Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Golden Age Care Center during CMS and state inspections, most recent first.
A controlled pain medication was removed from locked storage by an LPN and left unattended in a resident's room, resulting in the medication going missing. The resident had moderate cognitive impairment and multiple diagnoses. Facility policy and staff interviews confirmed that medications should not be left unsecured or unattended.
Several residents with chronic conditions were not offered the pneumococcal vaccine as required by CDC guidelines and facility policy. The DON confirmed that eligible residents had not been assessed or offered the vaccine, and documentation was lacking or inconsistent across records. Some residents had received earlier vaccines but were not offered updated versions, and staff interviews confirmed the deficiency.
A resident with diabetes, hypertension, and Parkinson's disease was allowed to self-administer insulin without thorough documentation of an assessment to determine clinical appropriateness. Despite staff facilitating the resident's self-administration and a note indicating he managed the task, the care plan and records lacked comprehensive assessment details as required by facility policy.
A resident with diabetes, hypertension, and Parkinson's disease, who was cognitively intact, reported being left in soiled briefs for hours and missing insulin administration. Multiple staff confirmed the resident voiced these concerns and some reported them to nursing leadership, but there was no documentation that the facility's grievance process was initiated or followed, in violation of policy.
Two residents with significant medical needs experienced delays in receiving assistance due to a malfunctioning call system that failed to alert staff at the nurse's station. Staff and administrator interviews confirmed the system was old, unreliable, and did not consistently provide sound or visual alerts, resulting in prolonged wait times for residents needing help.
A resident with a history of falls, diabetes, and a humerus fracture developed deep tissue injuries on both heels. Required wound care treatments, including application of skin prep, Santyl, and dressings, were not consistently documented or completed as ordered. Staff interviews revealed that missed treatments were due to staffing issues, and an order for PT positioning was not carried out. The DON confirmed that treatments and therapy orders should be completed as ordered.
A resident with diabetes did not receive prescribed insulin or blood sugar checks on two occasions, with medication records and progress notes lacking documentation of administration or refusal. Staff interviews confirmed the omission, and the DON acknowledged that refusals should be documented and the physician notified, but this was not done according to facility policy.
A facility failed to provide consistent restorative therapy for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. Despite the resident's intact cognitive status and prioritization of improving ambulation, several planned restorative tasks were not completed over a three-month period. Interviews revealed that the restorative aide was often pulled to other duties, and there was a lack of a designated restorative nurse to ensure the program was followed.
A resident with cognitive intactness and requiring assistance with daily activities experienced prolonged discomfort due to a sore groin and peri area. Despite complaints and visible symptoms, staff failed to utilize available barrier creams and instead applied an antifungal powder without an order. The resident's discomfort persisted for eight days before appropriate treatment was ordered, highlighting a lapse in timely intervention and assessment by the facility staff.
A resident with multiple health issues developed a blister on their foot, which was not reported to the physician or family by the nursing staff. Despite the blister's growth and a noticeable odor, the facility failed to communicate the condition's severity, leading to a deficiency in notification protocol.
A resident with multiple comorbidities developed a new blister on the foot, which was treated by a nurse without obtaining physician orders or notifying the power of attorney. The blister worsened, and the treatment was changed without proper authorization. The Advanced Practice Nurse Practitioner was unaware of the issue until later, highlighting a deficiency in communication and protocol adherence.
Controlled Medication Left Unattended and Unsecured
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to keep a controlled medication, Hydrocodone-Acetaminophen, secured and properly administered to a resident with moderate cognitive impairment and diagnoses including non-Alzheimer's dementia, diabetes, and depression. The LPN removed the medication from a locked storage and left it unattended in the resident's room on the bedside table while stepping out to attend to another task, without observing the resident take the medication as required. Upon returning, the LPN discovered the medication was missing and could not be located after searching the room and trash bins. The Director of Nursing confirmed that the expectation was for the medication to be administered immediately after removal from storage and not left unattended. The facility's policy also required medications to be administered as ordered and not left unsecured. Staff interviews corroborated that the medication was left unattended and subsequently went missing.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four out of five sampled residents reviewed for immunizations, despite CDC guidelines and facility policy requiring assessment and offering of the vaccine within 30 days of admission. The Director of Nursing (DON) acknowledged that some residents were eligible for the vaccine but had not been offered it, citing issues such as difficulty accessing the Iowa Immunization Registry Information (IRIS) account and discrepancies between hard chart, electronic records, and a separate file maintained by the DON. A recent pharmacy audit had also identified residents in need of vaccines, but the necessary follow-up had not occurred. Clinical record reviews revealed that several residents, including those with significant medical histories such as diabetes, dementia, coronary artery disease, COPD, and heart failure, either lacked documentation of being offered or receiving the appropriate pneumococcal vaccines per current CDC guidelines. In some cases, residents had received earlier versions of the vaccine but had not been offered the updated vaccines as recommended. Interviews with residents and staff confirmed that eligible residents had not been offered the vaccine, and the facility's policy, last updated in 2017, was not being followed as required.
