Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Panora Specialty Care during CMS and state inspections, most recent first.
MDS coding was inaccurate for three residents when diagnoses and health conditions were not entered correctly. One resident with COPD and a documented MDRO was not coded for the MDRO despite care plan and TAR references to infection precautions; another resident was incorrectly coded for an anticoagulant even though the only ordered medication was aspirin, an antiplatelet; and a third resident was marked as not using tobacco despite a nicotine dependence diagnosis, prior care plan documentation of active smoking, and a progress note showing the resident smoking.
Failure to complete an admission smoking evaluation for a resident who smoked. The resident had moderate cognitive impairment, recent pneumonia, dyspnea, anxiety, bipolar disorder, and depression, used a manual wheelchair, and required staff assistance for transfers. The care plan identified smoking and called for a smoking evaluation on admission, but no current admission evaluation was found in the EHR. The resident was observed smoking outside the facility unsupervised, while the DON stated smoking evaluations are completed on admission and quarterly.
Failure to perform hand hygiene and glove changes during resident care. Two CNAs provided catheter and personal care for a resident with MDRO, neurogenic bladder, paraplegia, and a urinary catheter while using EBP. After emptying the catheter bag, one CNA continued to catheter site care and then perineal care without hand hygiene or changing gloves, and the second CNA later assisted with repositioning without hand hygiene or a glove change. The DON stated gloves should be changed between different tasks and hand hygiene completed at the end of each specific care activity.
The facility did not update or revise care plans for three residents to include specific recommendations from PASRR Level II assessments, despite these residents having significant mental health diagnoses and documented needs for specialized services such as psychiatric medication management, therapy, and community placement supports. Instead, care plans contained only general statements about following PASRR recommendations, and staff interviews confirmed a lack of understanding and incomplete integration of these requirements.
The facility did not identify or document individualized target behaviors and side effects for psychotropic medications in care plans or EMARs for multiple residents with psychiatric diagnoses. Staff interviews revealed a lack of awareness about where to find or how to document this information, and records often contained only general orders rather than specific, updated details as required by facility policy.
The facility failed to maintain adequate staffing levels, resulting in prolonged call light response times. Observations showed that call lights were often addressed by a single CNA, with some remaining unanswered for over an hour. Resident interviews confirmed delays, with some experiencing discomfort due to long waits. The facility's staffing was particularly low on weekends, as indicated by a one-star staffing rating and several instances of insufficient CNA coverage.
The facility failed to follow infection control protocols during peri-care and catheter care, as well as during mealtime assistance. A CNA did not use a barrier when emptying a catheter, failed to change gloves or sanitize hands after handling contaminated items, and did not remove PPE before exiting an EBP room. Additionally, the CNA did not perform hand hygiene between assisting different residents during meals, contrary to the facility's policies.
A resident with Parkinson's, diabetes, and dementia was transferred without a gait belt by a CNA, contrary to facility policy. The resident was moved without gripper socks or shoes, and the call light was left out of reach, compromising safety. The DON confirmed the expectation of gait belt use for safety, highlighting a deficiency in transfer practices.
The facility failed to maintain a clean and homelike environment, with observations of unclean bathrooms, damaged walls and ceilings, and stained privacy curtains. Interviews revealed that the bathroom in a resident's room was not cleaned regularly, and the toilet bar had been rusted for about two months. The Administrator acknowledged the issues and mentioned that a contractor was scheduled to fix the damages.
Staff failed to prepare and serve food under sanitary conditions, with a cook and kitchen aide violating glove use and food handling policies. The cook's apron touched serving utensils, and the kitchen aide's shirt touched a piece of cake, both of which were then served to residents.
An RN failed to follow proper infection control practices during a blood glucose reading, including not changing gloves or sanitizing hands between steps, and placing used gloves directly on a resident's bedside table. Both the RN and the DON acknowledged these actions as infection control concerns.
