Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Azria Health Winterset during CMS and state inspections, most recent first.
Failure to sanitize a mechanical lift between resident transfers and to protect linen during transport. Staff used the same lift for multiple resident transfers in semi-private rooms without sanitizing it before or after use, and a CNA was observed transporting draw pads, gowns, and blankets on an uncovered cart down a resident hallway. The DON stated staff should have cleaned the equipment between residents and covered the linen during transport.
Failure to provide a homelike environment occurred when two residents were observed in bed without sheets on their mattresses. One resident with stroke, dementia, and hemiplegia was lying on a mattress without a sheet, and another resident with PE, HF, dementia, and assistance needs was lying directly on an un-sheeted mattress. CNAs and the DON gave differing explanations about air flow mattresses, while the facility policy called for clean bed and bath linens in good condition.
MDS coding for a resident on hospice was inaccurate. The resident’s significant change MDS showed intact cognition but failed to code the resident’s terminal prognosis and hospice enrollment, even though the EMR and resident matrix showed the resident had been admitted to hospice after returning from the hospital. The MDS Coordinator acknowledged the coding error and said the assessment had been completed because of the hospice admission.
Failure to Provide Adequate Oral Care: A resident who was dependent on staff for oral hygiene had heavy plaque buildup, and the resident’s toothbrush was found unopened and unused. Staff, including CNAs and an LPN, confirmed oral care was not being provided twice daily as expected, and the DON stated that oral care should be done twice a day. The facility mouth care policy directed staff to provide oral care to keep the mouth clean and prevent oral infection.
Failure to provide ordered supplemental oxygen for a resident with COPD and anemia. The resident had a care plan for continuous O2 via NC and a physician order for PRN O2 for SOB/comfort, but O2 sat documentation was absent after the last recorded check. Staff observed the resident on oxygen with the concentrator set at 2 L/NC, and later the resident was seen with NC tubing connected to an oxygen tank that was turned off. An LPN said he had not yet checked the resident’s oxygen or tubing, and the DON stated staff should have assessed the resident’s need for more than 1 L/NC and followed the order.
Failure to provide non-pharmacologic pain management for a resident with constant pain, degenerative disc disease, and multiple other chronic conditions. The resident received scheduled oxycodone and PRN Tylenol, had frequent moderate and severe pain scores, and stated the meds did not relieve her pain well; however, there was no documentation of non-pharmacologic interventions such as repositioning, heat, massage, or relaxation. The DON stated staff should have offered non-pharmacologic interventions and, if ineffective, contacted the MD for other options.
Delayed Response to Call Lights: The facility failed to provide enough nursing staff to answer call lights in a timely manner for three residents. Residents with moderate cognitive impairment or intact cognition reported call lights often took 15 minutes or longer, sometimes up to 30 minutes, and staff including CNAs and an LPN confirmed the delays. A Device Activity Report showed multiple call lights lasting 16 to 52 minutes, while the DON stated call lights were expected to be answered in 15 minutes or less.
A CNA served a meal to one resident, then removed that same plate and re-served it to another resident in the dining room. The Dietary Manager and DON both stated the meal should have been discarded after it was served to the first resident, and the DON identified the event as an infection control breach. Facility policy and the FDA Food Code cited in the report prohibit re-serving food that has already been in a consumer’s possession.
A resident with intact cognition, CP, dysphagia, diabetes, and total dependence for many ADLs had hospice care referenced in the care plan, but the plan did not identify the hospice provider, the specific services and functions each provider would perform, the split structure between the facility and hospice care plans, or the location of the hospice plan. EMR review showed hospice documents were scanned in, and the DON and MDS coordinator acknowledged the coordination details were not included in the resident’s care plan.
The facility failed to maintain proper infection control practices, with staff neglecting hand hygiene during resident interactions and medication administration. Shower equipment was not adequately sanitized between uses, and inappropriate cleaning agents were used. Additionally, the facility did not conduct sufficient influenza testing during a respiratory infection outbreak, despite available tests and CDC recommendations.
The facility failed to maintain a homelike environment, as several residents' rooms had unrepaired damages such as chipped drywall and missing paint. Observations and interviews revealed that maintenance issues were reported but not consistently addressed, with the Maintenance Director acknowledging delays in repairs. The lack of a systematic approach to maintenance led to unresolved environmental deficiencies, contrary to the facility's policy.
The facility failed to supervise medication administration, allowing residents to self-administer medications without proper oversight. An LPN left medications unattended for residents with varying cognitive abilities, and a resident applied medicated cream without a physician's order for self-administration. The DON confirmed the lack of assessments and policy adherence for self-administration.
The facility failed to secure shower rooms containing hazardous materials, allowing residents with severe cognitive impairments to access these areas unsupervised. Additionally, a resident with Huntington's Disease was observed being pushed in a wheelchair without foot pedals, contrary to facility policy, posing a risk of injury. Staff interviews confirmed these practices, and the DON was unaware of the door latching issue.
The facility failed to store food properly and maintain hand hygiene standards. Open food items were undated, and sanitization checks for the dish machine were inadequate. Staff did not perform hand hygiene between tasks, as observed with a cook and a CMA assisting residents. Interviews confirmed the expected protocol was not followed, highlighting deficiencies in maintaining a sanitary environment.
