Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Lyon Specialty Care during CMS and state inspections, most recent first.
A resident with dementia, anxiety disorder, muscle weakness, and moderate cognitive impairment was reportedly yelled at and had their lips forcibly held shut for several seconds by a CNA after the resident was yelling out. An LPN at the nurse’s station heard the CNA tell the resident to be quiet and saw the CNA’s hand move away from the resident’s face, and another CNA later reported witnessing the physical contact. The allegation was not communicated in a manner that ensured prompt administrative awareness, and the DON did not learn of the incident until the following day, after the CNA had completed one full shift and worked part of another. As a result, the facility’s self-report to the state survey agency was made more than 2 hours after the allegation was initially made, contrary to the facility’s abuse policy requiring immediate internal reporting and notification to the state within 2 hours.
A resident with dementia, anxiety, muscle weakness, and severe cognitive impairment was being pushed in a wheelchair while yelling out, which staff described as normal for him. An LPN at the nurses’ station heard a CNA tell the resident to “shut the fuck up” and saw the CNA’s hand move away from the resident’s face but did not intervene or separate them. Another CNA later reported that she had seen the same CNA pinch the resident’s lips closed for several seconds while again telling him to “shut the fuck up,” and that the resident was then assisted to bed. Although facility policy required immediate measures to prevent further potential abuse, including separating an employee accused of abuse from residents, the alleged abusive CNA continued working the rest of the shift and returned for the next shift before any separation occurred.
A resident with dementia, anxiety disorder, and muscle weakness, and a BIMS score indicating severe cognitive impairment, was allegedly told to shut up and be quiet and had their lips pinched by a CNA while being assisted to their room, as reported by another CNA and partially overheard by an LPN. However, no documentation of this alleged abuse incident was entered into the resident’s progress notes, and no incident report was found. The facility also lacked a policy on maintaining accurate and complete resident records, resulting in the resident’s medical record not reflecting the reported event.
The facility failed to serve full portions of food as per the menu, leading to a deficiency in meeting residents' nutritional needs. On a specified date, mixed vegetables were substituted with wax beans, and a staff member did not provide correct portions, serving a resident approximately 1/4 scoop of beans and another resident 1/2 scoop of ground turkey. The facility's policy outlines procedures for accurate food measurements, but these were not followed, resulting in the deficiency.
A facility failed to provide a bed hold notice to a resident or their representative before a planned therapeutic leave. The resident, with diagnoses including a pelvic mass and muscle weakness, was taken to the Mayo Clinic for testing and returned after two days. The facility's policy requires written information about bed-hold rights and limitations to be given before a transfer, but this was not done. The administrator confirmed the oversight, acknowledging the expectation for staff to complete such notices.
A resident, dependent on staff for transfers and diagnosed with dementia and traumatic brain dysfunction, was involved in an incident where CNAs failed to lock wheelchair brakes during a mechanical lift transfer. This action was against the facility's policy, as confirmed by the DON.
A CNA failed to follow proper infection control practices during incontinence care for a resident. The CNA did not change gloves or perform hand hygiene after touching a trash can and soiled catheter tubing, continuing care with soiled gloves. The facility's policies on hand hygiene and glove use were not adhered to, as confirmed by the DON.
Failure to Timely Report Alleged Verbal and Physical Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating moderate cognitive impairment. According to staff statements, Resident #1 was being assisted in a wheelchair to his room when he was yelling out, which staff described as normal for him. Staff B, a CNA, reported that Staff D, a CNA, came from behind the nurse’s station, grabbed the resident’s lips together with her thumb and index finger for approximately five seconds, and told him to “shut the fuck up.” Staff A, an LPN, did not witness the pinch but heard what was said to the resident and saw Staff D’s hand moving away from the resident’s face. Staff A documented the concern and left a note for the DON, then later messaged the DON the following evening asking if the note had been received. The DON was not working that day and did not become aware of the allegation until approximately 5:00 p.m. the following day, at which time she contacted Staff A and learned of the alleged incident. The DON confirmed that Staff D completed her full shift on the day of the alleged incident and worked again the following day before the DON became aware of the situation. Facility intake information showed the self-report to DIAL was submitted the evening after the DON learned of the allegation, which was more than 2 hours after the initial allegation was made to Staff A. Facility policy required that all allegations of abuse be reported immediately to the charge nurse, that the charge nurse immediately notify the Administrator or designee, and that all allegations be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made.
Failure to Immediately Separate Resident from Alleged Abusive Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to immediately separate a vulnerable resident from a staff member following an alleged abuse incident. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. On the evening of 12/22/25, Staff C was pushing Resident #1 in a wheelchair past the nurses’ station while the resident was yelling out, which staff described as normal for him. Staff A, an LPN, was at the nurses’ station charting when she heard Staff D, a CNA, tell the resident to “shut the fuck up.” Staff A looked up, verbally responded “really” to Staff D, and observed Staff D’s hand moving away from the resident’s face, but did not witness any physical contact. Staff A did not intervene to separate the resident from Staff D and did not assist with putting the resident to bed. Later that evening, after the shift ended, Staff B, a CNA, sent a message to Staff A reporting that she had seen Staff D walk out from behind the nurses’ station, pinch the resident’s lips closed with her thumb and index finger for approximately five seconds, and again tell him to “shut the fuck up” while Staff C continued to assist the resident to bed. Staff B stated that the resident’s yelling out was normal for him and that Staff A was present at the nurses’ station when this occurred. The facility’s Dependent Adult Abuse policy, dated November 2019, required that upon receiving a report of an allegation of resident abuse, the facility immediately implement measures to prevent further potential abuse, including separating the accused employee from all residents by suspension or reassignment. Despite this policy, the alleged abusive staff member continued to work the remainder of the shift on 12/22/25 and returned for the next shift before any separation occurred, and the Administrator later acknowledged the facility should have separated the staff member from others at the time of the incident.
