Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Community Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and dementia-related diagnoses was involved in an alleged abuse incident in which a CNA reportedly slapped the resident and used profane language after the resident put his hands down the CNA’s sweater. Two CNAs reported this allegation to the Administrator, and the event was documented on a Complaint Investigation form. However, review of the clinical record showed no notification to the resident’s physician or family, and both the DON and Administrator confirmed that neither the physician nor the family had been informed, despite facility policy requiring notification of the primary care provider and responsible party for abuse allegations.
Staff reported that a CNA stated she slapped a resident across the face and used profanity after the resident allegedly reached down her sweater and grabbed her breast during a prior holiday shift. Two CNAs independently relayed this allegation to the Administrator, and one also informed an RN, who responded with an inappropriate comment about how she would have reacted. Despite a written abuse policy requiring immediate internal reporting and notification to the state agency within 2 hours, as well as timely reporting to law enforcement under the Elder Justice Act, the Administrator did not submit a report to the state or notify police, stating she did not believe there was a potential for abuse.
The facility failed to follow its abuse prevention policy after CNAs reported that a CNA admitted to slapping a resident across the face and using profanity toward him following an incident in which he allegedly reached down her sweater and grabbed her breast. The CNAs reported the allegation to an RN and the Administrator, but the accused CNA continued to work full shifts and was not separated from the alleged victim or other residents while the allegation was under investigation, contrary to facility policy requiring immediate separation or supervision of staff accused of abuse.
Improper Hand Hygiene and Cross Contamination During Meal Prep: A Dietary Aid prepared lunch items while repeatedly placing utensils on the counter without a barrier and handling soiled oven mitts. During service, she wore the same gloves while touching bread, a meal ticket, surfaces, the refrigerator, and cheese, then removed the gloves and failed to wash her hands before returning to serve food. The DM said she witnessed the hand hygiene issues and discussed glove use and cross contamination concerns with the staff member.
An open EHR laptop was left in the dining room with 16 residents' information visible while three residents were present and no staff were nearby. An RN said she thought she had locked the laptop when she walked away, and the DON stated the laptop should be locked when staff are not present. The facility policy required resident records to be safeguarded at all times to ensure confidentiality.
Care plan for a resident with severe cognitive impairment, dementia, depression, and hallucinations lacked non-pharmacological interventions and targeted behaviors related to antipsychotic use. The resident was receiving Quetiapine for dementia, and the DON acknowledged the care plan did not include the expected interventions for psychotropic medications.
A resident with non-Alzheimer's dementia and severe cognitive impairment had no care plan goals, focus, or interventions related to the dementia diagnosis. The DON confirmed the dementia care plan was not implemented and stated more should have been included. Facility policy required resident needs and problems to be identified from available assessment and clinical information.
A resident with intact cognition, Parkinson’s disease, hallucinations, and multiple rib fractures required assistance with transfers and used a walker or wheelchair for mobility. Staff transferred the resident between a recliner and wheelchair while the wheelchair remained unlocked, and staff later stated it had been left unlocked or forgotten during the transfer. Facility staff and policy stated wheelchair wheels should be locked during transfers.
Four residents discharged to home did not receive required discharge summaries or post-discharge plans of care. Despite having complex medical conditions and receiving OT/PT services, their records lacked documentation summarizing their stay and outlining care needs after discharge. Facility staff confirmed that discharge summaries and plans of care were not provided to residents or their representatives, contrary to facility policy.
A resident with moderately impaired cognition and multiple medical conditions was discharged after receiving skilled therapy services. Although the facility discussed the end of Medicare coverage and appeal rights with the resident's POA by phone, staff failed to obtain a required signature on the Notice of Medicare Non-Coverage, resulting in incomplete documentation of the resident's right to appeal the discharge.