A facility failed to provide a resident with the required Notice of Medicaid Non-Coverage (NOMNC) when initiating a discharge before the resident had exhausted their Medicare Part A benefit days. Although an Advanced Beneficiary Notification (ABN) was present, the NOMNC was missing due to the absence of the responsible staff member. The facility's policy required written notification of coverage changes, which was not followed.
A resident with severe cognitive impairment was not accurately assessed for the use of a wander guard in the MDS, despite documentation and observations indicating its use. The facility's EHR and MAR noted the need to check the wander guard each shift, and the care plan identified a risk for wandering. The MDS Coordinator and DON acknowledged the coding error, which did not align with the facility's assessment policy.
A resident with severe cognitive impairment and a history of stroke did not receive proper contracture management as per physician's orders. Observations showed the absence of a required splint and carrot on the resident's left hand. Staff interviews confirmed the splint was not applied due to being lost, and the care plan needed updating to reflect the correct use of devices.
The facility failed to assist two residents with personal grooming. One resident with severe cognitive impairment was observed with unshaved facial hair, despite a care plan requiring staff assistance. Another resident was seen with crusted eyelids, although records showed hygiene tasks were marked as completed or not applicable. The DON confirmed staff were expected to provide necessary grooming assistance.
A resident with an enteral feeding tube received formula administered by an LPN using a piston syringe, contrary to facility policy requiring gravity flow. The LPN was unaware of the correct procedure, and the DON confirmed the residual check was performed incorrectly, highlighting a deviation from established protocols.
A facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medication to a resident with severe cognitive impairment. Despite care plan directives and facility policy, the MARs showed multiple instances of Ativan administration without prior non-pharmacological attempts, as confirmed by the DON. The facility lacked a specific policy for PRN medication administration.
A resident with type 2 diabetes received an incorrect dose of Humalog Lispro insulin due to a staff member's failure to prime the insulin pen as required. The facility's policy did not include procedures for insulin pen use, leading to a significant medication error.
A resident with moderate cognitive impairment was administered Oxycodone 5 mg every 4 hours for pain, but the medication label indicated it was to be given as needed. The discrepancy between the label and the physician's order was not noticed by the LPN during administration. The DON acknowledged the error, noting that the pharmacy sent the wrong order and the nurse failed to clarify the discrepancy. The facility's policy on verifying medication details before administration was not followed.
A resident with cerebral palsy and muscle weakness fell from bed due to improper use of a mechanical lift by a single CNA, contrary to facility policy requiring two staff members. The CNA encountered resistance while moving the lift, leading to the resident's fall and a forehead bruise. Staff interviews revealed a lack of awareness and competency assessment for the CNA regarding mechanical lift use.
The facility failed to ensure the Dietary Manager met the qualifications of a Certified Dietary Manager (CDM) in the absence of a full-time dietitian. The Dietary Manager, previously a CNA and Dietary Aide, had not completed the necessary certification course. Although she completed ServSafe training, she was not yet a CDM as required by the facility's job description. She was enrolled in a certification course at the time of the survey.
The facility was found to have improper food storage practices, including expired tomato juice, uncovered glasses of juice, and undated food items stored incorrectly. The Dietary Manager and Registered Dietitian had specific expectations for food storage that were not met, and the facility's policy requires all refrigerated or frozen foods to be covered, labeled, and dated.
A resident with bipolar disorder and non-Alzheimer's dementia, who valued taking care of personal belongings, frequently reported missing laundry items. Despite a history of trust issues and previous reports of missing laundry, the care plan was not updated to include these concerns or effective interventions, contrary to the facility's policy on person-centered care plans.
A resident at high risk for pressure ulcers did not receive consistent application of protective boots as ordered by the physician. Despite care plan directives and facility policy, observations showed the resident often without bunny boots, leading to a deficiency in care.
A resident with Alzheimer's and other conditions was not consistently provided with finger foods as per their care plan, leading to significant weight fluctuations. Despite being on hospice care and having a preference for finger foods, observations showed meals were not aligned with dietary needs, and staff did not assist during meals. Interviews revealed inconsistencies in understanding and implementing the resident's dietary requirements.
The facility did not post required notifications about survey agencies and advocacy support, nor did it provide access to updated survey results. Observations during a survey revealed missing information on contacting state agencies and outdated survey results since 2021. The Administrator confirmed the absence of updated postings and survey results, leading to a deficiency in meeting residents' rights.
