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 Careage Hills Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Food Handling and Glove Use During Meal Preparation: A cook handled ready-to-eat foods with gloved hands in an unsanitary manner, including opening bread and bun packages, tearing bread, pouring milk over bread, and handling chips with soiled gloves. Facility policy required minimal bare hand contact with food, use of utensils or single-use gloves, and changing gloves when changing tasks or after touching food packages.
The facility failed to notify the LTC Ombudsman of a hospital transfer and a discharge for two residents. One resident was sent to the ER and later admitted to the hospital, and another resident was discharged with return not anticipated and had intact cognition by BIMS. Monthly Ombudsman transfer forms did not include either resident, and staff stated the wrong EHR report was being used to generate the notifications.
Failure to update PASRR after new mental health diagnosis: A resident with a prior negative PASRR Level I result later had diagnoses including psychotic disorder, neurocognitive disorder, depression, delusions, and major depressive disorder, along with an order for duloxetine for depression. The record lacked an updated PASRR to reflect the new depression diagnosis and medication, and the DON and Administrator stated the PASRR was not updated after the social worker changed jobs.
Failure to document blood sugars and insulin administration on the MAR for a resident with DM, renal insufficiency, and HTN. The resident had intact cognition, checked his own blood sugar, and self-administered insulin after nurses dialed up the pen. Physician orders included scheduled Humulin, sliding scale Humulin, and Lantus, but the MAR lacked documentation of blood sugar results and insulin units on multiple occasions. The facility policy stated nursing was responsible for recording self-administered doses, and the DON said nurses were expected to obtain the blood sugar information and document the insulin on the MAR.
A resident with dementia, muscle weakness, and impaired mobility was transferred from bed to wheelchair by two CNAs using a mechanical lift while the wheels remained braked during the lift. The resident’s care plan required total dependence with 2-person assist using a mechanical lift, and the lift manual stated the casters should be left free and un-braked when lifting and lowering, except when lifting from the floor. Staff interviews showed uncertainty about the correct brake use, and the DON/Administrator stated the brakes should remain unlocked during transfers.
A CNA performed catheter care for a resident with an indwelling device without using EBP gown PPE, then handled the urine bag, bathroom items, and other surfaces before leaving the room without hand hygiene and entering another resident’s room. The resident’s room had no EBP signage or PPE, and an RN later confirmed that EBP was not being used consistently and that staff should wear a gown when emptying a catheter.
A resident who was totally dependent on staff for transfers and had advanced dementia and seizure disorder was injured when a CNA attempted a mechanical lift transfer alone, contrary to facility policy requiring two staff. The resident fell from the lift, sustaining a forehead laceration, nasal fracture, and multiple skin tears. Documentation and interviews confirmed the CNA did not seek required assistance, resulting in the incident.
A resident with multiple sclerosis was left without an accessible call light after her adaptive pad call light broke and was not returned, leaving her unable to call for assistance. Staff confirmed that neither the standard call light nor alternative solutions were usable or consistently available for the resident, contrary to facility policy requiring a means of communication with nursing staff.
The facility failed to complete a wound treatment as ordered for a resident with pressure ulcers after a dressing was removed, resulting in a significant delay before the treatment was performed. Additionally, staff did not complete or document an assessment for another resident after seizure-like activity was reported, with the responsible RN not returning to reassess due to personal health issues.
The facility failed to follow professional food safety standards during meal preparation and serving. The Dietary Supervisor (DS) was observed using the same gloves to touch various surfaces and handle ready-to-eat food without washing hands between tasks. The facility's food handling policy and the 2022 Food Code require proper glove use and handwashing to minimize contamination risk.
A facility failed to obtain bed hold notifications for a resident hospitalized twice. The resident's EHR confirmed the hospitalizations, but no bed hold form was available for review. The Administrator admitted the oversight and explained that a Performance Improvement Program (PIP) was in place. The facility's policy requires written notification of bed hold provisions upon admission and before hospital transfer, with a copy in the resident's health record.
A resident with severe cognitive impairment and multiple health conditions experienced a significant weight loss of 14.3% over a month, with no subsequent weights recorded. The facility failed to adhere to its policy of monitoring and addressing weight loss, as the Registered Dietitian did not address the issue, and the prescribed nutritional supplements were not administered. The Director of Nursing acknowledged the policy requirements, but the facility did not follow through with necessary evaluations and interventions.
