Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Methodist Manor Retirement Community during CMS and state inspections, most recent first.
Improper food storage, labeling, and hand hygiene during meal prep. Kitchen observations found multiple frozen, refrigerated, and dry storage items opened without dates, outside original packaging, or expired, including unlabeled meats, soups, produce, and dry goods. During prep of mechanical soft and pureed chicken, a Dietary Aide reused gloves while handling food and equipment, rinsed hands with water only after glove removal, used an ungloved scoop for service, and punctured packaging to check temps before serving pre-packaged pureed items to a resident.
Infection prevention practices were not followed during resident care. A resident with an indwelling catheter had observed care in which CNAs changed gloves without performing hand hygiene between tasks, and one CNA reached into the resident’s drawer during the procedure. In another observation, an RN caring for a resident on EBP for a PEG tube removed a gown after medication administration and hung it back on the wall for reuse instead of using a new gown.
A resident with cognitive deficits and total dependence on staff reported symptoms of a UTI, but staff delayed obtaining a urinalysis for six days and failed to document vital signs or nursing notes during this period. Communication issues between staff and the family contributed to the delay, and the facility did not follow its own protocols for assessment and documentation of changes in condition.
The facility did not develop or update comprehensive care plans for several residents, omitting critical information such as antipsychotic medication management, interventions for wandering, oxygen therapy, and PASRR-related services. These omissions were confirmed by staff and were not in accordance with facility policy.
The facility did not properly screen, educate, offer, or document COVID-19 vaccination status, consent, or refusal for several residents, including those with severe cognitive impairment and one who was cognitively intact. Clinical records lacked evidence of education or offers for additional vaccine doses, and in one case, a resident not up to date with vaccination was hospitalized for COVID-19. The DON confirmed the absence of required documentation, despite facility policy mandating these actions.
A resident with multiple chronic conditions experienced a fall resulting in a hand injury, followed by days of increasing pain and swelling in the left upper extremity. Despite repeated complaints and administration of PRN pain medication, the physician was not notified of the resident's worsening condition until the pain became severe and a fracture was discovered. Facility policy required prompt physician notification for such changes, but this did not occur.
Two residents were involved in a physical altercation during a meal, with one slapping the other after an exchange of negative comments. Although a nurse intervened and the DON was notified the next day, the required report to DIAL was not submitted within the mandated 2-hour window, and law enforcement was not notified as required by policy.
A resident with schizophrenia and moderate cognitive impairment was incorrectly marked on the MDS as not having a serious mental illness under the PASRR process, despite documentation confirming the presence of a PASRR condition. The nurse manager misinterpreted the PASRR documentation, leading to the inaccurate assessment.
A resident with schizophrenia and moderate cognitive impairment was not provided care planning or assessment that incorporated recommendations from the PASRR evaluation, including needs for neurocognitive evaluation, power of attorney assistance, psychiatric record retrieval, and ongoing psychotropic medication review. Staff only reviewed the PASRR summary and did not address the detailed recommendations, resulting in a deficiency.
A resident with COPD and moderate cognitive impairment was found using oxygen tubing that had not been changed or relabeled for over four months, contrary to facility policy requiring monthly replacement. Staff confirmed the tubing was last changed in November and documented on the TAR, but observations showed the same tubing remained in use.
The facility failed to notify the families of two residents about significant changes in their conditions. One resident experienced multiple episodes of hypoglycemia, while another had significant weight gain. Despite these changes, there was no documentation of family notification, contrary to the facility's policy.
A resident at high risk for falls, with a history of multiple health issues, fell and sustained injuries due to inadequate supervision by a CNA who failed to use a gait belt. The resident was left unattended while the CNA put clothes away, leading to the fall. The facility's standard practice of using a gait belt was not followed, resulting in the resident suffering rib fractures.
The facility failed to ensure proper sanitization of dishes and kitchen equipment, as three out of four dish machines did not consistently reach the required temperature. Temperature logs were incomplete, and high-temperature test strips were not used. Additionally, food thermometers were not adequately sanitized between uses, and staff were observed handling food with soiled gloves and failing to perform proper hand hygiene. These actions indicate a lack of adherence to infection control practices.