Failure to Notify Physician and Family of Abuse Allegation
Penalty
Summary
The facility failed to notify a resident’s physician and family of an allegation of abuse involving that resident. A resident with moderate cognitive impairment, as evidenced by a BIMS score of 12 on the 12/28/25 MDS and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and depression, was the subject of an internal Complaint Investigation dated 1/6/26. In that investigation, two CNAs (Staff A and Staff B) reported to the Administrator that another CNA (Staff C) told them she slapped the resident after the resident put his hands down her sweater, and that she told him to keep his “f***ing hands” off her. Review of the clinical record showed no documentation that this allegation of abuse was reported to the resident’s physician or family. The DON confirmed the family had not been called about the allegation, and the Administrator confirmed the physician had not been notified, despite facility policy requiring proper notification to the primary care provider and responsible party for allegations of resident abuse. The facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, revised 9/29/21, stated that the Administrator would complete documentation of the allegation of resident abuse and collect supporting documents related to the alleged incident, including providing proper notification to the primary care provider and responsible party. In this case, the required notifications were not made following the reported allegation that a staff member slapped the resident and used profane language, and this omission was verified through record review and staff interviews.
Failure to Report Alleged Staff-to-Resident Abuse to State Agency and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency (DIAL) and to law enforcement as required by facility policy and federal regulations. On 1/6/25 at approximately 4:15 PM, Staff A and Staff B, both CNAs, reported to the Administrator that Staff C, CNA, had told them she slapped Resident #1 after he put his hands down her sweater and that she told him to keep his “fucking” hands off her. Staff A stated that Staff C reported the incident occurred on Christmas while she was wearing an “ugly grinch” sweater and that Resident #1 reached down her shirt and grabbed her breast, at which point she smacked him across the face. Staff B similarly reported that Staff C told her she had been wearing a lighted Christmas sweater when the resident reached down her shirt, grabbed her “boob,” and she slapped him across the face, using profanity to describe the event. Staff A further reported that when she informed Staff D, an RN and mandatory reporter, Staff D responded that she would have “throat punched” the resident. The facility’s Complaint Investigation form dated 1/6/26 documented that Staff A and Staff B reported this allegation of abuse to the Administrator. Review of the facility’s Self Report List from January 2025 to January 2026 showed the facility did not file this abuse allegation with DIAL. The facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, revised 9/29/21, required that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation be reported immediately to the charge nurse, who must immediately notify the Administrator or designee, and that all allegations of resident abuse be reported to DIAL no later than two hours after the allegation was made. The policy also required reporting to law enforcement under the Elder Justice Act time frames, depending on whether serious bodily injury occurred. Despite these requirements, the Administrator stated on 1/26/26 that she did not file a report to DIAL because she did not believe there was a potential for abuse and later confirmed on 1/27/26 that she did not notify the police of the allegation. No information was provided in the report regarding Resident #1’s medical history or condition at the time of the incident.
Failure to Separate Alleged Abusive CNA From Resident After Abuse Report
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by not separating an employee accused of physical and verbal abuse from a dependent resident and other residents after an allegation was reported. On 1/6/26, two CNAs (Staff A and Staff B) reported to the Administrator that another CNA (Staff C) had told them she slapped Resident #1 across the face after he put his hands down her sweater and that she told him to keep his “fucking hands” off her. Staff A stated that Staff C had described an incident occurring on Christmas when she was wearing an “ugly grinch” sweater and Resident #1 reached down her shirt and grabbed her breast, and in response she smacked him across the face. Staff A reported that she informed an RN (Staff D) of the allegation because she was a mandatory reporter, and that Staff D responded she would have “throat punched” the resident. Staff A further reported that when she brought the allegation to the Administrator, the Administrator told her she was not believable because she was showing emotion. Staff B similarly reported that Staff C told her she refused to enter Resident #1’s room alone and that, on Christmas, while wearing a lighted Christmas sweater, Resident #1 reached down her shirt, grabbed her breast, and she slapped him across the face, using profanity to describe the event. Despite this reported allegation of abuse on 1/6/26 at approximately 4:15 PM, review of the Employee Time Cards showed that Staff C continued to work full shifts on multiple dates from 1/6/26 through 1/26/26. The Administrator verified that Staff C was not separated from Resident #1 during this period and acknowledged that the facility’s abuse policy was not followed. The written policy required immediate implementation of measures to prevent further potential abuse, including suspending or segregating the accused employee from all residents, or in rare instances allowing supervised contact only with other residents and maintaining separation from the alleged victim until completion of investigations by the facility and the Department.
