Below 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 Harmony Marshalltown during CMS and state inspections, most recent first.
Failure to use EBP during wound care: Two residents with pressure ulcers and care plans requiring EBP received wound care without staff wearing gowns during high-contact care activities. An RN, with CNA assistance for one resident, performed wound care while PPE supplies and EBP signage were present, and later acknowledged the gown requirement was not followed; the DON confirmed gowns should have been worn.
Dishwasher Final Rinse Temperature Below Required Minimum: The facility failed to ensure the dishwasher reached the manufacturer-recommended minimum final rinse temperature of 120 degrees. The DM observed the machine at 88 degrees, later reported it reached 110 degrees after about 30 minutes of use, and a Cook later observed a cycle that peaked at 92 degrees. Facility logs showed the dishwasher was consistently documented at 110 degrees, despite the dishwasher plaque, vendor guidance, and facility policy requiring a minimum of 120 degrees.
A resident with intact cognition, paraplegia, PTSD, and a CVA required assistance with bathing and shower transfers, but the EHR did not show baths were provided at the expected twice-weekly frequency. Staff, including the CNA, RN, and DON, acknowledged the resident’s record lacked documentation of baths or refusals, and the resident stated he had not received a shower when expected. The facility policy required EHR documentation but did not specify bathing frequency or how preferences and refusals were handled.
Failure to Post Daily Nurse Staffing Information: The facility's CMS staffing posting was observed taped on the Staffing Coordinator's office door, but it did not include the facility name or the current date and only showed prior staffing information. The Staffing Coordinator said she printed the posting after the day or weekend passed, and the DON acknowledged the posting did not meet the regulatory requirements. The facility also had no policy for daily nurse staff posting.
A resident with a wound and another resident receiving wound care were involved in infection control failures when staff did not follow EBP during peri care and did not perform hand hygiene between glove changes during wound care. In addition, a resident with COVID-19 did not have the correct TBP sign posted on the door, and staff reported confusion about the required PPE while one housekeeper entered the room with only a surgical mask and gloves.
A resident's transfer or discharge was not conducted in a manner that met their needs and preferences, and the facility did not adequately prepare the resident for a safe transition.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Multiple residents requiring assistance with ADLs, including those with muscle weakness, multiple sclerosis, diabetes, anxiety, and CHF, experienced call light response times exceeding 15 minutes. Staff and resident interviews confirmed that low staffing and the need to escort residents outside for smoking contributed to missed or delayed care, resulting in residents arriving late for meals and feeling upset.
A resident with intact cognition and a history of dementia, anxiety, and depression was left outside overnight. After the incident, facility leadership told the resident it was her responsibility to always carry a cell phone to regain entry, which made her feel blamed and disrespected. This response did not align with the facility's policy requiring staff to treat all residents with dignity and respect.
A resident with intact cognition and independence in ADLs was left outside overnight after being unable to open a heavy door to re-enter the facility. Although the resident later reported weakness and the nurse notified the physician of this symptom, there was no documentation that the physician was informed about the incident of the resident being left outside, as required by facility policy.
A resident who was left outside overnight was not properly documented in the EHR as required. Staff were directed by administration to record the incident only on a concern form, despite professional standards and facility policy mandating clinical record documentation. The resident, who was cognitively intact and independent in ADLs, was assessed after the incident and found to have no injuries.
A resident with severe cognitive impairment and multiple health issues was not thoroughly assessed after staff observed facial bruising and after an elopement event. Staff failed to initiate timely neurological checks and did not complete a head-to-toe assessment following these incidents. Interviews revealed confusion among nursing staff about assessment requirements, and the DON confirmed the absence of a facility policy for such assessments.
A resident with severe cognitive impairment and a history of elopement was able to leave the facility unsupervised despite having a wander guard and being identified as high risk for wandering. Staff did not immediately notice the resident's absence after a door alarm sounded, and the resident was later found cold and confused at the front door. The care plan and elopement risk procedures were not effectively implemented, and staff were unclear about some security protocols.
Nursing staff did not perform required head-to-toe or neurological assessments after a resident with severe cognitive impairment was found with facial bruising and after the same resident eloped and was returned to the facility. Staff interviews revealed a lack of knowledge about assessment requirements, and the facility lacked clear policies to guide appropriate responses in these situations.
Two residents with severe cognitive impairment did not have complete or adequate medical records. One resident's elopement event was not fully documented, with missing details and an unlinked incident report in the EHR. Another resident's multiple skin injuries were not properly assessed or followed up in the clinical record, and required documentation was missing. The facility lacked a policy for staff documentation, and the process outlined in the Skin Management Guide was not consistently followed.
The facility failed to prevent food contamination during meal service. Dietary staff were observed preparing food while touching various surfaces with gloved hands, including bread, countertops, and containers, without changing gloves. The Dietary Supervisor confirmed that staff should wear gloves when handling ready-to-eat food and prevent contamination, as per facility policy.
A resident with acute and chronic respiratory failure was prescribed oxygen therapy at 3 L/NC as needed for shortness of breath. However, observations showed the resident receiving oxygen at 4.5 L/NC, contrary to the physician's order. The MAR lacked documentation of oxygen administration, and the TAR did not indicate whether the resident was on room air or oxygen during assessments. Staff interviews revealed a lack of awareness of the resident's specific oxygen orders, and the facility's policy required adherence to active orders.
