Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Regional Medical - Klein Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced a choking and aspiration event during a meal. Despite ongoing respiratory distress and difficulty swallowing, the LPN did not perform vital assessments or initiate emergency interventions. The resident was left in bed with CPAP and supplemental oxygen, and her condition deteriorated over several hours, ultimately resulting in death before emergency services arrived.
A resident with moderate cognitive impairment and a history of falls experienced an unwitnessed fall when the bed alarm, intended to alert staff for assistance, failed to sound. Staff and family confirmed the alarm was in place but did not activate, and subsequent testing revealed intermittent function. The resident sustained a lumbar compression fracture, and the deficiency was linked to the malfunctioning alarm.
A resident with severe cognitive impairment and a known risk for elopement exited the facility without staff knowledge by following a contracted dietary worker through a secured area. Despite wearing a functioning wander alert device and the presence of door alarms, the resident was able to leave and was only discovered outside when seen by staff through a window. Staff interviews revealed gaps in supervision and awareness of the resident's movements.
Staff did not follow the approved menu or dietician recommendations for pureed diets, serving incorrect food items and portion sizes due to reliance on an inaccurate scoop size guide and lack of a pre-meal huddle. Additionally, required menu items such as fresh grapes were not served to residents on regular diets.
Multiple residents with intact cognition reported that food was frequently served cold, including items such as fries, scrambled eggs, and spaghetti and meatballs. Direct observation confirmed that food temperatures during meal service were below USDA guidelines, with staff acknowledging the issue and the need for further education. Management cited staff retention and training as ongoing challenges.
Staff failed to prevent verbal abuse of three cognitively impaired residents, with one staff member repeatedly using vulgar and derogatory language, including profanity and insults, despite care plans directing gentle communication and reassurance. Other staff witnessed and reported these incidents, which violated facility policy prohibiting verbal abuse.
Staff did not promptly report three incidents of potential verbal abuse involving residents with severe cognitive impairment. In each case, a CNA used vulgar and aggressive language toward residents, including telling one to sit down and calling others derogatory names. Other staff members who witnessed or were aware of these incidents delayed or failed to report them to administration, contrary to facility policy requiring immediate reporting of suspected abuse.
A CNA was reported for speaking loudly and disrespectfully to a resident and for disregarding a resident's complaint about hot water during a shower. Despite these allegations, the CNA continued to work with residents before being separated, contrary to facility policy requiring immediate removal of alleged abusers during investigations.
A resident with severe cognitive impairment exited a facility without staff knowledge, walking unsupervised for approximately ten minutes. The resident left a group activity and exited through an unlocked, unalarmed door to an unsecured courtyard area. The resident was later observed and escorted back inside without injury. The resident had a low elopement risk score and required supervision when ambulating more than 50 feet.
The facility failed to maintain safe food temperatures and provide palatable meals in two households. A dietary staff member did not check food temperatures before serving, resulting in unsafe temperatures for chicken salad and mechanical soft chicken. A resident with intact cognition reported dissatisfaction with the food quality, noting issues with temperature, texture, and lack of fresh options.
The facility failed to supervise medication administration for two residents, leading to unattended medication. A resident with moderate cognitive impairment had a pill left on a table, which was later returned to her by an RN. Another resident was left with a medication cup and eye drops without supervision. The facility's policy did not support leaving medications at the dining table, yet this practice was observed. The care plan and MAR lacked documentation for self-administration, contributing to the deficiency.
Failure to Assess and Intervene After Choking/Aspiration Event
Penalty
Summary
A resident with severe cognitive impairment, Down syndrome, gastroesophageal reflux disease, and sleep apnea experienced a choking and aspiration event during the evening meal. The resident began coughing and reportedly vomited while eating, which was observed by another resident who alerted nursing staff. Upon assessment, the LPN noted labored respirations and described the resident as choking, but did not perform a full clinical assessment such as checking lung sounds, vital signs, or oxygen saturation. The resident was assisted out of the dining area, encouraged to spit out sputum, and later taken to her room, where she continued to cough and struggle to clear her airway. Despite ongoing symptoms, including persistent coughing and difficulty swallowing, the LPN did not conduct further assessments or initiate emergency interventions. The resident was prepared for bed, placed on CPAP with supplemental oxygen, and left to sleep with her head of bed elevated. No documentation or evidence was found that the nurse monitored the resident's respiratory status or reassessed her condition after the initial event. The resident's condition deteriorated over several hours, with staff later finding her in significant respiratory distress, exhibiting audible crackles, cyanosis, and extremely low oxygen saturation. Multiple staff interviews confirmed that no vital signs, oxygen saturation, or lung assessments were performed by the LPN following the choking episode. The resident was not sent out for emergency care until she was found unresponsive and in severe distress several hours later. The lack of timely assessment and intervention following the aspiration event directly contributed to the resident's decline and subsequent death before emergency services could arrive.
