Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Simpson Memorial Home during CMS and state inspections, most recent first.
Failure to notify the physician of significant weight loss for a resident with COPD, heart failure, chronic respiratory failure with hypoxia, and moderate cognitive impairment. The RD documented significant weight loss on multiple weight reviews, but the EHR lacked physician notification and the physician visit notes did not address the weight loss. The DON stated there was no formal process for physician notification, and the RD said significant weight changes were forwarded to administrative nursing staff rather than the physician.
Inaccurate MDS coding affected three residents. Two residents with dementia and psychiatric diagnoses were coded as not meeting PASRR Level II serious mental illness criteria even though records and the PASRR showed bipolar disorder, depression, anxiety, and related findings; the MDS Coordinator later acknowledged the A1500 coding should have been yes. Another resident with severe cognitive impairment and an active wander guard on the right ankle was coded as not using a wander/elopement alarm, despite the care plan, physician orders, staff confirmation, and direct observation showing the device was in use.
A facility failed to follow proper infection control practices during meal service, as a cook used the same gloves to handle various items, including food, without changing them between tasks. The facility's policy requires the use of tongs instead of gloves to prevent cross-contamination, and gloves should be changed after each task.
A resident discharged from hospice services did not receive a required significant change in status assessment on the MDS, despite improvements in their condition. Interviews with the MDS Coordinator and DON confirmed the oversight, which was contrary to the facility's policy requiring timely assessments.
The facility inaccurately coded MDS assessments for two residents, one receiving hospice services and another taking an antiplatelet medication. The MDS Coordinator admitted to errors in coding, which were confirmed by the DON. These inaccuracies were identified through clinical record reviews and staff interviews, indicating a failure to ensure accurate resident assessments.
The facility failed to update care plans for two residents, one requiring warfarin management and another needing fall prevention interventions. Despite physician orders and multiple falls, the care plans were not revised to include necessary interventions, as acknowledged by the DON.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician or the physician’s designee of significant weight loss for Resident #17, who had diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and heart failure. The resident’s MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment. The care plan identified altered nutritional status related to poor appetite and progressive weight decline, with interventions including referral to the medical doctor or RD as necessary. The RD’s weight change progress notes documented significant weight loss at 30 days, 90 days, and 180 days, but the EHR did not contain documentation that the physician was notified of these weight changes. The physician’s long-term care facility/home visit notes did not address the significant weight loss. During interviews, the DON stated there was no formal process for physician notification related to significant weight changes and that these issues were typically addressed during the resident’s regulatory 60-day physician visit. The RD stated resident weights were reviewed during weekly facility visits and that significant weight changes were forwarded to administrative nursing staff, but the RD did not notify the physician.
Inaccurate MDS Coding for PASRR Status and Wander Alarm Use
Penalty
Summary
The facility failed to accurately complete MDS assessments for 3 of 12 residents reviewed. For Resident #6, the annual MDS documented diagnoses of non-Alzheimer's dementia, bipolar disorder, and anxiety disorder, but coded that the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The resident's care plan listed bipolar disorder, depression, and anxiety disorder, and the PASRR dated 5/17/17 identified bipolar disorder and depression while noting Level II evaluation was not required because dementia was the primary diagnosis. For Resident #20, the admission MDS documented diagnoses of non-Alzheimer's dementia, bipolar disorder, and anxiety disorder, but also coded that the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The resident's care plan listed bipolar disorder and noted a PASRR Level II determination. The PASRR dated 7/18/25 identified bipolar disorder, major depressive disorder, anxiety disorder, and dementia. The MDS Coordinator stated she completed the MDS assessments for Residents #6 and #20, entered diagnoses in section I, and manually filled out the PASRR questions, later acknowledging that A1500 should have been marked yes for both residents. The Social Services Director confirmed that bipolar disorder, major depressive disorder, or anxiety disorder would be classified as serious mental illness according to PASRR. For Resident #9, the MDS completed 8/28/25 showed a BIMS score of 7, indicating severe cognitive impairment, and listed diagnoses of CVA and non-Alzheimer dementia, but coded a wander/elopement alarm as not used. The care plan identified the resident as at risk for elopement related to impaired safety awareness and dementia, with interventions including a wander guard on the right ankle, and the physician order summary also documented wander guard placement and nightly function testing. During observation, a wander guard alarm was seen on the resident's right ankle, and staff confirmed the resident wore a wander guard. The MDS Coordinator acknowledged the alarm should have been coded on the MDS, and the DON acknowledged MDS coding discrepancies from the prior MDS Coordinator.