A facility failed to complete a PASRR for a resident with mental health changes. The resident's MDS assessment showed an incomplete BIMS due to inability to complete the interview, with diagnoses of psychiatric and mood disorders. Despite using psychotropic medications, the care plan lacked an updated mental health diagnosis. The initial PASRR indicated no known mental health diagnosis, but later medical records showed delusional disorders, major depressive disorder, generalized anxiety disorder, and hallucinations. No new PASRR screening was conducted after these updates.
The facility failed to update Care Plans for three residents, missing critical diagnoses and treatment details. A resident's Care Plan lacked dementia-related information, while another's did not reflect updated mental health diagnoses. Additionally, a resident's history of UTIs and prophylactic antibiotic use was omitted. Staff acknowledged these oversights.
A resident with severe cognitive impairment and an indwelling catheter was observed with the catheter bag improperly managed, leading to it being on the floor and under the wheelchair wheel. Staff failed to secure the catheter bag properly, and there was a misunderstanding regarding the resident's consent for a bag change. The facility's policy to keep catheter bags off the floor and in a dignity bag was not followed.
The facility did not meet the Federal Regulations requirement of having an RN on duty for eight consecutive hours per day. On one day, there was no RN present, and on another, an agency RN only provided two hours of coverage. The Administrator acknowledged the issue and noted the absence of a specific RN staffing policy.
A resident with severe cognitive impairment and an indwelling catheter was not properly managed under transmission-based precautions for C. diff infection. Despite completing antibiotics, the facility failed to send a final stool sample for testing, delaying clearance from contact precautions. Observations showed staff misunderstanding and non-compliance with infection control protocols, including improper use of gloves and gowns. The facility's guidelines, based on CDC recommendations, were not adequately followed.
The facility failed to document and offer pneumococcal vaccinations to two residents, one with moderately impaired cognition and another with intact cognition, after they had received the PCV13 vaccine. The Infection Preventionist confirmed the lack of documentation for offering or declining additional vaccinations, and the facility's policy did not align with updated CDC recommendations.
The facility failed to document the offer and education of COVID-19 vaccinations for two residents, one with severe cognitive impairment and another with intact cognition. Despite the Infection Preventionist's claim of offering the vaccinations, there was no documentation of consent or refusal, violating CDC guidelines and facility policy.
A resident's family member found another resident's death certificate in their room, which was a breach of confidentiality. The family member, who works in healthcare, reported the issue to the DON. The facility's Compliance Plan requires the protection of residents' PHI, but the DON could not determine how the document ended up in the room.
The facility failed to maintain Smart Stand Lifts properly, compromising resident safety during transfers. Two lifts were missing essential safety hook spring tabs, as required by the service manual. Staff reported that the lifts lacked these safety tabs since they started working at the facility, and the Maintenance Man confirmed the necessity of these components for safe operation.
The facility failed to provide adequate clean linen soaker pads and washcloths for resident care, impacting the quality of care. Staff reported a shortage of essential supplies due to a management transition, making it difficult to perform their duties. A resident confirmed the lack of sufficient supplies, hindering proper care. Although new washcloths were available in the laundry area, they were not readily accessible to staff, leading to the deficiency.
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. One resident, with severe cognitive impairment and multiple health issues, did not have their weight monitored as prescribed due to Covid isolation. Another resident, with no cognitive impairment and various health conditions, did not receive the ordered compression stockings as the facility failed to measure their legs. These oversights indicate a lapse in following prescribed care plans.
Two residents reported delays in call light responses, exceeding the facility's 15-minute policy. One resident, needing blood sugar monitoring, experienced a 45-minute delay, while another confirmed similar delays. Staff and the Administrator acknowledged the expectation for timely responses, highlighting a failure to meet facility standards.
The facility did not follow the dietitian-approved menus for residents' meals on several occasions. Meals served on different days did not match the planned menus, with substitutions made without adherence to the approved plan. The Corporate Dietitian noted the absence of a Dietary Supervisor, with the Administrator handling food orders until a new supervisor starts.
The facility did not maintain hot food items at the required temperature, as observed during a meal service where French fries were served at 127°F, below the required 135°F. A test tray confirmed the French fries were cool and chewy. The Corporate Dietitian acknowledged the issue, noting plans to replace the steam table to maintain consistent temperatures.
The facility was found to have deficiencies in food handling and kitchen sanitation. During an inspection, several food items were discovered open, unlabeled, and undated, including potato and ham salad, meat patties, taco shells, and buns. Additionally, chocolate milk was past its best-by date. The kitchen area was also found to be unsanitary, with food debris on the handwashing station, prep counter, oven griddle, steam table, and inside refrigerators and freezers. These findings were confirmed by the Corporate Dietitian, who noted the absence of a Dietary Supervisor.
A CNA failed to follow infection control protocols while assisting a resident with toileting, leading to a breach in hygiene practices. The CNA handled soiled materials and touched various surfaces and equipment without changing gloves, contrary to the facility's infection control policy. The resident required total assistance due to multiple medical conditions.
