Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rotary Senior Living during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke was on warfarin when providers added antibiotics known to affect INR, but staff did not obtain an INR order, did not have an internal INR tracking process, and relied on the pharmacist and the resident’s spouse for interaction alerts and INR checks. After staff discovered a large bruise in the groin area while the resident was on warfarin and antibiotics, they documented it but did not complete a skin sheet, investigation, or increased monitoring, and TAR entries failed to reflect the bruise or anticoagulant side effects. Two days later, the resident’s spouse obtained an INR of 7.3 and notified staff, who then contacted the anticoagulation clinic and received instructions to hold warfarin and give vitamin K or spinach, but the resident’s condition deteriorated before these could be implemented, leading to hospital transfer where an INR >13 and a large rectus sheath hematoma with hemoperitoneum were found. Surveyors concluded that the facility failed to adequately monitor and manage high-risk anticoagulant therapy and associated bruising and drug interactions, resulting in an Immediate Jeopardy deficiency.
A resident with severe cognitive impairment, dementia, polyneuropathy, and significant ADL dependence was found with marked swelling of the left hand, later confirmed by X-ray as an acute nondisplaced fracture of the middle finger. Nursing staff documented the edema, notified the physician, and obtained an X-ray, but no staff witnessed any incident causing the injury, and interviews only produced speculative explanations such as the resident twisting fingers or catching them on side rails. The facility completed only a brief, undated investigation and, despite its policy requiring all injuries of unknown origin to be reported to the state agency within 2 hours, the Administrator determined the event was not reportable, resulting in a failure to report and thoroughly investigate an injury of unknown origin.
A resident with intact cognition and multiple medical diagnoses, including diabetes and a non-pressure skin ulcer, had a care plan and facility policy requiring weekly documentation of skin injury locations and measurements. Over several weeks, staff recorded skin tears, abrasions, bruising, and scratches on the resident’s toes, feet, and arms, but repeatedly failed to include required measurements and precise locations on the Skin Observation Tools. The resident was observed with both feet resting against the bed footboard and reported that this caused sores on the bottom of the right foot and toes. Only later entries included measurements for a right toe and right lateral foot skin tear, and the DON acknowledged that the record lacked complete documentation of the locations and sizes of the skin areas, contrary to the facility’s weekly skin assessment process.
A resident with a history of stroke and hemiplegia required skin checks before and after applying an ankle-foot orthosis (AFO), but the LTC facility failed to document these checks. As a result, a wound on the resident's shin went unnoticed until a dermatology appointment, where it was found to be infected with MRSA. The facility also did not document required weekly skin assessments, leading to the oversight of the resident's wound and subsequent infection.
A resident with severe memory impairments and dementia was not treated with respect and dignity during care, leading to physical aggression. The resident required substantial assistance with daily activities and had a care plan to manage potential aggression. During an evening care session, a CNA acted roughly, causing the resident to become aggressive. The incident was not documented, and an internal investigation was initiated. Other residents and staff reported feeling safe and respected, but the facility's policy emphasizes the importance of dignity and respect for all residents.
A facility failed to report an alleged incident of mistreatment involving a resident with dementia to the Department of Inspection and Appeals within the required 2-hour timeframe. The incident involved a CNA acting roughly during care, leading to the resident's physical aggression. The facility's policy mandates reporting such allegations within 2 hours, but this was not adhered to.
A resident with moderately impaired cognition was served a mechanical soft diet instead of the ordered pureed diet due to a lack of proper documentation and communication among staff. A trial of the pureed diet was conducted without obtaining a formal order, leading to confusion about the correct diet. The DON changed the diet order without assessing the trial's outcome, contributing to the discrepancy.
The facility did not provide the mandated 8 hours of RN coverage on a particular day, as the DON, who was scheduled, did not work. The nursing schedule lacked documentation of RN coverage, and the Administrator confirmed this deficiency. The facility's policy requires daily 8-hour RN coverage to ensure resident health and safety.
