out for a walk, returning them to the facility later. The daughter mentioned that the resident watched her enter the door code, which he later used to exit the facility. Staff were unaware of the resident's absence until he returned with items from his home, indicating he had walked there and back. The staff did not hear any alarms or pages for a missing resident, and there was a lack of documentation for the required 15-minute visual checks following the incident. Interviews with staff revealed a lack of awareness and seriousness regarding the resident's elopement. Staff assumed the resident was with his daughter and did not verify his whereabouts. The facility's policy on missing residents and elopement was not effectively implemented, as evidenced by the incomplete documentation and lack of immediate response to the resident's absence. The resident's ability to leave the facility unnoticed highlighted deficiencies in supervision and security measures.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in their care. Resident #16, who had a history of a broken tailbone, reported ongoing severe pain that was not effectively managed by the facility. Despite having an order for a lidocaine patch for lower back pain, the Treatment Administration Record (TAR) showed it was not utilized for several months. Additionally, there was a lack of documented pain assessments, with the last numerical pain assessment recorded in April 2024. Staff interviews revealed that the resident frequently complained of pain, yet there was no evidence that the physician was notified about the inadequacy of the pain management regimen. Resident #21, who was under hospice care, also experienced inadequate pain management. The resident's relative confirmed that the morning pain medication was not administered as scheduled. The resident had a history of cancer, Alzheimer's disease, COPD, and scoliosis, and reported almost constant pain. The Medication Administration Record (MAR) showed that the resident's Hydrocodone-Acetaminophen was administered late on numerous occasions. The average pain rating for the resident was 4.8 out of 10, indicating persistent pain issues. The Director of Nursing (DON) acknowledged that the facility did not have a specific policy addressing pain management, relying instead on general regulations. The lack of consistent pain assessments and timely administration of pain medication contributed to the deficiencies in managing the residents' pain effectively. Staff interviews highlighted a gap in communication and documentation, which further exacerbated the residents' pain management issues.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 113 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Red Oak Rehab And Care Center | 6.5 mi | ★★★★★ | 8 | 0 |
| Good Samaritan - Villisca | 6.9 mi | ★★★★★ | 12 | 0 |
| Good Samaritan - Red Oak | 7.4 mi | ★★★★★ | 23 | 1 |
| Azria Health Clarinda | 17.4 mi | ★★★★★ | 0 | 0 |
| Griswold Rehabilitation & Health Care Center | 17.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.