Failure to Use EBP During Wound Care
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) during wound care for two residents who had pressure ulcers and care plans that included EBP for high-contact care activities. One resident had diagnoses including fractures, multiple trauma, heart failure, and hip fracture, and developed an unstageable right sacrum pressure ulcer. During wound care, the RN, assisted by two CNAs, helped the resident stand, removed clothing and a brief, and performed wound care while none of the three staff members wore a gown, despite EBP signage and PPE supplies being available outside the room. A second resident had diagnoses including stroke, renal failure, diabetes mellitus, and a pressure ulcer of the right heel, and also had a reopened stage 3 left ankle pressure ulcer. During wound care, the RN entered the room, performed hand hygiene, donned gloves, removed the dressing, and completed the wound care without wearing a gown. The RN later acknowledged that EBP was not performed appropriately for either resident and stated that a gown should have been worn during wound care; the DON also stated that staff should have worn gowns during the wound care for both residents.
Dishwasher Final Rinse Temperature Below Required Minimum
Penalty
Summary
The facility failed to ensure the dishwasher reached the manufacturer-recommended minimum final rinse temperature of 120 degrees. On 1/13/26 at 12:30 PM, the dishwasher was observed reaching 88 degrees during the rinse cycle while the Dietary Manager was present. The Dietary Manager confirmed the temperature was measured using the gauge on the right side of the dishwasher and reported that a Hydrion test strip placed on dishware was lost during the dishwashing cycle. The Dietary Manager also stated the dishwasher reached 110 degrees after staff had been washing dishes for approximately 30 minutes and acknowledged that the expected temperature was a minimum of 120 degrees during the rinse cycle. Later that day at 1:10 PM, Staff F, Cook, was observed washing dishes after lunch service. Staff F placed a Hydrion test strip on dishware and activated the dishwasher, and the strip turned light purple, a color not listed on the container chart. The highest dishwasher temperature observed during that cycle was 92 degrees. Review of the facility's Dishwashing Record Low Temperature/Chemical for October 2025 through January 2025 showed staff consistently documented the dishwasher temperature twice daily as 110 degrees. The dishwasher plaque listed a minimum rinse temperature of 120 degrees, the American Dish Service recommendation provided by the facility stated the water supply should reach at least 120 degrees, and the facility's Dishwashing: Machine Operation policy required dishwashing machines to operate according to manufacturer recommendations.
Failure to Provide and Document Required Bathing
Penalty
Summary
The facility failed to provide bathing/showering at least two times per week for a resident with intact cognition and significant physical assistance needs. Resident #18’s MDS identified a BIMS score of 15, paraplegia, PTSD, and a CVA. The resident required supervision or touching assistance to shower/bathe and substantial/maximal assistance for tub/shower transfers. Facility documentation showed bathing occurred 4 times in November 2025 and 3 times in December 2025, with one refusal documented in each month, but the record lacked documentation showing the resident received the expected bathing frequency. During interview, the resident stated he should have received a shower on Friday and had not yet received one. Staff J, a CNA, stated residents receive baths twice per week unless they refuse and that baths are recorded in the EHR. Staff B, an RN, and the DON both stated residents receive baths 2 times per week unless requested otherwise or refused, and both acknowledged Resident #18’s EHR lacked documentation showing baths were provided or refused. The DON also reported the resident’s bath schedule was changed from Tuesday and Friday morning to Monday and Thursday evening effective 1/13/26. The facility’s Hygiene-Bathing/Shower policy directed staff to document in the EHR but did not state the bathing frequency or how resident preferences and refusals were to be accommodated.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing data with the facility name, total number of staff, and actual hours worked at the beginning of each shift. On 1/12/26 at 9:46 AM, surveyors observed the CMS Staffing Report taped at eye level on the door of the Staffing Coordinator's office, but it only listed staffing for 1/5/26 through 1/8/26 and did not include the facility's name or the current date of 1/12/26. The facility reported a census of 49 residents. During interview, the Staffing Coordinator stated she was responsible for posting the daily nurse staff posting and said she printed it after the day/weekend passed. The DON later acknowledged the posting did not have the current date or the facility's name and stated the facility expected to follow the regulation. The facility also lacked a policy for daily nurse staff posting.