A facility failed to complete the required MDS assessment for a resident who was discharged home. The resident's discharge was documented, but the discharge MDS was not completed by the deadline. Nurse Managers responsible for the MDS assessments did not have the resident on their lists, and it was suggested that a notification email may not have been sent, resulting in the missed assessment.
A facility failed to update the Level 2 PASSR for a resident with a new mental health diagnosis and medication changes. The resident had moderate cognitive impairment and was prescribed high-risk medications for anxiety and delusional disorders. The only documented PASSR was from 2015, despite changes in the resident's mental health status. The Unit Manager confirmed that the PASSR had not been updated, contrary to the facility's policy requiring quarterly reviews and updates.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. One resident with intact cognition had a history of urinary tract infections and was on antibiotics, but the care plan lacked details on medications and monitoring. Another resident with severe cognitive impairment was on antidepressant and antianxiety medications, yet the care plan did not document their usage or side effects. These omissions were acknowledged by the RN/Nurse Manager.
A resident with intact cognition and multiple diagnoses, including heart failure and chronic respiratory failure, did not have their oxygen tubing changed as required by the facility's policy. Observations revealed that the tubing had not been updated since March, despite the Treatment Administration Record indicating it should be changed monthly. The DON confirmed the oversight, and the resident reported the tubing had not been changed.
A facility failed to provide a clinical rationale for declining a GDR for a resident on Risperdal, despite policy requirements. The resident, with moderately impaired cognition and diagnoses of anxiety and depression, was on psychotropic medications. Staff acknowledged the absence of a rationale, citing challenges in obtaining it from the physician.
The facility failed to provide adequate puree portion sizes for two residents, leading to insufficient calorie and protein intake. Observations revealed that staff used incorrect scoop sizes, serving less than the required portions. Despite having policies in place, the staff did not follow the correct procedures, resulting in leftover puree and inadequate servings for the residents.
A resident dependent on tube feeding was subject to infection control lapses when an LPN used a tube adapter dated several days prior and failed to change gloves after picking up items from the floor. The feeding equipment was also visibly soiled, and there was no routine cleaning schedule, contrary to the facility's infection control policy.
The facility failed to monitor long-term antibiotic use for two residents. One resident continued on Bactrim DS for bacteriuria without an end date, and another was on Cephalexin for chronic cystitis. The facility lacked a system to ensure the necessity of these antibiotics, despite having a policy for antibiotic stewardship.
Improper Food Storage, Labeling, and Hand Hygiene During Meal Preparation
Penalty
Summary
The facility failed to properly store and label food items with open dates, failed to identify items that were outside of original packaging, and did not discard expired items. During the initial kitchen observation, freezer items were found opened without open dates, including chicken wings, corn beef, chicken patties, white turkey patties, meat balls, bread dough rolls, and a large box of resealable plastic bags containing different kinds of frozen meat that were not specified on any of the bags. A coffee cake remained in its original plastic container with a best-by date of 2/13/26. In the walk-in freezer, vegetable soup and cheese soup were observed in plastic containers with green lids dated 2/4/26 and 2/12/26, and strawberry ice cream in individual cups had a best-by date of 5/14/25. The walk-in refrigerator contained items opened to air, expired, and without open dates, including a bag of spinach, a bag of lettuce that appeared soggy and brown to black with wilting leaves, pork loin wrapped in plastic wrap dated 3/10/26, roast beef in a large white container with plastic wrap dated 4/9/26, and a resealable plastic bag on top of a shelf that was not sealed, not labeled, and contained an unknown substance. Dry storage also contained items without open dates and expired items, including crackers in a resealable plastic bag, two bags of corn chips without open dates, and pasta noodles with an open date of 1/21/25. Staff B, the Certified Dietary Manager, stated that unidentified meat was donated to a local church and that expired items were expected to be thrown away. The facility also failed to complete appropriate hand hygiene during food preparation. During preparation of mechanical soft portions, Staff D, a Dietary Aide, removed chicken from the bone, handled the food processor lid and contents, sifted through the meat for bones and harder pieces, and repeated the process multiple times while wearing the same gloves. After removing gloves, Staff D rinsed her hands with water only and did not use soap before continuing food handling. Later, Staff D used a scoop that had been grasped with an ungloved hand to portion pureed chicken into containers. During food delivery, Staff E removed scoops wrapped with plastic wrap and laid them on the counter without a barrier before placing them into steam table containers with food. Staff D also punctured a thermometer probe through plastic covering on pre-packaged pureed corn and pureed bread items to check temperatures before the items were opened and served to a resident.
