Above 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 Scottish Rite Park Inc during CMS and state inspections, most recent first.
Unsafe Mechanical Lift Transfer Resulted in Severe Injury: A resident with intact cognition, morbid obesity, HF, and a seizure disorder fell from a full-body mechanical lift during a transfer after staff failed to ensure the sling loops remained securely attached. Staff found the resident on the floor with bleeding to the shin and a bump on the head, and hospital imaging later showed SDH, SAH, a type III dens fracture, a right clavicle fracture, and a left femur fracture.
A resident was discharged to home, but the required MDS discharge assessment was not completed and transmitted within the mandated timeframe. The MDS Coordinator missed the assessment due to being on vacation and not attending the care conference, and the facility lacked a written MDS policy.
A resident with left-sided weakness from a stroke did not consistently receive a prescribed overnight wrist splint as directed in the care plan. Documentation of splint application and removal was missing, and both the resident and staff reported that the splint was often forgotten or not applied due to lack of staff training. Therapy staff had recommended the splint to prevent contractures, but there was no record of refusals or consistent use.
A resident with a history of arthritis and osteoporosis fell and fractured her ankle due to the facility's failure to follow the Care Plan, which required the use of a gait belt during transfers. The resident, who had tested positive for COVID-19, was being assisted by a CNA when her knee gave out, and she was guided to the floor without a gait belt. The facility lacked a specific Care Plan policy, and staff were reminded to adhere to safety protocols after the incident.
A resident with a history of knee weakness fell and fractured her ankle due to a CNA's failure to use a gait belt during a transfer, as required by the care plan. The CNA, who lacked proper orientation and training documentation, assisted the resident without a gait belt, believing it was unnecessary. The facility's investigation revealed inadequate training and supervision contributed to the incident.
A resident with a history of stroke and high fall risk experienced multiple falls and injuries due to improper use of an EZ stand lift at the facility. The resident sustained a fracture after a strap broke during a transfer, and another incident occurred when the resident lost grip while standing for a treatment. Staff interviews revealed inconsistencies in the use of the EZ stand, including inadequate supervision and lack of adherence to manufacturer's recommendations.
The facility failed to complete and transmit MDS assessments for four residents within the required timeframe, resulting in incomplete assessments with multiple errors. This deficiency was due to staffing transitions, as the new MDS Coordinator was instructed to focus on assessments from her start date, leaving previous ones unfinished. The DON and ADON had been managing the assessments after the previous coordinator left abruptly.
A facility failed to include a resident's oxygen (O2) use in their care plan, despite the resident having diagnoses of COVID-19, heart failure, and end-stage renal disease. The care plan lacked details on O2 management, even though a physician's order specified O2 administration to maintain oxygen saturation. Observations confirmed the resident's O2 use, and staff interviews highlighted the expectation for O2 to be included in the care plan, though no policy on care plans existed.
Unsafe Mechanical Lift Transfer Resulted in Resident Fall and Severe Injury
Penalty
Summary
The facility failed to ensure a resident received a safe transfer using a full-body mechanical lift, and the resident fell from the lift during the transfer. The resident had a BIMS score of 15 and depended on staff for bed mobility and transfers. Her care plan required assistance from 3 staff members and use of a full-body mechanical lift for transfers. Her diagnoses included heart failure, morbid obesity, and a seizure disorder. On the evening of the incident, staff were transferring the resident from a wheelchair to bed with the full-body mechanical lift when she fell to the floor. Staff found her on the floor with the lift above her, her left leg up on the couch, her head toward the bed, and blood on her left lateral shin. Staff documented that the resident was yelling for help, requested EMS, and refused facility staff assistance and assessment. Staff applied gauze and wrapped the left shin to control bleeding until EMS arrived. Witness statements described three CNAs assisting with the transfer, with one staff member operating the lift controls, another guiding the legs, and another moving the wheelchair. Staff reported hearing a snap and then seeing the resident fall. One staff member stated the resident was high in the air when the snap occurred, and another stated the right upper strap loop appeared unhooked after the fall. The resident was sent to the hospital by ambulance after her representative persuaded her to go. The resident’s hospital evaluation documented severe injuries from the fall, including a subdermal hemorrhage, a subarachnoid hemorrhage, a type III dens fracture, a right clavicle fracture, and a left femur fracture. The trauma consult noted she arrived with a c-collar in place and tenderness on palpation, and imaging confirmed the head, neck, clavicle, and femur injuries.