Failure to Follow EBP, Hand Hygiene, and TBP Signage Requirements
Penalty
Summary
Enhanced Barrier Precautions were not followed during peri care for a resident with severe cognitive impairment, diabetes, osteoarthritis, and a Stage III pressure ulcer to the right heel. The resident’s care plan directed staff to wear a gown and gloves during high-contact care activities such as hygiene and brief changes. During observation, two CNAs provided peri care and an RN entered to apply ointment, but none of the staff wore gowns during the care. A CNA later stated the resident needed EBP for the foot wound, but staff did not need to wear EBP because they were not touching the wound. Hand hygiene was not performed between glove changes during wound care for a resident with severe cognitive impairment, total dependence for toileting hygiene, bowel and bladder incontinence, and an unhealed Stage III pressure ulcer to the coccyx. During observed wound care to the coccyx, right cheek, and nose, an LPN removed gloves after completing one part of the care, put on a new pair of gloves, and continued wound care without performing hand hygiene. The same pattern occurred again when the LPN removed gloves and then applied new gloves to complete the last dressing change without hand hygiene. Transmission Based Precautions signage was not posted on the door of a resident admitted with COVID-19 who had orders for contact and droplet precautions. The resident’s care plan directed isolation precautions related to COVID-19, and PPE was available outside the room, but multiple observations showed no TBP sign on the door. Staff reported they were unsure what PPE to wear because the sign was missing, and one housekeeper cleaned the room wearing only a surgical mask and gloves. Later, staff produced a different sign that directed people to stop and see the nurse, while staff stated it was not the correct COVID sign and identified the proper PPE as an N95 mask, face shield, gown, and gloves.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the needs and preferences of the resident and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the planning and execution of the transfer/discharge process, specifically noting that the resident's individual needs and preferences were not fully considered or addressed, and that the necessary preparation for a safe transition was lacking.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents are provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Delayed Call Light Response Due to Staffing Issues
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, defined as 15 minutes or less, for four residents. Resident interviews revealed that staff response times exceeded 15 minutes, resulting in residents arriving late for meals and experiencing distress. Specifically, one resident reported waiting over an hour for assistance, while others described repeated delays that caused frustration and upset. Staff interviews confirmed that call lights often went unanswered for longer than 15 minutes, particularly when staff were required to take residents outside to smoke, which left fewer staff available to respond to other residents' needs. The affected residents had varying degrees of assistance required for activities of daily living (ADLs), including transfers, dressing, personal hygiene, and meal attendance. Their medical histories included conditions such as muscle weakness, multiple sclerosis, diabetes mellitus, anxiety, and congestive heart failure. The facility's policy required prompt response to call lights, but both staff and residents reported that low staffing levels contributed to missed or delayed care, directly impacting the timeliness of assistance provided.
Resident Not Treated with Dignity After Being Left Outside
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 14, and diagnoses including non-Alzheimer's dementia, anxiety, depression, and dizziness, was identified as being independent with activities of daily living. The resident's care plan included interventions related to tobacco use, such as completing smoking evaluations as needed, keeping smoking accessories secured, checking in and out, carrying a cell phone while smoking, and smoking only in designated areas or times. On one occasion, the resident was left outside all night and subsequently reported feeling degraded and disrespected after being told by the DON and Administrator that it was her responsibility to always have her cell phone to re-enter the facility. Interviews with the Administrator and DON confirmed their expectation that the resident should ensure she had her cell phone at all times to regain entry. The resident expressed that this made her feel blamed for the incident and led her to avoid going outside alone. The facility's policy on dignity and respect instructs staff to treat all residents with dignity and respect, maintaining and enhancing self-esteem and self-worth, and providing reasonable accommodation of individual needs. The actions and statements of the facility leadership did not align with this policy, resulting in a failure to treat the resident with the required respect and dignity.
Failure to Notify Physician After Resident Left Outside Overnight
Penalty
Summary
The facility failed to notify the resident's physician of a significant incident involving a resident who was left outside all night. The resident, who was cognitively intact with a BIMS score of 14 and independent in activities of daily living, reported being unable to re-enter the facility after going outside to smoke due to difficulty opening a heavy door. The incident was discovered when a staff member heard the resident pounding on the courtyard door the following morning. Documentation shows that the resident reported feeling too weak to open the door, and while the nurse notified the physician of the resident's reported weakness, there was no documentation that the physician was informed about the resident being left outside overnight. The facility's policy requires immediate notification of the physician and the resident's representative in the event of an accident or change in condition. During interviews, the facility physician confirmed they were not informed of the incident and expressed that they expected to be notified. The DON also verified that the clinical record lacked documentation of physician notification regarding the incident, despite facility expectations for staff to report such events.
Failure to Document Resident Incident in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was left outside overnight. Although the incident was documented on a concern form and a handwritten note, it was not entered into the resident's electronic health record (EHR) as required by professional standards and facility policy. Staff members reported being directed by administration to document the incident only on a concern form and not in the clinical record, despite expressing discomfort with this approach. The resident involved was cognitively intact, had a history of non-Alzheimer's dementia, anxiety, depression, and dizziness, and was independent with activities of daily living. The incident involved the resident being unable to re-enter the facility after being outside, resulting in her remaining outside all night. Upon discovery, the resident was assessed and found to have no injuries or acute medical issues. The lack of documentation in the EHR meant that the incident, the resident's condition, and the follow-up actions were not properly recorded in accordance with accepted professional standards and facility policy, which requires all incidents and changes in resident status to be documented in the clinical record.
