Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Memorial Health Center during CMS and state inspections, most recent first.
A resident with anxiety, depression, cancer, and a BIMS of 15 was not accommodated for her preferred shower time of 6:00 to 6:30 p.m. Staff offered bathing before or after supper, and the resident said those times were too early or too late and that she had not taken a shower or bath for about 30 days. Bathing records showed refusals or N/A entries, and progress notes did not document the reason for refusal.
A resident with anxiety, depression, and PTSD had a PASRR on file that did not include the PTSD diagnosis, and the clinical record lacked an updated PASRR after the new psychiatric diagnosis was identified. The DON stated that PTSD should have been included on the PASRR and resubmitted.
A resident with an indwelling urinary catheter and recent UTI was observed with catheter tubing laying on the floor while a CNA emptied the drainage bag. The CNA disconnected the drain into a graduate, and the drain touched the inside of the container before being wiped and reconnected. The DON stated the tubing should be kept off the floor and the drain should not touch the graduate; facility policy required the tubing and collection bag to remain off the floor and the drain spout to avoid contact with the measuring container or other objects.
Incorrect transcription of psychotropic medication orders: The facility failed to accurately enter physician orders into the EMR for two residents receiving Lorazepam PRN. In both cases, the written order specified a 180-day duration, but the electronic order listed an indefinite end date. One resident had Parkinson's Disease, dementia, and anxiety with episodes of paranoia and crying, while the other had dementia, Alzheimer's Disease, and anxiety with physical aggression, restlessness, and agitation.
A CNA performed catheter care for a resident with an indwelling urinary catheter without wearing a gown, despite a posted sign directing staff to use EBP, including gown use, for catheter care. The DON, who also served as the Infection Preventionist, stated the CNA should have worn a gown and expected staff to follow the posted EBP guidance.
Residents with dementia were awakened, toileted, dressed, and placed in common areas during early-morning rounds instead of having their sleep and wake times based on choice. Staff said they were expected to get several residents up before day shift arrived, and one CNA stated the residents could not say no. The DON later stated residents should start getting up at 6 a.m. unless they were okay with getting up earlier or requested it.
A resident with advanced cognitive impairment was subjected to rough handling and forceful feeding by a CNA, as witnessed by another CNA. The incident was reported internally to the DON, but the required report to state authorities was not submitted within the mandated two-hour window, resulting in a delay of nearly two days.
A resident with significant cognitive and communication deficits was reportedly shaken and struck in the mouth by a CNA during feeding, as witnessed by another staff member. Although the incident was reported to the DON and to the state, there was no documentation of the event in the resident's medical record, contrary to facility expectations.
The facility failed to obtain signatures for bed hold notices for two residents transferred to hospitals. Despite verbal confirmations, the required signatures from residents or their representatives were not secured, contrary to facility policy.
A facility failed to investigate an alleged abuse incident involving a CNA and a resident with severe cognitive impairment. The CNA allegedly slapped the resident during care, but was allowed to continue working the shift, exposing other residents to potential abuse. The incident was not documented in the resident's progress notes, and the facility's initial investigation could not confirm the occurrence. The facility did not follow its policy to immediately separate the accused employee from residents, contributing to the deficiency.
The facility failed to have the Infection Preventionist (IP) present at quarterly Quality Assessment and Assurance (QAA) meetings, as required by their policy. The IP, a Registered Nurse, was working on the floor during these meetings and had not attended from January to May 2024. The Director of Nursing confirmed the IP's absence and noted that the IP was working towards certification but had not yet obtained it.
A resident with severe cognitive impairment was subjected to physical abuse by a CNA during incontinence care. The resident became agitated and combative, leading to the CNA slapping the resident on the thigh. The incident was reported by another CNA to the charge nurse and the DON. The facility's investigation revealed inconsistencies in staff accounts, and the incident was not documented in the resident's progress notes.
A resident with severe cognitive impairment was slapped by a CNA during care, and the incident was not reported to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The facility's policy mandates immediate reporting of abuse allegations, but the Director of Nursing was not reached immediately, leading to a delayed report to DIAL.
A resident with severe cognitive impairment was involved in an incident where a CNA slapped them during care. The incident was reported internally but was not documented in the resident's medical record, violating the facility's documentation policy. The Director of Nursing confirmed the lack of documentation, highlighting a failure to adhere to established procedures.