Failure to Timely Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) discharge assessment within the required timeframe for one resident. Clinical record review showed that the resident was admitted to the facility and later discharged to home, but the discharge MDS assessment was not completed at the time of discharge. The MDS Coordinator, who is responsible for tracking and submitting MDS assessments, missed the completion of the discharge MDS because she was on vacation and did not attend the care conference meeting where the discharge was discussed. The facility did not have an official written policy for MDS completion and submission. Documentation in the Electronic Health Record and staff interviews confirmed that the resident was discharged on a specific date, but the discharge MDS assessment was not completed and submitted until over a month later. The Resident Assessment Instrument (RAI) Manual requires that a discharge assessment be completed within 14 days of discharge and submitted to CMS within 14 days of completion, which was not met in this case.
Failure to Follow Care Plan for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of cerebrovascular accident (CVA) resulting in left-sided hemiplegia and hemiparesis. The care plan, initiated due to decreased mobility and function, directed staff to apply a left wrist brace overnight to prevent contractures. However, the clinical record lacked documentation of the splint's application or removal, and observations confirmed the resident was not wearing the splint as required. The resident reported that both he and staff would forget to apply the splint at night, and also noted that staff did not consistently use the recommended platform walker for transfers. Further interviews revealed that the resident did not always receive the splint, denied refusing it, and stated that some staff were not trained in its application. Therapy notes indicated ongoing goals for consistent splint use, and staff confirmed the resident experienced pain and tightness, supporting the need for the splint. The DON was unable to provide documentation of the splint's use or any record of refusals, and acknowledged that the intervention was removed from the care plan without clear evidence of resident refusal or clinical justification documented at the time.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement and follow safety interventions as outlined in the Care Plan for a resident, resulting in a fall and a fractured left ankle. The resident, who had a history of arthritis, osteoporosis, and physical debility, required partial to moderate assistance for transfers and ambulation. Despite the Care Plan indicating the need for a gait belt during transfers, the staff did not use one, leading to the resident's fall. On the day of the incident, the resident, who had tested positive for COVID-19, was being assisted by a CNA from the bathroom to a recliner. The CNA reported that as the resident turned to sit, her knee gave out, and she was guided to the floor. The resident complained of left ankle pain, and an X-ray later confirmed a fracture. Interviews with staff revealed that the use of a gait belt was standard practice unless otherwise specified in the Care Plan, but the CNA did not use one, believing it was unnecessary for this resident. The facility's investigation highlighted a lack of adherence to the Care Plan, as the CNA did not use a gait belt, which was required for the resident. The CNA admitted to not using a gait belt frequently for this resident, as she believed the resident did not require much assistance. The facility did not have a specific Care Plan policy, and staff were reminded to follow the Care Plan after the incident. The incident underscores the importance of adhering to established safety protocols to prevent accidents.