The facility did not notify the LTCO of a resident's discharge to the hospital, as required by federal regulation. The clinical record lacked documentation of this notification, and the facility's policy mandates that emergency transfer notices be sent to the LTCO monthly. The Administrator confirmed the absence of documentation and acknowledged the expectation to notify the LTCO.
A facility failed to notify a resident or their representative of the bed hold policy during a hospitalization. The resident's clinical record lacked documentation of this notification, despite the facility's policy requiring it upon admission and when hospitalization is confirmed. The Administrator confirmed the absence of documentation and the expectation for notification.
The facility failed to notify two residents of changes in their Medicare benefit coverage by not providing the Notice of Medicare Non-Coverage (NOMNC) when their Medicare Part A services were ending. The Administrator acknowledged that the NOMNC was not issued because the Social Services Designee did not realize the need to fill out two forms, leading to the omission.
The facility staff failed to perform scheduled controlled medication shift counts and did not destroy a discontinued narcotic medication for a resident with severe cognitive impairment. The medication card and narcotic sheet were left in the narcotic box, and subsequent counts were not performed as required by policy. When the medication was re-ordered, it was discovered missing, prompting an investigation.
Failure to Monitor Warfarin Therapy and Respond to Bruising and Drug Interactions
Penalty
Summary
Facility staff failed to ensure appropriate monitoring and management of anticoagulant therapy for a resident on warfarin whose regimen was affected by additional medications. The resident had a history of stroke, severe cognitive impairment, limited range of motion, and was care planned for anticoagulant therapy with goals to avoid discomfort or adverse reactions. The care plan directed staff to check INR per physician orders and to monitor, document, and report adverse reactions such as bruising and changes in mental status, but it did not include instructions on how to monitor INR or address interactions between warfarin and antibiotics. The January MAR showed warfarin administration and new orders for Rocephin and metronidazole, both of which can affect INR, yet there was no corresponding INR order on the MAR or TAR. On the morning after the physician ordered antibiotics, nursing staff discovered a large 7 cm by 5 cm bruise on the resident’s mons pubis/penis area while the resident was on warfarin and antibiotics. Staff documented the bruise in a nursing note and faxed a note to the physician, but there was no documented follow-up assessment, no skin sheet, no photograph, and no initiation of increased monitoring specific to the bruise or potential anticoagulant side effects. The TAR, which required staff to document monitoring for signs of anticoagulant adverse effects, showed an entry of “N” (no symptoms) on the day the bruise was found and no documentation at all the following day, despite the presence of the bruise. Staff interviews revealed that some nurses and CNAs saw or were told about the bruise, but they did not notify the physician or the resident’s wife in a timely manner, did not complete an investigation for an injury of unknown source, and did not obtain an INR when the bruise was first identified. The resident’s INR was instead checked by his wife two days after staff discovered the bruise, revealing a markedly elevated INR of 7.3, which she reported to staff. Nursing staff then contacted the anticoagulation clinic, received recommendations to hold warfarin and administer vitamin K or spinach, and were informed that Rocephin, metronidazole, and the recent illness could severely affect INR levels. Before staff could implement these orders, the resident’s condition deteriorated, with documented lethargy, inability to follow commands, drooling, and abnormal lung sounds, leading to transfer to the hospital where an INR greater than 13 and a large rectus sheath hematoma with hemoperitoneum were identified. Throughout this period, facility staff reported they relied on the pharmacist to notify them of drug interactions and did not have a standard expectation or standing orders for more frequent INR checks when residents on warfarin started antibiotics. The DON acknowledged that staff failed to investigate the bruise as a potential injury of unknown source and that there was no standing process for INR monitoring frequency when high-risk medications such as antibiotics were added to warfarin therapy. Surveyors determined that these failures constituted a deficiency in ensuring the resident’s drug regimen was free from unnecessary drugs, specifically by not adequately monitoring the INR and not responding appropriately to signs of possible anticoagulant-related bleeding while the resident was receiving interacting medications. The Department of Inspections, Appeals, and Licensing determined that the situation rose to the level of Immediate Jeopardy beginning when staff failed to implement increased monitoring after discovering the bruise while the resident was on medications that increased bleeding risk. The facility census included multiple residents on blood-thinning medications, and staff interviews showed inconsistent understanding of monitoring requirements for warfarin compared to newer anticoagulants, as well as reliance on the resident’s wife and the anticoagulation clinic for INR management without an internal tracking or standardized monitoring process.