A resident with severe cognitive deficits was pushed by another resident, resulting in a fall and a hematoma. The incident occurred after lunch, and staff did not witness it directly. The injured resident was known to become agitated, especially when waiting for cigarette breaks. The facility's abuse prevention policy was not effectively implemented to prevent this incident.
The facility failed to investigate an alleged abuse incident involving a resident with severe cognitive deficits, as well as an injury of unknown origin for another resident. In both cases, there was a lack of documentation, witness statements, and incident reports, which is a deficiency in the facility's compliance with its policies.
The facility failed to provide adequate supervision and safety measures, resulting in accidents for several residents. A resident fell from a recliner due to improper transfer practices, while another was left unattended on the toilet, leading to a fall. A resident slid off a whirlpool seat due to inadequate securing, and another sustained a fracture when a staff member's dog caused her to fall. Ineffective interventions and lack of supervision led to multiple falls for another resident.
A resident with moderate cognitive deficits and a history of falls experienced multiple falls due to the facility's failure to implement care plan interventions. Despite requiring assistance with mobility, staff did not consistently follow interventions such as having a wheelchair behind the resident during ambulation and keeping the walker out of sight. Observations showed these measures were not adhered to, contributing to the resident's repeated falls.
A resident with severe cognitive impairment and multiple health issues fell in the bathroom during a transfer due to a CNA not using a gait belt, resulting in an acute fracture of the right femur neck. The facility's policy mandates gait belt use during transfers, which was not followed.
The facility failed to provide reasonable access to personal funds for two residents, limiting access to $10 after business hours and on weekends, and requiring advance requests for additional funds. This practice did not align with the facility's policy to protect and ensure accessibility of personal funds.
The facility failed to complete the required Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License information prior to the re-employment of two staff members, an LPN and a CNA. The oversight was confirmed by the Business Office Manager and the Executive Director, despite facility policies mandating pre-employment screening.
The facility failed to obtain bed hold notifications for a resident who was hospitalized. Clinical records showed the resident was in the hospital, but no bed hold form was available. Interviews with the Administrator and DON confirmed the expectation to obtain bed hold notifications for all transfers or discharges, as per facility policy.
Food Handling and Glove Use During Meal Preparation
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions. During an observation in the kitchen, a cook applied gloves after performing hand hygiene, then used the gloved hands to grab a bread sack, open it, pour about 6 pieces of bread onto small bowls, tear up the bread with the same soiled gloves, and grab a milk jug to pour milk over the bread before removing the gloves and putting on new gloves. In a separate observation, the same cook wore gloves while opening a hamburger bun bag, removed a bun with the gloved hand and placed it on a plate, then used the same soiled glove hand to grab potato chips from a bag and place them on the plate. The facility policy on Food Handling stated ready-to-eat foods will not be touched with bare hands and that proper utensils such as tissue, spatula, tongs, or single-use gloves will be used, with minimal bare hand contact during preparation. The Administrator stated the expectation was to use tongs to get bread out of the bread sack and to put on new gloves when touching food and after touching the outside of food packages.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital and a discharge to home for 2 of 3 residents reviewed, Resident #38 and Resident #43. Resident #38’s MDS showed discharge with anticipation to return to the facility, and the EHR documented that the resident was sent to the emergency room for evaluation and was later admitted to the hospital. Resident #43’s MDS showed discharge with return not anticipated, and the BIMS score was 15, indicating intact cognitive functioning. Review of the facility’s Notice of Transfer Form to the Long-Term Care Ombudsman for November 2025 did not include Resident #38, and the January 2026 form did not include Resident #43. Staff A, Activities, stated she completed the monthly Ombudsman notifications by pulling a report from the EHR, but acknowledged Resident #38 was not on the November 2025 notification and was unsure why. Staff A later stated she had been pulling the wrong report because it did not include transfers, and said she then pulled the correct report and notified the Ombudsman of the missed residents. The facility policy titled Admission, Transfer and discharge dated 10/2022 stated that when the facility transfers or discharges a resident, the facility shall ensure the transfer is reported to the ombudsman per monthly report.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer one resident with a negative PASRR Level I result for a Level II PASRR evaluation after the resident later had newly evident or possible serious mental disorder, intellectual disability, or other related condition identified. Resident #7’s record included diagnoses of psychotic disorder, neurocognitive disorder, and depression, and the MDS assessment documented a BIMS score of 14, indicating no cognitive impairment. The medical diagnosis list also showed delusions, mild neurocognitive disorder, and major depressive disorder. The clinical record for Resident #7 also showed an order for duloxetine 20 mg daily for depression, but the record lacked an updated PASRR to include the diagnosis of depression and the new medication. During interview, the Administrator and DON stated the facility failed to update the resident’s PASRR after the depression diagnosis and duloxetine order were added. The Administrator reported the facility’s social worker had changed jobs, the facility was in the process of hiring a replacement, and a later-hired social worker no longer worked at the facility.
