Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lamoni Specialty Care during CMS and state inspections, most recent first.
A resident's supply of morphine was found to be missing 4 milliliters, but staff did not immediately report the discrepancy to the DON as required. Instead, staff assumed the loss was due to spillage or manufacturer variance, signed off on the count, and discarded the bottle. The DON was informed the next day, conducted an internal review, and did not report the incident to the State Agency, as drug diversion was not suspected.
A resident receiving liquid morphine for pain management experienced a discrepancy in the amount of medication remaining, with several milliliters unaccounted for. Staff failed to complete required shift change narcotic counts, did not immediately report the missing medication to the DON, and provided inconsistent explanations for the loss. The facility did not follow proper procedures for documenting, reconciling, and reporting controlled substance discrepancies.
Two staff members, including an LPN, signed the narcotic count record at shift change, indicating a count was completed, even though both later admitted the count was not performed together as required. This resulted in inaccurate documentation of controlled substance records.
A resident with moderate cognitive impairment did not receive a scheduled ear flush due to an LPN's failure to correctly transcribe a physician's order. The resident received ear drops for earwax buildup, but the ear flush was omitted from the EHR, delaying her audiology appointment. The facility's policy on medication orders was not followed, leading to this deficiency.
A resident received an incorrect dosage of Fluconazole due to a transcription error by an LPN, leading to hospitalization for shortness of breath, unsteady gait, and a change in mental status. The error was discovered after the resident experienced a seizure and cardiac arrest, and it was determined that a drop in sodium levels caused the mental status change and seizure.
Failure to Report Missing Narcotic
Penalty
Summary
The facility failed to report a discrepancy involving 4 milliliters of morphine missing from a resident's supply. The resident, who was cognitively intact and had multiple medical diagnoses including atrial fibrillation, coronary artery disease, diabetes mellitus, and emphysema, was prescribed morphine sulfate for pain management. According to the Individual Narcotic Record, the resident should have had 4 milliliters remaining in the bottle, but only 0.25 milliliters could be drawn. Staff involved in the medication administration and narcotic count did not immediately report the missing narcotic to the Director of Nursing (DON) as required. Instead, staff assumed the discrepancy was due to spillage or manufacturer variance and signed off on the count as corrected, discarding the bottle without further investigation or notification. The DON was not informed of the missing morphine until the following day, after which she conducted an internal review. Staff interviews revealed that narcotic counts were not consistently performed at shift changes, and staff were unaware of the requirement to report missing narcotics immediately. The DON ultimately determined that the discrepancy could be explained by possible spillage and manufacturer variance, and did not report the incident to the State Agency, as she did not suspect drug diversion. The failure to promptly report the missing controlled substance and the results of the internal investigation to the appropriate authorities constituted the deficiency.
Failure to Accurately Reconcile and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications for a resident who was prescribed liquid morphine sulfate for pain management. The resident, who was cognitively intact and had multiple medical diagnoses including atrial fibrillation, coronary artery disease, diabetes mellitus, and emphysema, received morphine as ordered. According to the Individual Narcotic Record (INR), there should have been 4 milliliters remaining in the bottle on a specific date, but only 0.25 milliliters could be drawn from the bottle. Staff interviews revealed that a proper shift change narcotic count was not completed between two nurses, and the discrepancy in the morphine count was not immediately reported to the Director of Nursing (DON) as required. Staff involved in the incident provided conflicting accounts regarding the missing morphine. One nurse stated she assumed the missing medication was due to spillage over time and signed off on the INR as corrected without reporting the discrepancy. Another nurse admitted to not completing the required narcotic count at shift change and later felt pressured by the DON to claim she had spilled the morphine, despite not recalling such an event to the extent of the missing amount. The DON, upon being informed of the discrepancy, initiated an investigation and attempted to account for the missing morphine through staff interviews and reference to manufacturer’s instructions regarding possible volume variance in the bottle. Despite these efforts, the missing morphine was not discovered during numerous prior shift change narcotic counts, and the facility did not report the discrepancy to the State Agency. The documentation and reconciliation process for controlled substances was not followed as required, and staff failed to ensure that all doses were properly accounted for and discrepancies promptly reported and investigated.
Inaccurate Documentation of Narcotic Shift Change Counts
Penalty
Summary
Staff failed to accurately document medical records related to controlled substances. On one shift, a staff member worked from 2:00 p.m. to 10:00 p.m. and signed the Controlled Drugs-Count Records at the 2:00 p.m. shift change, indicating all narcotics were accounted for. However, at the 4:00 p.m. shift change, the same staff member handed over the medication cart keys to another LPN without completing the required narcotic count together. Both staff members later acknowledged in interviews that the shift change narcotic count was not performed as required, despite both signing the record to indicate it had been completed. The documentation did not accurately reflect the actual events, resulting in inaccurate medical records.
Failure to Transcribe Physician Order Correctly
Penalty
Summary
The facility failed to accurately transcribe a physician's order for a resident with moderate cognitive impairment, resulting in the order not being fully completed in a timely manner. The resident, who had a history of earwax buildup and was hard of hearing, was supposed to receive ear drops for five days followed by an ear flush. However, the order was incorrectly transcribed by an LPN, leading to the omission of the ear flush from the Electronic Health Record (EHR). As a result, the resident did not receive the ear flush as scheduled, which delayed her ability to make an audiology appointment for hearing aid adjustments. The Medication Administration Report (MAR) documented that the ear drops were administered for five days, but the ear flush was not recorded as a separate order. The LPN responsible for transcribing the order acknowledged the error and stated that the resident had not mentioned the issue until several days later. The Director of Nursing confirmed that the order should have been entered as two separate orders to ensure completion. The facility's policy on medication and treatment orders emphasizes the importance of including all necessary details, such as start and stop dates and any interim follow-up requirements, which were not adhered to in this case.
Incorrect Transcription of Physician's Order
Penalty
Summary
The facility failed to accurately transcribe and implement a physician's order for a resident, leading to the administration of an incorrect dosage of Fluconazole. The resident, who had intact cognition and multiple diagnoses including hyponatremia, non-Alzheimer's dementia, Parkinson's disease, schizophrenia, anxiety, and depression, was supposed to receive 300 mg of Fluconazole once per week for four weeks. However, the order was incorrectly transcribed by an LPN as 300 mg daily for 14 days. This error was discovered when the resident was sent to the hospital for shortness of breath, unsteady gait, and a change in mental status, which led to a seizure and cardiac arrest. The resident was subsequently life-flighted to a larger hospital where it was determined that a drop in sodium levels caused the mental status change and seizure. The facility's pharmacist confirmed that the dosage given was within the safe range, and the ARNP stated that the resident was not on the medication long enough for the error to cause the hospitalization. The LPN admitted to misreading the order and expressed that the error had traumatized her. The facility has since implemented a double-check system for new orders to prevent future errors.
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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 Lamoni
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Acres Care Center | 13.1 mi | ★★★★★ | 0 | 0 |
| Mount Ayr Health Care Center | 16.6 mi | ★★★★★ | 6 | 0 |
| Clearview Home | 17.4 mi | ★★★★★ | 2 | 0 |
| Pearl's Ii Eden For Elders | 23.8 mi | ★★★★★ | 0 | 0 |
| Crestview Home | 25.5 mi | ★★★★★ | 0 | 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.