Failure to Complete Timely Assessments After Injury and Elopement
Penalty
Summary
The facility failed to initiate and complete timely and thorough assessments for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, muscle weakness, and a history of fracture. On one occasion, staff observed facial bruising on the resident after she reported being knocked into a wall by another resident, but did not conduct a comprehensive head-to-toe assessment or initiate neurological checks at the time of discovery. Documentation of vital signs was inconsistent, and neurological checks were not started until the following day, with incomplete entries and no ongoing monitoring as required. Additionally, after the resident eloped from the facility and returned, staff did not perform a thorough assessment to evaluate her condition post-elopement. Interviews with nursing staff revealed a lack of understanding regarding the need for assessments after such incidents, and the Director of Nursing confirmed that assessments should be completed after falls, altercations, or elopements, but acknowledged the absence of a facility policy guiding these practices. The facility also lacked documentation of a policy for head-to-toe assessments or neurological checks.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive impairment, required substantial to maximum assistance with transfers and ambulation, and had a history of elopement and exit-seeking behaviors. The care plan included the use of a wander guard, regular checks of the device, and staff assistance with mobility and reorientation. Despite these interventions, the resident was able to leave the facility unsupervised. On the morning of the incident, staff statements and interviews revealed that a CNA heard a door alarm and subsequently noticed the resident was missing from their room. Staff searched both inside and outside the building, and the resident was eventually found at the front door, cold and confused, wearing a wander guard that was still functional. Staff accounts indicated that the resident had attempted to leave the facility multiple times in the days prior, and another resident reported seeing the individual moving quickly down the hall earlier that morning. The nurse on duty had exited the building around the time of the incident, and the front door alarm was triggered, but the resident was not immediately located. The facility's elopement risk evaluation and care plan identified the resident as high risk for elopement, with a history of not responding to redirection and attempts to remove the wander guard. The facility's missing patient response plan outlined procedures for searching and notification, but the resident was able to exit and re-enter the building without staff immediately realizing. There were no operational cameras, and staff were unclear about certain security procedures, such as locking the sun room door, under new management.
Failure to Ensure Nursing Staff Competency in Resident Assessment After Injury and Elopement
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary knowledge and competencies to initiate appropriate clinical responses during resident care, as evidenced by the care of one resident with severe cognitive impairment and multiple medical conditions. The resident required substantial to maximum assistance with transfers and ambulation, had a history of falls, dementia, and used a wander/elopement alarm. Despite these needs, the clinical record showed that when facial bruising was first observed on the resident, staff did not perform a comprehensive head-to-toe assessment or initiate neurological checks, as would be expected following an unexplained injury. Additionally, after the resident eloped from the facility and was subsequently found, staff again failed to conduct a thorough nursing assessment or neurological checks within an hour of the incident. Interviews with nursing staff revealed a lack of awareness regarding the need for such assessments following incidents of injury or elopement. One nurse assumed the bruising had already been addressed and did not further assess the resident, while another was unaware of the requirement to perform a head-to-toe assessment after the resident was found outside the facility. The facility did not have a policy in place regarding the completion of nursing head-to-toe assessments or neurological checks, although the Missing Patient Response Plan instructed staff to examine the patient and document findings. The absence of clear protocols and staff knowledge led to incomplete assessments and documentation following significant events involving the resident.
Failure to Maintain Adequate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that the medical records for two residents contained sufficient and adequate information in accordance with accepted professional standards. For one resident with severe cognitive impairment, a history of falls, and a risk for elopement, the clinical record did not include a detailed account of an elopement event. While a progress note documented physician communication regarding the elopement, there was no further progress note detailing the specifics of the event, such as the time, summary, or the resident's condition. Additionally, the incident report related to the event was not properly linked within the electronic health record due to formatting issues, resulting in incomplete documentation. For another resident with severe cognitive impairment and dependent on staff for mobility and transfers, the clinical record lacked adequate documentation and follow-up assessments for multiple skin injuries. After a skin tear was identified, there was no further documentation of skin assessments or the healing process. Similarly, when bruises and another skin tear were later noted, the required skin condition reports and follow-up assessments were missing from the record. The facility's process for documenting and closing out skin injuries was not consistently followed, and there was no policy in place guiding staff documentation practices. The facility's Skin Management Guide required that skin alterations be evaluated and documented by a licensed nurse, with a specific form initiated upon identification of a skin injury and used for ongoing documentation. However, this process was not adhered to, resulting in incomplete medical records for the residents involved. The lack of comprehensive documentation for significant events and injuries constituted a failure to maintain medical records in accordance with professional standards.
Failure to Prevent Food Contamination During Meal Service
Penalty
Summary
The facility failed to protect food from contamination during meal service, as observed on multiple occasions. Staff F, a Dietary Aide, was seen preparing peanut butter and jelly sandwiches while repeatedly touching the bread with gloved hands. During the preparation, Staff F also touched various surfaces such as the outside of the bread bag, the counter, a pen, the peanut butter container, the jelly squeeze bottle, and storage bags, all with the same pair of gloves. Similarly, Staff G, a Cook, was observed preparing toast and touching the bread after handling different surfaces like the countertop, drawer handle, and toaster with gloved hands. Additionally, Staff E, another Dietary Aide, was observed preparing a grilled turkey and cheese sandwich while touching the bread, cheese, and turkey with gloved hands. Staff E also touched several surfaces, including the counter, refrigerator doors, and items inside the refrigerator, as well as containers of butter and cheese slices, and turkey packaging. Furthermore, Staff E used the same knife to spread butter on the bread after using it to open the plastic turkey package. The Dietary Supervisor confirmed that staff were expected to wear gloves when handling ready-to-eat food and to prevent foodborne illness by not touching food with bare hands or contaminated gloves. The facility's policy on disposable glove use required gloves to be worn for single tasks only and to be discarded if soiled, torn, or contaminated.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and manage oxygen use for a resident with acute and chronic respiratory failure. The resident, who had intact cognition, was prescribed oxygen therapy at 3 liters per nasal cannula (L/NC) as needed for shortness of breath. However, observations revealed that the resident was receiving oxygen at a rate of 4.5 L/NC, which was not in accordance with the physician's order. The Medication Administration Record (MAR) lacked documentation of the administration of oxygen, indicating non-compliance with the prescribed treatment. Additionally, the Treatment Administration Record (TAR) did not document whether the resident was breathing room air or receiving oxygen during respiratory assessments. Interviews with staff revealed a lack of awareness regarding the specific details of the resident's oxygen orders, and the facility's policy required that active orders be followed as written. The administrator confirmed that staff should adhere to physician orders and seek clarification if needed, highlighting a deficiency in the facility's management of the resident's respiratory care.