Failure to Sanitize Mechanical Lift Between Resident Transfers and Protect Linen During Transport
Penalty
Summary
The facility failed to sanitize a mechanical lift between resident transfers during a continuous observation on 3/16/26. Staff A, a CMA, used the lift to transfer one resident from a semi-private room and stored it in the hallway without sanitizing it. Staff B, a CNA, then took the same lift into another semi-private room with Staff A and transferred one resident into a chair, and the lift was again not sanitized before or after the transfer. At 1:50 PM, Staff A and Staff C, CNA, used the lift in another semi-private room to transfer a resident, and the staff again failed to sanitize the lift before or after the transfer. At 1:52 PM, Staff C exited the room with the mechanical lift and then, with Staff D, CMA, took it into another semi-private room for another resident transfer without sanitizing it before or after use. On 3/18/26 at 10:42 AM, Staff B stated she forgot to sanitize the mechanical lift between resident transfers on 3/16/26. The facility also failed to transport linen in a manner to prevent contamination when, on 3/16/26 at 2:44 PM, Staff E, CNA, was observed transporting draw pads, gowns, and blankets on an uncovered cart down a resident hallway. A policy titled Laundry and Bedding, Soiled stated that clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.
Failure to Provide Sheets on Resident Beds
Penalty
Summary
The facility failed to provide a homelike environment by not placing sheets on the beds of 2 residents. Resident #22, who had diagnoses including stroke, non-Alzheimer's dementia, and hemiplegia, was observed lying in bed without a sheet on the mattress, and the resident stated the facility did have a sheet but it was not on the bed. Resident #28, who had diagnoses including pulmonary embolus, heart failure, non-Alzheimer's dementia, and a need for assistance with personal care, was also observed lying in bed without a fitted sheet and lying directly on top of the mattress. During staff interviews, CNAs gave differing explanations about whether sheets should be used on air flow mattresses, with one stating they are not supposed to put fitted sheets on air flow mattresses and another stating sheets should be on all beds unless it is an air flow bed. Both CNAs confirmed Resident #28 should have a sheet on the mattress. The DON stated she expected air flow mattresses to not have a fitted sheet and only a pad placed under the resident, while also stating other mattresses should have a fitted sheet because it would make the room more homelike. The facility policy on Homelike Environment directed staff and management to maximize characteristics of a personalized, homelike setting, including clean bed and bath linens in good condition.
MDS Did Not Accurately Reflect Hospice Status
Penalty
Summary
The facility failed to accurately reflect the status of one sampled resident receiving hospice care in the MDS assessment. Resident #35’s significant change in status MDS, dated 2/11/26 and signed by the MDS Coordinator on 2/25/26, coded the resident as having intact cognition with a BIMS score of 14, but did not indicate that the resident had a prognosis of less than 6 months at section J1400 and did not code hospice care at section O0110K1. The MDS therefore did not match the resident’s hospice status as documented in the facility records. Review of the EMR showed the resident returned from the hospital on 2/5/26 and was admitted to hospice care that same day. The facility’s Resident Matrix also identified the resident as currently receiving hospice services. During interview, the MDS Coordinator acknowledged the error and stated the significant change in status assessment had been completed because of the resident’s admission to hospice care, but the prognosis and hospice sections were not coded accurately. The facility policy stated the MDS Coordinator was responsible for ensuring timely and appropriate resident assessments and that persons completing any portion of the MDS must sign attesting to the accuracy of the information.
Failure to Provide Adequate Oral Care
Penalty
Summary
The facility failed to provide adequate oral care for one resident who was dependent on staff for oral hygiene, eating, and toileting hygiene. The resident’s MDS identified diagnoses of non-traumatic brain dysfunction, cerebral palsy, seizure disorder, and severe intellectual disabilities. The care plan included an intervention for staff assistance with brushing teeth, but on observation the resident had heavy plaque buildup on the teeth, and the resident’s toothbrush was found unopened and unused in a plastic wrapper in the medicine cabinet. Staff interviews confirmed the oral care was not being completed as expected. A CNA stated it was very difficult to brush the resident’s teeth and confirmed staff had not been brushing the resident’s teeth twice a day as they should. Another CNA verified staff did not brush the teeth twice daily for residents who needed assistance and confirmed the toothbrush was still in the plastic wrapper. An LPN stated staff did not brush residents’ teeth twice a day because they got busy and forgot to complete it. The DON stated she expected staff to provide oral care twice a day. The facility policy on mouth care directed staff to provide oral care to keep the resident’s lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection.
Failure to Provide Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to provide supplemental oxygen as ordered for Resident #48, who had diagnoses including anemia, COPD, and syncope and collapse and whose MDS indicated use of supplemental oxygen within the 7-day lookback period. The care plan revised 11/26/25 directed staff to provide 2 LPM of continuous oxygen via nasal cannula, and the EHR also contained a physician order dated 1/12/26 for oxygen 1 L via nasal cannula every hour as needed for shortness of breath/comfort. The Oxygen Saturation Summary showed the resident’s most recent documented pulse oximeter level was on 3/10/26, and there were no documented O2 saturation levels in the EHR after that date. On 3/16/26, the resident was observed using oxygen with the concentrator set at 2 L/NC. The next day, an LPN stated nursing staff administered the resident’s oxygen based on the physician’s order, but later that day the resident was observed at the nurses’ station wearing nasal cannula tubing connected to an oxygen tank that was turned off. The LPN stated he had not checked the resident’s oxygen or tubing yet. The facility’s oxygen administration policy directed staff to review the physician’s order or facility protocol and assess vital signs and oxygen saturation while the resident was receiving oxygen therapy. The DON stated staff should have assessed the resident’s need for more than 1 L/NC of oxygen and, if needed, contacted the physician to change the order; otherwise, staff should have followed the physician’s order.
