Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Martin Health Center, Inc during CMS and state inspections, most recent first.
Surveyors identified failures in proper food storage, staff hair restraint use, and maintenance of hot food holding temperatures. Opened thickened beverages were kept past manufacturer discard dates, staff did not fully contain their hair in hairnets while preparing and serving food, and hot food was held below the required 135°F during meal service, contrary to facility policy and staff knowledge.
A nurse failed to verify the placement of a g-tube before flushing and administering medications to a resident with severe cognitive impairment and multiple medical conditions. Despite facility policy and physician orders requiring daily measurement and placement checks before medication administration, the nurse did not perform these checks and proceeded with the medication pass, even after encountering resistance.
A resident with diabetes and memory impairment was not served the prescribed consistent carbohydrate (CCHO) diet, receiving a larger portion of sweet potatoes than ordered. Staff acknowledged serving the regular diet instead of the CCHO diet, and interviews confirmed that menu extensions and serving sizes were not followed as required by facility policy.
A resident with intact cognition and dependent on staff for transfers fell during a Hoyer lift transfer, resulting in a right femur fracture and left rib fractures. Two CNAs were involved in the transfer, and both reported triple-checking the sling's attachment. Despite their efforts, the right upper strap of the sling became unhooked during the transfer, causing the fall. The Hoyer lift had been inspected and was in good condition prior to the incident.
The facility failed to complete Significant Change MDS assessments within 14 days for residents who experienced significant changes, such as starting or revoking hospice services. Staff misunderstood the requirements, leading to delays in assessments for multiple residents.
The facility failed to notify the state ombudsman of emergency transfers for two residents. One resident with intact cognition was transferred to the hospital, but the transfer was not documented in the Ombudsman notification form. Another resident with moderately impaired cognition was admitted to the hospital on multiple occasions, but these transfers were not documented in the corresponding Ombudsman notification forms. The Administrator admitted the reports were not completed correctly and that there was no policy for Ombudsman notification.
A facility failed to complete a new Level I PASRR for a resident with new diagnoses and medication changes. The resident's MDS assessment indicated intact cognition with diagnoses of anxiety, bipolar disorder, psychotic disorder, and non-Alzheimer's disease. The PASRR from a previous facility was not updated, contrary to the facility's policy requiring a new evaluation when there are changes in a resident's condition.
Deficiencies in Food Storage, Staff Hygiene, and Hot Food Holding Temperatures
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, staff hygiene, and food temperature control within the facility's kitchen. Specifically, opened cartons of Ready Care thickened orange juice and Thick It Clear Advantage Thickened Water were found stored beyond the manufacturer's recommended discard dates, with staff unable to confirm whether the dates marked were for delivery or opening. Staff interviews revealed inconsistent understanding of discard protocols, with some staff following a three-day rule and others referencing manufacturer instructions. Additionally, food storage policies required items to be labeled and dated appropriately, but these were not consistently followed. Further observations revealed that staff working in the kitchen did not have all hair fully contained within hairnets, with several instances of 4-5 inches of hair hanging out while preparing and serving food. During meal service, hot food, specifically green beans, was held at temperatures below the required 135 degrees Fahrenheit, with the food sitting in a steam pan with the burner off for over 30 minutes. Staff interviews confirmed knowledge of the temperature requirements, but the practice did not align with policy. Facility policies reviewed directed proper food storage, temperature maintenance, and use of hair restraints, but these were not adhered to during the survey.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to check the placement of a resident's gastrostomy tube (g-tube) prior to flushing it with water and administering medications. The nurse did not aspirate for gastric contents or measure the tube from the insertion site to the end, as required by facility policy and physician orders. Instead, the nurse proceeded to flush the tube and administer medications, even encountering resistance while pushing water into the tube. The nurse later acknowledged that she did not check tube placement before administering medications. The resident involved had severe cognitive impairment, was dependent on staff for all care, and received the majority of nutrition and hydration via the g-tube due to multiple diagnoses including dementia, end stage renal disease, and dysphagia. Facility policy and physician orders required daily measurement of the g-tube to confirm placement and mandated checking tube placement before medication administration. Interviews with staff and review of facility policies confirmed that the expected practice was not followed during the observed medication administration.
Failure to Serve Physician-Ordered Consistent Carbohydrate Diet
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic polyneuropathy, who was prescribed a consistent carbohydrate (CCHO) diet of 60-75 grams of carbohydrates per meal, was not served the physician-ordered diet. The resident's care plan and physician orders specified the CCHO diet, and the approved menu detailed specific serving sizes, including a 2-ounce portion of mashed sweet potatoes. However, during meal service, staff served the resident a 4-ounce portion of sweet potatoes, which exceeded the prescribed amount for the CCHO diet. The staff member responsible for plating the meal acknowledged serving the regular diet instead of the CCHO diet as indicated on the meal ticket. Interviews with the Dining Hospitality Coordinator, Certified Dietary Manager, and Dietitian confirmed that the staff did not follow the posted menu extensions and serving sizes, which are intended to prevent such errors. The facility's policy directed that the menu and serving sizes be followed as approved by the Registered Dietitian Nutritionist Supervisor or Lead Hospitality Coordinator. The failure to adhere to the prescribed diet and serving sizes resulted in the resident not receiving the ordered therapeutic diet.
