Average — CMS composite of the measures below.
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 Eastern Star Masonic Home during CMS and state inspections, most recent first.
Failure to Timely Report Resident-to-Resident Abuse: The facility did not report an allegation of resident-to-resident abuse to DIAL within the required 2 hours. A resident was found after a confrontation with his roommate, who was lying on the floor in a pool of blood with a 13 cm head laceration and was sent to the ER. The self-report was not documented as called in until the next day, and DIAL call logs did not show a call from the facility that evening.
Medication administration errors occurred when staff failed to follow physician orders and the 3 checks/6 rights. One resident on hospice received Oxycodone instead of ordered Tramadol after a CMA confused medication cards for two residents with similar last names, and another resident with osteoarthritis received discontinued Tramadol instead of the newly ordered Oxycodone because the old med card remained in the cart. Both residents were documented as alert after the errors, and one was drowsy but responsive.
Failure to supervise a resident at high risk for wandering led to an elopement when a dietary aide let the resident out of the supervised area into an unsecured exit route. The resident was found outside near the RCF building by an RCF CNA and brought back to the health center. The resident’s wandering risk was identified on assessment, but the baseline care plan did not address the risk, and door #15 leading to the loading dock, dumpsters, sidewalk, and street was not secured or alarmed.
A facility failed to provide required dependent adult abuse training within 6 months of hire for an RN. Record review showed the RN completed the 2-hour mandatory reporter training after the policy deadline, and the Director of Compliance acknowledged the training was late and said the facility had recently changed its process for enrolling new hires in the class right away.
The facility did not consistently document food temperatures for prepared meals and failed to ensure proper storage, labeling, and cleanliness of food and kitchen areas. Observations revealed unlabeled and undated food items, dirty utensils, and significant grime and debris in kitchen and dishwashing areas, despite staff signing off on daily cleaning logs.
A cook prepared pureed turkey burgers and wax beans for residents on a pureed diet but did not include hamburger buns in the mixture, as required by the facility's menu and standard practice. The Dietary Manager confirmed this omission resulted in the meal not meeting nutritional requirements, and there was no policy in place for pureeing food.
Staff failed to follow enhanced barrier precautions for two residents, including not wearing gowns and gloves during wound care and G-tube medication administration. Despite care plans and facility expectations, staff either omitted or forgot to use the required personal protective equipment, as confirmed by both staff interviews and resident statements.
The facility failed to maintain a comfortable environment due to malfunctioning air conditioning, affecting the memory care unit and resident rooms. Observations showed high temperatures, with residents reporting discomfort and difficulty sleeping. Staff attempted temporary solutions, but the issue persisted, with one unit working at half capacity and another non-functional.
A resident with intact cognition and multiple health conditions, including coronary artery disease and diabetes, experienced significant weight gains without appropriate follow-up actions as per a physician's order. The order required staff to assess, re-weigh, and notify the physician if the resident's weight changed by more than 3 pounds in a day or 5 pounds in a week. Despite multiple instances of weight gain, staff failed to comply with these directives, and the Director of Nursing acknowledged the oversight without providing an explanation.
A resident with moderate cognitive impairment was pushed in a wheelchair by a CNA without engaging the foot pedals, contrary to the care plan. The resident's feet were left hanging off the floor, posing a safety risk. Staff interviews confirmed the expectation to use foot pedals for safety, as noted in the care plan cover sheet.
The facility failed to follow the prescribed menu for 18 residents, providing a peanut butter and jelly sandwich instead of the specified meal. This deviation was confirmed by multiple staff members.
The facility failed to date and label open food items in the kitchen's coolers and walk-in freezer. Staff were unable to verify the contents or duration of storage for these items, and the Assistant Dietary Manager confirmed the items should have been dated and labeled when opened.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 2 residents reviewed. Resident #74 was documented as coming to the nurse and stating that his roommate, Resident #80, was lying on the floor in a pool of blood above his head after a confrontation between the two residents. Resident #74 was separated from Resident #80 and taken to the west dining room. An incident report documented Resident #80 was found on the floor in a pool of blood with a 13 centimeter laceration to the back of his head and was sent to the emergency room. The facility’s self-report showed the state agency was contacted about the allegation on 2/19/26 at 5:03 PM. The Director of Compliance later stated the self-report was initially called in around 9 or 10 PM on 2/18/26 and then filed online the next day after additional information was gathered, but he had no documentation that the phone call was made. DIAL’s Intake Specialist reported there were no calls documented from the facility on the call logs around 9 or 10 PM on the evening of 2/18/26. The facility policy stated that if an incident results in serious bodily injury and there is reasonable belief it was the result of a crime, the matter must be reported to law enforcement and DIAL within two hours by all persons having knowledge of the matter.