Failure to Provide Non-Pharmacologic Pain Management
Penalty
Summary
The facility failed to provide non-pharmacologic pain management for Resident #7, who had intact cognition with a BIMS score of 15 and diagnoses including diabetes mellitus, heart failure, muscle wasting, morbid obesity, and degenerative disc disease. The resident required assistance with several ADLs and mobility, and the MDS indicated she had constant pain that frequently affected her sleep. Her record showed orders for scheduled oxycodone, PRN Tylenol, and documentation of non-pharmacological pain interventions, and the care plan identified pain medication therapy with an intervention to manage pain per physician treatment orders. The January through March 2026 MARs documented multiple pain assessments and administration of oxycodone and Tylenol, including frequent moderate and severe pain scores, but there were no documented non-pharmacologic interventions during that period. On 3/16/26, the resident stated her oxycodone did not help her pain as much as she would like, Tylenol did not affect her pain at all, and the facility had not done anything non-pharmacological to help with her pain. The DON stated on 3/19/26 that staff should have offered non-pharmacologic interventions and, if ineffective, contacted the physician for other options.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide an adequate amount of nursing staff to assure resident safety by not responding to call lights in a timely manner for 3 of 6 residents reviewed. Resident #15’s MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent on staff for sitting to standing, chair/bed-to-chair transfers, and toileting. During interview, Resident #15 stated call lights often took longer than 15 minutes and said she could read a clock to tell the time. Resident #20’s MDS showed a BIMS score of 15 and that he required moderate assistance with sitting to standing, chair/bed-to-chair transfers, and toileting. He reported that call lights usually took 15 minutes or longer and could last up to 30 minutes, and that he watched the clock to tell time. Resident #22’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and that the resident was dependent on staff for toileting hygiene, personal hygiene, and upper and lower body dressing. Resident #22 reported call lights could take longer than 15 minutes and said he watched the TV to tell how long it took. Multiple staff members confirmed call lights lasting longer than 15 minutes, including CNAs and an LPN, who stated the facility had many 2-assist residents and staff became tied up with assisting, causing call lights to last longer than 15 minutes. The DON stated she expected call lights to be answered in 15 minutes or less. A Device Activity Report documented several call lights lasting from 16 minutes to 52 minutes, and the facility policy instructed staff to answer the call system timely.
Re-serving a meal after it was served to the wrong resident
Penalty
Summary
Food was not served in accordance with safe food handling practices during the noon meal service in the Main Dining Room. Staff J, a CNA hired on 1/20/26, served a divided plate meal to Resident #50 at 12:40 p.m. and then left the table. One minute later, Staff J returned through the dining room, removed the same meal from in front of Resident #50, and served that same meal to Resident #45 at another table. When asked about the event, Staff J acknowledged removing the plate after serving it and then re-serving the same meal to another resident. During interviews, the Dietary Manager stated that if a meal is served to the wrong resident, the meal should be removed, the correct meal provided, and the DON informed of the error. She stated the meal that had already been served was contaminated and should not be served to another resident or returned to the kitchen, but should be discarded. The DON also stated the meal should have been disposed of in the trash and described the event as an infection control breach. Facility policy directed staff to prepare and serve food in a manner that complies with safe food handling practices, and the FDA Food Code cited in the report states that food that has been served and is in the possession of a consumer may not be offered for human consumption again.
Hospice Care Plan Lacked Required Coordination Details
Penalty
Summary
Failure to arrange for hospice services or to assist the resident in transferring to a facility that would arrange hospice services was identified for a resident whose MDS dated 2/11/25 showed a BIMS score of 14, indicating intact cognition. The MDS also showed the resident needed partial/moderate assistance with eating, was dependent on staff for hygiene, dressing, transfers, showering or bathing, used a manual wheelchair, and was always incontinent of bowel and bladder. Diagnoses listed on the MDS included cerebral palsy, dysphagia, diabetes mellitus, and cognitive communication deficit, but the MDS did not identify a terminal prognosis or hospice care. The care plan revised 3/5/26 identified increased risk for limitations in ADLs, need for supervision with meals and reminders to swallow, need for one to two staff for all ADLs, a pureed diet with honey thick liquids, and a terminal prognosis related to a stroke with hospice care. The care plan also directed staff to work effectively with the hospice team to meet the resident's spiritual, emotional, intellectual, physical, and social needs. However, the care plan did not identify the hospice provider and the specific services and functions it would provide, did not describe the structure of the coordinated care plan as divided between the nursing home and hospice, and did not identify the location of the hospice care plan. Review of the resident's EMR showed scanned hospice documents including a billing document, a hospice report with clinical team names, contact information, care needs, goals, interventions, and medications, and hospice records with physician orders and a hospice care plan identifying disciplines responsible. During interviews, the DON stated the facility worked with three hospice providers and scanned resident-specific information from e-mails into the EMR, while the MDS Coordinator stated hospice providers came weekly and were invited to care plan conferences. Both agreed the resident's care plan did not identify the structure of the coordinated plan or the location of the hospice care plan. The hospice agreement stated the provider would supply the most recent hospice plan of care, including personnel names and contact information, and that the plan must identify which provider was responsible for each agreed-upon function.
