Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Bloomfield Care Center during CMS and state inspections, most recent first.
Incomplete Dishwasher Sanitization Monitoring: The facility failed to monitor the dishwasher to ensure proper sanitization of resident dishes and utensils. An observation found the dish washer at a low temperature, and review of the dishwasher temperature/sanitizer logs showed very limited documentation of wash temperature, rinse temperature, and sanitizer PPM across multiple months. The Dietary Mgr acknowledged the incomplete logs, and a Dietary Aide stated the sanitizer is tested three times daily with meal times and recorded in the log book.
Failure to update care plans for three residents. One resident developed a Stage II pressure injury, had significant weight loss, and later transitioned to hospice, but the care plan did not reflect those changes or the resident-centered interventions in the MDS. A second resident had multiple pressure injuries and vascular wounds, yet the care plan was not revised to include those wounds or related consults. A third resident had ongoing significant weight loss, but the care plan did not document the nutritional decline or specific interventions. Staff and the DON stated the interdisciplinary team is responsible for updating care plans, and the facility policy required person-centered care plans to be reviewed and revised with changes that warrant revision.
A resident’s EHR was not updated to include a newly identified Cefepime allergy after an allergic reaction and antibiotic change, even though the order directed staff to add the medication to the allergy list. In a separate issue, an RN did not document notifying the physician of multiple elevated blood glucose readings for a resident with DM, despite an order to report BS results outside the ordered parameters.
A resident with moderately impaired cognition, Parkinson’s disease, and non-Alzheimer’s dementia had repeated falls while using a manual wheelchair. The care plan identified wheelchair pedals as a tripping hazard and noted they should be removed when the resident was sitting, but incident reports showed the resident was found on the floor multiple times with the pedals involved, including one witnessed fall when he tried to step over a pedal. Staff gave inconsistent accounts of when the pedals should be removed, and the DON confirmed the resident fell again with the pedals still on.
A resident with multiple health conditions and significant care needs was discharged without a comprehensive plan addressing their goal to return home, especially after alternative therapy services could not be arranged. The care plan lacked focus on discharge goals, and there was no documented assessment of the resident's transfer abilities, home environment, or the caregiver's capacity to provide necessary support. As a result, the resident was unable to safely return home and was taken to a hotel post-discharge.
A resident with multiple medical conditions was discharged without receiving the required 30-day written notice or information on appeal rights. The facility provided discharge instructions but did not include the necessary details about the right to appeal, the process for appealing, or contact information for the state entity responsible for appeals. The Administrator confirmed that only discharge instructions and the bed hold policy were provided, resulting in a deficiency.
Incomplete Dishwasher Sanitization Monitoring
Penalty
Summary
The facility failed to monitor the dishwasher to ensure proper sanitization of resident dishes and utensils. During an observation on 11/17/25 at 10:55 AM, the dish washer was noted to have a low temperature. Review of the Dishwasher Temperature/Sanitizer Checklist showed incomplete documentation for wash temperature, rinse temperature, and sanitizer parts per million (PPM), with only 15 of 90 entries completed in September 2025, 13 of 93 entries completed in October 2025, and 4 of 48 entries completed in November 2025. During an interview on 11/17/25 at 11:00 AM, the Dietary Manager acknowledged the incomplete dish machine temperature logs. During an interview on 11/19/25 at 11:15 AM, a Dietary Aide stated the dish machine sanitizer is tested three times per day with meal times and that the ideal range is 50 ppm, with the temperatures and test results written in the log book. The Dishwasher Temperature/Sanitizer Checklist directed staff to record the temperature or test strip results prior to washing dishes for each meal, and the U.S. FDA Food Code 2017 section 4-703.11 was cited regarding sanitizing equipment food-contact surfaces and utensils with a chlorine sanitizing solution at a minimum temperature of 120 degrees.
