Above 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 Southeast Iowa Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, whose personal funds were managed by the facility, did not receive required quarterly trust fund statements. The administrative assistant responsible for resident fund accounts reported that quarterly statements were not routinely provided and were only printed upon request, without tracking which residents received them. Facility records showed dozens of residents had personal accounts managed by the facility, and policy required quarterly trust fund statements to be available to residents or their legal representatives.
The facility failed to ensure accurate MDS assessments for two residents when the MDS Coordinator coded weekly Trulicity (dulaglutide) injections as insulin administration and documented invasive mechanical ventilator use for a resident who only had orders for CPAP therapy. Review of care plans and active orders showed no insulin or invasive ventilator orders, while care plan entries for one resident incorrectly stated that the resident received insulin injections. Staff interviews confirmed that Trulicity is not insulin and that no residents used invasive mechanical ventilators, demonstrating that the MDS documentation did not reflect the residents’ actual treatments or physician orders.
A resident with diabetes receiving daily Admelog insulin via pen was given insulin in a manner inconsistent with manufacturer instructions when an LPN withdrew insulin from the pen using an insulin syringe instead of a pen needle and then injected it subcutaneously. Staff reported they had been trained to draw insulin from the pen with a syringe, citing cost and safety concerns with pen needles. The RN and DON confirmed this practice for the resident’s insulin pen, and the DON stated a preference for vials. Manufacturer directions for the Admelog Solostar pen specifically prohibit using a syringe to remove insulin, and the facility’s insulin policy did not address adherence to manufacturer instructions.
A resident with schizophrenia, DM2, COPD, moderate cognitive impairment, and mobility limitations required assistance with ADLs, including hygiene. Surveyors observed the resident with long, jagged fingernails with debris underneath and long, jagged toenails. The resident reported staff did not trim his nails and that no podiatrist or physician had done so. Although the record contained a physician order for annual podiatry care due to diabetes, there was no documentation that podiatry services were provided. An RN stated nursing staff perform nail care and diabetic residents are usually referred to podiatry, and a CNA reported she typically alerts nurses and marks the shower sheet when nail care is needed but may not have done so for this resident. The DON confirmed the shower sheet indicated no nail care was needed and that the resident had not been scheduled with podiatry, despite facility policy requiring annual podiatry visits for diabetic residents’ toenail and foot care.
Two residents experienced multiple episodes of three or more days without a bowel movement during which staff did not consistently implement the facility’s bowel protocol or PRN constipation orders. One cognitively intact resident with diagnoses including GERD, functional dyspepsia, and constipation reported going several days without a BM, requesting medication, and not receiving it, despite PRN orders for Milk of Magnesia, Miralax, and a bisacodyl suppository and no constipation problem addressed in the care plan. Another resident with severe cognitive impairment and chronic constipation, care planned to follow the bowel protocol and with PRN orders for bisacodyl tablets, suppositories, and enemas, had several days without documented BMs and received an enema without evidence of earlier stepwise interventions, and later had another multi-day period without a BM with no documented PRN use. Staff and DON interviews confirmed the existence of a bowel protocol and tracking process but could not explain the lack of timely interventions.
A resident with severe cognitive impairment, incontinence, and orders for daily coccyx and mid-back wound care received treatment from an RN who did not perform required hand hygiene between glove changes or between care of different wound sites. After providing perineal care for a bowel movement and removing soiled gloves, the RN donned new gloves without hand hygiene to apply Calmoseptine to the coccyx wound and complete brief care, then again changed gloves without hand hygiene before cleansing and redressing a mid-back wound with blood-tinged drainage using wound cleanser, gauze, skin prep, Calcium Alginate, and Mepilex. Facility policies and staff interviews confirmed that hand hygiene is required after removing gloves, after contact with body fluids, and between wounds, which was not followed during this observed procedure.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide required quarterly personal account statements to a resident whose funds were managed by the facility. Clinical record review showed that Resident #1 was admitted on 12/30/24 and had a BIMS score of 11/15 on the 12/18/25 MDS, indicating moderate cognitive impairment. During an interview, Resident #1 stated the facility assisted with managing her money and reported she had not received a quarterly statement, nor had she requested one. A review of the facility’s list of resident personal accounts showed 46 residents, including Resident #1, had funds managed by the facility. In an interview, the Administrative Assistant, who was responsible for maintaining resident fund accounts, reported that she did not provide quarterly account statements to residents. She stated she only printed statements when residents or their representatives asked and did not track which residents had received statements. She confirmed that Resident #1 had not received a quarterly statement and would only receive one upon request. Review of the facility’s “Resident Trust Fund” policy, dated 10/17/25, revealed that quarterly statements regarding resident trust funds were to be available to the resident and/or the legal resident representative, which was not being done for Resident #1.