Failure to Document Assessment for Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure thorough documentation of an assessment regarding a resident's ability to self-administer insulin. Clinical record review, policy review, and staff interviews revealed that a resident with diagnoses including diabetes, hypertension, and Parkinson's disease was self-administering insulin without comprehensive documentation of an assessment to determine if this was clinically appropriate. Although the resident had an intact cognitive status as indicated by a perfect BIMS score, the care plan did not document the resident's ability to self-administer insulin, and the facility's policy required such an assessment. Staff interviews indicated that nursing staff either handed the insulin to the resident or left it on his table, and the resident administered it himself, particularly after refusing to have certain staff administer his insulin. The Director of Nursing was unaware if a formal assessment had been documented, and only a brief handwritten note was found stating the resident had self-administered insulin and "did fine." No further details or formal assessments were available, and it was unclear if staff observation was required during administration. The lack of detailed documentation and assessment constituted the deficiency.
Failure to Promptly Address Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve grievances raised by a resident with diagnoses including diabetes, hypertension, and Parkinson's disease, who was cognitively intact. The resident reported having to remain in soiled briefs for extended periods, specifically stating that on one occasion he sat in his own waste for 4-5 hours before being changed, and described this as humiliating. Additionally, the resident reported that staff failed to check his blood sugar or administer insulin on a previous occasion. Multiple staff members confirmed that the resident had voiced these concerns to them, and some reported relaying the complaints to nursing leadership or social services. Despite these reports, there was no documentation indicating that the facility's grievance process was initiated or followed in response to the resident's complaints. The facility's grievance policy required prompt efforts to resolve issues, but the administrator stated she was unaware of the concerns and would have expected the grievance process to be carried out if staff had reported them. The lack of documented follow-up or resolution demonstrates a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by facility policy.
Failure to Maintain Functioning Call System in Resident Areas
Penalty
Summary
The facility failed to provide a properly functioning call system in resident bathrooms and bathing areas for two residents. One resident, with diagnoses including traumatic brain injury, heart disease, renal insufficiency, neurogenic bladder, and reduced mobility, required substantial assistance for transfers and was instructed to use the call light for help. This resident reported waiting up to forty-five minutes for staff assistance, attributing the delay to the malfunctioning call system, which was not visible or audible at the nurse's station. Another resident, with diabetes, depression, vision deficits, and heart disease, used a walker and required prompt staff response. This resident confirmed awareness of the call system malfunction and described having to search for staff when assistance was needed, as the call light in their room was not detected at the nurse's station unless staff happened to walk by and see the overhead light. Staff interviews confirmed the call system was old, frequently malfunctioned, and did not consistently activate sound or light at the nurse's station for several halls. Staff reported that only one hall had a functioning sound system, while others relied solely on overhead lights, which could be missed if not directly observed. The administrator acknowledged ongoing issues with the system, frequent repairs, and the need for replacement. Facility policy required each resident room to have a functioning call light system, but observations and interviews demonstrated that this standard was not met for the affected residents.
Failure to Complete Ordered Pressure Ulcer Treatments and Interventions
Penalty
Summary
The facility failed to carry out ordered interventions and treatments for a resident with pressure ulcers. Clinical record review showed that the resident, who had a history of humerus fracture, falls, and diabetes, was at risk for pressure ulcers and developed deep purple, boggy blisters on both heels, later assessed as suspected deep tissue injuries. The Treatment Administration Records (TARs) indicated multiple instances where required wound care treatments, such as application of skin prep, Santyl ointment, and dressings, were not documented as completed on several dates. Additionally, an order for Physical Therapy for positioning related to heel wounds was not documented as carried out. Staff interviews confirmed that due to staffing issues, some dressing changes and treatments were not completed as ordered, with some shifts failing to follow up on missed treatments. Nursing staff acknowledged that there were times when wound care was not performed as scheduled, and the DON stated that staff are expected to carry out treatments and therapy orders in a timely manner. The lack of documentation and completion of ordered treatments and interventions led to the deficiency in pressure ulcer care for the resident.
