Above 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 Buchanan County Health Center during CMS and state inspections, most recent first.
Shared glucometers were used for multiple residents, and staff cleaned them with alcohol prep pads instead of following the manufacturer’s disinfection instructions. Observation and staff interviews confirmed one meter on each med cart was used for several residents, including residents with DM who were receiving routine blood sugar checks and insulin. The meter was wiped briefly after use and returned to the cart, despite guidance stating the device was for single-patient use and that 70% ethanol is not effective against bloodborne pathogens.
The facility's commercial dishwasher failed to reach the required hot water sanitizing levels, with the digital display non-functional and temperature monitoring inadequate. Staff interviews and temperature logs revealed consistent issues with maintaining the necessary sanitizing temperatures, posing a risk of foodborne illness.
A facility failed to prime an insulin pen before administering Humalog to a resident. During a medication pass, an RN was observed preparing to give 5 units of insulin without priming the needle, contrary to the manufacturer's instructions. The facility lacked a specific insulin administration policy, and the Nurse Manager confirmed the expectation to prime the needle. The general medication policy directs adherence to manufacturer instructions, which was not followed.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS for a resident who elected hospice services. Despite the resident's admission to hospice care, the required assessment was not conducted, as confirmed by the MDS Coordinator and Nurse Manager. This oversight violated CMS guidelines and federal regulations requiring timely comprehensive assessments.
A facility failed to update a resident's Care Plan to include hospice services despite the resident's moderate cognitive impairment and terminal prognosis. Hospice services began as documented by a Medicare Hospice Election Statement, but the Care Plan lacked necessary interventions. Staff interviews confirmed the Care Plan should have been updated when hospice services started.
A resident with severe cognitive impairment exited a nursing facility through an unsecured door into an Independent Living area and then into a parking lot, remaining unsupervised for 31 minutes. The resident, known for wandering and quick mobility, attempted to open a vehicle door before being noticed. The facility's failure to secure the door and supervise the resident led to this incident.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and exit-seeking behaviors. Despite the resident's Alzheimer's disease and anxiety disorder, the care plan lacked specific interventions. Staff interviews revealed inconsistent strategies, with some staff aware of the resident's preferences and others unfamiliar with effective interventions. The administrator acknowledged the need for personalized interventions, but the deficiency was noted due to the absence of a detailed care plan.
The facility failed to employ a certified nutrition professional, as the Nutrition Manager is not a Certified Dietary Manager (CDM) and has not completed the necessary class due to staffing issues. The Clinical Registered Dietician works part-time, focusing on MDS Assessments, leaving the Nutrition Manager, who lacks nursing facility experience, responsible for kitchen-related tasks.
The facility's kitchen was found to be unsanitary, with unclean equipment, undated food items, and improper food handling practices. Observations included yellow splatters in the microwave, frost buildup in the milk cooler, and undated food in the refrigerator. Staff were seen using dirty gloves to handle food and not wearing hair restraints properly. Cleaning logs showed incomplete documentation, and interviews revealed a lack of training and oversight.
A facility failed to complete a significant change MDS within the required 14 days after a resident's condition declined. The MDS coordinator misunderstood the guidelines, resulting in a delay of 26 days for completion. The facility lacked a specific policy for MDS completion, relying on the RAI manual.
The facility failed to include monitoring for signs, symptoms, or side effects of specific medications in the care plans of four residents. A resident's care plan did not document monitoring for azithromycin, Lasix, or lorazepam. Another resident's care plan lacked monitoring for amoxicillin, fentanyl, Lantus insulin, Lasix, Novolog insulin, and warfarin. Two residents with cognitive loss were prescribed anticoagulants, but their care plans did not include monitoring for these medications.
A resident with limited range of motion did not receive the prescribed restorative care due to staff transitions and documentation issues. The resident's exercise program was inconsistently delivered, with significant gaps in the frequency of sessions. The new RCNA faced challenges balancing duties and lacked training in documenting refusals or absences, contributing to incomplete records. The facility did not have a restorative policy, and staffing issues further impacted the program's consistency.