Infection Prevention Practices Not Followed During Resident Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow appropriate infection prevention practices during resident care. Resident #3 had a BIMS score of 15 and used an indwelling catheter. During observed catheter care, two CNAs completed hand hygiene at the start and used gowns and gloves, but after removing gloves they did not perform hand hygiene before putting on new gloves. One CNA also opened the resident’s drawer to obtain alcohol wipes while providing care, and both staff continued the procedure, including emptying urine from the catheter bag and cleaning the graduated cylinder, with multiple glove changes that were not followed by hand hygiene. The DON stated hand hygiene should occur between glove changes and when moving from a dirty area to a clean area. The facility also failed to follow its Enhanced Barrier Precautions practice for a resident with a PEG tube. During observation, an RN entered the room, performed hand hygiene, took a gown from the wall and put it on, administered medications, then removed the gown and hung it back on the wall for the next usage before performing hand hygiene and leaving the room. The facility policy for Enhanced Barrier Precautions stated gowns and gloves are used during high-contact activities with increased risk for MDRO transmission to staff clothing and hands, and the DON stated staff should be using a new gown when providing care.
Failure to Timely Assess and Intervene for UTI Symptoms
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a urinary tract infection (UTI). The resident, who had moderate cognitive deficits and was totally dependent on staff for activities of daily living, reported burning with urination and had a history of incontinence and previous UTIs. Despite the family reporting symptoms to nursing staff on a weekend, no urinalysis (UA) was ordered until six days later. Staff responses included monitoring and providing peri care, but there was no documentation of vital signs or nursing notes during the period when symptoms were reported. The resident's chart lacked nursing progress notes from several days and no vital signs were recorded for over a week, despite the resident exhibiting symptoms consistent with a UTI. Interviews with staff revealed that communication breakdowns occurred between staff and the resident's family, and that staff did not escalate the resident's symptoms to a physician or obtain a UA in a timely manner. The facility's policy required documentation, assessment, and follow-up for changes in condition, including full vital signs and nursing notes, but these were not completed. The deficiency was identified through observation, interview, and record review, confirming that the facility did not follow its own protocols for assessment and documentation when a resident exhibited a change in condition.
Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for four residents. For one resident with severe cognitive impairment and multiple behavioral health diagnoses, the care plan did not address the use of antipsychotic medication, including target behaviors, potential side effects, or necessary monitoring, despite a physician's order for Risperdal. Staff confirmed that high-risk medications were not included in the care plan as expected. Another resident with severe cognitive impairment and a history of wandering was not care planned for wandering behaviors or interventions to prevent entry into other residents' rooms, despite multiple documented incidents of wandering and redirection by staff. The nurse manager acknowledged that these behaviors and interventions were not addressed in the care plan and should have been. A third resident with moderate cognitive impairment and chronic medical conditions, including COPD, had physician orders for oxygen therapy, but the care plan did not document the use of oxygen. Additionally, a resident with moderate cognitive impairment and a diagnosis of schizophrenia had a PASRR approval requiring the facility to care plan for identified services, but the care plan lacked any reference to the PASRR or related services. Facility policies required individualized, comprehensive care plans addressing all relevant needs, but these were not followed for the residents identified.
