Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Davis Center during CMS and state inspections, most recent first.
A facility failed to ensure residents were treated with respect and dignity, as an LPN made derogatory comments and used profanity towards two residents. One resident, with intact cognition, reported the LPN's inappropriate remarks about her weight and family. Another resident, with mental health issues, was subjected to disrespectful treatment when refusing medication. CNAs witnessed these incidents but did not report them due to the LPN's position.
The facility failed to attempt Gradual Dose Reduction (GDR) for psychotropic medications for five residents, despite their policy requiring regular review and efforts to reduce dosages. The DON and ADON acknowledged the oversight, citing a lack of tracking and communication with the psychiatric provider and pharmacist.
The facility failed to record accurate advanced directives for two residents. One resident, with intact cognition, expressed a wish for life-saving measures, but the EHR incorrectly listed her as DNR. Another resident's IPOST status was also inaccurately recorded as DNR in the EHR, despite the paper chart indicating full code. Staff interviews revealed inconsistencies in where they were trained to check for IPOST status, and the facility's policy did not specify where to look.
A resident with severe cognitive impairment experienced multiple falls over several months. The facility failed to update the Care Plan with new interventions and did not conduct a root cause analysis. Staff interviews revealed inconsistencies in the process, and the facility's policies on incident reporting and care plan updates were not adequately followed.
A resident with schizoaffective disorder expressed suicidal thoughts to a state inspector, but the facility failed to document or follow up with necessary interventions. Interviews with staff revealed inconsistencies in awareness and handling of the situation, and the facility's policy on behavior documentation was not adhered to.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by the behavior of a Licensed Practical Nurse (LPN) towards two residents. Resident #1, who had intact cognition, reported an incident where the LPN made derogatory comments about her weight and family, after she defended her roommate against the LPN's inappropriate remarks. This incident was witnessed by a Certified Nursing Assistant (CNA), who did not initially report it. The LPN was also reported to have used profanity and disrespectful language towards residents on multiple occasions, particularly targeting those who were overweight. Resident #5, who had a history of mental health issues and exhibited challenging behaviors, was also subjected to disrespectful treatment by the same LPN. The LPN used an expletive when the resident refused medication, which was witnessed by another CNA. Despite witnessing these incidents, the CNAs did not report the behavior due to the LPN's position as a charge nurse. The facility's failure to address these behaviors promptly and ensure a respectful environment for residents led to the deficiency.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt Gradual Dose Reduction (GDR) for psychotropic medications for five residents. Resident #14, with severe cognitive impairment and multiple psychotropic medications, had no documented attempts at GDR. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the oversight, citing a lack of tracking and communication with the psychiatric provider and pharmacist. The facility's policy mandates regular review and efforts to reduce psychotropic medication dosages, which were not followed in this case. Resident #6, with slightly impaired cognition and multiple psychotropic medications, also had no documented GDR attempts. The DON and ADON admitted to not having contacted the pharmacy or prescribing doctor regarding GDRs. Despite the facility's policy requiring documented rationale and regular review of psychotropic medications, these steps were not taken for Resident #6. Residents #11, #13, and #8, all with various diagnoses including anxiety, depression, and schizophrenia, had active orders for multiple psychotropic medications without documented GDR attempts. The facility's failure to comply with its own policy and federal regulations regarding the use of psychotropic medications and GDRs was evident in the lack of documentation and communication with relevant healthcare providers for these residents.
Inaccurate Recording of Advanced Directives
Penalty
Summary
The facility failed to record accurate advanced directives for two residents. Resident #13, who had intact cognition, expressed a wish for life-saving measures, but the electronic health record (EHR) incorrectly listed her as DNR (Do Not Resuscitate). Similarly, Resident #6's IPOST status was also inaccurately recorded as DNR in the EHR, despite the paper chart indicating full code. Interviews with staff revealed inconsistencies in where they were trained to check for IPOST status, with some relying on the EHR and others on the paper chart. The facility's policy on advanced directives did not specify where staff should look to obtain a resident's IPOST status, leading to these discrepancies.
Failure to Revise Care Plan and Implement New Interventions for Falls
Penalty
Summary
The facility failed to revise the Care Plan, implement new interventions, and find the root cause of falls for a resident with severe cognitive impairment. The resident, who had a history of major depressive disorder, non-Alzheimer's Disease, and depression, experienced multiple falls over a period of several months. Despite these incidents, the Care Plan was not updated with new interventions since December, and the facility did not conduct a root cause analysis to determine the reasons for the falls. The resident's falls were documented in various progress and incident notes, detailing the circumstances and injuries sustained. The resident was found on multiple occasions either in the dining room or in his room, having tripped, stumbled, or lost balance. Staff interviews revealed that while the resident was encouraged to wear gripper socks and take wider steps, these interventions were not consistently updated or effective in preventing further falls. Interviews with staff, including the RN, LPN, ADON, MDS Coordinator, and DON, indicated a lack of a systematic approach to updating the Care Plan and conducting root cause analyses. The staff acknowledged the need for a Performance Improvement Project (PIP) for falls and recognized that the current process was insufficient. The facility's policies on incident reporting and care plan updates were not adequately followed, leading to repeated falls and potential harm to the resident.
Failure to Follow Up on Resident's Suicidal Thoughts
Penalty
Summary
The facility failed to follow up with a resident after he expressed suicidal thoughts. Resident #21, who had a diagnosis of schizoaffective disorder, depressive type, and was on multiple psychotropic medications, expressed suicidal thoughts to a state inspector. Despite this, there was no documentation of any further interventions or progress notes following the resident's expression of suicidal thoughts. The resident's care plan included monitoring and documenting his feelings and providing support, but these interventions were not followed through after the incident. Interviews with various staff members, including LPNs, RNs, the ADON, and the DON, revealed inconsistencies in their awareness and handling of the resident's suicidal thoughts. Some staff members were unaware of the resident's expressed thoughts of harm, while others acknowledged the need for immediate intervention, such as 1:1 monitoring and contacting the psychiatric provider. However, these actions were not documented or carried out as required by the facility's policy. The facility's policy on behavior documentation required that behaviors be identified and documented on every shift, with interventions and their outcomes recorded. In the case of Resident #21, this policy was not adhered to, as there was no follow-up documentation or evidence of interventions after the resident expressed suicidal thoughts. The DON admitted to a lack of follow-up and emphasized the need for staff training on documentation and handling such situations. The facility's failure to document and follow up on the resident's suicidal thoughts represents a significant deficiency in providing necessary behavioral health care and services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bloomfield Care Center | 4.4 mi | ★★★★★ | 5 | 0 |
| Schuyler County Nursing Home District | 19.9 mi | ★★★★★ | 30 | 0 |
| Country Lane Manor | 20.4 mi | ★★★★★ | 22 | 0 |
| Good Samaritan - Ottumwa | 20.6 mi | ★★★★★ | 13 | 0 |
| Ridgewood Specialty Care | 20.9 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.