Failure to Update Care Plans for Skin Integrity and Nutritional Changes
Penalty
Summary
The facility failed to develop and maintain updated, individualized care plans for 3 residents after changes in their conditions were identified in the clinical record. The care plan policy stated that after the comprehensive assessment is completed, person-centered care plans are to be put in place and reviewed and revised by the interdisciplinary team after MDS assessments when applicable and with changes that warrant revision. Review of records, policies, and staff interviews showed that the care plans for Residents #1, #21, and #30 were not updated to reflect significant clinical changes documented in the MDS, physician orders, wound assessments, and dietary notes. Resident #1 had diagnoses including anemia, cancer, muscle wasting, pain, and rheumatoid arthritis, with intact cognition on the MDS. The MDS documented no pressure injuries at the time of assessment but identified the resident as at risk for pressure injuries, with interventions including pressure-reducing devices, turning/positioning, nutrition/hydration interventions, and ointment/medications. A later skin assessment identified a Stage II pressure injury to the right lower buttock, and physician orders were entered for wound treatment and nutritional supplementation. The resident also had significant weight loss and transitioned to hospice services. The care plan reviewed later listed risk for altered skin integrity and altered nutritional status, but did not include the newly identified Stage II pressure injury, the significant weight loss, the hospice transition, or the resident-centered interventions reflected in the MDS. Resident #21 had diagnoses including COPD, chronic respiratory failure, diabetes, and seizure disorder, with intact cognition on the MDS. The MDS documented two unstageable pressure injuries and interventions including pressure-reducing devices, nutrition interventions, pressure injury care, and non-surgical dressings and ointments/medications. A later skin assessment documented Stage II pressure injuries to the left heel and left second toe, along with vascular wounds to the left third toe and left outer heel. The care plan reviewed later still listed only risk for altered skin integrity and did not include the Stage II pressure injuries, the vascular wounds, or the resident-centered interventions noted in the MDS, including wound care consults with podiatry and the wound care clinic. Resident #30 had diagnoses including CVA, CKD, hemiplegia, and non-Alzheimer's dementia, with severe cognitive impairment on the MDS. The MDS and RD notes documented significant weight loss, and a physician order for a Mighty Shake mixed with ice cream was initiated for weight loss. The care plan reviewed later continued to list only potential risk for altered nutritional status and did not reflect the ongoing significant weight loss or specific resident-centered nutritional interventions.
Failure to Document New Allergy and Notify Physician of Elevated Blood Sugars
Penalty
Summary
Professional standards of care were not followed for Resident #21 when the clinical record was not updated to include a newly identified Cefepime allergy. The resident’s MDS showed intact cognition with a BIMS score of 15. Physician orders dated 11/2/25 directed staff to discontinue Cefepime, add the medication to the allergy list, and monitor closely for signs of an allergic reaction for the next three days. Although the orders were acknowledged by nursing staff and reprinted for provider signature with a note about an allergic reaction and changing antibiotics, the Allergy tab in the EHR on 11/18/25 still listed Gabapentin, Metformin, and Sulfa antibiotics only, and did not include Cefepime. The DON stated newly identified allergies should be entered into the EHR once identified, but she was not aware of the Cefepime allergy. Professional standards of care were also not followed for Resident #6 when ordered blood glucose results were not documented as reported to the physician. The resident’s MDS showed a BIMS score of 10 out of 15 and a diagnosis of diabetes mellitus. The care plan directed staff to monitor glucose levels as ordered and report to the practitioner per parameters. A physician order required weekly fasting blood glucose checks on Tuesdays and notification of the physician if blood sugar was less than 60 or greater than 150. The EHR showed multiple blood sugar readings above 150 mg/dl, including 169, 196, 196, 154, 195, 162, and 238 mg/dl, but there was no documentation that the physician was notified of these results as ordered. Staff interviews confirmed the order required provider notification when readings were outside the parameters, and the DON stated nurses were supposed to notify the provider if blood sugars were not within the parameters.