Medication Administration Errors Due to Failure to Follow Orders
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not following physician orders, resulting in medication errors for two residents. One resident was admitted for hospice services and had no MDS completed. On 5/9/26, the resident was incorrectly given Oxycodone 5 mg instead of the ordered Tramadol 50 mg. The medication error form documented that the resident was drowsy but alert and responsive to verbal stimuli after the error, and the MAR did not contain a physician order for Oxycodone while directing Tramadol 50 mg, two tablets every 6 hours as needed for low back pain. Staff D, a CMA, stated she confused two new residents with similar last names and grabbed the wrong medication card. She reported that she gave one resident Oxycodone 5 mg and gave the other resident two Oxycodone tablets, and that she realized the narcotic count was off when she later counted the medication. The controlled medication records showed corrections were made after the fact, and the Director of Compliance stated the staff should have followed the 3 checks and 6 rights of medication administration. He also acknowledged that the medication error report did not reflect that two tablets of Oxycodone were given. A second resident with diagnoses of osteoarthritis and pain had Tramadol discontinued and Oxycodone 20 mg twice daily started on 2/17/26. The MAR showed the new Oxycodone order and the discontinued Tramadol order, but the medication card for Tramadol remained in the cart. On 2/18/26, Staff H, CMA gave Tramadol 50 mg, two tablets, by mistake instead of the discontinued medication. The medication error form documented the resident was alert, responsive to verbal stimuli, and vital signs were stable after the error. The Director of Compliance stated he expected the CMA to follow the 6 rights of medication administration and to remove discontinued medication from the cart.
Failure to Supervise Resident at High Risk for Wandering
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent an elopement for one resident who was identified as high risk for wandering. The resident’s wandering risk assessment completed on 2/13/26 gave a score of 11, indicating high risk to wander, but the baseline care plan signed the same day did not address the resident’s high risk for wandering. The resident had been admitted to the health center on 2/13/26 and did not have an MDS completed. The incident report and SBAR documented that a dietary staff member let the resident out of the supervised health center area into a non-supervised area. The resident then went outside and was seen wandering near the RCF building by an RCF CNA, who brought him back to the health center. Staff interviews described that the resident exited through the west hallway area and then out door #15 near the dumpsters and sidewalk. Staff reported the resident was outside without supervision for a brief period and was found by RCF staff near the sidewalk by the elementary school area. Observation showed the west hallway doors in the health center were secured, but door #15 leading to the loading dock, dumpsters, sidewalk, and residential street was not secured or alarmed. The dietary aide stated she believed the resident still lived in the RCF and let him out, while other staff reported the resident was outside by himself when found. The facility policy required residents at risk for wandering or elopement to receive adequate supervision and for interventions to be added to the care plan and communicated to staff, but the resident’s care plan did not address the identified wandering risk.
Late Dependent Adult Abuse Training for New RN
Penalty
Summary
The facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed. Personnel file review showed Staff F, an RN hired on 8/5/25, completed the 2-hour dependent adult abuse mandatory reporter training on 3/24/26, which was later than the facility policy requirement. The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy, reviewed 07/2025, stated each employee must complete 2 hours of training related to identification and reporting dependent adult abuse within six months of initial employment. During interview on 5/20/26 at 10:00 AM, the Director of Compliance acknowledged the training was completed late and stated the facility had recently changed its process so new hires would be enrolled in the DAA class right away instead of waiting 4-6 months.
Failure to Maintain Food Safety and Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain food safety standards by not consistently documenting food temperatures for meals prepared in the main kitchen. Review of temperature logs over a four-month period showed that only a small fraction of meals had recorded food temperatures, despite the facility's policy requiring such documentation before food is sent to satellite kitchenettes. The Dietary Manager confirmed that staff were not following the established procedure for recording food temperatures. Additionally, the main kitchen was observed to have multiple issues with food storage, labeling, and cleanliness. Several food items in the walk-in cooler and freezer were found uncovered, unlabeled, or undated, including containers with unidentifiable contents and open bags of lettuce and cheese. Serving utensils and squirt bottles had visible dried food residue, and there was significant debris, dust, and grime on the floors and equipment surfaces in both the main kitchen and dish machine room. These findings were acknowledged by the Dietary Manager, and review of cleaning logs indicated that staff had signed off on daily cleaning tasks that were not completed as required by facility policy.
Failure to Prepare Pureed Foods According to Nutritional Requirements
Penalty
Summary
The facility failed to properly prepare pureed foods to meet the nutritional needs of residents on a pureed diet. During lunch service, a cook prepared pureed turkey burgers and wax beans but did not add hamburger buns to the pureed mixture, which is a standard industry practice and required by the facility's diet spreadsheet menu to ensure adequate nutrition. The Dietary Manager confirmed that the omission of buns meant the menu was not followed as written and the nutritional content of the meal was not met. Additionally, the facility did not have a policy outlining the process for pureeing resident food.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention practices by not adhering to enhanced barrier precautions (EBP) for two residents. For one resident with a history of a pressure ulcer, seizure disorder, and osteoporosis, the care plan did not mention EBP, and during an observed treatment of a left heel pressure ulcer, the registered nurse did not apply EBP prior to the procedure. The resident confirmed that staff had only recently started using gloves and gowns, and the nurse admitted to forgetting to wear the required EBP during the treatment. The co-director of nursing stated that the expectation is for staff to wear EBP when providing care or treatments. For another resident with a history of stroke, hemiplegia, and a G-tube, the care plan documented the need for EBP. However, during an observed medication administration via G-tube, two staff members sanitized their hands and applied gloves but did not wear gowns as required. One staff member acknowledged knowing the protocol but stated she forgot to wear the gown. The director of compliance confirmed that the expectation is to wear both gown and gloves for EBP during such procedures.