Inaccurate MDS Coding for Ventilator Use and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) quarterly assessments accurately reflected the current clinical status and treatment orders for two residents. For one resident, the MDS dated 10/16/25 documented use of an invasive mechanical ventilator under Section O (Special Treatments, Procedures, and Programs) and receipt of insulin injections on one of seven days in the look-back period under Section N (Medications – Insulin). However, the resident’s active orders as of 1/07/25 showed only a weekly Trulicity (dulaglutide) subcutaneous injection for type 2 diabetes mellitus and nightly CPAP for obstructive sleep apnea, with no orders for an invasive mechanical ventilator or insulin administration. The resident’s care plan, revised on 10/21/25, also lacked any indication of invasive mechanical ventilator use or insulin injections. For the second resident, the MDS quarterly assessment dated 10/23/25 documented insulin injections on one of seven days in the look-back period, and the care plan included a focus area for diabetes mellitus with interventions stating that the resident received insulin injections and that staff could administer insulin and check blood sugars in various locations. Review of active orders as of 1/07/25 showed weekly Trulicity (dulaglutide) injections and daily oral Tradjenta (linagliptin) for type 2 diabetes mellitus, with no orders for insulin administration. Staff interviews confirmed that Trulicity had been incorrectly coded as insulin on the MDS for both residents and that the facility had no residents with invasive mechanical ventilators, indicating that the MDS entries did not follow the facility’s MDS Assessments policy or the RAI guidelines referenced therein.
Improper Insulin Pen Use Contrary to Manufacturer Instructions
Penalty
Summary
Facility nursing staff failed to follow manufacturer instructions for administration of Admelog Solostar insulin, resulting in insulin being withdrawn from an insulin pen using a syringe rather than the manufacturer-approved pen needle. Resident #15, who had intact cognition with a BIMS score of 14 and a diagnosis of diabetes mellitus, had a physician order for Admelog U-100 insulin, 6 units subcutaneously with meals, and received insulin injections daily. During observation, Staff D, an LPN, prepared the resident’s lunch insulin by wiping the insulin pen hub with an alcohol pad and inserting an insulin syringe into the pen to withdraw 6 units, instead of attaching and using a pen needle as directed by the manufacturer. Staff D then checked the resident’s blood glucose, which was 140 mg/dL, and administered the insulin into the resident’s right arm. In interviews, Staff D stated they did not use the pen needles because of cost and reported being trained at hire to draw insulin from the pen with a syringe. Staff A, an RN, reported also drawing insulin from the pen into a syringe, stating it was safer than using the non-safety pen needle and believed this resident was the only one prescribed an insulin pen. The DON confirmed that Resident #15 was the only resident using an insulin pen, expressed a preference for vials due to perceived lower risk of error, and stated they knew the resident received the correct insulin and did not think there was an issue with drawing insulin from the pen using a syringe. Manufacturer instructions for the Admelog Solostar pen explicitly stated not to use a syringe to remove insulin from the pen, and the facility’s Insulin Preparation and Administration Policy did not address following manufacturer instructions for insulin administration.