Failure to revise fall interventions after repeated wheelchair-related falls
Penalty
Summary
The facility failed to evaluate the effectiveness of fall interventions and revise them after repeated falls for one resident who had a BIMS score of 8 out of 15, indicating moderately impaired cognition, and diagnoses including Parkinson’s disease and non-Alzheimer’s dementia. The resident used a manual wheelchair and needed partial/moderate assistance with transfers. The MDS documented multiple falls with and without injury since the last assessment, and the care plan identified the resident as at risk for falls with an intervention to remove wheelchair pedals when the resident was in the wheelchair to decrease tripping hazards. The record showed several fall incidents involving the wheelchair foot pedals. One incident report noted the resident was found on the floor in the hallway with his knees on the foot pedals and stated he had fallen while reaching for something. Another report described the resident found on the floor with the wheelchair pedals under his buttocks while sitting at the nurse’s station. A third report documented a witnessed fall in the dining room when the resident stood up, tried to step over a pedal, and fell onto the foot pedal. A later incident report described the resident on the floor with the right foot pedal caught on a table leg. The reports included varying preliminary recommendations, including removing the pedals while the resident was sitting and educating staff, but one report listed no further preventative measures. Interviews showed inconsistent understanding and implementation of the pedal intervention. The resident’s wife stated he had multiple falls and would trip over his foot pedals, which led to removal of the pedals when he sat in his wheelchair. Staff responses differed on when the pedals should be on or off, with some stating they should be removed whenever the resident was sitting and others stating they should remain on unless he was moving. The DON stated the team reviewed falls daily and identified the need to remove the pedals for some incidents, but also confirmed the intervention was communicated later and that the resident fell again with the pedals still on. The facility policy required residents to be evaluated for fall risk and for additional interventions to be implemented post-fall, with the IDT able to change interventions if a more appropriate one was identified.
Failure to Develop and Implement Adequate Discharge Plan for Resident Returning Home
Penalty
Summary
The facility failed to develop and implement an adequate discharge plan that addressed a resident's goal to return home, particularly in the event that alternative therapy services could not be obtained. The resident, who had diagnoses including heart failure, diabetes, unsteadiness, and an ostomy, required significant assistance with activities of daily living such as transferring, showering, and toileting. Despite the resident's and his wife's expressed desire for referrals to other facilities for continued therapy, the care plan did not include a focus area for discharge goals or planning related to these requests or for a safe return home if such services were unavailable. Clinical record review revealed that while the resident and his wife were informed of the end of skilled care and provided with a Notice of Medicare Non-Coverage, there was no documentation of a comprehensive assessment or discharge planning to address the resident's specific needs for a safe transition home. This included a lack of evaluation of transfer ability, safety and supervision needs, required equipment, the caregiver's capacity to provide necessary care, and the suitability of the home environment. The resident's wife ultimately took him to a hotel after discharge, as she was unable to get him into their home due to physical barriers, highlighting the absence of adequate planning for his return. Interviews with staff indicated that while some discussions occurred with the resident's wife regarding post-discharge care, there was no evidence of a formal home assessment or evaluation of the wife's ability to care for the resident. The facility's administrator confirmed that the only relevant policy was the bed hold policy and that no additional discharge planning documentation was present. The lack of a structured discharge plan and assessment resulted in the resident being discharged without assurance that his needs and preferences for a safe transition were met.
Failure to Provide Required 30-Day Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a resident or the resident's representative with a 30-day written notice prior to discharge, as required. The clinical record review showed that the resident, who had diagnoses including heart failure, diabetes, and unsteadiness, required varying levels of assistance with daily activities and had intact cognition. Documentation in the electronic health record indicated that the resident was informed of the last day of therapy and had plans to return home, with subsequent orders for discharge and therapy at a new facility. However, there was no evidence that a formal discharge notice, including required information about appeal rights, was given. The discharge instructions provided to the resident included details about the discharge location, responsible party, primary physicians, pharmacy, and some care instructions. The document was signed by the resident, the MDS Coordinator, and the social worker. Despite this, the instructions did not constitute a 30-day notice and did not include information on the right to appeal the discharge, the process for appealing, or contact information for the state entity responsible for appeals. During an interview, the Administrator confirmed that the only policy related to discharges was the bed hold policy and that the resident's wife was provided with discharge instructions, but no other form was given. The facility's bed hold and return policy was reviewed, but it did not address the requirements for discharge notice or appeal rights. The lack of proper notice and appeal information constituted the deficiency identified during the survey.
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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 Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davis Center | 4.4 mi | — | 0 | 0 |
| Good Samaritan - Ottumwa | 17.1 mi | ★★★★★ | 13 | 0 |
| Ridgewood Specialty Care | 17.4 mi | ★★★★★ | 5 | 0 |
| Accura Healthcare Of Ottumwa | 17.9 mi | ★★★★★ | 2 | 0 |
| Schuyler County Nursing Home District | 21.1 mi | ★★★★★ | 30 | 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.