Resident Bathing Preference Not Honored
Penalty
Summary
The facility failed to accommodate an appropriate bathing time to honor the resident’s preference for 1 of 17 residents reviewed. Resident #6 had diagnoses of anxiety, depression, and cancer, and her MDS documented a BIMS score of 15, indicating no cognitive impairment. The resident stated she preferred to shower between 6:00 and 6:30 p.m. because there were fewer people in the hallways at that time, but she had not been taking showers because staff offered bathing at times that were too early or too late for her preference. She also stated that by the time staff offered bathing later in the evening, she had already taken bedtime medications and was sleepy. Bathing documentation from 12/25/25 through 1/19/26 showed the resident refused scheduled bathing days or was marked not applicable, and the progress notes did not document the reason for refusal during that period. The resident stated she had not taken a shower or bath in the facility for the last 30 days and denied that anyone from the facility had discussed her bathing preferences with her or why she had not bathed. The DON stated staff had offered showers before supper and after supper and said the resident had never expressed what time she wanted to bathe, while the resident reported she had told the Social Worker during care conferences that she did not want baths so late at night.
Failure to Update PASRR for New PTSD Diagnosis
Penalty
Summary
The facility failed to refer one resident with a negative Level I PASRR result for a Level II PASRR evaluation after the resident was later identified with a newly evident or possible serious mental disorder, intellectual disability, or other related condition. Resident #4’s MDS documented diagnoses of anxiety disorder, depression, and PTSD, and the BIMS score was 15, indicating no cognitive impairment. Review of the resident’s clinical record showed that the PASRR dated 3/19/24 did not include the PTSD diagnosis, and the record lacked an updated PASRR reflecting that diagnosis. The facility’s policy stated that a change in status includes a new psychiatric diagnosis not included on the initial review. During interview, the DON stated that PTSD should have been included on the PASRR and resubmitted.
Improper Foley Catheter Handling and Tubing Placement
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to prevent urinary tract infection for a resident with an indwelling urinary catheter. The resident had a BIMS score of 13, indicating no cognitive impairment, and diagnoses included renal insufficiency and retention of urine. The care plan identified the urinary catheter and included changing the catheter monthly and for dislodgement, as well as keeping the urinary drainage bag covered at all times. The resident had returned from the hospital after a stay for UTI. During observation, the resident was seated in a chair with the catheter bag in a dignity bag hanging from the walker, while 1-1/2 to 2 feet of catheter tubing was laying on the floor. A CNA entered, washed her hands, and donned a gown and gloves, then brought a barrier, graduate, and alcohol wipes to the bedside. She removed the catheter bag from the dignity bag, disconnected the drain from its port, and wiped with an alcohol wipe; the drain hit the inside of the graduate while emptying the bag. After draining, she wiped the drain again, reconnected it, and returned the catheter bag to the dignity bag, but the catheter tubing remained on the floor. The DON stated staff should keep the tubing off the floor and thought the drain should not touch the graduate. Facility policy required the tubing and collection bag to be kept off the floor at all times and the drain spout not to contact the measuring container or other objects.
Incorrect transcription of psychotropic medication orders
Penalty
Summary
The facility failed to accurately transcribe physician orders for psychotropic medications into the electronic medical record for 2 of 2 residents reviewed. For Resident #3, the record showed diagnoses of Parkinson's Disease, dementia, and Anxiety Disorder, with a BIMS score of 00 indicating the resident was unable to complete a cognitive interview. The care plan noted use of anti-anxiety medications related to anxiety, and the resident was described as becoming anxious, raising her voice, verbalizing paranoia, and crying uncontrollably at times. A written physician order for Lorazepam 0.5 mg every 6 hours as needed for 180 days was present, but the electronic clinical physician order listed the same medication as PRN with an end date of indefinite. For Resident #22, the record showed diagnoses of dementia, Alzheimer's Disease, and Anxiety Disorder, with a BIMS score of 00 indicating inability to complete a cognitive interview. The care plan stated the resident used anti-anxiety medications routinely for physical aggression, increased periods of restlessness, and agitation. A written physician order for Lorazepam 0.5 mg every 6 hours as needed for 180 days was present, but the electronic clinical physician order listed the medication as PRN with an end date of indefinite. The DON stated staff failed to enter the physician's order into the electronic medical record as written and that the stop date should have been entered as 180 days.