Resident Injured in Hoyer Lift Transfer Incident
Penalty
Summary
The facility failed to provide a safe mechanical lift transfer for a resident, resulting in a fall and subsequent injuries. The resident, who had intact cognition and was dependent on staff for all transfers, required the use of a Hoyer lift with assistance from two staff members. During a transfer from a recliner to a bed, the right upper side of the sling became unhooked, causing the resident to fall and sustain a right femur fracture and left rib fractures. Interviews with the resident and staff involved revealed that the transfer process was initiated with the resident already positioned in the sling. Two Certified Nurse Aides (CNAs) were responsible for attaching the sling to the Hoyer lift. Both CNAs reported that they triple-checked the sling's attachment before beginning the transfer. However, during the move, the right upper strap of the sling came unhooked, leading to the resident's fall. The incident occurred quickly, and staff were unable to prevent the fall. The resident reported that the staff did not appear to be in a rush and that the sling was hooked up correctly to the best of his knowledge. Despite the staff's efforts to ensure the sling was secure, the failure of the right upper strap resulted in the resident's injuries. The facility's records indicated that the Hoyer lift had been inspected and deemed in good condition prior to the incident.
Removal Plan
- Took the Hoyer out of commission until inspected by EZ-Way
- The facility completed staff education and testing
- Ongoing facility audits of staff with the Hoyer lifts
- The Hoyer company representative reviewed the proper procedures and demonstrated how to use the Hoyer lift
Failure to Timely Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete the Significant Change Minimum Data Set (MDS) assessments for four residents within the required 14-day period after a significant change in their condition. Resident #14 elected to receive hospice services on April 12, 2024, and revoked them on April 16, 2024, but the facility did not complete a significant change MDS assessment following these changes. Staff A, a Nurse Mentor, incorrectly believed that a significant change assessment was not necessary because the resident went off hospice within 14 days and did not trigger two significant changes. Resident #32 began receiving hospice services on June 19, 2024, but the facility completed the Significant Change in Status Assessment (SCSA) more than 14 days later. Resident #35 started hospice services on May 18, 2023, but the SCSA was completed 11 days past the required timeframe. Similarly, Resident #37 began hospice services on November 21, 2023, but the SCSA was completed late. Staff B, another Nurse Mentor, reported following the Assessment Reference Date (ARD) set by Staff A, who was unaware of the 14-day requirement for completing the hospice MDS SCSA.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the state ombudsman as required for emergency transfers for two residents. Resident #2, with intact cognition as indicated by a BIMS score of 15, was transferred to the hospital on 12/24/23, but the December 2023 Ombudsman notification form lacked documentation of this transfer. Similarly, Resident #8, with moderately impaired cognition as indicated by a BIMS score of 10, was admitted to the hospital on multiple occasions, including 8/29/23, 9/15/23, and 12/21/23, but the corresponding Ombudsman notification forms for August, September, and December 2023 did not document these transfers. During an interview, the Administrator acknowledged that the facility did not complete the 2023 Ombudsman reports correctly and lacked a policy related to Ombudsman notification.
Failure to Complete New PASRR for Resident
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASRR) for a resident, identified as Resident #26, who was reviewed during a survey. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 15, suggesting intact cognition, and included diagnoses of anxiety, bipolar disorder, psychotic disorder, and non-Alzheimer's disease. The PASRR Level I Screening Outcome dated November 30, 2020, showed a Level I determination with no Level II required. However, this PASRR was transferred with the resident from another facility, and the current facility did not submit a new PASRR despite the resident having new diagnoses and medication changes. The facility's PASRR policy, dated November 2022, outlines the process for ensuring appropriate placement and services for residents with serious mental illness or intellectual and developmental disabilities. The policy requires a Level I evaluation before admission and, if necessary, a Level II evaluation. In this case, the facility did not adhere to its policy, as it failed to submit a new PASRR for Resident #26 after changes in the resident's condition. The administrator acknowledged the oversight during an interview, noting that the facility missed the requirement to submit a new PASRR.
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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 Cedar Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newaldaya Lifescapes | 1.2 mi | ★★★★★ | 1 | 0 |
| Cedar Falls Health Care Center | 1.2 mi | ★★★★★ | 20 | 0 |
| The Suites At Western Home Communities | 2.7 mi | ★★★★★ | 1 | 0 |
| Pinnacle Specialty Care | 2.7 mi | ★★★★★ | 6 | 0 |
| Pillar Of Cedar Valley | 4.8 mi | ★★★★★ | 13 | 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.