Failure to Document Blood Sugars and Insulin Administration
Penalty
Summary
The facility failed to document blood sugars and insulin on the MAR for 1 of 1 residents reviewed, Resident #4. Resident #4 had diagnoses of diabetes mellitus, renal insufficiency, and hypertension, and the MDS assessment documented a BIMS score of 15, indicating intact cognition. The resident stated that he checks his blood sugar with his glucose monitoring device, notifies the nurse, and then nurses dial up the insulin pen before he self-administers the insulin. The physician orders included Humulin 3 units SQ three times a day, Humulin sliding scale insulin three times a day, and Lantus Pen 10 units SQ at bedtime. The physician fax form dated 10/2/25 showed an order for Resident #4 to check his own blood sugars and administer insulin independently. Review of the January 2026 MAR showed the facility failed to document the blood sugar and the amount of insulin given on multiple dates, and the February 2026 MAR showed the same failure on multiple dates. The facility policy for Self Administration of Medications, revised 2/2026, stated nursing is responsible for recording self-administered doses in the resident's MAR. The DON stated the expectation was for nurses to obtain the blood sugar information from Resident #4, administer the insulin, and document the blood sugar and insulin units on the MAR.
Mechanical Lift Used With Brakes Applied During Resident Transfer
Penalty
Summary
The facility failed to ensure a safe transfer using a mechanical lift for one resident with dementia, muscle weakness, and abnormalities of gait and mobility. The resident’s MDS assessment documented a BIMS score of 00, indicating the resident could not complete the interview. The care plan, initiated 7/28/22, directed that transfers required total dependence with assistance from two staff members using a mechanical lift. During an observation on 3/3/26 at 11:55 AM, two CNAs transferred the resident from bed to wheelchair with a mechanical lift while the lift wheels remained braked during both the raising and lowering portions of the transfer. The lift’s user manual stated that when lifting, the casters should be left free and un-braked, except when lifting a patient from the floor, and that applying the brakes causes the patient to swing to the center of gravity. The facility’s mechanical lift use policy also required staff to follow the manufacturer’s guidelines. In interviews, an RN stated she thought the lift should be unlocked but would need to check, and the Administrator stated the brakes should remain unlocked when lifting and lowering a resident.
Failure to Use EBP and Perform Hand Hygiene After Catheter Care
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) and failed to provide proper hand hygiene after catheter care for one resident who had an indwelling catheter. During observation, a CNA performed catheter care and emptied the catheter bag without donning a gown as part of PPE for EBP. After completing care with soiled gloves, the CNA wiped the urine bag spout with an alcohol wipe, handled the resident’s pants and urine colander, and completed bathroom tasks before doffing gloves without performing hand hygiene. The CNA then exited the bathroom, touched the bedside table and call light box, left the room, entered the dirty utility area, discarded the garbage bag, and went into another resident’s room to answer a call light. The resident’s room did not display signage or PPE required for EBP. The resident reviewed had an indwelling medical device, which was identified in the report as a condition for EBP use under CDC guidance. During interview, an RN hesitated and could not initially answer whether staff used EBP. When asked if a gown should be used when emptying a catheter, the RN answered yes. The RN stated that an EBP sign and PPE outside a resident’s room would indicate the need for EBP, and after observing the halls, reported that none of the resident rooms had EBP signage or PPE. The Administrator and DON acknowledged the issue and stated staff needed to readdress EBP and hand hygiene practices.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, seizure disorder, and total dependence on staff for all activities of daily living, including transfers, was injured during a transfer using a mechanical lift. The resident's care plan specified the need for two staff members to assist with all mechanical lift transfers. Despite this, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone using a Hoyer lift, contrary to facility policy and the resident's care plan. During the transfer, the CNA raised the resident in the sling and attempted to move her toward a wheelchair. The resident began to lean forward and subsequently fell out of the sling, landing face-first on the floor. The CNA immediately called for nursing assistance. Upon arrival, nursing staff found the resident on the floor with significant head trauma, including a forehead laceration, nasal fracture, and multiple skin tears. Emergency services were called, and the resident was transported to the hospital for further evaluation and treatment. Interviews and documentation confirmed that the CNA did not request assistance from another staff member prior to the transfer, despite knowing that two staff were required. The CNA stated that other staff were occupied and felt she had no other choice but to proceed alone. Facility policy explicitly required two staff for all mechanical lift transfers, and this policy was not followed in this instance, directly leading to the resident's fall and injuries.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide an adaptive call light for a resident with multiple sclerosis who was unable to operate a standard button call light. The resident had previously been given a pad call light that she could use, but it broke and was removed by the facility for repair, after which it was not returned. During an observation of a transfer using a mechanical lift, the resident confirmed she had no means to call for assistance in her room. Staff interviews corroborated that the resident was unable to use the standard pendant call light and that alternative solutions, such as a bell, were not consistently available or accessible. Facility policy requires that residents be provided with a means of communication with nursing staff, but this was not met for the resident in question.