Failure to Screen, Educate, Offer, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to properly screen, educate, offer, and document COVID-19 vaccination status, consent, or refusal for four out of five residents reviewed. Clinical record reviews showed that these residents, some with severe cognitive impairment, were not up to date with their COVID-19 vaccinations, and there was no documentation that they or their responsible parties had been educated about, offered, or had consented to or refused additional COVID-19 vaccinations since their last recorded dose. This lack of documentation was found despite the facility's policy requiring assessment of vaccination status, education, and documentation of consent or refusal for each resident upon admission and for subsequent doses as per CDC guidelines. Specific findings included residents with severe cognitive impairment who had not received updated COVID-19 vaccinations and whose records lacked evidence of education or offers for additional doses. One resident, who was cognitively intact, also had no documentation of being educated or offered the vaccine since admission. In one case, a resident who was not up to date with vaccination tested positive for COVID-19 and required hospitalization. The facility's Director of Nursing confirmed that there was no documentation of education, offer, or consent/refusal for these residents regarding the COVID-19 vaccine. The facility's policy outlined that all residents should be assessed for vaccination status, educated about the vaccine, and provided the opportunity to consent or decline, with all actions documented in the medical record. The policy also required the facility to coordinate vaccine administration and maintain records of all efforts, including off-site vaccination opportunities if on-site administration was not possible. However, the facility did not follow these procedures for the residents reviewed, resulting in the identified deficiency.
Failure to Notify Physician of Change in Condition After Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident following a fall. The resident, who had diagnoses including anemia, neurogenic bladder, and COPD, was found on the floor after sliding from her wheelchair. Initial assessment documented a bruise to the left hand, with no other injuries or pain reported at that time. Over the following days, the resident developed swelling, bruising, and increasing pain in the left upper extremity, including the hand, shoulder, and arm, with pain ratings escalating from 4/10 to 10/10. Despite these ongoing and worsening symptoms, there was no documentation that the physician was notified of the resident's pain and swelling until several days after the fall, when the pain became severe. The resident received as-needed pain medication on multiple occasions due to these symptoms, but the physician was not informed until the pain reached its peak. An x-ray subsequently revealed a fracture in the left elbow area. The facility's policy required that any significant change in a resident's condition, such as accidents resulting in direct harm or physical decline, be promptly assessed and reported to the physician. Staff interviews and record reviews confirmed that the physician was not notified in a timely manner, and the DON acknowledged that the expectation was for staff to notify the physician of such changes, but in this case, monitoring was deemed sufficient until the situation escalated.
Failure to Timely Report Resident-to-Resident Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for two residents involved in a resident-to-resident altercation. During a supper meal, one resident made a negative comment to another, who responded by slapping the first resident on the neck. A nurse witnessed the incident and intervened. The incident was reported to the Director of Nursing (DON) the following day, but the official report to DIAL was not submitted until two days after the event, exceeding the facility's policy and regulatory requirements for timely reporting. Additionally, the facility did not notify law enforcement of the suspected abuse or potential crime, as required by both facility policy and federal regulations under the Elder Justice Act. The DON confirmed that law enforcement was not contacted regarding the incident. The facility's policy mandates immediate reporting of abuse allegations to the charge nurse, prompt notification to the administrator, and timely reporting to both DIAL and law enforcement, depending on the severity of the incident. Documentation reviewed during the investigation confirmed these reporting failures.
Inaccurate MDS Assessment Related to PASRR Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, the MDS for a resident with a diagnosis of schizophrenia and a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment was marked as not having a serious mental illness under the state Level 2 Preadmission Screening and Resident Review (PASRR) process. However, documentation from the PASRR outcome indicated that the resident did meet the criteria for a PASRR condition due to her diagnoses of paranoid schizophrenia and delusional disorder, as well as her need for assistance with self-care. The nurse manager stated that she only reviewed the front page of the PASRR, which noted approval without specialized services, and therefore believed no further action was necessary.
Failure to Incorporate PASRR Recommendations into Resident Care Planning
Penalty
Summary
The facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASRR) evaluation report into the assessment, care planning, and transition of care for a resident with a diagnosis of schizophrenia and moderate cognitive impairment. The PASRR Level 2 outcome indicated the resident met criteria for serious mental illness and required specific services and supports, including evaluation for neurocognitive disorder, assistance with designating a power of attorney, obtaining archived psychiatric records, and ongoing evaluation of psychotropic medications. However, the clinical record did not show evidence that these recommendations were utilized in the resident's assessment or care planning process. Staff interviews revealed that the nurse manager only reviewed the front page of the PASRR report, which stated approval without specialized services, and therefore did not pursue further actions based on the detailed recommendations. The facility's own PASRR policy required that care plans address the services identified in the PASRR, but this was not reflected in the resident's documentation. The lack of integration of the PASRR findings into the resident's care plan and transition of care constituted the deficiency identified by surveyors.
