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 Mount Ayr Health Care Center during CMS and state inspections, most recent first.
Food service safety practices were not followed during kitchen storage and meal service. The Cook's Refrigerator had an incomplete temp log with missing entries, the upright freezer contained a milky white frozen substance and crumbs, and a Dietary Aide donned gloves without hand hygiene and used the same gloved hand to touch pie slices and dessert dishes while serving pie. The Food Service Supervisor and Administrator acknowledged the incomplete logs, unclean freezer condition, and improper food handling.
Failure to notify the LTC Ombudsman of two resident moves: one resident with moderately impaired cognition was sent to the hospital after a fall and returned shortly after, and another resident with intact cognition was discharged home with family. The facility's transfer/discharge form did not show Ombudsman notification for either event, and the Administrator said one was missed because the stay away was brief and the other because it occurred on a weekend.
A resident with anxiety, depression, and mild intellectual disability later developed a new diagnosis of delusional disorder/paranoid delusions, with MDSs and the care plan documenting psychotic/behavioral symptoms and ongoing use of antipsychotic, antianxiety, and antidepressant meds. The facility’s most recent PASRR remained the one completed earlier, and the DON and Administrator acknowledged that a new PASRR should have been completed when the new mental health diagnosis was added.
An LPN left an EHR laptop open on a medication cart in the lobby on two occasions, allowing two residents' medication lists to remain visible when she walked away. One resident was wandering nearby during one of the incidents. The facility policy required resident records to be kept confidential and secure, and the DON stated staff should have locked the laptop screen before leaving the cart.
Failure to perform hand hygiene and change gloves during catheter care. A CNA transferred a resident with an indwelling urinary catheter, then used the same gloves to handle the urine measuring cylinder and access the catheter drainage spigot without hand hygiene or a glove change. The resident had moderately impaired cognition, multiple diagnoses including BPH, kidney failure, and neurogenic bladder, and required extensive assistance with ADLs and mobility.
A Certified Dietary Manager did not follow proper hand hygiene and glove use protocols while preparing raw pork chops, handling non-food items and food without changing gloves or washing hands as required by facility policy.
Four residents were not offered the recommended pneumococcal vaccine, as required by CDC guidelines and facility policy. Vaccine records showed that these individuals had neither received nor refused the vaccine, and staff interviews confirmed that the omission was due to a focus on COVID-19 and influenza vaccinations, with no documented rationale for not addressing pneumococcal immunization.
The facility did not fully develop or implement comprehensive, individualized care plans for three residents with complex behavioral and mental health needs. One resident's care plan interventions, such as weekly social service visits and activity invitations, were not consistently documented or carried out. Two other residents receiving psychotropic medications had care plans that lacked specific target behaviors and non-pharmacological interventions, despite documented incidents of disruptive and inappropriate behaviors. Staff interviews confirmed these omissions, and facility policy required individualized, resident-centered care planning.
A resident with diabetes experienced a critically low blood sugar reading, but staff did not provide timely intervention or document a follow-up assessment. Despite facility policy and staff knowledge that interventions and rechecks were required, no action was taken or recorded after the low reading, and the resident did not receive a snack until hours later.
The facility failed to update its infection control policy since 2020 and did not maintain proper infection control practices during catheter care for a resident with renal insufficiency. A CNA was observed touching contaminated surfaces with gloved hands before performing catheter care, contrary to facility policy. The DON confirmed the lapse in procedure adherence.
The facility failed to include two residents in their care plan conferences, despite documentation indicating their attendance. Interviews revealed inconsistencies in care conference practices, with staff initially stating residents and families do not attend, later claiming they are invited but choose not to. The facility lacks a formal care conference policy, contributing to the deficiency.