Inadequate Infection Control and Testing Practices
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations of staff neglecting hand hygiene protocols. Staff members, including a Certified Nursing Assistant (CNA) and Licensed Practical Nurses (LPNs), were observed not performing hand hygiene before and after resident contact, during medication administration, and after glove removal. This lack of adherence to hand hygiene protocols was noted during interactions with residents, including those with wounds and those receiving medications, potentially increasing the risk of infection transmission. Additionally, the facility did not ensure proper sanitization of shower equipment between resident uses. A CNA was observed using a shower chair with a visible brown stain without sanitizing it before assisting a resident. The CNA used a diluted Clorox solution, prepared without precise measurement, to clean the chair, and did so without wearing gloves. The Housekeeping Manager confirmed that Clorox was used instead of a healthcare-grade disinfectant, and the dilution process lacked documentation and standardization. The facility also failed to conduct adequate influenza testing during a period of increased respiratory infections. Despite having influenza tests available, the facility only tested for influenza after a resident tested positive, relying primarily on COVID-19 testing. The Infection Preventionist was unaware of a regional influenza outbreak and had not maintained regular communication with public health authorities. This oversight in testing practices did not align with CDC recommendations for testing residents with respiratory symptoms for both SARS-CoV-2 and influenza.
Failure to Maintain Homelike Environment Due to Unrepaired Damages
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple instances of unrepaired damages in resident rooms. Observations revealed chipped drywall, missing paint, and exposed sharp edges in the rooms of several residents. For instance, Resident #31's room had chipped drywall and missing paint behind the bed and under the window. Resident #33's room had a quarter-sized area of missing paint with deep grooves behind the chair. Resident #43's room had missing paint near the bathroom and above the light fixture, which the resident found bothersome. Resident #47, who had recently moved into the facility, noted large areas of different colored paint and chipped paint in her room, which had not been addressed before her admission. Staff interviews indicated that maintenance issues were reported through 'fix it tickets,' but the Maintenance Director did not receive many of these tickets and did not document repairs or touch-ups. The Maintenance Director acknowledged the need for regular touch-ups but admitted that repairs were often delayed, with some areas only being painted over without proper repair. The Administrator stated that environmental concerns should be reported via fix it tickets, but there was no formal procedure for checking rooms for repairs. Despite the policy requiring the maintenance department to maintain the facility in a safe and operable manner, the lack of a systematic approach to addressing and documenting maintenance issues led to unresolved environmental deficiencies. This failure to provide a homelike environment was evident in the observations and resident interviews, highlighting a gap in the facility's maintenance processes.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards by allowing residents to self-administer medications without proper supervision. Resident #8, with no cognitive impairment, was observed self-administering medications outside the view of the LPN, who had left the room to retrieve a glucose machine. Similarly, Resident #31, also with no cognitive impairment, had a medication cream left unattended in their room, which the LPN later denied leaving. Resident #33, with mild cognitive impairment, was left alone with medications on the bedside table while the LPN attended to another staff member's request, resulting in the resident self-administering the medications unsupervised. Resident #41, with intact cognition but diagnosed with non-Alzheimer's dementia, was observed applying a medicated cream to his trunk without a physician's order for self-administration. The DON confirmed that none of the residents had been assessed or authorized for self-administration of medications, and the facility lacked a policy for such assessments. The facility's policy required that medications be administered safely and timely, with residents only self-administering if deemed capable by a physician and care planning team, which was not adhered to in these cases.