MDS Coding Errors for Diagnoses, Medication Use, and Tobacco Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to code required information on MDS assessments for three residents. For one resident with COPD and a documented MDRO, the MDS did not indicate the MDRO even though the care plan identified a risk for infection related to a MDRO and the TAR directed staff to use enhanced barrier precautions for a resistant organism such as ESBL. The MDS Coordinator stated she completed MDS assessments using medical records and resident interviews, and confirmed that if a resident had an MDRO, the MDS should be coded to indicate it. The RAI Manual stated that section I disease conditions require a physician-documented diagnosis in the past 60 days and should be coded when they have a direct relationship to the resident's current status, treatments, monitoring, or risk of death during the look-back period. For another resident, the admission MDS coded use of an anticoagulant even though the only medication identified was aspirin 81 mg daily, which is an antiplatelet and not an anticoagulant; no anticoagulant medications were found in the physician orders. The MDS Coordinator said aspirin had been directed to be coded as an anticoagulant by staff from a mock survey, but could not recall when that instruction was given. For a third resident, the admission MDS marked current tobacco use as no even though the resident had a diagnosis of cigarette nicotine dependence, the prior facility's care plan documented active smoking with unsupervised smoking, and a progress note recorded the resident going in and out of the building to smoke. The MDS Coordinator said the smoking status was not well known on admission, while the RAI Manual stated tobacco information may come from the resident or the medical record and that if there are indications of tobacco use, J1300 should be marked yes.
Failure to Complete Admission Smoking Evaluation
Penalty
Summary
The facility failed to complete an admission smoking evaluation for one resident who was identified as a smoker. The resident’s EHR showed a current admission date of 12/5/25, with a prior admission earlier in the year. The MDS completed on 12/8/25 showed a BIMS score of 9, indicating moderate cognitive impairment, and listed diagnoses including recent pneumonia, dyspnea, anxiety, bipolar disorder, and depression. The resident used a manual wheelchair independently but required staff assistance for transfers, and the MDS indicated use of tobacco products. The care plan, last updated 12/26/25, documented that the resident smokes and included an intervention to complete a smoking evaluation on admission and as needed. During observation on 12/31/25 at 8:00 AM, the resident was seen smoking a cigarette outside the facility unsupervised. A smoking evaluation for the current admission was not found in the EHR. During interview, the DON stated smoking evaluations are completed upon admission and quarterly, and that the DON or MDS Coordinator collaborate to complete them. The facility policy required residents to be evaluated on admission to determine smoking status and, if a smoker, to assess the ability to smoke safely with or without supervision.
Failure to Perform Hand Hygiene and Glove Changes During Resident Care
Penalty
Summary
The facility failed to follow infection control practices to prevent cross contamination during resident care for a resident with multidrug-resistant organism, neurogenic bladder, paraplegia, and a urinary catheter. The resident’s MDS assessment showed intact cognition, and the care plan identified a risk for infection related to the drug-resistant microorganism and directed staff to use enhanced barrier precautions, including gowns and gloves, during high-contact care activities. During an observation, two CNAs completed catheter and personal care for the resident while wearing gowns and gloves and performing hand hygiene at the start. After emptying the catheter drainage bag, one CNA moved directly to cleaning around the suprapubic catheter site without hand hygiene or a glove change. That same CNA then proceeded to perineal care, including cleaning the genital and anal areas, again without hand hygiene or a glove change. After the perineal care was completed, the second CNA assisted with repositioning the resident, placing pillows, and rearranging blankets without hand hygiene or a glove change. The DON stated that hand hygiene and glove changes should occur at the end of a specific task or care, and that gloves should not be worn for multiple or different types of care.
Failure to Incorporate PASRR Level II Recommendations into Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for three out of four residents reviewed, specifically neglecting to incorporate recommendations from the PASRR Level II assessments. Clinical record reviews revealed that for each of these residents, the care plans did not include the specific specialized services and supports recommended by the PASRR Level II, despite the presence of significant mental health diagnoses such as schizophrenia, depression, anxiety, PTSD, and other related conditions. The care plans instead contained general statements about following PASRR recommendations without detailing the individualized interventions required for each resident. For one resident with severe cognitive impairment and multiple mental health diagnoses, the PASRR Level II recommended ongoing psychiatric medication management, individual therapy, rehabilitative services, and community placement supports. However, the care plan only referenced following PASRR recommendations and failed to specify these services. Another resident with normal cognitive function and a history of schizoaffective disorder, depression, and anxiety also had a care plan lacking the detailed interventions outlined in the PASRR Level II, such as psychiatric medication management, rehabilitative services, and community placement supports. The care plan included incomplete interventions and did not address the resident's specific needs as identified in the PASRR. A third resident with normal cognitive function and multiple psychiatric diagnoses similarly had a care plan that did not reflect the individualized recommendations from the PASRR Level II, including psychiatric medication management, individual therapy, and community placement supports. Staff interviews confirmed that the PASRR Level II recommendations were not fully integrated into the care plans, with staff expressing uncertainty about the requirements and acknowledging that the care plans were incomplete. Facility policies required that care plans be comprehensive, person-centered, and revised as resident conditions changed, and that PASRR Level II findings be incorporated, but these standards were not met for the residents reviewed.