Food Service Safety Lapses During Storage and Meal Service
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with food service safety practices during mealtime service. During an initial kitchen observation, the Cook's Refrigerator had an incomplete temperature log with missing entries for 4/8 and 4/10/26. The bottom of the upright freezer contained a milky white frozen substance and crumbs across the bottom, and the freezer held a 5-gallon container of ice cream on the top shelf with frozen meats on the bottom shelf. The Food Service Supervisor stated the temperature logs were expected to be completed as required and acknowledged that the melted ice cream on the bottom of the freezer should have been cleaned up. The Administrator also concurred that cleaning of kitchen appliances and logging of temperatures needed to be completed. During meal service, Staff D, Dietary Aide, donned gloves without hand hygiene and used the right hand to cut pie and load slices onto a pie server. Using the left gloved hand, Staff D obtained dessert plates, placed them on the counter, and touched the pie slices while moving them from the pie server onto dessert plates and a dessert bowl. This process continued for 16 pieces of pie, with Staff D touching both the dessert dishes and the pie slices with the same gloved hand before removing gloves and washing hands. The Food Service Supervisor stated that pie should be served with a pie server and fork and that staff should not touch the pie with gloved or non-gloved hands. The facility's policy stated hand washing should occur before and after glove use, gloves should be changed when touching contaminated surfaces and after interruptions, and refrigeration temperatures should be taken and recorded daily.
Failure to Notify Ombudsman of Resident Transfers and Discharge
Penalty
Summary
The facility failed to notify the Long-Term Care State Ombudsman of two resident transfers, including one hospital transfer and one discharge home. Resident #13 had a BIMS score of 12 out of 15, indicating moderately impaired cognition, and diagnoses that included high blood pressure, coronary artery disease, diabetes mellitus, thyroid disorder, and non-Alzheimer's dementia. After a fall, the resident was transferred to the hospital for evaluation and then returned to the facility shortly afterward, but the Notice of Transfer Form to the Long-Term Care Ombudsman did not document Ombudsman notification for that hospital transfer. Resident #28 had a BIMS score of 15 out of 15 and diagnoses of diabetes mellitus and hypothyroidism. The resident was discharged home with family on the planned discharge date, but the Notice of Transfer Form to the Long-Term Care Ombudsman did not document Ombudsman notification for the discharge. The Administrator stated he was not aware Resident #13's transfer required Ombudsman notification because of the short time away from the facility, and he overlooked Resident #28's discharge notification because it occurred on a weekend day. The facility policy stated it was responsible for notifying the long term care ombudsman monthly of transfers to the hospital and discharges that may occur.
Failure to Complete PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a PASRR for one resident who developed a new mental disorder diagnosis after admission. The resident had been admitted with existing diagnoses of generalized anxiety disorder, major depressive disorder, and mild intellectual disability, and the most recent PASRR on file from 12/29/21 identified major depression, anxiety disorder, and mental retardation with no current mental health symptoms and no Level II required at that time. The resident’s clinical record later documented a new diagnosis of delusional disorder/paranoid delusions during the stay, along with ongoing use of antipsychotic, antianxiety, and antidepressant medications. The resident’s MDS assessments documented diagnoses including anxiety disorder, depression, and psychotic disorder, with one assessment noting other behavioral symptoms not directed toward others for 1 to 3 days over the prior 14 days. The care plan identified behavioral problems due to delusional disorder and paranoia, and physician orders included aripiprazole, clonazepam, and sertraline for the resident’s psychiatric conditions. During interview, the DON acknowledged that the most recent PASRR was from 12/29/21 and that a new PASRR should have been completed when the additional diagnosis of delusions was added. The Administrator also acknowledged that a new PASRR should have been completed with the new mental health diagnosis.
Resident Information Left Visible on Open EHR Laptop
Penalty
Summary
The facility failed to properly protect resident information from unauthorized access when an LPN left an EHR laptop open on the medication cart in the lobby on two separate occasions. On 4/11/26 at 11:44 AM, the LPN walked away from the cart to get a cup for a resident, and Resident #16's medication list was visible on the screen while Resident #6 was continuously wandering around the lobby. The LPN returned at 11:46 AM and stated she usually closes the laptop but thought the task would be completed quickly. Later that same day at 11:57 AM, the LPN again walked away from the medication cart to administer medications to a resident in the dining room, and Resident #10's medication list was visible on the screen. The facility's Securing Resident Records Policy dated 9/12/25 stated that resident records, including electronic records, must be kept confidential and secure, and that all staff are responsible for protecting resident information from unauthorized access, use, or disclosure at all times. On 4/13/26, the DON stated staff should have locked the laptop screen before leaving the medication cart.