Failure to Secure Hazardous Areas and Ensure Safe Mobility
Penalty
Summary
The facility failed to protect residents from hazards, accidents, and injuries by not securing two shower rooms that contained chemicals, sharp razors, and biohazard containers. Observations revealed that the shower room doors were often left open and unattended, allowing residents with severe cognitive impairments, such as those with Alzheimer's disease, to access these hazardous areas. Staff interviews confirmed that the doors were not consistently shut, and the cabinets containing dangerous items were not locked. The Director of Nursing (DON) was unaware of the issue with the door not latching properly and had not been informed by staff about residents entering the shower rooms unsupervised. Resident #43, who had a severe cognitive impairment and a history of wandering, was observed near the shower room, which was across the hall from her room. Staff acknowledged that Resident #43 would sometimes enter the shower room unattended, searching for personal items like hair rollers. Despite the presence of a wander guard, the resident was able to access the shower room, which posed a significant risk due to the unsecured hazardous materials inside. The DON had a conversation with staff about keeping the door closed but did not document any formal corrective actions. Additionally, Resident #39, who had severe cognitive impairment and Huntington's Disease, was observed being pushed in a wheelchair without foot pedals, causing his feet to drag on the ground. This practice was against facility policy, as it posed a risk of injury to the resident. Staff interviews confirmed that they were instructed not to push residents without foot pedals, yet this practice was observed multiple times. The DON stated that the expectation was for staff to use foot pedals to avoid injury, but this was not consistently followed, leading to potential harm for Resident #39.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitization, as observed during a survey. In the kitchen, open food items such as orange juice, apple juice, and cranberry cocktail were found undated in the refrigerator, and chicken cordon bleu and hamburgers were left open to the air in the freezer. Staff A, the Certified Dietary Manager, acknowledged these items should have been properly sealed and dated. Additionally, the facility did not conduct appropriate chemical sanitization checks for the low-temperature dish machine, as test strips showed no color change, indicating a lack of chlorine. Staff A admitted that the dish machine was supposed to be checked daily, but the facility did not keep track of the chemical strip test results. Further observations revealed lapses in hand hygiene practices among staff. Staff B, a cook, was seen handling food and touching various surfaces without performing hand hygiene. This included using a slotted spoon on a soiled surface and then using it again without cleaning it. Similarly, during dining room service, Staff V, a Certified Medication Aide, assisted two residents with eating without sanitizing her hands between tasks or after touching her face. Interviews with other staff members, including CNAs and the Director of Nursing, confirmed that the expected protocol was to sanitize hands before assisting residents and after touching anything outside the dining table. The facility's policies on sanitization and food storage were not followed, as evidenced by the lack of proper labeling and dating of food items and inadequate sanitization practices. The Certified Dietary Manager and other staff members acknowledged the need for more rigorous hand hygiene and sanitization measures during food preparation and resident assistance. The facility's failure to adhere to these standards was confirmed through staff interviews and policy reviews, highlighting deficiencies in maintaining a safe and sanitary environment for residents.
Failure to Provide Required Notice of Medicaid Non-Coverage
Penalty
Summary
The facility failed to provide a resident with the required Notice of Medicaid Non-Coverage (NOMNC) when initiating a discharge before the resident had exhausted their Medicare Part A benefit days. The clinical records indicated that the resident's Medicare Part A coverage began upon entering the facility and that the resident was discharged from skilled services without receiving the NOMNC. Although an Advanced Beneficiary Notification (ABN) was present in the file, the NOMNC was missing. The facility administrator confirmed that the staff member responsible for providing the notice was not available at the time it was required, resulting in the omission. The facility's policy stated that residents should be notified in writing of changes in coverage as soon as possible, but this was not adhered to in this instance.
Inaccurate MDS Documentation of Wander Guard Use
Penalty
Summary
The facility failed to accurately assess and document the use of a wander guard for a resident with severe cognitive impairment. The Quarterly Minimum Data Set (MDS) for the resident did not reflect the use of a wander guard, despite observations and documentation indicating its presence on the resident's walker. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was observed ambulating with an unsteady gait and attempting to exit the facility, necessitating redirection by staff. The facility's Electronic Health Records (EHR) and Medication Administration Record (MAR) documented an order to check the placement and function of the wander guard each shift, and the resident's care plan identified a risk for wandering/elopement. However, the MDS section P, which should have documented the use of wander/elopement alarms, was inaccurately coded. Both the MDS Coordinator and the Director of Nursing (DON) acknowledged the error, which was contrary to the facility's policy on comprehensive assessments that require accurate representation of a resident's clinical status.
Failure to Implement Comprehensive Care Plan for Resident with Contracture
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with severe cognitive impairment and a history of stroke, osteoporosis, and muscle weakness. The resident required staff assistance with most Activities of Daily Living (ADLs) and had a physician's order for a left hand splint to be applied each morning and removed after lunch. However, observations on two separate occasions revealed that the resident's left hand contracture was not being managed as ordered, with neither a brace nor a carrot present on the left hand. Interviews with staff, including a Restorative Aide and the Director of Nursing (DON), confirmed that the resident typically wore a splint for contracture prevention, but it was not applied due to being possibly lost in the laundry. The DON acknowledged that the care plan and Minimum Data Set (MDS) needed updating to accurately reflect the use of both the brace and carrot for contracture prevention. The therapist involved was a new graduate and did not specify that the carrot and brace were two different devices to be applied to the resident's left hand.
Failure to Assist Residents with Personal Grooming
Penalty
Summary
The facility failed to assist two residents with their activities of daily living, specifically in the area of personal grooming. Resident #11, who has severe cognitive impairment due to a stroke and other health conditions, was observed with long, unshaved facial hair on multiple occasions. Despite the care plan indicating the need for staff assistance with personal hygiene, the grooming task was not completed as expected. The Director of Nursing confirmed that staff were aware of the resident's needs and that the expectation was for grooming to be carried out during bathing. Similarly, Resident #26, who also depends on staff for personal hygiene, was observed with dried crust around both eyelids on two separate occasions. The clinical records indicated that personal hygiene tasks were either marked as completed or not applicable without explanation. However, subsequent observations showed no concerns with grooming. The Director of Nursing reiterated the expectation for staff to provide necessary hygiene and grooming assistance to residents requiring help.