Failure to Use EBP During Catheter Care
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) during catheter care for Resident #24. During observation on 1/21/26 at 10:19 AM, Staff A, a CNA, performed catheter care without wearing a gown, even though a sign posted in the resident’s room instructed staff to don EBP, including a gown, when providing catheter care. The resident was one of 2 residents reviewed, and the facility reported a census of 47 residents. During an interview on 1/21/26 at 11:36 AM, the DON, who also served as the Infection Preventionist, stated that Staff A should have worn a gown when performing catheter care and expected staff to follow the EBP guidelines posted in the resident’s room. The report cited CDC guidance stating that EBP includes gown and glove use during high-contact resident care activities, including device care such as urinary catheter care, for residents with indwelling medical devices.
Residents Woken and Dressed Before Their Chosen Wake Times
Penalty
Summary
The facility failed to ensure residents’ right to self-determine when to get dressed and get up for the day for 5 of 5 residents reviewed with dementia. The report states that the facility’s resident rights included the right to choose schedules, including sleeping and waking times, and that staff were observed waking residents in the early morning and dressing them before day shift began, rather than based on resident choice. Resident #1 had severe cognitive impairment, Alzheimer’s disease, and insomnia, and depended on staff for toileting hygiene and dressing. During the early morning round, a CNA checked the resident’s incontinent pad, found it dry, removed the resident’s gown, dressed her in daytime clothing, covered her, and left the room. The CNA later stated that multiple residents with dementia were dressed during rounds because they could not say no and were then kept in or returned to bed. Resident #2 had severe cognitive impairment, non-Alzheimer’s dementia, and sleep disturbance with frequent nighttime waking. Staff assisted the resident to the bathroom, removed pajamas, dressed her in daytime clothes, provided incontinent care, and returned her to bed. Resident #3, who had severe cognitive impairment and Alzheimer’s disease, was already dressed and seated in a recliner in the common area after staff had gotten her up and toileted her. Resident #4, who had severe cognitive impairment and Alzheimer’s disease, was also found dressed and seated in a recliner after staff had already gotten her up. Resident #5, who had severe cognitive impairment, non-Alzheimer’s dementia, and insomnia, was awakened, assisted to the bathroom, dressed while on the toilet, and then placed in a recliner where he fell asleep. Staff stated they were expected to get six residents up before day shift arrived, and the Administrator and DON stated they were unaware residents were being gotten up that early; the DON said residents should start getting up at 6 a.m. unless they wanted to get up earlier.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required two-hour timeframe for one resident. The incident involved a resident with Alzheimer's Disease, aphasia, and cognitive communication deficit, who was not able to be assessed with the Brief Interview for Mental Status (BIMS) due to being rarely or never understood. During a supper meal, a CNA was observed by another CNA to have forcefully fed the resident, hitting the resident's tooth with a spoon and shaking the resident while urging her to eat. The observing CNA reported the incident to the DON, and the staff member involved was sent home immediately. Despite the facility's policy requiring all allegations of abuse to be reported to the state within two hours, the self-report to DIAL was not submitted until nearly two days after the incident. Interviews with staff and review of facility records confirmed the delay in reporting. The administrator stated he believed the DON had submitted the report to the state office, but documentation showed otherwise.
Failure to Document Incident in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident following an incident involving alleged rough handling by a CNA during mealtime assistance. The resident, who had diagnoses of Alzheimer's Disease, aphasia, and cognitive communication deficit, was reportedly shaken and had her tooth struck by a spoon while being fed, as witnessed by another staff member. Although the incident was reported to the DON and a self-report was submitted to the state agency, a review of the resident's progress notes revealed no documentation of the incident in the medical record. The DON confirmed that she expected documentation of the incident to be present in the resident's chart, but it was missing.
Failure to Obtain Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for two residents. The first resident, who had diagnoses of heart failure, diabetes mellitus, and urinary retention, was transferred to a hospital on unpaid leave. Although verbal permission for bed hold authorization was obtained via phone, the required signature from the resident or their representative was missing. The resident returned to the facility after a few days. The second resident, with diagnoses of hypertension, bradycardia, and anemia, experienced multiple hospital transfers, both unpaid and paid. In each instance, verbal confirmation for bed hold was obtained, but the necessary signatures were not secured. The facility's policy required verification of room reservation within 24 hours of hospital admission, but the Director of Nursing confirmed that the facility did not send bed hold notices for signatures if verbal confirmation was received.
