Above average — CMS composite of the measures below.
The next survey window likely opens 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 Lone Tree Health Care Center Inc during CMS and state inspections, most recent first.
Failure to report alleged financial exploitation: A resident with moderate cognitive impairment and ADL assistance needs initially refused to have her money secured in a lock box and would not disclose the amount she had. Later, POAs reported cash missing from the resident’s room, staff searched but did not find it, and the Administrator did not report the allegation to the State Agency because the amount missing had changed and could not be confirmed.
A facility failed to complete a significant change MDS in a timely manner after a resident was admitted to hospice. The MDS showed the resident entered hospice within the last 14 days, and the Administrator confirmed the assessment had not been completed within the expected timeframe. The facility stated it did not have a specific policy or protocol for completing significant change MDS assessments and followed the RAI manual.
A resident with malnutrition, anemia, and heart failure experienced complications with tube feeding due to staff not following the physician's order. Staff added water to the feeding to make it run faster, leading to the resident's tube feeding site leaking fluid and requiring hospital evaluation. The facility policy directed staff to administer the feeding slowly by gravity and to flush the tube with water before and after feeding.
Failure to Report Alleged Financial Exploitation
Penalty
Summary
The facility failed to report an allegation of potential financial exploitation to the State Agency for one resident. Resident #33 had a BIMS score of 9, indicating moderate cognitive impairment, and the MDS noted no behavioral symptoms or psychiatric/mood disorders. The care plan showed the resident needed staff assistance with ADLs, including toileting and transferring. Progress notes documented that the resident initially refused to have her money placed in a lock box and declined to state how much money she had in her possession, saying she had enough. Later, both POAs reported to the nurse that the resident had $350 cash in her room and that it was missing, and staff searched the room but did not find the cash. The POA stated it was a lesson learned because the resident had not allowed staff to lock up all of the money, and reported that the resident had given staff $90 to lock up even though she had initially had $350. The Administrator stated she did not report the allegation to DIAL because the sister could not confirm the resident had actually been missing money since the amount missing had changed. Facility policy stated that any alleged misappropriation of resident property must be immediately reported to the administrator, who then reports the allegation to the appropriate authorities.
Delayed Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS assessment in a timely manner after a resident was admitted to hospice care. Resident #10’s clinical census showed an admission to hospice on 7/18/25, and the MDS for the resident was identified as a significant change assessment indicating the resident entered hospice care within the last 14 days. During interview on 11/19/25 at 11:35 AM, the Administrator confirmed that a significant change MDS had not been completed within 14 days following the resident’s admission to hospice care. The Administrator also stated the facility did not have a specific policy or protocol for completing a significant change MDS and instead followed the RAI manual.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to provide tube feeding according to the physician's order for a resident with malnutrition, anemia, and heart failure. The resident, who had moderate cognitive impairment, required tube feeding due to swallowing problems. The care plan directed the staff to follow the physician's order for tube feeding and water flushes. However, staff members were found to be adding water to the feeding to make it run faster, contrary to the physician's order and facility policy. This led to the resident's tube feeding site leaking fluid, resulting in the resident being sent to the hospital for evaluation. The hospital records indicated that the feeding tube was functioning appropriately but emphasized the need for the feeding to be administered slowly over several minutes rather than quickly as a bolus. Staff interviews revealed that both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) admitted to adding water to the feeding to thin it out, which was against the physician's order. The Assistant Director of Nursing (ADON) confirmed that the facility policy directed staff to follow the physician's orders and that adding water to the feeding was not in compliance with these orders. The facility's policy on enteral feeding specified that the feeding should be administered slowly by gravity and that the tube should be flushed with water before and after feeding to prevent clogging. The failure to adhere to these guidelines resulted in the resident experiencing complications with their tube feeding.
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What surveyors actually found near you
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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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Illustrative
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Nursing homes near Lone Tree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Simpson Memorial Home | 10.7 mi | ★★★★★ | 6 | 0 |
| Iowa City Rehab & Health Care | 13.3 mi | ★★★★★ | 27 | 0 |
| Briarwood Healthcare Center | 13.5 mi | ★★★★★ | 1 | 0 |
| Oaknoll Retirement Residence | 13.6 mi | ★★★★★ | 5 | 0 |
| Crestview Specialty Care | 13.8 mi | ★★★★★ | 15 | 1 |
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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.