Failure to Provide Required Nail and Podiatry Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary assistance with nail care for a resident who required help with activities of daily living. The resident had moderate cognitive impairment, schizophrenia, diabetes mellitus type 2, and COPD, and used a wheelchair and walker for mobility. The MDS indicated the resident required partial to moderate staff assistance for showering and setup assistance for eating and oral hygiene, and the care plan stated the resident was independent with ADLs but should be assisted as needed. During observation, the resident was seen at the nurse’s station with long, jagged fingernails and a brown-like substance under some nails. In an interview, the resident reported that staff did not trim his fingernails, stated they needed to be done, and further reported that his toenails were worse. When the resident removed his socks, his toenails were observed to be long and jagged. The resident stated nursing staff did not cut or trim his toenails and denied that a podiatrist or other physician had trimmed them. The clinical record contained a physician order for an annual podiatry visit for diabetic foot care, but there was no documentation that podiatry care had been provided. An RN stated that nursing staff trimmed and filed residents’ nails and that diabetic residents were usually referred to a podiatrist for toenail care, and reported having trimmed the resident’s fingernails in the past but never his toenails, with no known refusals. A CNA, who provided the resident’s showers and bed baths, stated she would normally notify nurses and mark the shower sheet if nail care was needed and thought she had indicated this for the resident but may not have due to being busy. The DON reviewed the shower sheet and confirmed it documented that the resident did not need nail care and that the resident, a diabetic, had not been scheduled with the facility’s podiatrist, despite facility policy requiring diabetic residents to see a podiatrist at least annually for toenail and/or foot care.
Failure to Implement Bowel Protocol and PRN Constipation Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide timely constipation interventions according to physician orders, the bowel protocol, and resident preferences for two residents who went three or more days without a bowel movement (BM). One resident with intact cognition, continent bowel status, and diagnoses including gastro-esophageal reflux disease, functional dyspepsia, and constipation reported going three or more days without a BM and not receiving any medication despite requesting help. The resident had PRN orders for Milk of Magnesia, Miralax, and a bisacodyl suppository as part of a bowel management regimen, but the care plan did not address a bowel problem area. Record review showed multiple periods of three or more days without a documented BM, with only one administration of Milk of Magnesia during one such episode and no documented PRN constipation medications during later episodes, despite the facility’s bowel protocol requiring escalating interventions on days three, four, and five without a BM. A second resident with severe cognitive impairment, bowel incontinence, and dependence for all ADLs had a care plan problem for chronic constipation directing staff to follow the bowel protocol and had PRN orders for bisacodyl tablets, bisacodyl suppositories, and enemas. Documentation showed several days without recorded BMs, followed by a BM after an enema, with no evidence of earlier, stepwise interventions per the protocol. In another episode, the resident again went multiple days without a documented BM and there was no documentation of PRN constipation medications being administered. Staff interviews confirmed the existence of a bowel protocol requiring oral laxatives on day three without a BM, suppositories on day four, and enemas on day five with physician notification, and that night shift tracked BMs and day shift was responsible for administering protocol medications. The DON was unable to explain why the required interventions were not provided for either resident.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care as required by its infection prevention and control program. A resident with severe cognitive impairment, bowel and bladder incontinence, dependence for all ADLs, and risk for pressure ulcers had physician orders for daily Calmoseptine application to a coccyx wound and daily cleansing and dressing of a right mid-back wound with Calcium Alginate, skin prep, and Mepilex. During an observed wound care procedure, an RN performed initial hand hygiene, donned PPE, sanitized the over-bed table, and set up a clean field with wound care supplies. While the resident was lying in bed on her right side, the RN loosened the incontinent brief, discovered a bowel movement, and provided perineal care with removal of the soiled brief while the DON assisted with placing a clean brief. After completing perineal care, the RN removed her gloves and donned a new pair without performing hand hygiene, then applied Calmoseptine ointment to the coccyx wound and finished applying the new brief. The RN again removed her gloves and donned another pair without hand hygiene before proceeding to the mid-back wound. With the same pair of gloves on, the RN and DON repositioned the resident, removed a dated dressing with blood-tinged drainage from the mid-back wound, sprayed wound cleanser on the wound bed and surrounding tissue, dabbed the area dry with 4x4 gauze, applied skin prep to the surrounding area, placed Calcium Alginate in the wound bed, and covered it with Mepilex. Interviews with the RN and DON confirmed that facility policy and staff training require hand hygiene with glove changes and after contact with body fluids, and policy documents specify hand hygiene after removing dirty gloves and between cleansing different wounds, which did not occur during this observed treatment.
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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 Keokuk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mississippi Valley | 0.6 mi | ★★★★★ | 1 | 0 |
| River Hills Village In Keokuk | 0.8 mi | ★★★★★ | 6 | 0 |
| Montrose Health Center | 7.3 mi | ★★★★★ | 4 | 0 |
| Birkwood Village Of Fort Madison | 14.2 mi | ★★★★★ | 6 | 0 |
| Clark County Nursing Home | 16.4 mi | ★★★★★ | 1 | 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.