Failure to Perform Hand Hygiene and Glove Change During Catheter Care
Penalty
Summary
The facility failed to implement infection control practices when Staff B, a CNA, manipulated Resident #1’s urinary catheter drainage spigot with gloves that had already been used during the resident’s transfer from a wheelchair to a recliner. Resident #1 had a BIMS score of 9 out of 15, indicating moderately impaired cognition, and diagnoses included cancer, BPH, kidney failure, and neurogenic bladder. The resident required extensive assistance with ADLs and mobility and had an indwelling urinary catheter in place. During continuous observation, Staff B and Staff C transferred the resident using a mechanical lift. After the resident was seated, Staff B used the same gloves to handle the urine measuring cylinder, raise the resident’s pant leg, unscrew the catheter drainage bag spigot, and empty urine into the cylinder, then into the toilet. Hand hygiene and a glove change were not performed during the process. Staff C stated Staff B should have performed hand hygiene and changed gloves before accessing the urinary drainage bag, and Staff B stated she did not believe hand hygiene or a glove change was needed. The DON later stated staff should have performed hand hygiene and changed gloves prior to accessing the drainage bag.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
A Certified Dietary Manager (CDM) failed to maintain sanitary practices in the kitchen by not performing hand hygiene between handling non-food items and raw food. During observations, the CDM was seen opening packages of raw pork chops, using a can of cooking spray and a bottle of olive oil blend with a gloved hand, and then handling raw pork chops with both gloved and ungloved hands without changing gloves or washing hands. The CDM repeated this process multiple times and later stated she believed touching raw food with bare hands was permitted, acknowledging she did not perform hand hygiene or change gloves after handling non-food items. Facility policy required employees to wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident, as well as to use gloves for direct food contact and wash hands before donning and after removing gloves.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the recommended pneumococcal vaccine to four out of eight residents reviewed for vaccines, despite CDC guidelines and facility policy requiring such vaccinations. Clinical record reviews showed that these residents had neither received nor refused the appropriate pneumococcal vaccine, and there was no documentation of any rationale for not offering the vaccine. The residents involved were all of advanced age, as indicated by their dates of birth, and their electronic health records did not reflect any action regarding the pneumococcal vaccine. Interviews with facility staff revealed that the issue was not addressed by physicians, and there was no explanation for why the vaccine was not offered. The Assistant Director of Nursing stated that the facility's focus had been on COVID-19 and influenza vaccinations, leading to the oversight. The Administrator acknowledged that staff should have used an interdisciplinary approach to identify residents eligible for vaccinations, as required by both CDC guidance and facility policy.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to follow and fully develop comprehensive, resident-centered care plans for three residents. For one resident with intact cognition and diagnoses including anxiety disorder, depression, neurocognitive disorder with Lewy bodies, and borderline personality disorder, the care plan included interventions such as behavioral health consults and weekly social service visits. However, documentation revealed that these weekly visits were not consistently documented, and the social services designee admitted to not recording refusals or all visits. The resident reported that visits were infrequent and often occurred incidentally during housekeeping, rather than as planned, sit-down visits. Staff observations confirmed the resident spent most of her time in bed with the lights off, and staff did not consistently invite her to participate in group activities as outlined in her care plan. For a second resident with severe cognitive impairment and a history of behavioral symptoms, the care plan included administration of antipsychotic and antidepressant medications but failed to specify target behaviors for these medications. Progress notes documented multiple incidents of sexual inappropriateness, combativeness, and disruptive behaviors, including inappropriate touching of staff, yelling, cursing, and physical aggression. Despite these documented behaviors, the care plan did not address or include interventions for these specific behaviors, nor did it provide guidance for staff on how to manage them. A third resident with severe cognitive impairment and diagnoses of chronic kidney disease, dementia, anxiety, depression, and insomnia was prescribed multiple psychotropic medications. The care plan referenced the use of these medications but did not include individualized target behaviors for staff to monitor or non-pharmacological interventions to attempt if behaviors were observed. Staff interviews confirmed that the care plan lacked this information, and the facility's policy required care plans to be individualized and comprehensive, incorporating behavioral and emotional health needs. The failure to individualize and fully implement care plans for these residents constituted the deficiency.