Failure to Timely Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to change and label oxygen tubing as required for one resident with chronic obstructive pulmonary disease (COPD), hypertension, and depression, who had moderate cognitive impairment. Observations on two consecutive days showed that the oxygen tubing in use was last changed and labeled over four months prior, with the date and staff initials from November. The resident reported using oxygen as needed, and the Treatment Administration Record (TAR) confirmed the tubing was last changed on the 15th of November, matching the observed date. Facility policy requires monthly inspection and replacement of oxygen tubing, as well as proper storage when not in use. Staff interviews confirmed the practice of changing tubing monthly and documenting it on the TAR, but the tubing in use had not been replaced according to policy.
Failure to Notify Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the family or responsible party of changes in the condition of two residents, which required physician notification. Resident #2, who had moderate cognitive impairment and diabetes, experienced several episodes of hypoglycemia with blood sugar levels dropping as low as 37. Despite these significant changes in condition, there was no documentation that the facility attempted to notify the resident's family. The nurse manager acknowledged that the resident's son was difficult to reach but confirmed that other contacts were available. Resident #3, also with moderate cognitive impairment, had a history of atrial fibrillation, coronary artery disease, heart failure, hypertension, renal insufficiency, and diabetes. The resident experienced significant weight gain over several months, with an 18% increase in weight over 180 days. Although the physician was notified of the weight changes, the facility did not document any attempts to inform the resident's family or responsible party about the new orders or the significant weight gain. The facility's policy required that changes in a resident's condition, such as medication reactions or significant weight changes, should prompt immediate nurse assessment and notification of both the physician and the family or responsible party. However, the facility's records lacked evidence of family notification for both residents, indicating a failure to adhere to this policy.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent a fall for a resident, who was identified as being at high risk for falls. The resident had a history of hypertension, renal failure, hyperlipidemia, and chronic respiratory failure with hypoxia, and was cognitively intact with a BIMS score of 14. The resident used a walker daily and required assistance from one staff member for ambulation. Despite this, the resident experienced a fall in her room while a staff member was present but not providing direct support. The incident occurred when the staff member, a CNA, was assisting the resident with getting clothes for a shower. The CNA left the resident unattended to put clothes away in a dresser, during which time the resident fell and sustained injuries, including abrasions and skin tears. The resident reported feeling dizzy before the fall. The CNA did not use a gait belt, which was against the facility's standard practice, and the resident was left without adequate supervision. Following the fall, the resident experienced significant pain and was later diagnosed with two rib fractures. The facility's policy on accidents and incidents requires thorough assessment and documentation, but the CNA's failure to use a gait belt and provide continuous supervision contributed to the incident. The facility did not have a specific gait belt policy but followed standard practice, which was not adhered to in this case.
Deficiencies in Kitchen Sanitization and Infection Control Practices
Penalty
Summary
The facility failed to ensure that resident dishes and kitchen equipment were properly sanitized, as three out of four dish machines did not consistently reach the appropriate sanitizing temperature. Observations and documentation revealed that temperature logs for the dish machines were incomplete or missing for several days, and there was no evidence of high-temperature test strips being used to verify that the machines reached the required 180°F. Staff interviews indicated a lack of awareness regarding issues with the dish machines and the proper procedures for ensuring they reached the necessary temperatures. Additionally, the facility did not adequately sanitize food thermometers between uses, as dietary staff were observed using the same alcohol prep pad to clean the thermometer probe after taking multiple food temperatures. This practice was noted during lunch services on different floors, with staff changing the prep pad only when it became visibly soiled. The Dietary Manager acknowledged this improper practice during an interview, indicating a lack of adherence to proper sanitization protocols to prevent cross-contamination. Furthermore, during a meal service observation, a staff member was seen handling food with soiled gloves, failing to perform hand hygiene between glove changes, and using the same alcohol wipe for cleaning the thermometer probe multiple times. The facility's infection control policy requires appropriate hand hygiene and the use of new alcohol wipes for each use, but these standards were not followed. This indicates a failure to adhere to infection control practices, potentially compromising the safety and hygiene of food services.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete the appropriate Minimum Data Set (MDS) assessment for a resident who was reviewed for discharge. The resident entered the facility in late December and had an admission assessment completed in early January. The resident was documented to have been discharged home with her spouse at the end of February. However, the discharge assessment reference date was set for the same day as the discharge, with a completion deadline in mid-March, but no additional assessments were completed. Staff interviews revealed that the Nurse Managers responsible for completing the MDS assessments did not have the resident on their lists, and the discharge MDS was not completed. One Nurse Manager stated that typically an email notification would be sent when a resident was discharged, but it appeared that this notification was not sent, leading to the oversight.