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to ensure proper infection control practices during meal service, which could lead to contamination and food-borne illness. During an observation of the lunch service, a cook, identified as Staff B, was seen wearing gloves while handling various items, including slider buns, plates, utensils, ketchup bottles, and resident menu orders. Staff B changed gloves only twice during the meal service, but continued to touch multiple surfaces and food items without changing gloves between tasks, which is against the facility's infection control policy. The facility's policy on bare hand contact with food and the use of plastic gloves states that gloves are considered a food contact surface that can become contaminated. The policy directs staff to use single-use gloves for only one task and to change them when they become soiled or when there is an interruption in the operation. The Dietary Supervisor confirmed that staff are expected to use tongs instead of gloved hands to serve items on bread or buns to prevent cross-contamination, and that gloves should not be used during food service.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment on the Minimum Data Set (MDS) for a resident who was discharged from hospice services. The resident, identified as having severe cognitive impairment with a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) exam, was previously receiving hospice care due to senile degeneration of the brain and malnutrition. Despite the resident's discharge from hospice services, which indicated an improvement in their condition, the facility did not conduct the required significant change in status assessment. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that a significant change in status assessment should have been completed following the resident's discharge from hospice services. The facility's policy, dated March 2022, mandates that the resident assessment coordinator ensures timely and appropriate assessments, including significant change in status assessments, are conducted. The failure to perform this assessment was identified as a deficiency during the review.
Inaccurate MDS Coding for Hospice and Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their medical records. Resident #24 was incorrectly coded as taking an anticoagulant, despite only being prescribed clopidogrel bisulfate, an antiplatelet medication. This error was acknowledged by the MDS Coordinator, who admitted to mistakenly selecting the wrong option. The Director of Nursing (DON) confirmed that the resident did not take an anticoagulant and expected the MDS to reflect the correct medication classification. Resident #15's MDS assessment failed to indicate that the resident was receiving hospice services, despite the care plan and physician orders confirming hospice involvement. The MDS Coordinator admitted to not marking the hospice status on the assessment, and the DON confirmed that the resident had been on hospice for a significant period. These inaccuracies in the MDS assessments were identified through clinical record reviews and staff interviews, highlighting a failure to ensure accurate resident assessments as per facility policy.
Failure to Update Care Plans for Medication and Fall Prevention
Penalty
Summary
The facility failed to revise the care plan for Resident #19 to include the use of warfarin, a blood thinner, and the necessary INR testing. Resident #19 was admitted with diagnoses including atrial fibrillation and COPD, and had physician orders for warfarin and Zithromax. However, the care plan did not reflect these medications or the required interventions for their management. The Director of Nursing acknowledged that new orders should be reviewed and incorporated into the care plan by the MDS nurse, but this was not done in this case. Additionally, the facility did not update the care plan for Resident #21 to include personalized interventions following multiple falls. Resident #21, who has moderate cognitive impairment and a history of falls, experienced several incidents where they fell or were found on the floor. Despite these occurrences, the care plan was not updated to reflect specific interventions to prevent further falls. The Director of Nursing noted that interventions were identified but not documented in the care plan, and staff were not comfortable adding these interventions. The facility's policy requires that care plan interventions be derived from a comprehensive assessment and updated as the resident's condition changes. However, in these cases, the care plans were not revised to include necessary interventions for medication management and fall prevention, leading to deficiencies in the care provided to Residents #19 and #21.
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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 West Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Specialty Care | 8.2 mi | ★★★★★ | 15 | 1 |
| Lone Tree Health Care Center Inc | 10.7 mi | ★★★★★ | 5 | 0 |
| Accura Healthcare Of Muscatine | 12.8 mi | ★★★★★ | 1 | 0 |
| Wilton Retirement Community | 12.9 mi | ★★★★★ | 2 | 0 |
| Iowa City Rehab & Health Care | 13.1 mi | ★★★★★ | 27 | 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.