Facility Fails to Maintain Comfortable Environment Due to Air Conditioning Issues
Penalty
Summary
The facility failed to maintain a comfortable environment and safe functional equipment, specifically regarding the air conditioning system, affecting the memory care unit and resident rooms. Observations revealed that the thermostat in the conference room leading to the memory care unit was at 83.2°F, and the hallway outside a resident's room was at 82.1°F. Interviews with staff and family members indicated that the air conditioning had been malfunctioning for an extended period, with temperatures reaching up to 85°F at the beginning of the summer. Staff attempted temporary solutions such as using fans and portable devices, but these measures were insufficient to maintain a comfortable environment. Residents reported discomfort due to high room temperatures. One resident's room was observed at 87.3°F, and the resident expressed that it had been as high as 91°F, making it difficult to sleep. Another resident's room was consistently warm, with temperatures often in the 80s, and the resident reported discomfort and difficulty sleeping. The facility's administration acknowledged the issue, noting that one air conditioning unit was working at half capacity while another was non-functional, and they were in the process of obtaining bids for replacement units.
Failure to Follow Physician's Order for Daily Weight Monitoring
Penalty
Summary
The facility failed to adhere to a physician's order for a resident requiring daily weight monitoring. The order specified that if the resident's weight changed by more than 3 pounds in one day or 5 pounds in one week, staff were to assess, re-weigh, notify the provider and family, and document the change in the nurse's notes. However, multiple instances of significant weight gain were recorded without any follow-up actions, such as re-weighing, assessment, or notification to the physician. These discrepancies were noted over several months, indicating a pattern of non-compliance with the physician's order. The resident involved had a BIMS score indicating intact cognition and had multiple diagnoses, including coronary artery disease, hypertension, diabetes, arthritis, and chronic ischemic heart disease. The resident's electronic health record also documented an increase in bilateral lower extremity edema over the same period. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed awareness of the daily weight order but acknowledged the lack of appropriate follow-up actions. The Director of Nursing could not provide an explanation for the failure to address the weight discrepancies.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency. Resident #17, who has moderate cognitive impairment and multiple diagnoses including non-traumatic brain function and non-Alzheimer's dementia, was observed being pushed in a wheelchair by Staff C, a CNA, without the foot pedals engaged. The resident's feet were hanging approximately one inch off the floor as Staff C pushed him down the hallway. This action was contrary to the resident's care plan, which required the use of foot pedals for safety during wheelchair transport. Interviews with staff revealed that although Resident #17 is mostly independent in propelling himself, staff occasionally assist him. Staff D, another CNA, acknowledged that the resident sometimes removes the foot pedals and that staff should retrieve and use them for safety. The Director of Nursing (DON) confirmed the expectation that foot pedals should be engaged when staff assist the resident in his wheelchair. The facility's Master Pocket Care Plan cover sheet also indicated that foot pedals must be used when pushing a resident in a wheelchair, but the facility lacked a specific policy on wheelchair assistance, relying instead on state regulations and the care plan cover sheet.
Failure to Follow Prescribed Menu
Penalty
Summary
The facility failed to follow the prescribed menu for 18 of 18 residents in the unit on the evening of January 25, 2024. The menu specified an open-face hot turkey sandwich, mashed potatoes, turkey gravy, brown sugar peaches, cottage cheese, and milk. However, it was observed that the evening nurse provided a peanut butter and jelly sandwich instead. This deviation from the menu was confirmed by the assistant Dietary Manager, the Director of Quality Improvement, and the Director of Nursing during interviews conducted on April 9, 2024. The facility's census at the time was 72 residents, and the failure to adhere to the menu was documented as a deficiency in the clinical records and staff interviews.
Failure to Date and Label Food Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that open items in the coolers and walk-in freezer in the kitchen were properly dated and labeled. During an observation on 4/8/24 at 11:35 a.m., several items were found without dates or labels, including a half-opened bag of mild cheddar cheese in Cooler #2, a clear pitcher with brown liquid, and a container with round brown items in Cooler #1, and a half bag of brown, round items in the walk-in freezer. Additionally, a tin container with small, round brown/gray items in the cook's cooler was also not dated or labeled. Staff interviews confirmed the lack of proper dating and labeling, with both the Dietary Aide and the cook unable to verify the contents or duration of storage for these items. The Assistant Dietary Manager acknowledged that the items should have been dated and labeled when opened.
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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 Boone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westhaven Community | 0.4 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Ogden, Llc | 6.3 mi | ★★★★★ | 11 | 0 |
| Northridge Village | 12.5 mi | ★★★★★ | 4 | 0 |
| Madrid Home For The Aged | 13.1 mi | ★★★★★ | 7 | 0 |
| Green Hills Health Care Center | 13.8 mi | ★★★★★ | 1 | 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.