Failure to Update PASSR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASSR) evaluation for a resident with a new mental health diagnosis and medication revision. The resident, identified as Resident #5, had a documented Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident's diagnoses included anxiety, depression, and a psychotic disorder, and they were prescribed high-risk medications such as an antipsychotic and an antidepressant. The clinical record showed current medication orders for Sertraline HCl and Seroquel, which were related to anxiety and delusional disorders, respectively. The resident's care plan, dated April 19, 2024, included monitoring for adverse consequences of the medications and addressing increased anxiety and paranoia. However, the only documented PASSR in the clinical record was from 2015, which noted a depression diagnosis and the use of Sertraline HCl. During an interview, the Unit Manager confirmed that all PASSRs are located in the resident's permanent record and acknowledged that the PASSR for Resident #5 had not been updated since 2015, despite changes in mental health diagnoses and medications. The facility's policy stated that the MDS Coordinator should review and update the PASSR each quarter or as needed, but this had not been done for Resident #5.
Deficiencies in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #22, with intact cognition, had a history of urinary tract infections, neurogenic bladder, and parkinsonism. Despite receiving antibiotics and anti-infective medications for chronic cystitis, the care plan did not include these medications, their potential side effects, or monitoring requirements. Additionally, the care plan lacked information on the resident's risk for bladder infections and the signs and symptoms to observe. This oversight was acknowledged by Staff H, RN/Nurse Manager, who confirmed that the care plan did not address these critical aspects. Similarly, Resident #15, who had severe cognitive impairment, was diagnosed with hypertension, Alzheimer's Disease, and depression. The resident was prescribed sertraline and lorazepam, but the care plan did not document the usage or side effects of these medications. Staff H acknowledged this omission during an interview, confirming that the care plan should have included information on the antidepressant and antianxiety medications. The facility's policy requires that care plans be comprehensive and individualized, yet these deficiencies indicate a failure to adhere to this policy.
Failure to Change Oxygen Tubing for Resident
Penalty
Summary
The facility failed to change the oxygen tubing for a resident who was receiving respiratory services. The resident, identified as having intact cognition, was diagnosed with heart failure, chronic respiratory failure with hypoxia, pneumonia, and obstructive sleep apnea. The resident's care plan indicated the use of continuous oxygen and a CPAP machine at night. The Treatment Administration Record (TAR) specified that the oxygen tubing should be changed on the 15th of each month, and the tubing was reportedly changed on that date. However, observations on May 7th revealed that the oxygen tubing connected to the resident's oxygen concentrator and portable concentrator had not been updated since March, and the tubing for the CPAP machine was not dated. The Director of Nursing (DON) confirmed during an observation that the oxygen tubing had not been changed as required. The resident also reported that the tubing had not been changed. The facility's policy on the administration of oxygen directed staff to change the oxygen cannula and tubing monthly, which was not adhered to in this case. The DON later reported changing the tubing on May 7th and documented it in the nurse's notes, but this action was taken after the deficiency was identified.