Improper Administration of Enteral Feeding
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the administration of enteral feeding for a resident. The resident, who was rarely or never understood and utilized an enteral feeding tube, was observed receiving enteral formula administered by a Licensed Practical Nurse (LPN) using a piston syringe. The LPN poured the formula into the syringe and manually pushed the piston to administer the feeding, contrary to the facility's policy which required the feeding to flow by gravity. The LPN admitted to not knowing if it was acceptable to push the formula, indicating a lack of proper training or understanding of the facility's procedures. Additionally, the Director of Nursing (DON) confirmed that the residual check, which is necessary to ensure the resident had digested the previous formula and to prevent dumping, was performed incorrectly after the feeding instead of before. The DON acknowledged that the resident received bolus feedings and disagreed with the method of pushing the formula, emphasizing the need for gravity flow. The facility's policy, revised in November 2018, clearly stated that the feeding should be allowed to flow by gravity, highlighting a deviation from established protocols in the care of the resident.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure that staff documented non-pharmacological interventions before administering as-needed (PRN) anti-anxiety medication to a resident with severe cognitive impairment. The resident, diagnosed with non-Alzheimer's dementia, anxiety disorder, and depression, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severely impaired cognition. The facility's policy required medications to be administered according to prescriber orders, and the resident's care plan directed staff to attempt non-pharmacological approaches to manage behaviors. However, the Medication Administration Records (MARs) for January, February, and March 2025 showed multiple instances where the resident received Ativan without documentation of attempted non-pharmacological interventions. The Director of Nursing confirmed that staff should document non-pharmacological interventions before administering PRN anti-anxiety medications, but the facility lacked a specific policy for PRN medication administration. The resident's care plan entries from 2017 and 2024 indicated the use of non-pharmacological approaches and anti-anxiety medications, respectively. Despite these directives, the MARs and progress notes lacked evidence of non-pharmacological interventions being attempted prior to administering the medication, leading to the deficiency identified during the survey.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The incident involved a resident with a diagnosis of type 2 diabetes, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. During an observation, a staff member administered Humalog Lispro insulin to the resident without priming the insulin pen with 2 units as required. The resident's blood glucose level was 108, and the staff member drew up 4 units of insulin without priming the pen, which is against the manufacturer's instructions. The insulin was administered to the resident's right thigh, and the pen was returned to the medication cart without proper priming. The facility's policy on insulin administration, revised in September 2014, stated that nursing staff should have access to specific instructions on all forms of insulin delivery systems. However, the policy provided by the facility only included procedures for insulin injections via syringe, not for insulin pens. The Director of Nursing (DON) confirmed that the insulin pen should have been primed with 2 units before dialing the dose to be administered. The failure to follow the correct procedure for insulin administration led to the potential for the resident to receive an incorrect dose of insulin.
Medication Labeling Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with currently accepted professional principles, resulting in a discrepancy between the medication label and the physician's order for a resident. The resident, who had moderate cognitive impairment and a diagnosis of unspecified pain, was prescribed Oxycodone 5 mg to be administered every 4 hours for pain. However, the medication bubble pack label indicated that the Oxycodone was to be administered as needed for post-operative and chronic back pain. This discrepancy was observed when a Licensed Practical Nurse (LPN) administered the medication to the resident without noticing the mismatch between the label and the Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged the discrepancy and stated that the medication label should have matched the order. The DON explained that the resident had returned from the hospital with both as-needed and routine orders for Oxycodone, but the as-needed order was supposed to be discontinued. The pharmacy sent the wrong order, and the nurse did not clarify the discrepancy after receiving the medication. The facility's policy required staff to verify the right resident, medication, dosage, time, and route before administering medications, but this was not followed, leading to the deficiency.
Failure to Ensure Proper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure the presence of two staff members during the use of a mechanical lift for resident transfers, which is a requirement according to the facility's policy. This deficiency was identified during a review of an incident involving a resident with cerebral palsy, deep vein thrombosis, and muscle weakness, who required extensive assistance for bed mobility and total dependence on two staff for transfers. The resident experienced a fall from the bed due to improper handling of the mechanical lift by a single Certified Nursing Assistant (CNA), Staff M, who attempted to transfer the resident alone. During the incident, Staff M used a Hoyer lift to transfer the resident from a wheelchair to the bed. After placing the resident in bed, Staff M attempted to pull the lift away, encountering resistance. Believing the resistance was due to the lift's wheels, Staff M continued to tug on the lift, inadvertently causing the resident to fall to the floor. It was later discovered that one of the sling straps was still attached to the lift, which led to the fall. The resident sustained a bruise on the forehead as a result of the fall. Interviews with staff revealed that Staff M was not aware of the requirement for two staff members during mechanical lift transfers and had not completed a competency assessment for the use of such equipment. The Director of Nursing (DON) and other staff members confirmed that there was no orientation checklist or competency sign-off for Staff M regarding the mechanical lift. The facility's policy clearly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift, and this policy was not adhered to during the incident.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary service manager met the required qualifications of a Certified Dietary Manager (CDM) in the absence of a full-time dietitian. During an initial kitchen walkthrough, the Dietary Manager, identified as Staff F, admitted to not having taken the course to become a certified dietary manager. Her prior experience included working as a Certified Nurse Aide (CNA) and a Dietary Aide. Although the facility provided a certificate showing that Staff F completed ServSafe training, it was noted that she was not yet certified as a dietary manager. The facility's job description for the Dietary Manager position, revised in February 2021, required that the individual be a CDM within one year of employment. At the time of the survey, Staff F was enrolled in an Iowa Food Manager Certification Course, which she was expected to complete soon.