Shared glucometers were used for multiple residents and cleaned with alcohol only
Penalty
Summary
The facility failed to provide an infection prevention and control program by using shared blood glucose meters for multiple residents and by disinfecting those meters with alcohol prep pads rather than following the manufacturer’s instructions and CDC/FDA guidance. Observation during the morning medication pass showed a nurse performing a blood sugar check for Resident #34, then wiping the blood glucose machine with an alcohol prep pad and placing it back in the medication cart. Staff interviews later confirmed that the same meters on the 300 and 400 medication carts were being used for multiple residents and were being cleaned with alcohol after use. Resident #8 had diabetes mellitus, a BIMS score of 15 out of 15, and received insulin injections seven days a week. The resident’s care plan directed blood sugar checks as ordered, and the March 2026 EMAR showed blood sugar monitoring was due and performed as ordered. During observation, a nurse prepared the glucometer and supplies on a barrier paper, entered the resident’s room, completed the blood sugar check, and then cleaned the meter with a 70% alcohol prep pad for only a few seconds before returning it to the medication cart. The nurse stated this was how the meters had always been cleaned. Further interviews showed the nurses used one blood glucose meter on the 300 hallway cart for Residents #8, #11, and #14, and one meter on the 400 hallway cart for Residents #9 and #34. The Nurse Manager confirmed both meters were shared among these residents and that only alcohol had been used for cleaning. The facility policy required reusable resident care items, including glucometers, to be cleaned and disinfected according to the manufacturer’s instructions, while the manufacturer’s guide stated the meter was for single-patient use only and that 70% ethanol solutions are not effective against viral bloodborne pathogens. CDC guidance stated that if meters must be shared, they should be cleaned and disinfected after every use per the manufacturer’s instructions.
Dishwasher Fails to Reach Sanitizing Temperatures
Penalty
Summary
The facility failed to ensure that the commercial dishwasher reached the required hot water sanitizing levels, as observed during a follow-up walkthrough of the kitchen. The dishwasher's digital display, which shows wash and final rinse temperatures, was not functioning. Staff were instructed to monitor the gauge between the booster heater and dishwasher to ensure the water temperature maintained 180°F. However, the CDN dishwasher thermometer and temperature test strip used during the inspection revealed that the dishwasher did not reach the necessary sanitizing levels, with the maximum temperature recorded at 153.7°F and the temperature strip failing to indicate the required 180°F. Interviews with staff revealed that the digital display on the dishwasher had not been operational for a long time, and the water heater temperature was set at 140°F, with the booster heater intended to raise it to 187°F. Despite this, the gauge displayed a temperature of 180°F, which was not sufficient for proper sanitization. The High-Temperature Dish machine Temperature Log showed multiple instances where the temperature strips failed to indicate the required temperature, and there was a lack of recorded corrective actions or manager review. The facility's Dietary Infection Control policy required maintaining a final sanitation rinse of 180°F and wash water of 160°F or higher, but these standards were not met. The failure to reach the necessary sanitizing temperatures posed a risk of foodborne illness, as acknowledged by the nutrition service manager. The report highlights a consistent issue with the dishwasher's temperature monitoring and recording, which was not adequately addressed by the facility staff.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in the administration of insulin to a resident. During a morning medication pass, a Registered Nurse (RN) was observed preparing to administer Humalog (Insulin Lispro) to a resident without priming the needle of the insulin pen. The RN had already set the dose to 5 units and was about to administer the insulin when the surveyor intervened, noting that the needle had not been primed. The RN acknowledged the oversight, confirming that the needle should have been primed before administration. Further investigation revealed that the facility did not have a specific policy for insulin administration. The Nurse Manager confirmed that the expectation was for the needle to be primed prior to administration. The manufacturer's instructions for the KwikPen, revised in July 2023, clearly state that the pen should be primed with 2 units before each use to ensure proper functioning and accurate dosing. The facility's general medication administration policy, last revised in December 2021, directs staff to follow manufacturer directions, which were not adhered to in this instance.
Failure to Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment for a resident who elected hospice services. The resident's electronic healthcare record indicated hospice as the primary payer, and the resident was admitted to hospice care services. Despite this, the facility did not complete the required SCSA MDS assessment, which is mandated by the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. This manual specifies that an SCSA is required when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. Interviews with facility staff revealed that the MDS Coordinator was aware of the resident's hospice election but failed to complete the necessary assessment. Additionally, the Nurse Manager/Infection Preventionist was also aware that the SCSA MDS had not been completed. According to federal regulations at 42 CFR 483.20 (b)(2)(ii), the facility must conduct a comprehensive assessment of a resident within specified time frames, which was not adhered to in this case.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for a resident with moderate cognitive impairment, progressive neurological conditions, coronary artery disease, and depression. The resident's Minimum Data Set (MDS) assessment indicated a need for hospice services, which began on February 10, 2025, as documented by a Medicare Hospice Election Statement signed by the resident's family member. However, the Care Plan initiated on June 24, 2024, did not include a focus area for the terminal prognosis or interventions for hospice care. During interviews, the MDS Coordinator acknowledged that the Care Plan should have been updated when hospice services began, and the Nurse Manager/Infection Preventionist confirmed that the expectation was for the Care Plan to be updated at the start of hospice services.