Failure to Complete Wound Treatment and Seizure Assessment
Penalty
Summary
The facility failed to complete a wound treatment as ordered for one resident and failed to complete an assessment for another resident. For the first resident, who had diagnoses including type 1 diabetes and pressure ulcers, staff did not perform a prescribed wound treatment to the left ischium in a timely manner after the dressing was removed following a bowel movement. The resident reported the dressing was removed around 4:30 AM, but the wound treatment was not completed until 9:30 AM. Interviews revealed that the assigned RN did not complete the treatment due to not feeling well and was unable to stand long enough to perform the procedure. The DON was informed of the situation and instructed the RN to review the physician orders and complete the treatment, but the RN deferred the task to the next shift. For the second resident, who had Alzheimer's disease, a seizure disorder, and was dependent on staff for all activities of daily living, staff failed to complete and document an assessment after seizure-like activity was reported by CNAs. The RN on duty was notified of pre-seizure behavior but only performed a brief visual check, did not administer medication due to its expiration, and did not return to reassess the resident, citing personal health issues. Progress notes lacked documentation of an assessment related to the reported seizure activity, contrary to facility policy requiring assessment and documentation when seizure activity occurs.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and serving of a meal. During an observation, the Dietary Supervisor (DS) was seen removing gloves, washing hands, and applying new gloves before starting to serve the noon meal. However, the DS then proceeded to touch various surfaces, including plates, utensils, steam table covers, diet cards, and menus, without changing gloves. The DS retrieved a bun from its bag with the same gloves and used tongs to place a hamburger on the bun. After sending the hamburger out, the DS changed gloves without washing hands and continued to serve food, touching multiple surfaces. The DS also made a peanut butter sandwich and handled a package of cheese, removing a slice with the same gloves that had touched other surfaces. The facility's Guidelines for Food Handling policy stated that food should be handled in a manner that minimizes contamination risk, and ready-to-eat foods should not be touched with bare hands. The policy required proper use of utensils and gloves, including washing hands before and after wearing or changing gloves. The 2022 Food Code also documented that single-use gloves should be used for only one task and discarded when soiled or when interruptions occur. The Dietician confirmed that gloves touching other surfaces should not be used to handle ready-to-eat food, and handwashing is necessary when changing gloves.
Failure to Obtain Bed Hold Notifications for Hospitalized Resident
Penalty
Summary
The facility failed to obtain bed hold notifications for a resident who was hospitalized on two separate occasions. The resident's Electronic Healthcare Record (EHR) confirmed hospitalizations, but there was no bed hold form available for review for these dates. During an interview, the Administrator acknowledged that the bed holds were missed and explained that a Performance Improvement Program (PIP) had been initiated after the last annual survey. The Administrator was responsible for auditing the bed holds at the time, and the process required a bed hold form to be completed for any resident going out, with verbal consent obtained if the resident was unable to sign. The facility's policy, revised in 2016, mandates informing the resident or their representative in writing about the bed hold provision upon admission and before hospital transfer, with a copy of the notification included in the resident's health record.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adhere to its policy regarding significant weight loss for a resident with severe cognitive impairment, diabetes mellitus, cerebrovascular accident, and non-Alzheimer's dementia. The resident experienced a significant weight loss of 14.3% over a period from December 2024 to January 2025, with no subsequent weights recorded after January 8, 2025. Despite the facility's policy requiring monthly weights and additional monitoring for residents with weight loss, the resident's weight was not monitored weekly as required. Furthermore, the Registered Dietitian's progress note on February 5, 2025, did not address the resident's weight loss, and the facility failed to implement the physician's order to increase nutritional supplements. The Director of Nursing acknowledged that the facility's policy is to conduct monthly weights and weekly weight meetings, with additional measures for residents experiencing weight loss. However, the facility did not follow through with these procedures for the resident in question. The facility's policy also mandates that any significant weight change should be evaluated by the Interdisciplinary Team, but there is no evidence that this evaluation occurred. The lack of adherence to the facility's nutrition policy and failure to implement prescribed interventions contributed to the deficiency in maintaining the resident's nutritional status.