Failure to Complete PASRR for Resident with Mental Health Changes
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) for a resident who experienced mental health changes. The resident's Minimum Data Set (MDS) assessment indicated an incomplete Brief Interview for Mental Status (BIMS) due to the resident's inability to complete the interview. The resident had diagnoses of psychiatric and mood disorders, including anxiety, depression, and psychotic disorders, and was using antipsychotic and antidepressant medications. Despite these conditions, the resident's care plan did not reflect an updated mental health diagnosis. The PASRR Level I Screen Outcome initially indicated that the resident did not have a known or suspected mental health diagnosis and was not receiving mental health services. However, subsequent medical diagnoses included delusional disorders, major depressive disorder, generalized anxiety disorder, and hallucinations. The clinical record did not show a new PASRR screening following these updated diagnoses. A Licensed Practical Nurse acknowledged the need to resubmit a PASRR with the new mental health diagnosis, and the Administrator noted that the facility did not have a specific policy for PASRRs.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to fully review and revise the comprehensive Care Plan for three residents, leading to deficiencies in their care management. Resident #1, with a BIMS score indicating intact cognition, had a diagnosis of unspecified dementia, among other conditions. However, the Care Plan lacked information related to the dementia diagnosis. The MDS Coordinator acknowledged missing this aspect, and the Administrator confirmed the expectation for the Care Plan to include dementia-related focus, goals, and interventions. Similarly, Resident #40's Care Plan did not reflect updated mental health diagnoses, despite the resident's use of psychotropic medications and a history of psychiatric disorders. Staff C, an LPN, admitted to missing the addition of these diagnoses to the Care Plan. Resident #38's Care Plan also lacked critical information, specifically regarding the history of urinary tract infections (UTIs) and the use of a prophylactic antibiotic. The MDS assessment indicated intact cognition, and the resident had a history of various medical conditions, including UTIs. The MDS Coordinator initially included the history of UTIs in the Care Plan but resolved it without considering the prophylactic antibiotic. This oversight was acknowledged by the MDS Coordinator, who recognized the expectation for the Care Plan to include such details.
Inadequate Management of Urinary Catheter
Penalty
Summary
The facility failed to adequately manage a resident's urinary catheter, which increased the risk of infections. The resident, who had severe cognitive impairment and an indwelling catheter due to obstructive uropathy, was observed with the catheter bag on the floor and under the wheelchair wheel. Staff D, a CNA, acknowledged that the catheter bag had two hooks and if only one was hooked, it would not stay in place. Despite this, the catheter bag was not properly secured, leading to it being on the floor. On another occasion, the resident was seen holding the catheter bag, which had come loose and was dragging. Staff H, another CNA, initially walked past the resident without addressing the issue until prompted by the surveyor. Staff H noted that the tubing was too short, which contributed to the problem. The Nurse Manager, Staff C, later offered to change the catheter bag, but there was a misunderstanding with the resident, who initially declined the change. The facility's policy required that catheter bags be secured off the floor and in a dignity bag, which was not adhered to in this case.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day as required by Federal Regulations. The deficiency was identified through a review of the facility's Daily Staffing Sheets, which revealed that on Saturday, 11/23/24, there was no RN present, and on Sunday, 11/24/24, an agency RN only worked from 10:00 PM to 6:00 AM, providing just two hours of RN coverage for the entire day. The facility had a census of 55 residents at the time. The Administrator acknowledged the lack of RN coverage during an email communication on 12/12/24, stating that they had identified the issue the week prior to the survey. The Administrator also confirmed that the facility did not have a specific policy for RN staffing, as they were following Federal Regulations.
Failure to Maintain Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to maintain proper infection control interventions for a resident on transmission-based precautions due to Clostridium difficile (C. diff) infection. The resident, who had severe cognitive impairment and an indwelling catheter, was receiving antibiotic therapy for C. diff. Despite the completion of antibiotics, the facility had not yet cleared the resident from contact precautions as they had not sent the final stool sample for testing as per the physician's order. Observations revealed that a sign on the resident's door indicated contact precautions, requiring visitors to report to the nursing station, perform hand hygiene, and wear gloves and gowns when entering the room. However, staff interviews and observations indicated a lack of adherence to these precautions. A CNA reported that the resident had not been cleared from contact precautions, and an LPN confirmed that the final stool sample had not been sent for testing. Additionally, a staff member from Social Services interacted with the resident without following the required precautions, mistakenly believing that gloves and gowns were only necessary for direct care involving the catheter. This misunderstanding was later corrected by the nursing staff, who directed the staff member to wash their hands. The facility's infection control guidelines, adapted from the CDC, emphasized the importance of contact and standard precautions for C. diff, including consistent environmental cleaning and handwashing with soap and water due to the ineffectiveness of alcohol-based hand rubs against C. diff spores.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly screen, offer, educate, and document consent or refusal for pneumococcal vaccinations for two residents. Resident #33, with moderately impaired cognition, was admitted to the facility and had previously received the PCV13 vaccine. However, there was no documentation indicating that the resident was educated about, offered, or consented to additional pneumonia vaccinations such as PPSV23, PCV20, or PVC21. Similarly, Resident #24, who had intact cognition, also lacked documentation of being educated about or offered additional pneumonia vaccinations after receiving the PCV13 vaccine. The facility's Infection Preventionist confirmed the absence of documentation for offering or declining additional pneumonia vaccinations for both residents. The facility's policy, dated September 2023, required reviewing a resident's immunization status upon admission and offering the PPSV23 vaccine one year after receiving PCV13. However, the policy did not reflect the updated CDC recommendations, which suggested offering PCV20 or PVC21 at least one year after PCV13. This oversight in policy update and documentation led to the deficiency identified during the survey.