Resident Elopement Due to Unsecured Door
Penalty
Summary
The facility failed to ensure the safety of a resident with severe cognitive impairment, who was able to exit the nursing home and enter an attached Independent Living facility without staff awareness. The resident, who had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment, was independent in mobility and had Alzheimer's disease and an anxiety disorder. On the day of the incident, the resident was last seen in her room by a Certified Nurse Aid (CNA) before she exited through an unlocked door into the Independent Living area, and subsequently into an unsafe parking lot off the premises. The resident remained unsupervised in the parking lot for approximately 31 minutes, during which time she attempted to open the door of an unknown vehicle. The staff was unaware of her absence until a tenant from the Independent Living facility reported the incident to the local police. The resident's cognitive condition, characterized by fluctuating levels of confusion and a tendency to wander, contributed to the risk of her elopement. Staff interviews revealed that the resident was known to be very mobile, quick on her feet, and difficult to redirect, often making multiple attempts to exit the facility. The facility's policy on elopement and abduction was not effectively implemented, as the door mechanics failed to prevent the resident from leaving the premises. Staff interviews indicated that the door to the Independent Living area was expected to be locked at all times, yet it was found to be unlocked, allowing the resident to exit unnoticed. The facility's failure to secure the door and adequately supervise the resident led to a situation where she was exposed to potential harm outside the facility.
Removal Plan
- A Wander Alert System was installed on doors exiting the nursing facility into the Independent Living Facility.
- Hourly checks of the doors exiting the nursing facility into the independent living facility to ensure they were secure and verify an employee badge or badge assigned to an independent living facility resident was required to be scanned to open the doors. Continues to remain in place.
- Door locks changed on doors exiting the nursing facility into the Independent Living facility to prevent the door from being left unlocked. In the event a key is used to unlock the door, the key must be returned to the locked position before it is able to be removed from the lock. This ensures the doors are locked at all times.
Failure to Implement Comprehensive Care Plan for Exit-Seeking Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan with resident-specific interventions for a resident with identified exit-seeking behaviors. The resident, who had severe cognitive impairment due to Alzheimer's disease and an anxiety disorder, was independent in walking, transferring, and toileting. Despite her cognitive challenges, the care plan lacked specific approaches and interventions to address her exit-seeking behavior. Interviews with various staff members revealed that the resident required significant supervision and had a tendency to wander, often attempting to go outside. Staff members used various ad-hoc interventions such as providing one-to-one supervision, engaging her in activities like folding towels or walking with her, and redirecting her as needed. The staff interviews highlighted a lack of consistent and effective strategies tailored to the resident's needs. While some staff members were aware of the resident's preferences, such as her enjoyment of cleaning and carrying items, others, including a full-time CNA, were not familiar with effective interventions for her exit-seeking behavior. The facility's administrator acknowledged the need for personalized interventions in the care plan for residents with wandering behaviors. However, the absence of a detailed and resident-specific care plan contributed to the deficiency identified by the surveyors.
Deficiency in Employing Qualified Nutrition Staff
Penalty
Summary
The facility failed to employ a certified nutrition professional or director who met the required qualifications within the allowed time frame, affecting the care of 37 residents. The Nutrition Manager, who is not a Certified Dietary Manager (CDM), reported that she is enrolled in the necessary class but has not completed it due to staffing issues, resulting in a delay. Her employee file lacked documentation of a CDM certificate, confirming her current unqualified status. The Clinical Registered Dietician, who works part-time and is allocated only 8 hours a week in the long-term care facility, primarily focuses on Minimum Data Set (MDS) Assessments rather than kitchen-related duties. The Nutrition Manager, who previously worked as a food service supervisor in a county jail, is responsible for most of the kitchen-related tasks and training, despite her lack of experience in a nursing facility. The Executive Director of Senior Operations acknowledged the Nutrition Manager's prior experience was not in a nursing facility and confirmed her ongoing enrollment in the dietary manager class.