Resident Abuse Incident Leading to Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where one resident pushed another, causing the latter to fall and sustain a hematoma on the back of his head. The resident who was pushed had a severe cognitive deficit, as indicated by a BIMS score of 5, and was known to have periods of agitation. The incident occurred after the resident had finished lunch and was pacing the hallway, eventually sitting near a fish tank. The altercation happened when another resident, also with a severe cognitive deficit, pushed him, leading to the fall. The incident was reported by the nurse on duty who heard a loud bang and found the resident on the floor. The resident accused another resident of pushing him, which was corroborated by other residents who witnessed the event. The injured resident was taken to the emergency room, where a small subdural hematoma was diagnosed. Despite the injury, the resident was returned to the facility with instructions for increased monitoring. Interviews with staff revealed that none of them witnessed the incident directly, but they were aware of the resident's tendency to become agitated, especially when waiting for cigarette breaks. The staff also noted that the resident had previously shown aggressive behavior towards others. The facility's Director of Nursing and Administrator were unaware of any prior aggressive behavior from the resident who pushed, and the facility's policy on abuse prevention and reporting was not effectively implemented to prevent this incident.
Failure to Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive deficits. The incident occurred when a resident was found on the floor, claiming to have been pushed by another resident. Despite the seriousness of the allegation, the Director of Nursing (DON) did not have documentation of witness statements, and staff members who were present did not recall being interviewed or providing signed statements. This lack of thorough investigation and documentation is a deficiency in the facility's response to alleged abuse. Additionally, the facility did not investigate an injury of unknown origin for another resident, who also had severe cognitive deficits. This resident was found with scattered bruising on her lower extremities, but there was no documentation of an investigation into the cause of the bruising. Nursing notes indicated the presence of bruising, but lacked detailed descriptions or measurements. Staff members acknowledged the bruising but did not follow the facility's policy to initiate a risk management incident report or conduct a thorough investigation. The facility's policy requires that all alleged violations, including injuries of unknown origin, be thoroughly investigated. However, in both cases, the facility failed to adhere to its policy, as evidenced by the lack of documentation, witness statements, and incident reports. This failure to investigate and document alleged abuse and injuries of unknown origin constitutes a deficiency in the facility's compliance with its own policies and procedures.
Inadequate Supervision and Safety Measures Lead to Resident Accidents
Penalty
Summary
The facility failed to ensure proper supervision and use of interventions to prevent accidents for five residents. Resident #1, who was totally dependent on staff for transfers, fell from a recliner and sustained injuries due to improper transfer practices by staff. The CNA involved did not use a gait belt and moved the resident before a nurse could assess her, leading to further complications. Additionally, Resident #5, who required substantial assistance, was left unattended on the toilet without a gait belt or proper footwear, resulting in a fall. Resident #3, with moderate cognitive deficits and impaired mobility, slid off a whirlpool seat during a bath due to inadequate securing with safety straps. The staff member responsible lacked specific training on the use of the whirlpool bath, which contributed to the incident. Furthermore, Resident #4, who had intact cognitive ability, sustained a fracture when a staff member's dog, not on a leash, slid into her, causing her to fall. The facility's policy on pet management was not adhered to, leading to this accident. Resident #2, with moderate cognitive deficits and a history of falls, experienced multiple falls due to ineffective interventions and lack of supervision. The care plan interventions, such as keeping the walker out of sight and having a wheelchair behind the resident when ambulating, were not consistently implemented. The facility's policies on gait belt use and fall management were not followed, contributing to the residents' accidents and injuries.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions established in the care plan to prevent falls for a resident with a history of falls. The resident, who had moderate cognitive deficits and required assistance with mobility, experienced multiple falls despite specific interventions outlined in her care plan. These interventions included having a wheelchair behind her when ambulating and placing her walker out of sight to prevent her from reaching for it. However, observations revealed that these interventions were not consistently followed by the staff, as evidenced by the resident being found with her walker within reach and without a wheelchair behind her during ambulation. The resident's care plan was not effectively communicated or implemented, leading to repeated falls. Staff members, including a CNA and the DON, acknowledged the challenges in finding effective interventions due to the resident's belief in her ability to self-transfer. The DON also expressed uncertainty about the continued implementation of certain interventions, indicating a lack of clarity and consistency in the care plan's execution. This failure to adhere to the care plan contributed to the resident's repeated falls, highlighting a deficiency in the facility's care practices.