Failure to Document COVID-19 Vaccination Offers and Education
Penalty
Summary
The facility failed to properly screen, educate, offer, and document COVID-19 vaccinations for two residents, leading to a deficiency in compliance with CDC guidelines and facility policy. Resident #56, who has severe cognitive impairment, was admitted on 8/29/24, and although he received a COVID vaccination on 7/6/22, there was no documentation of an offer or education regarding an additional COVID-19 vaccination since his admission. Similarly, Resident #24, with intact cognition, was admitted on 5/21/24 and had received a COVID vaccination on 11/17/23, but there was no documentation of an offer or education for an additional vaccination since her admission. The Infection Preventionist confirmed the lack of documentation for both residents, acknowledging that while the vaccinations were offered, the necessary documentation or declination forms were not completed. The facility's policy requires reviewing a resident's immunization status upon admission, determining eligibility, and documenting consent, refusal, or ineligibility for the COVID-19 vaccine. The policy also mandates obtaining physician orders if the resident consents to vaccination and recording the administration in the medical record. The deficiency was identified through clinical record reviews, staff interviews, and policy reviews, highlighting a failure to adhere to established procedures for COVID-19 vaccination management.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically involving a death certificate of another resident. Resident #27 reported that their family member discovered the death certificate of another resident who had passed away on 11/23/34 on a bedside table in Resident #27's room. The family member, who works in the healthcare field, identified this as a confidentiality issue and reported it to the Director of Nursing (DON). The family member initially mistook the document for a list of upcoming appointments before realizing it was a death certificate. The DON confirmed the incident, acknowledging that Resident #27's family member brought the document to her attention. However, the DON was unable to determine how the death certificate ended up in Resident #27's room, as no staff admitted to leaving it there. The facility's Compliance Plan, last revised on 1/1/24, mandates the protection of residents' Protected Health Information (PHI) in accordance with state and federal privacy laws, which includes maintaining the confidentiality of all resident-related information.
Inadequate Maintenance of Smart Stand Lifts
Penalty
Summary
The facility failed to ensure the safety of residents during transfers by not maintaining adequate equipment. Specifically, two out of four Smart Stand Lifts observed were missing essential safety components. The Smart Stand Lift Service Manual, dated 6/7/24, requires that safety tabs be checked to ensure they are correctly installed and not missing or torn, with any deficiencies rectified before use. However, on 9/21/24, one lift was found missing a safety hook spring tab on one side, and another lift was missing both safety hook spring tabs. Staff interviews revealed that the Smart Stand Lifts had been without safety tabs since the staff members began working at the facility. Additionally, the Maintenance Man confirmed that the lifts should have safety tabs where the loops connect to the harness for safety.
Inadequate Linen Supply and Accessibility
Penalty
Summary
The facility failed to provide adequate clean linen soaker pads and washcloths for resident care, as observed during an environmental tour and through interviews with staff and residents. A Certified Nursing Assistant (CNA) reported a shortage of essential supplies such as washcloths and gloves, attributing the issue to a transition in management, which was delaying the ordering of new supplies. This shortage made it difficult for staff to perform their duties effectively, impacting the quality of care provided to residents. A resident confirmed the lack of sufficient washcloths, soaker pads, and linens, which hindered the staff's ability to care for her properly. Further investigation revealed that while the facility had a stock of new washcloths in the laundry area, these were not readily accessible to the staff on the floors. Staff members had to go to the laundry area themselves to retrieve necessary supplies, as they were not consistently stocked in the linen rooms or on the carts. The Housekeeping Supervisor indicated that linens were delivered only once a day, although staff could request additional supplies if needed. Despite the availability of supplies in the laundry area, the lack of efficient distribution and accessibility led to the deficiency in providing a safe and comfortable environment for the residents.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident #3, who had severely impaired cognition and multiple health issues including heart disease and kidney failure, was prescribed daily weight monitoring due to their use of a diuretic. However, the facility did not obtain Resident #3's daily weights on several occasions because the resident was in isolation due to Covid. This failure to monitor the resident's weight as ordered by the physician represents a lapse in adhering to the prescribed care plan. Resident #4, who had no cognitive impairment and was diagnosed with conditions such as cancer, heart failure, and diabetes, returned from a wound clinic with new treatment orders, including the daily use of compression stockings. Despite the physician's order, the facility did not measure the resident's legs for the compression stockings, and the resident confirmed this oversight. A registered nurse verified that the facility's policy required staff to follow physician's orders as written, yet this was not done in Resident #4's case, indicating a failure to implement the necessary care as prescribed.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by interviews with residents and staff, and a review of facility policy. Resident #2, who has intact cognition and requires assistance with various activities of daily living, reported that staff took over 30 minutes to respond to a call light. This delay occurred when Resident #2 needed their blood sugar checked due to a tendency for low blood sugar levels. The blood sugar was eventually checked at 2:45 AM, revealing a level of 200. Staff C, a CNA, confirmed that it took over 15 minutes to answer the call light, which is against the facility's expectation of a 15-minute response time. Similarly, Resident #4, who also has intact cognition and requires total dependence for toileting hygiene and transfers, verified that their call light was on for longer than 15 minutes. The facility's Call Light Policy, dated September 2023, instructs staff to respond promptly to residents' calls for assistance, with a procedure to answer call lights in a timely manner. The Administrator confirmed the expectation for staff to answer call lights within 15 minutes, indicating a failure to adhere to the facility's policy.