Improper Hand Hygiene and Cross Contamination During Meal Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff used adequate hand hygiene practices to prevent cross contamination during meal service. On 12/9/25, Staff A, a Dietary Aid, prepared one pureed and seven ground meat servings for lunch. During food preparation, she removed a pan of stew from the oven, stirred it with a large serving spoon, and repeatedly laid the spoon directly on the counter without a barrier while scooping portions into the mixer. She also placed the scoop on the counter alongside large oven mitts that were described as very stained and soiled while preparing meat balls for five mechanical soft and one pureed meal. During lunch service on 12/9/25 at 12:20 PM, Staff A donned gloves, handled bread, buttered it, and placed it on the grill for a grilled cheese sandwich. With the same gloved hands, she took a meal ticket from a staff member, touched several surfaces, opened the refrigerator, retrieved cheese slices, and placed them on the bread. She then removed the disposable gloves and failed to wash her hands before returning to serving plates of food. On 12/10/25, the Dietary Manager stated she witnessed the hand hygiene issues during lunch service and had spoken with Staff A about placing utensils on the counter between scoops of stew and about glove use and cross contamination concerns. The facility policy stated that gloves are an adjunct to, not a substitute for, hand washing and should be removed with hand washing after contaminating activities.
Resident Information Left Accessible on Open EHR Laptop
Penalty
Summary
The facility failed to properly safeguard resident-identifiable information when an EHR laptop was left open and accessible in the dining room, allowing 16 residents' information to remain visible while no staff were present. Surveyors observed the open laptop at 2:59 PM with three residents in the dining room, including two who were ambulatory, and no staff nearby. At 3:00 PM, an RN stated she thought she had locked the laptop when she walked away and said resident information is not left open when staff leave the computer. At 8:34 AM on 12/11/25, the DON stated the laptop should be locked when staff are not present. The facility's Dignity, Privacy, and Confidentiality policy stated resident records are limited to staff use and must be safeguarded at all times to ensure confidentiality.
Care Plan Lacked Psychotropic Medication Interventions
Penalty
Summary
Unnecessary psychotropic medication use was cited because the facility failed to identify non-pharmacological interventions and targeted behaviors for a resident receiving antipsychotic medication. Resident #3 had a BIMS score of 7, indicating severe cognitive impairment, and the MDS showed diagnoses of non-Alzheimer's dementia, depression, and hallucinations, along with use of an antipsychotropic medication during the review period. The EHR physician orders showed Quetiapine 50 mg at bedtime for dementia with an order dated 10/29/25, and another order for Quetiapine 25 mg in the morning for dementia with a start date of 11/24/25. Review of the care plan with a revised date of 12/2/25 showed it lacked non-pharmacological interventions and targeted behaviors related to the antipsychotic medications. During interview on 12/09/2025 at 12:05 PM, the DON stated she would expect nonpharmacological interventions to be included in the care plan for residents receiving psychotropic medications and acknowledged that none were currently on Resident #3's care plan.
Incomplete Care Plan for Resident With Dementia
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with non-Alzheimer's dementia. Review of the resident's MDS dated 11/5/25 showed a BIMS score of 7, indicating severe cognitive impairment, and the MDS identified a diagnosis of non-Alzheimer's dementia. However, the resident's care plan, revised on 12/2/25, contained no goals, focus, or interventions related to the dementia diagnosis. During an interview on 12/9/2025 at 12:36 PM, the DON confirmed there was no care plan implementation concerning dementia for the resident and stated she would expect more to be on the care plan concerning dementia. The facility's policy on Care Plan Creation, revised 9/27/25, stated that resident needs and problems are to be identified based on nursing history and assessment, physician's orders, inter-facility transfer forms when available, past history and physical examination, and any other available information.
