Above 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 Anamosa Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependence on staff for toileting was told by a CNA to be incontinent in bed after requesting to use the restroom at bedtime, rather than being assisted as directed by their care plan. This action was contrary to facility policy and standard practice, as confirmed by staff interviews and the resident's care documentation.
Two residents with severe cognitive impairment and high care needs did not receive timely staff assistance for toileting, with one waiting 35 minutes and another waiting 21 minutes after requesting help. Staff interviews confirmed delays in call light response, and review of training records showed a CNA had not completed required competency training on response times.
A resident with severe cognitive impairment suffered second-degree burns after spilling hot coffee during a meal. Staff failed to assess the resident immediately after the spill, and the burns were only discovered during bedtime care. The facility lacked a policy for checking the temperature of hot beverages, contributing to the incident.
The facility failed to conduct annual performance evaluations for five CNAs, with records showing missed reviews for multiple years. Interviews revealed systemic issues, including a lack of follow-up on reminders and inconsistency in the evaluation process, acknowledged by the DON and Administrator.
The facility failed to maintain an effective pest control program, resulting in a fly infestation observed in the kitchen, dining room, and resident areas. Flies were seen landing on food and residents, with staff and residents reporting increased fly activity. The pest control measures, including monthly visits, were insufficient, and staff interviews revealed a lack of awareness and action regarding the issue.
A dietary aide in an LTC facility used her bare hand to clean a pepper shaker before serving a resident, violating sanitary protocols. The resident, who requires assistance for eating, was unaware of the unsanitary action. Staff interviews revealed that condiment containers were cleaned infrequently, and the Dietary Supervisor acknowledged the breach in procedure.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
A resident with diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety, and a severely impaired cognitive status (BIMS score of 5), was identified as dependent on staff for toileting and hygiene. The resident's care plan directed staff to assist with toileting before and after meals, at bedtime, and as needed, and the care card in the resident's room indicated the need for toileting assistance. On the evening in question, after being put to bed by a CNA, the resident requested to use the restroom. Instead of assisting, the CNA instructed the resident to be incontinent in bed and stated she would return later to provide incontinence care. This action was reported by the resident's family, who expressed distress over the incident. Interviews with other staff, including CNAs and the restorative nurse, confirmed that the standard practice and expectation was to assist residents to the bathroom or provide alternatives such as a bedpan or urinal if needed. Facility policy also emphasized the right of residents to dignity and individualized care. The incident demonstrated a failure to honor the resident's right to a dignified existence and appropriate toileting assistance as outlined in their care plan and facility policy.
Failure to Provide Timely Staff Assistance for Residents with High Care Needs
Penalty
Summary
The facility failed to provide timely staff assistance for two residents with severe cognitive impairment and significant care needs. One resident, diagnosed with Parkinson's disease, non-Alzheimer's dementia, and anxiety, was identified as dependent on staff for toileting and transfers. Despite a care plan directing staff to assist with toileting at specific times and as needed, the resident's family reported that a CNA walked by the room while the call light was on and did not respond for 35 minutes, requiring the family to seek out staff assistance. Another resident, with diagnoses of heart failure and diabetes mellitus and also severely cognitively impaired, called out for help to use the bathroom. Although staff were present in the area, they informed the resident they were busy and would assist shortly, but the resident waited 21 minutes before receiving help. Staff interviews confirmed that call light response times could reach up to 15 minutes or more, and the DON stated the expectation was a maximum of 15 minutes for response. Review of staff training records revealed that one CNA had not completed the required competency training on call light response times.
Failure to Assess Resident After Hot Coffee Spill
Penalty
Summary
The facility failed to assess a resident after an incident where hot thickened coffee was spilled during meal service, resulting in a second-degree burn. The resident, who had severe cognitive impairment and required supervision with eating, was served coffee in a styrofoam cup with a lid. During the meal, the resident pulled a blanket towards herself, causing the coffee to spill. Staff noticed the spill and cleaned it up but did not assess the resident for any injuries at that time. It was only during bedtime care that staff discovered red areas and blisters on the resident's thighs, indicating burns. The incident investigation revealed that there was no documentation of an immediate assessment of the resident following the spill. Interviews with staff confirmed that the resident was not checked for burns until later in the evening. Additionally, it was noted that prior to the incident, there was no policy in place to check the temperature of hot beverages like coffee or hot chocolate. The lack of immediate assessment and absence of a temperature-checking policy contributed to the deficiency, as the resident required subsequent medical treatment for the burns.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for five Certified Nurses Aides (CNAs), as required. Personnel records revealed that Staff B, C, D, E, and F did not receive their annual performance reviews for multiple years. Staff B, hired in 2019, had a review in 2020 but none in 2021, 2022, or 2023. Staff C and D, hired in 2022, had no reviews since their hire dates. Staff E, hired in 2020, also lacked any performance reviews since hiring. Staff F, hired in 2014, had a review in 2020 but none in the subsequent years. Interviews with facility staff highlighted systemic issues in the evaluation process. The Director of Nursing (DON), who assumed the role in November 2023, acknowledged that annual reviews were not conducted. The Administrative Assistant, responsible for tracking evaluation due dates, admitted to sending reminders but lacked a follow-up system to ensure completion. The Administrator confirmed the inconsistency in conducting evaluations, indicating an ongoing effort to establish a consistent process.
Inadequate Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in various areas of the facility, including the kitchen, dining room, common areas, and resident rooms. On several occasions, flies were seen landing on food, residents, and furniture, indicating a widespread issue. Residents and staff reported an increase in fly activity, with one resident expressing frustration over the flies landing on him and his food. The facility's pest control measures, which included monthly visits from a pest control company, were insufficient to address the problem. Interviews with staff revealed a lack of awareness and action regarding the fly issue. The maintenance staff was unaware of the fly problem, focusing instead on addressing spiders. The pest control receipt lacked documentation of specific pests addressed, and the facility's policy on insect and rodent control emphasized the importance of pest elimination to prevent infection spread. Despite these policies, the facility's actions were inadequate in controlling the fly infestation, leading to the observed deficiencies.
Sanitary Breach in Dining Service
Penalty
Summary
The facility failed to maintain sanitary conditions during a dining service for a resident. The incident involved a dietary aide, identified as Staff A, who used her bare hand to clean the top of a pepper shaker before sprinkling pepper on a resident's salad. This action was observed in the main dining room where Resident #58, who has intact cognition and requires supervision or assistance for eating, was seated with two other residents. The resident was unaware of the unsanitary action taken by the staff member. Interviews with the facility's staff revealed that the condiment containers, including the pepper shakers, were typically cleaned when they were empty, as needed, or every other week. The Dietary Supervisor confirmed that the top of the shakers should not be cleaned with a bare hand, indicating a lapse in following proper sanitary procedures. The facility's Infection Prevention and Control Plan, effective since 2017, aims to prevent food-borne illness, but the actions observed during this incident did not align with the facility's stated goals.
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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.
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Nursing homes near Anamosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monticello Nursing & Rehab Center | 9.6 mi | ★★★★★ | 8 | 0 |
| Mechanicsville Specialty Care | 13.6 mi | ★★★★★ | 4 | 0 |
| Rehabilitation Center Of Lisbon | 14 mi | ★★★★★ | 5 | 0 |
| Hallmark Care Center | 15.2 mi | ★★★★★ | 11 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 16.5 mi | ★★★★★ | 14 | 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.