Improper Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary food storage practices as observed during a survey. A pitcher of tomato juice was found in a refrigerator with a used by date that had already passed. Additionally, a soiled tub containing two uncovered glasses of juice was observed on a refrigerator shelf. In the walk-in cooler, a pound cake was seen in an undated, zippered food storage bag placed on top of a package of turkey lunch meat. In the dry storage room, a bag of pasta and a bag of brownie mix were found open to the air without any open dates. The Dietary Manager stated that juice glasses should be covered and stored in a clean bin, while the Registered Dietitian expected meats to be stored on the bottom shelf of the walk-in cooler, with bread or cakes stored on higher shelves. The facility's policy, revised in October 2017, requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, which was not adhered to in these instances.
Failure to Update Care Plan for Resident with Trust Issues
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a diagnosis of bipolar disorder and non-Alzheimer's dementia, who exhibited moderate cognitive impairment. The Minimum Data Set (MDS) assessment indicated that it was very important for the resident to take care of their personal belongings and choose their clothing. However, the resident reported frequent issues with missing laundry items, which were not addressed in the care plan. Interviews with staff revealed that the resident had a history of trust issues and had previously reported missing laundry, but the care plan was not updated to reflect these concerns or include effective interventions. The facility's policy on comprehensive person-centered care plans required that care plans be updated with interventions after data gathering and when there is a change in the resident's condition. Despite this, the care plan for the resident did not include information about the resident's history of making statements about missing laundry items. Staff interviews confirmed that the care plan should have been updated to address the resident's behavior and trust issues, but this was not done, leading to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to follow physician's orders and implement necessary interventions to prevent pressure ulcer development for a resident at high risk. The resident, who had diagnoses of diabetes, cancer, and a hip fracture, was on hospice care and had severely impaired cognition. The care plan required frequent repositioning, heel floating, and the use of foot protectors while in bed. However, observations revealed that the resident was often without the prescribed bunny boots, both in bed and while seated in a chair, contrary to the physician's orders and care plan directives. Interviews with staff, including a CNA, CMA, LPN, MDS Coordinator, and the DON, confirmed inconsistencies in the application of protective boots. Staff reported that protective boots were documented as being used, but observations showed otherwise. The facility's policy on pressure injury prevention emphasized the use of medical devices and support surfaces to minimize tissue damage, yet these were not consistently applied for the resident, leading to a deficiency in care.
Failure to Provide Finger Foods as Per Resident Preference
Penalty
Summary
The facility failed to provide a diet with finger foods per resident preference to maintain nutrition and weight for a resident with Alzheimer's disease, dementia, GERD, diabetes, and anemia. The resident was on hospice care and had a severely impaired cognition score. The care plan indicated the resident was at nutritional risk due to diminished appetite and significant weight loss, with directives to provide finger foods and honor food preferences. Despite these directives, observations revealed that the resident was not consistently provided with finger foods, and staff did not assist or cue the resident during meals, leading to untouched meals. The resident's weight fluctuated significantly over several months, with a noted weight loss deemed unavoidable. The resident's care plan included a general diet with regular texture and finger foods, along with a nutritional supplement. However, observations showed that the meals provided did not always align with the finger food diet, as items like bread with pot pie, spinach, and pudding were not considered finger foods by the dietician. The dietician had previously provided staff education on finger foods but noted that the meals served did not adhere to the resident's dietary needs. Interviews with staff, including the LPN, RD, and DON, revealed inconsistencies in the understanding and implementation of the resident's dietary requirements. The RD acknowledged that certain items served were inappropriate for a finger food diet and planned to provide further education to the kitchen staff. The DON expressed concerns that limiting the diet to finger foods might result in the resident eating less, indicating a lack of adherence to the resident's dietary preferences and needs.
Failure to Post Required Notifications and Survey Results
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting necessary notifications regarding survey agencies and advocacy support in areas accessible to residents. During a survey conducted over several days, it was observed that there was no information displayed on how to contact state agencies, and previous survey results were not made available within the facility. An interview with the Administrator and other staff revealed that the required postings, including contact information for state regulatory and informational agencies, were missing. Additionally, the binder containing previous survey results was outdated, with no updates since 2021, which the Administrator confirmed. This lack of updated information and accessibility to survey results constitutes a deficiency in meeting the residents' rights to receive notices in a format and language they understand.
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What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 1 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.
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Nursing homes near Winterset
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater, A Wesleylife Community | 18.4 mi | ★★★★★ | 4 | 0 |
| Community Care Center | 19.1 mi | ★★★★★ | 14 | 0 |
| Cedar Ridge Village | 19.1 mi | ★★★★★ | 9 | 0 |
| Adel Acres | 19.6 mi | ★★★★★ | 8 | 0 |
| Arbor Springs Of West Des Moines L L C | 19.8 mi | ★★★★★ | 2 | 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.