Failure to Document Alleged Abuse Incident in Resident Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records regarding an alleged abuse incident involving one resident. The resident had diagnoses including non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. According to a written statement by an LPN (Staff A), a CNA (Staff B) reported that two CNAs (Staff C and Staff D) were assisting the resident to his room when the resident was talking and Staff D told him to shut up and be quiet. Staff B further reported that she saw Staff D pinch the resident’s lips together. Staff A did not witness the pinch but stated she heard what was said to the resident and, when she looked up from her charting, she saw Staff D’s hand moving away from the resident’s face. Despite this alleged incident, review of the resident’s progress notes showed no documentation of the event that occurred on that date. The facility had submitted a self-report of an allegation of abuse, but there was no corresponding entry in the resident’s medical record describing the incident. Additionally, the facility did not have a policy on maintaining accurate and complete resident records. A regional nurse consultant confirmed there was nothing charted in the resident’s record regarding the incident and that there was no incident report of any type, demonstrating the lack of required documentation for this event.
Deficiency in Food Portioning and Menu Adherence
Penalty
Summary
The facility failed to serve the full portions of food as outlined in their menu, which led to a deficiency in meeting the nutritional needs of residents. On the specified date, the facility's menu for both regular and mechanical diets included an open-faced turkey sandwich, mashed potatoes, turkey gravy, mixed vegetables, and melon. However, during meal service, mixed vegetables were substituted with wax beans, and the staff member responsible for serving the meals did not provide the correct portions. Specifically, Resident #30 received approximately 1/4 scoop of beans instead of the planned 1/2 cup, and Resident #1 received approximately 1/2 scoop of ground turkey instead of the full portion. Additionally, the staff member failed to properly fill and empty the scoop when serving wax beans, resulting in inconsistent portion sizes. The facility's Kitchen Weights and Measures policy, last revised in April 2007, outlines the training and procedures for ensuring accurate food measurements and portion sizes. Despite this policy, the staff member did not adhere to the guidelines, leading to the deficiency. The Dietary Manager confirmed the expectation for staff to serve correct portions using the appropriate utensils, emphasizing the importance of proper nutrition for residents. The failure to serve the correct portions and the substitution of menu items without proper adjustments contributed to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notice for Therapeutic Leave
Penalty
Summary
The facility failed to provide a bed hold notice to Resident #33 or their representative prior to the resident's departure for a planned therapeutic leave. This deficiency was identified through a review of clinical records, staff interviews, and facility policy. Resident #33, who had diagnoses including a pelvic mass, pulmonary nodule, and muscle weakness, was taken by family to the Mayo Clinic for testing and returned to the facility after two days. The facility's policy, dated March 2017, requires that residents and their representatives receive written information about bed-hold rights and limitations, payment policies, and transfer details before a transfer occurs. However, upon review of the clinical chart on July 23, 2024, it was found that the facility did not issue a bed hold notice for Resident #33's therapeutic leave from March 28 to March 30, 2024. The facility's administrator confirmed in an interview on July 24, 2024, that the staff failed to complete the required bed hold notice for the resident's leave. The administrator acknowledged the expectation that staff should complete a bed hold notice whenever residents leave the facility for therapeutic leave.
Failure to Lock Wheelchair Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift, leading to a deficiency in preventing accidents and hazards for a resident. The Minimum Data Set (MDS) assessment for the resident did not document a Brief Interview for Mental Status (BIMS) score, but indicated the resident was dependent on staff for care and transfers, with diagnoses including dementia, traumatic brain dysfunction, and altered mental status. The care plan had initiated the use of a mechanical lift for transfers. During an observation, two Certified Nurse's Aides (CNAs) used a mechanical lift to transfer the resident from the bed to a wheelchair but failed to lock the wheelchair brakes before lowering the resident, contrary to the facility's policy. The Director of Nursing confirmed the requirement to lock the wheelchair brakes during such transfers.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident. During an observation, a Certified Nursing Assistant (CNA), referred to as Staff A, was seen performing perineal care on a resident. While doing so, Staff A used their left gloved hand to take a trash can from another CNA, Staff B, and placed it on the floor. Despite touching the trash can, Staff A did not change gloves or perform hand hygiene before continuing with the perineal care. Staff A then took a clean wipe from Staff B and continued the care with the same soiled gloves. Further observations revealed that Staff A touched the soiled catheter tubing and leg strap on the resident's leg without changing gloves or performing hand hygiene, and continued with the perineal care. After completing the care, Staff A used the same soiled gloves to clean the catheter tubing. Only after completing all tasks did Staff A and Staff B remove their gloves and perform hand hygiene. The facility's policies on hand hygiene and glove use, which emphasize the importance of hand hygiene in preventing infection spread, were not followed. The Director of Nursing confirmed that the staff was expected to change gloves and perform hand hygiene after the gloves became soiled.
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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 Rock Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - George | 10.3 mi | ★★★★★ | 19 | 0 |
| Parkview Manor Nursing Home | 10.6 mi | ★★★★★ | 10 | 0 |
| Tuff Memorial Home | 11.4 mi | ★★★★★ | 9 | 0 |
| Fellowship Village | 15 mi | ★★★★★ | 2 | 0 |
| Hegg Memorial Health Center | 16 mi | ★★★★★ | 4 | 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.