Failure to Report and Adequately Investigate Finger Fracture of Unknown Origin
Penalty
Summary
The facility failed to timely report an alleged violation involving mistreatment, neglect, or injury of unknown origin to the Iowa Department of Inspections and Appeals and Licensing (DIAL) after a resident was found to have a left middle finger fracture. The resident had severe cognitive impairment with a BIMS score of 3, diagnoses including non-Alzheimer’s dementia, polyneuropathy, and macular degeneration, and required substantial to maximal assistance with all ADLs and two staff with a full-body mechanical lift for transfers. The care plan directed staff to protect the resident’s arms with long sleeves, use pillows to prevent bumping arms and feet, and observe and report changes to the physician as needed. On one morning, staff notified the nurse that the resident’s left hand was significantly swollen. The nurse documented non-pitting edema of the left hand without pain on touch, removed the arm protector due to circulatory restriction, and elevated the arm on a pillow. Later that night, the nurse faxed the physician about the significant edema, noting no pain with movement and no edema elsewhere, and received an order to elevate the arm above heart level and a question about obtaining an X-ray. An X-ray obtained the next day showed an acute nondisplaced fracture of the third middle phalanx of the left hand. Nursing documentation reflected that the resident did not cooperate during splint application to the fractured finger. Despite the confirmed fracture and the lack of a witnessed cause, the facility did not report the injury of unknown origin to DIAL within 2 hours as required by its abuse prevention, identification, investigation, and reporting policy. The facility’s investigation consisted of a brief, undated, one-page document stating that no staff witnessed an incident and that the resident frequently rubbed his fingers together, put his hands in his shirt, and had degenerative changes on X-ray. Staff interviews indicated they did not know how the fracture occurred and suggested possibilities such as the resident twisting his own fingers or getting a finger caught in side rails, but no definitive cause was identified. The Interim DON acknowledged that a more thorough investigation should have been conducted, while the Administrator concluded the fracture did not meet criteria for reporting, resulting in the failure to report an injury of unknown origin as required by facility policy.
Failure to Consistently Document Weekly Skin Locations and Measurements
Penalty
Summary
The deficiency involves the facility’s failure to document weekly skin locations and measurements for a resident with identified skin impairments, as required by the care plan and facility policy. The resident had no cognitive impairment, could communicate effectively, and had diagnoses including hypertension, diabetes mellitus, pneumonia, and a non-pressure skin ulcer. The care plan for actual/potential skin impairment, initiated on 10/15/25, directed staff to monitor and document the location, size, and treatment of skin injuries and to complete weekly treatment documentation including measurements (length, width, depth, tissue type, exudate, and notable changes). Multiple Skin Observation Tools documented skin tears and abrasions on the resident’s toes, right foot, and other areas, but repeatedly lacked required measurements and specific locations. For example, a 1/25/26 entry noted skin tears on the left and right toes without measurements, and subsequent entries on 1/28/26, 2/4/26, and 2/11/26 described bruising, scratches, abrasions, and skin tears but did not include measurements or precise locations. The resident was observed on more than one occasion lying in bed with the bottoms of both feet resting against the bed’s footboard, and the resident reported that resting his feet against the footboard caused sores on the bottom of his right foot and toes. A later Skin Observation Tool on 2/25/26 documented a right toe skin tear with measurements and noted scabs on the bottom and side of the right 5th digit, and a 3/2/26 Skin Issues Note recorded a right lateral foot skin tear with specific dimensions, acquired in-house with an unknown onset. Despite these later measurements, the DON acknowledged that the clinical record lacked documentation of the locations and sizes of the areas on the bottom of the resident’s right foot, and stated that nursing staff were expected to follow the facility’s Weekly Skin Assessment and Documentation Process policy, which required weekly documentation and separate assessments for each skin/wound alteration. This failure to consistently document weekly skin locations and measurements for the resident’s skin impairments constituted the cited deficiency.