Failure to Document Target Behaviors and Side Effects for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not identifying and documenting target behaviors and/or side effects of psychotropic medications for four residents. Clinical record reviews revealed that care plans and electronic medication administration records (EMARs) did not specify the target behaviors for which antianxiety, antidepressant, and antipsychotic medications were prescribed, nor did they consistently document the side effects to be monitored. This deficiency was observed in residents with a range of cognitive abilities and psychiatric diagnoses, including severe cognitive impairment, anxiety, depression, schizophrenia, PTSD, and other mental health conditions. The care plans and EMARs lacked individualized information, often containing only general orders from admission without subsequent updates to reflect specific behaviors or side effects related to each medication. Staff interviews indicated a lack of awareness and understanding among certified nursing assistants (CNAs) and medication aides regarding where to find information about target behaviors and medication side effects. Several staff members reported relying on word of mouth or general knowledge of residents’ usual behavior rather than documented, individualized information. Some staff stated that behaviors would be documented if observed, but there was no clear process for linking specific behaviors or side effects to particular medications in the care plans or EMARs. The care plan coordinator and DON acknowledged that while behaviors were being added to care plans, they were not specifically related to medications, and that the process of updating records to include individualized information was incomplete. The facility’s own policy required the identification and documentation of behavioral symptoms, individualized interventions, and monitoring for medication efficacy and adverse effects. However, the policy was not followed, as evidenced by the lack of detailed documentation in both care plans and EMARs for residents receiving psychotropic medications. This failure to document and monitor target behaviors and side effects as required contributed to the deficiency identified during the survey.
Inadequate Staffing Leads to Prolonged Call Light Response Times
Penalty
Summary
The facility failed to ensure sufficient nursing staff was present during scheduled shifts, leading to prolonged response times to call lights. Observations on the 100 and 300 nursing halls revealed that call lights were primarily addressed by one CNA, with assistance from a CNA from another hallway and a Restorative Aide. During a specific observation period, one call light remained unanswered for over an hour. Interviews with residents indicated that call light response times could range from 30 to 60 minutes, with some residents experiencing discomfort due to prolonged waits. The Director of Nursing acknowledged that meal times posed challenges in maintaining timely responses. The facility's staffing levels were found to be inadequate, particularly on weekends, as evidenced by the Payroll Based Journal report and staffing schedules. The facility had a one-star staffing rating for the fiscal year quarter 4 of 2024, with several instances of low CNA coverage on weekends. The Director of Nursing admitted to low weekend staffing and even personally covered a shift due to insufficient staff, which was not reported to the PBJ. The facility's assessment report indicated that staffing needs were evaluated and adjusted as needed, but the observed deficiencies suggest these measures were not effectively implemented.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the provision of peri-care and catheter care for residents. Specifically, a Certified Nursing Assistant (CNA) did not use a barrier when emptying a catheter and failed to change gloves or sanitize hands after handling contaminated items. The CNA also did not remove personal protective equipment (PPE) before exiting an Enhanced Barrier Precautions (EBP) room, contrary to the facility's policy. These actions were observed during care for a resident with a multidrug-resistant organism (MDRO) and other serious health conditions, including a pressure ulcer and osteomyelitis. In another instance, the same CNA did not change gloves or perform hand hygiene while providing perineal care to a resident with incontinence. The CNA continued to wear the same gloves while handling clean items and dressing the resident, failing to follow the facility's hand hygiene policy. This oversight occurred despite the resident's care plan requiring assistance with activities of daily living and perineal cleansing. Additionally, during mealtime assistance, the CNA did not perform hand hygiene between assisting different residents, even after handling food and utensils. This lack of hand hygiene was observed while the CNA assisted three residents with their meals, which is against the facility's hand hygiene policy that emphasizes the importance of hand hygiene in preventing the spread of infections.