Failure to Follow Dietitian-Approved Menus
Penalty
Summary
The facility failed to adhere to the dietitian-approved menus for residents' meals on multiple occasions. On 9/9/24, the lunch menu was supposed to include fire braised pork on a bun, baked yams, pea salad, bread with margarine, and fruit crisp. Instead, residents were served fire braised pork ribs, baked yams, buttered peas, and pudding. Similarly, on 9/10/24, the menu called for a cheeseburger on a bun, French fries, creamy coleslaw, and a scotcheroo, but residents received an ice cream cone or ice cream sandwich instead of the scotcheroo. On 9/11/24, the menu was supposed to include Italian pasta bake, seasonal vegetables, garlic toast, and pears, but residents were served [NAME] beans and a dinner roll instead of the seasonal vegetables and garlic toast. The Corporate Dietitian confirmed that the facility expected staff to follow the approved menu as written. However, the facility was operating without a Dietary Supervisor at the time, and the Administrator was responsible for ordering food supplies. A new Dietary Supervisor was expected to start at the end of the month. The facility's policy, dated 2020, indicated that menus should be planned in advance, varied, and revised semi-annually, taking residents' input into consideration.
Non-compliance with Food Temperature Standards
Penalty
Summary
The facility failed to maintain hot food items at the required temperature of 135 degrees Fahrenheit or greater, as observed during a noon meal service. Specifically, the temperature of French fries was recorded at 127 degrees Fahrenheit, which is below the required minimum. A test tray provided by the facility contained a cheeseburger, coleslaw, and French fries, where the French fries were noted to be cool and chewy, indicating they were not palatable. The Corporate Dietitian acknowledged the non-compliant temperature of the French fries and noted that the kitchen would be acquiring a new steam table to help maintain consistent temperatures. The facility's policies from 2020 require hot food items to be held at temperatures between 135 degrees Fahrenheit and 170 degrees Fahrenheit.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling and storage protocols, as observed during an inspection of the kitchen. Several refrigerated and frozen food items were found open, unlabeled, and undated, including tubs of potato and ham salad, bags of meat patties, taco shells, and buns. Additionally, 11 gallons of chocolate milk were discovered with a past best-by date. These lapses in labeling and dating food items contravene the facility's food handling policy, which mandates that all prepared food must be covered, labeled, and dated before storage. The inspection also revealed significant sanitary issues within the kitchen area. The handwashing station sink, prep counter, oven griddle, steam table, and both the three-door refrigerator and two-door freezer were found to be dirty, with food debris and crumbs present. The facility's cleaning rotation policy requires that work tables and counters be cleaned after each use, and that the stove top, grill, steam table, and handwashing sink be cleaned daily, with refrigerators and freezers cleaned monthly. The Corporate Dietitian confirmed these expectations and noted the absence of a Dietary Supervisor, although one had been hired to start at the end of the month.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the care of a resident. The incident involved a Certified Nursing Assistant (CNA), identified as Staff E, who did not adhere to hand hygiene protocols while assisting a resident with toileting. The resident, who had a BIMS score of 13 indicating no cognitive impairment, required total dependence on staff for toileting hygiene and transfers due to medical conditions including cancer, heart failure, and respiratory failure. During the observation, Staff E was seen handling soiled materials and then touching various surfaces and equipment without changing gloves, which is a breach of infection control procedures. The resident was observed to be soiled with urine, and Staff E, after removing the soiled pad, continued to touch the full-body mechanical lift, its remote, the sling, a clean soaker pad, and the wheelchair without changing gloves. This action was contrary to the facility's infection control policy, which requires changing gloves after handling soiled items. The facility's Administrator confirmed that staff are expected to follow these procedures, indicating a lapse in adherence to established infection control protocols.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marshalltown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Marshalltown | 1.2 mi | ★★★★★ | 14 | 0 |
| Southridge Specialty Care | 1.4 mi | ★★★★★ | 0 | 0 |
| Iowa Veterans Home | 2.5 mi | ★★★★★ | 6 | 0 |
| Oakview Nursing Home | 13.6 mi | ★★★★★ | 1 | 0 |
| Westbrook Acres | 14.1 mi | ★★★★★ | 8 | 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.