Failure to Document Skin Checks Leads to Undetected Wound Infection
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards for a resident with a wound. The resident, who had a history of hypertension, stroke, hemiplegia, hemiparesis, anxiety, and depression, required dependent assistance for activities of daily living and wore an ankle-foot orthosis (AFO) on the right foot. The care plan directed staff to inspect the resident's skin before and after applying the AFO, but the facility did not document these skin checks. As a result, a wound on the resident's right shin went unidentified until a dermatology appointment, where it was discovered to be infected with Methicillin-resistant Staphylococcus aureus (MRSA). The resident's care plan also required weekly skin inspections, but the facility failed to document these assessments. The resident's Minimum Data Set (MDS) assessment indicated no skin issues, yet the dermatology clinic identified a wound during a routine appointment. The clinic took a sample of the wound, ordered an antibiotic, and cultured the drainage, which revealed MRSA. The facility's records lacked documentation of completed skin assessments after removing or applying the AFO, both before and after the infection was identified. Interviews with staff, including Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs), confirmed the absence of documentation for skin checks related to the AFO. The Director of Nursing also verified the lack of documentation for these checks. The facility's Weekly Skin Assessment Policy required comprehensive skin assessments weekly and additional assessments based on changes in the resident's condition, but these were not conducted or documented as required, leading to the oversight of the resident's wound and subsequent infection.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which compromised the resident's quality of life. The resident, who had severe memory impairments and was diagnosed with Alzheimer's disease and non-Alzheimer's dementia, displayed physical behaviors such as hitting, kicking, scratching, and grabbing towards others. The resident required substantial to maximal assistance with all activities of daily living, including ambulation. The care plan for the resident indicated that he could become aggressive and combative during care, and staff were instructed to approach him calmly and have assistance present during his care. On one occasion, two CNAs were involved in providing evening care to the resident. Staff A reported that Staff B acted very rough during the process of undressing and completing peri-care for the resident, which led to the resident becoming physically aggressive. Staff A attempted to comfort the resident by placing a hand gently on his shoulder, but the resident continued to exhibit physical aggression, a common behavior associated with his dementia. The incident was not documented in the clinical record, and the facility's internal investigation was initiated after the report was made. Interviews with other residents and staff indicated that they felt safe and treated with respect and dignity, with no concerns about their care. Staff members who worked closely with Staff B described them as helpful and attentive, with no concerns about the quality of care provided. However, the facility's policy and procedure emphasized the importance of treating all residents with dignity and respect, and the incident involving the rough handling of the resident during care was a clear violation of these standards.
Failure to Timely Report Alleged Mistreatment
Penalty
Summary
The facility failed to report an alleged incident of mistreatment involving a resident to the Department of Inspection and Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe memory impairments and a history of physical aggression due to Alzheimer's disease and dementia. During an evening care session, a Certified Nurse Aide (CNA) was reported to have acted roughly while assisting the resident, which led to the resident becoming physically aggressive. This incident was reported by another CNA, but the facility did not notify DIAL promptly as required by their policy. The resident's clinical record did not document the incident, and the facility's Administrator confirmed the failure to report within the specified timeframe. The facility's policy, dated May 2023, mandates that all allegations of resident abuse be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made. This deficiency highlights a lapse in the facility's adherence to its own abuse prevention and reporting policies.