Failure to Ensure Safe Transfer Practices
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #39, who had diagnoses of Parkinson's Disease, diabetes, and dementia, and required partial to moderate assistance for transfers. The resident's care plan indicated a need for assistance with activities of daily living and highlighted poor safety awareness due to cognitive impairment. On one occasion, a CNA was observed transferring the resident without using a gait belt, which is contrary to the facility's policy. The CNA moved the resident's feet over the edge of the bed, pulled on the resident's arm, and assisted the resident to stand and transfer to a wheelchair without the use of a gait belt. Additionally, the resident was transferred without wearing gripper socks or shoes, and the call light was left out of reach, further compromising the resident's safety. The Director of Nursing confirmed that the use of a gait belt is expected for safety during transfers, even if not explicitly mentioned in the care plan. The facility's policy on assisting a resident, revised in 2018, outlines the necessary steps for safe transfers, including the use of a gait belt and ensuring the call light is within reach. The failure to adhere to these procedures resulted in a deficiency, as the resident was found on the floor with injuries on a previous occasion, indicating a pattern of inadequate supervision and unsafe transfer practices.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of unclean and damaged areas. On 4/9/24, the bathroom in room [ROOM NUMBER] was found with fecal matter on the toilet rim, inside the bowl, on the wall, and on the floor. Rust was observed around the toilet rim and on the bar attached under the toilet seat. Additionally, wallpaper was peeling, and plaster was coming off the wall by the shower room in the 100 hallway. The dining room ceiling had water damage and was covered by a piece of plastic. On 4/10/24, a resident was seen coming out of the shower room with a staff member, and the door jamb was splintered and broken. Room [ROOM NUMBER] had a section of the ceiling covered with black plastic and blue tape, and the privacy curtain next to a resident's bed was stained with formula from tube feeding. Interviews with residents and staff revealed that the bathroom in room [ROOM NUMBER] was not cleaned regularly, and the toilet bar had been rusted for about two months despite a request for replacement. The Administrator acknowledged the issues, stating that a contractor was scheduled to fix the ceiling and wall damage on April 15th. The Administrator also mentioned that the facility had received a grievance in February regarding the cleanliness of room [ROOM NUMBER] and had added the room to the daily cleaning list. However, the Administrator was unsure about the exact timing of some of the damages and the reasons behind them. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unclean and damaged areas observed. The Administrator admitted that the rusted toilet handle and the stained privacy curtain were not homelike. The facility had a slow leak in the dining room ceiling, which led to water damage, and a staff member had kicked the shower room door, causing it to splinter. The facility's failure to maintain a clean and homelike environment was evident through these observations and interviews.
Sanitary Food Preparation and Service Deficiency
Penalty
Summary
Staff failed to prepare and serve food under sanitary conditions, increasing the risk of contamination and foodborne illness. During a lunch service, a cook placed serving utensils on the counter attached to the front of the steam table and repeatedly leaned over, causing her apron to touch the utensils. The cook also used the same gloves to open the refrigerator, touch a slice of cheese, and handle buns, violating the facility's policy on glove use. Additionally, a kitchen aide scooped a piece of cake onto a plate and leaned across to scoop another piece, causing her shirt to touch the first piece of cake. Both pieces of cake were then served to residents. The facility's policy on food preparation and service, revised in April 2019, requires gloves to be worn when handling food directly and changed between tasks. The Dietary Manager confirmed that gloves should be single-use and not touch other items when handling food. The 2013 Food Code, considered a standard of practice for the food service industry, also mandates single-use gloves for one task only and prohibits bare hand contact with ready-to-eat food. These observations and policy violations were confirmed through staff interviews and policy reviews.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to perform appropriate infection prevention and control practices during medication administration, specifically during the process of obtaining a blood glucose reading for a resident. An RN, identified as Staff C, did not change gloves or sanitize hands between steps of the procedure. Staff C placed gloves directly on the resident's bedside table, not on the wax barrier, and reused the same gloves after handling the medication cart without sanitizing hands. This occurred multiple times during the observation, leading to potential contamination and infection control concerns. During interviews, Staff C acknowledged the failure to change gloves and sanitize hands as required by the facility's infection control policy. The Director of Nursing also recognized these actions as infection control concerns. The facility's Handwashing/Hand Hygiene policy, revised in August 2019, states that glove use does not replace hand hygiene and that integrating glove use with routine hand hygiene is best practice for preventing healthcare-associated infections.
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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 Panora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The New Homestead Care Center | 6.8 mi | ★★★★★ | 1 | 0 |
| Community Care Center | 13.6 mi | ★★★★★ | 14 | 0 |
| Perry Lutheran Home | 16.9 mi | ★★★★★ | 6 | 0 |
| Aspire Of Perry | 16.9 mi | ★★★★★ | 15 | 0 |
| Adel Acres | 17.4 mi | ★★★★★ | 8 | 0 |
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