Lack of Clinical Rationale for GDR Declination
Penalty
Summary
The facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident receiving psychotropic medication. The resident, who had moderately impaired cognition with a BIMS score of 8, was diagnosed with anxiety and depression and was receiving both antidepressant and antianxiety medications. Despite requests for a GDR for the antipsychotic medication Risperdal, the physician denied these requests without providing a clinical rationale, as documented on facility forms dated December 2023 and February 2024. Staff acknowledged the lack of clinical rationale for continuing the medications without changes, citing difficulties in obtaining this information from the physician. The facility's policy on unnecessary medication and GDRs requires that a rationale be provided by the physician or practitioner to support either an attempted reduction or the continuation of medication if clinical symptoms indicate a need. However, this policy was not adhered to in the case of the resident in question.
Inadequate Puree Portion Sizes for Residents
Penalty
Summary
The facility failed to provide appropriate puree main entree portion sizes to ensure adequate calorie and protein intake for two residents on puree diets. During an observation of puree food preparation, it was noted that the staff had a total volume of 6 cups of pureed hamburger but needed a total of 7 servings, indicating a shortfall in portion size. The staff used incorrect scoop sizes for serving the puree diets, which were not in accordance with the facility's policy. The policy required marking the serving size measurement on the top of each container, but this was not effectively implemented, leading to incorrect portion sizes being served. Resident #48, who was on a pureed diet, was served only a #12 scoop of pureed meat instead of the required #8 and #12 scoops, resulting in inadequate portion size. Similarly, Resident #76, who required substantial assistance with meals, was served with only a #8 scoop of pureed hamburger, contrary to the required #8 and #12 scoops. The dietary staff confirmed the errors in portion sizes during interviews, acknowledging that the correct scoop sizes were not used, and there was leftover puree after meal service, indicating that the residents did not receive the appropriate amount of food.
Infection Control Lapses in Tube Feeding Practices
Penalty
Summary
The facility failed to adhere to infection prevention practices during the care of a resident who was dependent on staff for all care and relied on tube feeding for nutritional intake. The resident had multiple medical diagnoses, including diabetes, renal insufficiency, and cerebral palsy, and was on a diet order of nothing by mouth, receiving nutrition and medication through a gastric tube. During an observation, a Licensed Practical Nurse (LPN) was seen using a tube adapter dated several days prior, and after dropping a cup and syringe on the floor, the LPN picked them up with gloved hands and discarded them without changing gloves. The LPN then proceeded to clean the feeding tube adapter with the same gloves, compromising infection control protocols. Further observations revealed that the feeding equipment, including the feeding pump, pole, and stethoscope, was visibly soiled with a dried yellow substance, identified as formula. A Registered Nurse (RN) acknowledged the equipment was dirty and admitted there was no routine cleaning schedule in place, indicating that staff cleaned the equipment only as needed. The facility's infection control policy mandates the use of standard precautions to prevent the transmission of pathogens, which was not followed in this instance.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to maintain a system to monitor the long-term use of antibiotics for two residents. Resident #61 had an ongoing order for Bactrim DS for bacteriuria without an end date, and the clinical records lacked documentation of monitoring the long-term use of this antibiotic. The Infection Preventionist confirmed that there was no system in place to ensure the continued necessity of the antibiotic. The facility's Antibiotic Stewardship Program policy outlined the role of the Consulting and/or Dispensing Pharmacist in reviewing antibiotics during monthly medication reviews and making recommendations to the Antibiotic Stewardship Committee, but this process was not effectively implemented. Resident #15, who had severe cognitive impairment and was always incontinent of urine, was on a prophylactic antibiotic, Cephalexin, for chronic cystitis without hematuria. The resident's care plan noted the use of Cephalexin for chronic urinary tract infections and instructed staff to monitor for side effects and symptoms of a UTI. However, there was no evidence of a system to monitor the long-term use of this antibiotic, indicating a failure to adhere to the facility's policy on antibiotic stewardship.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 68 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Storm Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Aurelia, Llc | 12.4 mi | ★★★★★ | 10 | 0 |
| Accura Healthcare Of Cherokee, Llc | 18.1 mi | ★★★★★ | 6 | 0 |
| Cherokee Specialty Care | 18.6 mi | ★★★★★ | 0 | 0 |
| Careage Hills Rehabilitation And Healthcare | 18.8 mi | ★★★★★ | 9 | 0 |
| Fonda Specialty Care | 19.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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