Failure to Use Proper Transfer Techniques Resulting in Resident Injury
Penalty
Summary
The facility failed to provide proper transfer techniques while transferring a resident, leading to an accident. Resident #21, who has severe cognitive impairment, aphasia, stroke, hemiplegia, difficulty in walking, and requires assistance with personal care, fell in the bathroom during a transfer. Staff A, an LPN, found Resident #21 on the floor without a gait belt and showing non-verbal cues of pain. The resident was transferred to a wheelchair using a gait belt and sent to the emergency room, where an acute fracture of the right femur neck was diagnosed, requiring surgical repair. Staff B, a CNA on her first or second day, admitted to not using the gait belt during the transfer, which led to the fall. Staff B revealed that she had removed the gait belt after positioning Resident #21 on the toilet and stepped outside the bathroom door to give privacy, during which the resident fell. The facility's policy mandates the use of gait belts during transfers and ambulation for non-independent residents. Staff B had received training on gait belt use and transfer techniques but failed to adhere to the policy. The Director of Nursing confirmed that gait belts should be used at all times during transfers and kept on residents when toileting. The facility conducted an in-service training on gait belt use and transfer techniques following the incident.
Failure to Provide Reasonable Access to Personal Funds
Penalty
Summary
The facility failed to provide ready and reasonable access to personal funds upon request for two residents. Resident #30 reported that they could not access money when needed because the responsible person was not available, and they had to plan ahead for the weekend. Resident #25 mentioned that they had not asked for money because the staff responsible for funds was not available on weekends, and they would have to call their son if they needed money. Interviews with staff confirmed that residents could only access up to $10 from their funds after business hours and on weekends, and any additional amount had to be requested in advance. The funds available in the envelopes of Resident #25 and Resident #30 were found to be insufficient, with only 29 cents and $7.75 respectively. The facility's policy stated that personal funds should be protected and accessible, but the practice of limiting access to $10 and requiring advance requests for more funds did not align with this policy. The Operations Manager acknowledged ongoing discussions to improve access to personal funds, but no effective solution had been implemented at the time of the survey. The deficiency was identified based on the facility's failure to ensure residents had reasonable access to their personal funds as needed, particularly after business hours and on weekends.
Failure to Complete Pre-Employment Background Checks
Penalty
Summary
The facility failed to complete the required Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License information prior to the re-employment of two staff members, Staff E (LPN) and Staff F (CNA). Staff E was rehired on 7/18/22, and Staff F was rehired on 10/11/22. On 3/26/24, it was discovered that their personnel files did not contain the necessary background checks. The Business Office Manager confirmed that the background checks were not completed before these staff members began working. The Executive Director also confirmed this oversight. The facility's policies, revised in January 2022 and May 2007, clearly state that pre-employment screening must be completed before employment begins to ensure that potential employees do not have disqualifying events and have the appropriate certification.
Failure to Obtain Bed Hold Notification
Penalty
Summary
The facility failed to obtain bed hold notifications for a resident who was transferred to the hospital. Clinical record review revealed that the resident was hospitalized from 11/1/23 through 11/4/23, but there was no bed hold form available for these dates. During interviews, both the Administrator and the Director of Nursing confirmed that their expectation was to obtain a bed hold notification every time a resident is transferred or discharged. The facility's policy, revised in 11/2016, mandates that residents or their representatives be informed in writing of their right to exercise the bed hold provision in the event of a transfer to a general acute care hospital. However, this procedure was not followed for the resident in question.
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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 Cherokee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee Specialty Care | 0.5 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Cherokee, Llc | 0.8 mi | ★★★★★ | 6 | 0 |
| Accura Healthcare Of Aurelia, Llc | 6.3 mi | ★★★★★ | 10 | 0 |
| Heartland Care Center | 13.5 mi | ★★★★★ | 8 | 0 |
| Aspire Of Sutherland | 15.1 mi | — | 0 | 0 |
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