Dietary Order Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that the dietary orders for a resident were accurately followed, leading to a discrepancy in the diet provided. Resident #11, who had moderately impaired cognition and was independent in eating, was observed being served a mechanical soft textured diet during a meal observation. However, the physician's order indicated that the resident was supposed to receive a pureed textured diet. This discrepancy arose after a nursing trial of the pureed diet was conducted without proper documentation or confirmation of the correct diet order. The confusion regarding Resident #11's diet order was evident among the staff. Staff A, who served the meal, and the Certified Dietary Manager (CDM) both believed the resident's order was for a mechanical soft diet. The CDM mentioned that a trial of pureed food was conducted due to the resident's stroke, but it was decided to continue with the mechanical soft diet as the resident performed better with it. Staff B, an LPN, confirmed that there was no official order for the pureed diet and that the trial was based on nursing judgment. The Director of Nursing (DON) later obtained a doctor's order for the pureed diet without assessing the trial's outcome, leading to the order discrepancy. The facility's policy on assessment and reassessment of changes in condition was not adhered to, as there was a lack of documentation and communication regarding the trial and subsequent diet order. The DON admitted to changing the diet order without proper assessment, which contributed to the confusion. The policy required comprehensive assessment and documentation to ensure continuity of care, which was not followed in this case, resulting in the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on a specific day, as mandated by regulations. The nursing schedule for that day lacked documentation of RN coverage, and the Director of Nursing (DON), who was scheduled to work, did not fulfill their shift. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of the required RN coverage. The facility's policy, updated in March 2021, clearly states the necessity for 8-hour RN coverage daily to ensure resident health and safety, which was not adhered to on the day in question.
Failure to Notify LTCO of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman (LTCO) of a discharge/transfer to the hospital for a resident reviewed for hospitalization. The clinical record review showed that the resident was discharged from the facility to the hospital and returned a week later. However, the clinical record lacked documentation of LTCO notification regarding this discharge, as required by federal regulation. The facility's policy stated that copies of notices for emergency transfers must be sent to the Office of the State LTCO on a monthly basis. During an interview, the Administrator admitted they could not locate documentation of the LTCO notification for the resident's hospitalization, acknowledging that it is expected to notify the LTCO when a resident is discharged to the hospital.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or their representative of the bed hold policy during a hospitalization event. Specifically, the clinical record of a resident who was discharged to a hospital and later returned to the facility lacked documentation indicating that the resident or their representative was informed of the facility's bed hold policy. The facility's policy, revised in 2015, mandates that the bed hold policy be presented to residents or their responsible parties upon admission and again when hospitalization or therapeutic leave is confirmed. During an interview, the Administrator acknowledged the absence of the required documentation for the resident's hospitalization period and confirmed the expectation that such notification should occur.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to notify two residents of changes in their Medicare benefit coverage. Specifically, the facility did not provide the Notice of Medicare Non-Coverage (NOMNC) to two residents who were receiving Medicare Part A services, which were ending. During the survey, the facility was unable to produce the NOMNC for these residents when requested. The Administrator acknowledged that the NOMNC was not issued because the Social Services Designee (SSD) did not realize the need to fill out two forms, resulting in the omission of the NOMNC for these residents.
Failure to Perform Narcotic Counts and Destroy Discontinued Medication
Penalty
Summary
The facility staff failed to perform scheduled controlled medication shift counts as directed by facility policy and did not destroy a discontinued narcotic medication for one resident. Resident #1, who had severe cognitive impairment and multiple diagnoses including arthritis, osteoporosis, recent hip fracture, Alzheimer's dementia, and anxiety, had an order for Oxycodone 5 mg to be given as needed for pain. The medication was discontinued by the primary care physician, but the staff did not destroy the remaining medication as required by the facility's policy. Instead, the medication card and narcotic sheet were left in the narcotic box and binder. Subsequently, the staff failed to perform the required narcotic counts at the end of their shifts on two occasions. When the resident complained of hip pain, the physician re-ordered the Oxycodone, but the staff discovered that the medication card and narcotic sheet were missing. The incident was reported to the Director of Nursing and the Administrator, who initiated an investigation. The facility's policy mandates that narcotic counts be completed by two employees within 60 minutes prior to the end of each shift and that any discrepancies be reported immediately.
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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 Eagle Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarion Wellness And Rehabilitation Center | 9.1 mi | ★★★★★ | 12 | 0 |
| Crestview Nursing And Rehabilitation | 14.6 mi | ★★★★★ | 13 | 0 |
| Southfield Wellness Community | 14.8 mi | ★★★★★ | 24 | 0 |
| Marian Home | 17.2 mi | ★★★★★ | 0 | 0 |
| Humboldt County Memorial Hospital | 17.8 mi | ★★★★★ | 5 | 0 |
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