Wheelchair Left Unlocked During Resident Transfers
Penalty
Summary
The facility failed to lock the wheelchair during transfers for one resident who had a BIMS score of 14 out of 15 and diagnoses including thyroid disorder, Parkinson’s disease, hallucinations, and multiple right rib fractures. The resident required varying levels of assistance with activities of daily living, including moderate assistance with sit-to-stand, dependence for toilet, tub, and car transfers, and use of a walker or wheelchair for mobility. The care plan directed one-person assistance with transfers, to keep the wheelchair brakes locked next to the resident’s bed, and noted the resident sometimes tried to self-transfer. The progress notes also indicated the resident had fallen during a self-transfer attempt. During observation, staff transferred the resident from a recliner to a wheelchair and later from a wheelchair to a recliner while the wheelchair remained unlocked during the transfer process. Staff later stated the wheelchair had been left unlocked, with one staff member saying she forgot to lock it before the transfer and another saying it was left unlocked so it could be moved out of the way after the resident shuffled to the recliner. Staff interviews confirmed that wheelchair wheels should be locked when transferring a resident to or from a wheelchair, and the facility policy on assisted transfer directed staff to lock the wheels during wheelchair transfers.
Failure to Provide Discharge Summaries and Plans of Care for Discharged Residents
Penalty
Summary
The facility failed to complete and provide discharge summaries and discharge plans of care for four residents who were discharged to home. Each resident's medical record lacked the required documentation summarizing their course of stay, therapy services received, and a post-discharge plan of care. Although transfer/discharge reports and progress notes indicated that residents were discharged and that some discharge instructions were given, there was no comprehensive discharge summary or plan of care included in the records or provided to the residents or their representatives. The residents involved had varying degrees of cognitive impairment and multiple medical diagnoses, including anemia, hypertension, renal failure, diabetes, heart failure, and recent orthopedic surgeries. All had received occupational and physical therapy services during their stay. Documentation reviewed showed that while some therapy notes and home evaluations were completed, these were not attached to the medical records or given to the residents or their families at discharge. In some cases, discharge instructions were noted as given and understood, but there was no indication of who received them or if all necessary information was provided. Interviews with facility staff, including the DON and ADON, confirmed that the facility did not provide discharge summaries or plans of care to residents at the time of discharge. The facility's own policy required a discharge summary and post-discharge plan of care for residents discharged to home or another care setting, detailing the resident's status, care needs, and education provided. However, this process was not followed, resulting in incomplete documentation and lack of required information for discharged residents.
Failure to Obtain Signature on Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to inform a resident of the option to appeal a discharge from Medicare Part A Skilled Services. The resident, who had moderately impaired cognition and multiple medical diagnoses including anemia, hypertension, renal failure, malnutrition, and metabolic encephalopathy, was receiving occupational and physical therapy services. Documentation showed that the resident was discharged home with her daughter after completing skilled rehabilitation services. Although the Notice of Medicare Non-Coverage (NOMNC) was prepared and a call was made to the resident's Power of Attorney (POA) to discuss the end of skilled care and appeal rights, the NOMNC document lacked a signature from either the resident or the POA, indicating that receipt and understanding of the right to appeal was not properly documented. Staff interviews revealed that while the staff member responsible discussed the discharge and appeal process with the POA over the phone, she was unaware that a signature was required to confirm receipt of the NOMNC. The Director of Nursing also stated that the facility did not realize a signature was necessary if the conversation was documented. Facility policy required that the Advance Beneficiary Notice (ABN) or NOMNC be reviewed with the beneficiary or representative, all questions answered, and the form signed before providing a copy to the beneficiary or representative. This process was not followed in this instance.
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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 Stuart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Panora Specialty Care | 13.6 mi | ★★★★★ | 7 | 0 |
| Greenfield Rehabilitation & Health Care Center | 15 mi | ★★★★★ | 2 | 0 |
| The New Homestead Care Center | 15.2 mi | ★★★★★ | 1 | 0 |
| Adel Acres | 17 mi | ★★★★★ | 8 | 0 |
| Azria Health Winterset | 19.1 mi | ★★★★★ | 10 | 0 |
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