Deficiency in CNA Competency Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) possessed the necessary competencies and skills to safely transfer a resident, leading to an incident where the resident sustained a fracture. The resident, who required partial to moderate assistance for transfers and ambulation, was being assisted by the CNA without the use of a gait belt, contrary to the care plan directives. The resident, who had a history of knee weakness and wore a knee brace, experienced a fall when her knee gave out, resulting in a fracture of the left ankle. The CNA involved in the incident had been employed at the facility since May 2024 and had completed a CNA course earlier that year. However, her employee file lacked an orientation checklist or documentation of completed education specific to gait belt use. The CNA reported that her orientation consisted of shadowing another CNA for four shifts, and she did not recall receiving specific training on gait belt use. On the day of the incident, the CNA assisted the resident without a gait belt, believing it was unnecessary as the resident did not typically require much assistance. Interviews with facility staff revealed that the use of a gait belt was a standard practice unless otherwise specified in the care plan. However, the CNA had not been adequately trained or supervised in this regard. The Chief Nursing Officer (CNO) confirmed the absence of an orientation checklist or competency evaluation for the CNA at the time of the incident. The facility's investigation highlighted the lack of proper training and documentation as contributing factors to the incident.
Improper Use of EZ Stand Lift Leads to Resident Falls and Injury
Penalty
Summary
The facility failed to appropriately use an EZ stand mechanical lift and transfer a resident safely, resulting in multiple incidents involving Resident #2. Resident #2 had a history of cerebrovascular accident (CVA), right shoulder pain, osteoporosis, and a fracture, and was assessed as having a high risk for falls. The care plan directed staff to use an EZ stand with two staff for transfers. However, there were multiple instances where the resident was not transferred safely, leading to falls and injuries. In one incident, the resident was transferred using an EZ stand, and the strap broke, causing the resident to fall and sustain a displaced fracture of the right humerus. The resident reported pain in her right shoulder, and an x-ray confirmed the fracture. Despite the care plan's directive, only one staff member was present during the transfer, which contributed to the unsafe transfer and subsequent injury. The facility did not report this incident to the State Department of Inspections, Appeals, and Licensing (DIAL) as it was not classified as a major injury. Another incident occurred when the resident was standing in the EZ stand for a treatment, and she lost her grip, leading to her being lowered to the floor by staff. The resident expressed fear of using the EZ stand due to her previous fall and injury. Interviews with staff revealed inconsistencies in the use of the EZ stand, including not following the manufacturer's recommendations and the lack of a specific policy or competency checklist for its use. The facility's failure to ensure proper use of the EZ stand and adequate supervision during transfers resulted in repeated falls and injuries for Resident #2.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments for four residents within the required timeframe. The assessments for Residents #2, #7, #9, and #16 were found to be incomplete and contained multiple errors. The MDS assessments for these residents were due by specific dates in May 2024, but they remained in progress with numerous sections incomplete. The errors ranged from 13 to 25, with additional warnings noted in some cases. The deficiency was attributed to staffing issues and transitions within the facility. The MDS Coordinator, Staff A, who began working at the facility in May 2024, reported that she was instructed to complete MDS assessments from her start date forward, leaving previous assessments incomplete. Prior to her employment, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for the MDS assessments after the previous MDS Coordinator left without notice in December 2023. The DON acknowledged the issue of untimely MDS completions and had identified this concern when the previous coordinator resigned.
Failure to Include Oxygen Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident, who had diagnoses of COVID-19, heart failure, and end-stage renal disease. The resident's care plan, revised on June 28, 2024, did not include information about the resident's use of oxygen (O2) or interventions related to its management, despite a physician's order from March 28, 2024, specifying O2 administration via nasal cannula to maintain oxygen saturation above 90%. Observations on multiple dates confirmed the resident was using O2, yet this was not reflected in the care plan. Staff interviews revealed that the MDS Coordinator, responsible for developing and revising care plans, acknowledged that O2 should be included if a resident uses it. Additionally, the Director of Nursing confirmed the expectation for O2 to be listed on the care plan but noted the absence of a policy on care plans.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley On Grand | 0.4 mi | ★★★★★ | 0 | 0 |
| Iowa Jewish Senior Life Center | 1.3 mi | ★★★★★ | 20 | 0 |
| Ramsey Village | 1.4 mi | ★★★★★ | 44 | 0 |
| University Park Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Calvin Community | 2.1 mi | ★★★★★ | 12 | 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.