Sanitation and Food Handling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of unclean equipment and improper food storage practices. During an initial kitchen tour, surveyors noted yellow splatters in the microwave, a crusty substance on the standing mixer, and significant frost buildup in the milk cooler. Additionally, several food items in the Continental refrigerator and walk-in refrigerator were found to be undated, including orange juice, chopped garlic, cheddar cheese, and various meats. The knife rack and preparation table were observed with a buildup of grime, and the stove griddle had a gritty substance running across it. The walk-in freezer also contained undated food items and food particles on the floor. Further observations during a follow-up visit revealed that the stove top and knife rack remained unchanged, and the same undated food items were still present in the refrigerator. Staff members were observed handling food with dirty gloves, failing to change gloves between tasks, and improperly wearing hair restraints. For instance, a dietary aide used the same gloves to handle multiple food items and utensils, and another staff member was seen with her hair not fully covered by her cap. The facility's cleaning logs for March, April, and May 2024 showed numerous blanks, indicating that required cleaning tasks were not documented as completed. Interviews with staff and management revealed a lack of proper training and oversight in the kitchen. The Nutrition Manager admitted that the facility had a system for labeling opened food items, but it was not consistently followed. The Executive Director of Senior Operations acknowledged the absence of documentation for cleaning tasks and the recent resignation of the Nutritional Services Supervisor, who was responsible for overseeing kitchen operations. The facility's Dietary Infection Control Policy outlined the need for clean and sanitary conditions, but the observed practices did not align with these guidelines.
Failure to Timely Complete Significant Change MDS
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) within the required 14 days after determining a significant change in condition for a resident. The clinical record review and staff interview revealed that during the completion of a quarterly MDS, a decline in multiple areas was noted for the resident, which was considered a significant change. An Assessment Reference Date (ARD) was set, but the significant change MDS was not completed until 26 days later, exceeding the regulatory requirement. The MDS coordinator misunderstood the guidelines, believing she had additional time to complete the MDS, and the facility lacked a specific policy for MDS completion, relying solely on the RAI manual.
Failure to Monitor Medication Side Effects in Care Plans
Penalty
Summary
The facility failed to include monitoring for signs, symptoms, or side effects of specific medications in the care plans of four residents. Resident #5's care plan did not document monitoring for azithromycin, Lasix, or lorazepam. Similarly, Resident #13's care plan lacked monitoring for amoxicillin, fentanyl, Lantus insulin, Lasix, Novolog insulin, and warfarin. During an interview, the Director of Nursing acknowledged the expectation for these medications and their side effects to be included in the care plans. Resident #6, who has severe cognitive loss, was prescribed Xarelto for atrial fibrillation, but their care plan did not include monitoring for this anticoagulant. Resident #15, with moderate cognitive loss and a history of venous thrombosis, was prescribed Apixaban, yet their care plan also lacked documentation for monitoring the anticoagulant. The facility's failure to document and monitor these medications in the care plans was identified during a review of medication administration records and care plans.
Inadequate Restorative Care for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the appropriate assistance to prevent decline or maintain mobility. The resident, who had a history of cerebrovascular accident and other medical conditions affecting mobility, was supposed to participate in a restorative program involving active and active assist range of motion exercises. However, the facility's records showed significant gaps in the delivery of this program, with the resident receiving the exercises far less frequently than prescribed. The deficiency was partly due to a transition in staff roles, with a new Restorative Certified Nursing Assistant (RCNA) taking over the position in March 2024. The RCNA reported challenges in balancing her duties, often prioritizing floor assistance over the restorative program due to short staffing. Additionally, there was a lack of proper documentation, as the RCNA was not trained on how to document refusals or the resident being out of the facility, leading to incomplete records of the resident's participation in the program. Interviews with staff revealed that the facility did not have a restorative policy in place, and the transition in staff roles contributed to the inconsistency in the restorative program. The Director of Nursing acknowledged the staffing issues and the need to return to the prescribed frequency of the restorative program. Despite these challenges, the facility reported no functional declines in residents due to the inconsistency in the restorative program.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 83 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Centers Of Independence West Campus | 0.2 mi | ★★★★★ | 14 | 1 |
| Oelwein Health Care Center | 14 mi | ★★★★★ | 9 | 0 |
| Grandview Healthcare Center | 14.1 mi | ★★★★★ | 5 | 0 |
| Laporte City Specialty Care | 20.2 mi | ★★★★★ | 3 | 0 |
| Virginia Gay Nursing & Rehab, Llc | 21.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Buchanan County Health Center.
100% money-back within 48 hours.
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.