Failure to Administer and Document Insulin for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with diabetes, hypertension, and Parkinson's disease did not receive prescribed insulin and blood sugar checks as ordered. The resident's Minimum Data Set indicated insulin dependence, and the Medication Administration Records (MARs) showed orders for blood sugar checks and Novolog insulin administration three times daily. On two separate occasions, the MARs lacked documentation and staff initials for both insulin administration and blood sugar checks during evening shifts. Progress notes also did not indicate whether the resident received or refused insulin on those dates. Interviews with staff revealed that the DON discussed documenting a refusal for insulin, although staff accounts and the resident indicated that the insulin was not administered and the resident was upset about missing a dose. The DON stated that refusals should be documented with reasons and the physician notified, but there was no documentation to support that this process was followed. The facility's policy required accurate recording of physician orders and avoidance of medication errors, which was not adhered to in this instance.
Failure to Provide Consistent Restorative Therapy
Penalty
Summary
The facility failed to provide restorative activity as planned for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who had an intact cognitive status and required moderate assistance with various activities, was supposed to receive restorative tasks 3-6 times per week as part of a Nursing Restorative Care Program. However, documentation indicated that several tasks were not completed in January, February, and March 2025. Interviews with staff and the resident revealed inconsistencies in the provision of restorative therapy, with the restorative aide being pulled to other duties and not consistently providing the planned therapy. The resident, who had a history of a broken hip and other medical conditions, expressed frustration over the lack of progress in his mobility goals, attributing it to the insufficient restorative therapy. The Assistant Director of Nursing acknowledged the lack of a designated restorative nurse and the need for better tracking of the restorative programs. Despite the resident's prioritization of improving ambulation, the facility's failure to consistently implement the restorative care plan contributed to the deficiency.
Failure to Provide Timely Treatment for Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed and provided with timely interventions to maintain their optimal health and well-being. A resident with an intact cognitive status and requiring moderate assistance with daily activities, including having a catheter and occasional bowel incontinence, complained of a sore groin and peri area. Despite the resident's complaints of discomfort and visible redness and tenderness, the staff did not produce a skin sheet or provide immediate appropriate treatment. The resident's discomfort was not addressed promptly, as the staff failed to utilize available barrier creams listed in the Treatment Administration Record (TAR) and instead applied an antifungal powder without an order. The delay in obtaining a physician's order for a barrier cream resulted in the resident experiencing discomfort for eight days before receiving the appropriate treatment. Staff interviews revealed that the nurse on duty was aware of the resident's complaints but did not thoroughly review the TAR, which contained orders for barrier creams that could have alleviated the resident's discomfort. The Director of Nursing indicated that the process for addressing resident complaints involves assessing the resident and contacting the physician for necessary orders, with the only difference on weekends being the need to contact the on-call physician.
Failure to Notify Physician and Family of Resident's Blister
Penalty
Summary
The facility failed to notify a physician and the family representative of a resident upon the discovery of a blistered area on the resident's left foot. The resident, who had an intact cognitive status and required significant assistance with daily activities, was diagnosed with lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, measuring 6 cm by 3.5 cm. Staff A, a registered nurse, noted the blister in a progress note and indicated that the physician was updated, but later admitted in interviews that neither the physician nor the resident's power of attorney (POA) was contacted about the blister. Further interviews revealed that the blister had grown in size by the next assessment, yet there was still no notification to the physician or the POA. The Advanced Practice Nurse Practitioner (ARNP) was unaware of the blister until her return from vacation. The resident's POA discovered the blister's severity during a visit, noting a strong odor in the room attributed to the resident's wounds. The lack of communication regarding the resident's condition and the progression of the blister represents a deficiency in the facility's protocol for notifying relevant parties of changes in a resident's condition.
Failure to Obtain Treatment Orders for New Wounds
Penalty
Summary
The facility failed to obtain treatment orders for a resident who developed new wounds. The resident, who had an intact cognitive status, required significant assistance with daily activities and had multiple diagnoses including lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, which was initially covered with Xeroform and cling wrap by a registered nurse. However, the nurse did not contact the physician to obtain an order for this treatment, nor did she notify the resident's power of attorney about the change in condition. The situation worsened when the blister increased in size, and the nurse changed the treatment to a non-stick telfa dressing without obtaining a physician's order. Again, the physician was not contacted, and the power of attorney was not informed of the condition's progression. The Advanced Practice Nurse Practitioner was unaware of the blister until after returning from vacation, despite the resident's multiple comorbidities that contributed to skin issues. This lack of communication and failure to obtain necessary treatment orders led to the deficiency identified in the report.
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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 Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercyone Centerville Medical Center | 0.9 mi | ★★★★★ | 15 | 0 |
| Centerville Specialty Care | 1.8 mi | ★★★★★ | 6 | 0 |
| Putnam County Care Center | 17.6 mi | ★★★★★ | 4 | 0 |
| Oakwood Specialty Care | 20.9 mi | ★★★★★ | 2 | 0 |
| Schuyler County Nursing Home District | 23.1 mi | ★★★★★ | 30 | 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.