Failure to Investigate Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving a Certified Nurse Aide (CNA) and a resident. On April 3, 2024, a nurse learned that a CNA allegedly slapped a resident on the leg during incontinence care. Despite this allegation, the facility allowed the CNA to continue working the scheduled night shift and to work unattended with other residents, exposing them to potential abuse. This incident was not documented in the resident's progress notes, and the facility's initial investigation was unable to confirm or deny the occurrence of the incident. The resident involved in the incident had a history of Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. During the incident, the resident became agitated and combative, swinging and kicking at the staff. According to staff statements, the CNA slapped the resident on the thigh and later expressed regret for the action. The charge nurse was informed of the incident, and an attempt was made to contact the Director of Nursing (DON), but the call was not answered, and no further immediate action was taken to separate the CNA from the residents. The facility's policy on abuse prevention and investigation requires immediate measures to prevent further potential abuse, such as suspending the accused employee or segregating them from residents. However, these measures were not implemented promptly, as the CNA continued to work the remainder of the shift. The facility's failure to separate the alleged abuser from residents and to document the incident in the resident's progress notes contributed to the deficiency identified by the surveyors.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to include the Infection Preventionist (IP) in their quarterly Quality Assessment and Assurance (QAA) meetings, as required by their policy. A review of the Quality Assurance Process Improvement (QAPI) sign-in sheets for the months of January through May 2024 revealed the absence of the IP's signature, indicating non-attendance. An interview with the Director of Nursing (DON) confirmed that the IP, a Registered Nurse, was typically working on the floor during these meetings and had not attended them. Additionally, the DON mentioned that the IP was in the process of obtaining her certification but had not yet completed it. This oversight is contrary to the facility's policy, which mandates the Administrator to ensure compliance with federal, state, and local regulatory requirements for the QAPI program.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two CNAs and a resident with severe cognitive impairment. The resident, diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, became agitated and combative during incontinence care. According to staff statements, one of the CNAs, identified as Staff F, slapped the resident on the thigh after the resident began swinging and kicking. This incident was reported by Staff E, who witnessed the event, to the charge nurse and subsequently to the Director of Nursing (DON). The facility's investigation into the incident revealed discrepancies in the accounts provided by the involved staff. Staff E reported the slap to the charge nurse immediately after the incident, while Staff F's account did not acknowledge the slap. The facility's policy on abuse prevention clearly states that all residents have the right to be free from abuse, including physical abuse such as slapping. However, the facility's documentation, including the resident's progress notes, lacked any record of the incident, and the administrator could not confirm or deny the occurrence of the incident after their investigation.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment, diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction. During incontinence care, the resident became agitated and combative, leading to a Certified Nursing Assistant (CNA) slapping the resident on the thigh. The incident was initially reported to the charge nurse, who instructed the reporting to the Director of Nursing (DON). However, the DON was not reached immediately, and the incident was only reported to DIAL several hours later. The facility's policy mandates that all allegations of abuse be reported immediately to the charge nurse and subsequently to the Administrator or designated representative. Furthermore, the policy requires that such allegations be reported to DIAL within two hours. Despite these guidelines, the report was delayed, as the DON did not respond to the initial call or text message, and the incident was not reported to DIAL until later in the morning. This delay in reporting constitutes a deficiency in adhering to the facility's abuse prevention and reporting policy.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, who exhibited severe cognitive impairment. An incident occurred where two CNAs attempted to provide incontinence care, and the resident became agitated, resulting in one CNA slapping the resident on the thigh. This incident was reported internally, but the resident's progress notes lacked documentation of the event, which is a violation of the facility's Charting and Documentation policy. The facility's policy mandates that all services provided, progress toward care plan goals, and any changes in the resident's condition, including incidents, should be documented in the medical record. However, the incident involving the resident was not recorded, as confirmed by the Director of Nursing. This omission indicates a failure to adhere to the established documentation procedures, which are crucial for effective communication among the interdisciplinary team regarding the resident's care and condition.
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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 Hartley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Home | 7.9 mi | ★★★★★ | 0 | 0 |
| Aspire Of Sutherland | 14.6 mi | — | 0 | 0 |
| Spencer Post Acute Rehabilitation Center | 16.8 mi | ★★★★★ | 43 | 0 |
| Sanford Senior Care Sheldon | 18.1 mi | ★★★★★ | 8 | 0 |
| St Luke Lutheran Nursing Home | 18.5 mi | ★★★★★ | 15 | 1 |
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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.