Failure to Provide Follow-Up for Critically Low Blood Sugar
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate follow-up assessment and intervention for a diabetic resident who experienced a critically low blood sugar (BS) result of 30 mg/dL. The resident, who had intact cognition and multiple diagnoses including diabetes mellitus, peripheral vascular disease, and paraplegia, reported a recent episode of low blood sugar. Clinical records showed that on the day of the incident, the resident's BS was recorded as 30 mg/dL by the facility's glucometer and 57 mg/dL by the resident's own meter. Despite this, there was no documentation of any intervention, such as providing carbohydrates or quick-acting sugar, nor was there evidence of a follow-up BS check or further progress notes for that day. Interviews with staff confirmed that the facility lacked a specific protocol for identifying and managing low blood sugar events, and that interventions and follow-up checks should have been documented. The resident did not receive a snack until several hours after the low BS reading, and there was no evidence that staff followed the care plan or the American Diabetes Association's guidelines for hypoglycemia. The Director of Nursing acknowledged that staff should have intervened and rechecked the BS within 30 minutes, but this was not done.
Infection Control Policy and Practice Deficiencies
Penalty
Summary
The facility failed to update its infection control policy and maintain proper infection control practices, specifically in the care of a resident with an indwelling catheter. The infection control policy was last reviewed on April 8, 2020, and had not been updated since, despite the facility's practice of annual reviews. The Director of Nursing (DON) and the Administrator acknowledged that the policies were reviewed annually but lacked signatures to confirm recent reviews. This oversight in policy updating was identified during a survey, highlighting a lapse in administrative procedures. Additionally, the facility did not adhere to proper infection control practices during catheter care for a resident diagnosed with renal insufficiency. During an observation, a Certified Nurse Aide (CNA) was seen touching contaminated surfaces with gloved hands before performing catheter care, which is against the facility's policy. The policy requires staff to wash hands, apply clean gloves, and avoid touching contaminated surfaces before providing catheter care. The DON confirmed the observation and acknowledged the expectation for staff to use clean gloves prior to emptying the catheter, indicating a failure in following established infection control procedures.
Failure to Include Residents in Care Plan Conferences
Penalty
Summary
The facility failed to include two residents in their care plan participation conferences, despite documentation indicating their attendance. Resident #4, who has no cognitive impairment, stated she had never been invited to or attended a care conference, contradicting the Care Plan Conference Note that documented her attendance. Similarly, Resident #12, with mild cognitive impairment, expressed uncertainty about attending any care plan conferences, despite documentation stating otherwise. Interviews with staff revealed inconsistencies in the facility's care conference practices. Staff B initially stated that residents and families do not attend care conferences, which are held for staff only, but later claimed residents are invited but choose not to attend. The Activity Director confirmed that residents are not present at their care conferences, and the Director of Nursing acknowledged that the team does not meet with residents and the entire care plan team simultaneously. Additionally, the facility lacks a formal care conference policy, contributing to the deficiency.
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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 Mount Ayr
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clearview Home | 0.8 mi | ★★★★★ | 2 | 0 |
| Lamoni Specialty Care | 16.6 mi | ★★★★★ | 3 | 0 |
| Worth County Convalescent Center | 18.2 mi | ★★★★★ | 9 | 0 |
| Lenox Care Center | 21 mi | ★★★★★ | 6 | 0 |
| Accura Healthcare Of Creston | 25 mi | ★★★★★ | 2 | 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.