Failure to Ensure Proper Functioning of Bed Alarm Results in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a bed alarm intervention worked properly for a resident with a history of falls and moderate cognitive impairment. The resident required substantial to maximal assistance with mobility and had a care plan that included the use of bed and chair alarms to alert staff when assistance was needed. Despite these interventions, the resident experienced a fall in the bathroom during the night, and it was discovered that the bed alarm did not sound as intended. Clinical documentation and staff interviews revealed that the bed alarm was in place but failed to activate when the resident left the bed. Staff members, including a CNA and RN, confirmed that the alarm did not sound on their phones or audibly, and the issue was only discovered after the resident was found on the bathroom floor. The alarm was later tested and found to function intermittently, with staff noting that wiggling the cord could restore its function. The resident's husband also confirmed that bed alarms were present but did not prevent the fall. The facility's policy required that fall prevention interventions, such as bed alarms, be in working order and checked regularly. However, the failure to ensure the alarm's functionality directly contributed to the resident's unwitnessed fall. The resident sustained a compression fracture of the lumbar spine, as indicated by radiology reports, although the acuity of the fracture was indeterminate. Staff interviews further confirmed reliance on the alarm system for resident safety, and the deficiency was attributed to the alarm's malfunction at the time of the incident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, was assessed as being at risk for elopement and had a care plan in place for this risk. Despite these precautions, the resident was able to exit the facility without staff knowledge. The resident left their assigned area, traversed an unoccupied wing, and exited the building, ultimately being observed outside by staff and subsequently brought back inside. The resident was wearing a wander alert device, which was reported to be functioning at the time of the incident. Staff interviews revealed that the resident was known to wander and had a history of attempting to leave the facility, often expressing confusion and a desire to go home. On the day of the incident, it was believed that the resident followed a contracted dietary worker out of a secured area while staff were preparing to serve breakfast. The dietary worker did not notice the resident following him and was not aware of the resident's status or risk. Multiple staff members confirmed that alarms on exit doors were sounding, but the resident was still able to leave the building unnoticed for a period of time. The incident was discovered when a nurse saw the resident outside through a window and alerted other staff, who then retrieved the resident. Staff interviews indicated that there was a lack of awareness regarding the resident's whereabouts, and some staff were unsure when or how the resident left the unit. The facility's policy defined elopement as a resident leaving a secured area or the building alone and unwitnessed by staff, which occurred in this case.
Failure to Follow Menu and Dietician Recommendations for Pureed Diets
Penalty
Summary
The facility failed to follow the approved menu and dietician recommendations for residents requiring pureed diets. On the observed date, staff prepared a taco salad instead of the taco casserole specified on the menu, and did not adhere to the portion sizes directed by the Registered Dietician. During food preparation, the kitchen staff used incorrect measurements and did not follow the conversion chart accurately, resulting in residents receiving improper portion sizes of both the pureed taco mixture and rice. Additionally, the dietary staff relied on an inaccurate scoop size guide posted in the kitchen, which led to further errors in serving sizes. The required pre-meal huddle, where menu and portion expectations are reviewed, did not occur on the day of the deficiency. Furthermore, the facility did not serve fresh grapes to residents on a regular diet as required by the menu. Interviews with staff revealed a lack of awareness regarding the correct menu items and portion sizes, and the kitchen manager acknowledged the presence of an incorrect scoop size poster in the kitchen. The dietician confirmed that the menu was not followed and expressed concern about the incorrect scoop sizes used during meal service.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food was served at safe and appetizing temperatures, as evidenced by multiple resident and staff interviews, as well as direct observation of meal service. Several residents with intact cognition reported that food was often cold, with specific complaints about cold fries, scrambled eggs, and spaghetti and meatballs. Staff interviews confirmed that food frequently arrived at residents' tables at temperatures below recommended guidelines, and that the distance food traveled before being served contributed to the issue. During a continuous observation of meal service, food temperatures were measured and found to be below the United States Department of Agriculture guidelines, with ground meat/bean mixture dropping from 133°F to 84°F and hamburger patties served at 131°F. Staff acknowledged awareness of the temperature requirements and the need to alert management when food temperatures were not within safe ranges. The kitchen manager and dietician both recognized ongoing concerns with food temperature and identified a need for further staff education, while the general manager noted challenges with staff retention and the necessity for continued training.
Failure to Prevent Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
Staff at the facility failed to protect residents from verbal abuse, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral symptoms. Staff F was reported to have used vulgar and derogatory language towards residents, including telling one resident to 'sit your f**** a*** down,' calling another a 'b****,' and instructing a resident to 'shut the f*** up and sit down.' These actions were witnessed and documented by other staff members, including a CNA and a housekeeper, who reported that Staff F frequently used a 'filthy mouth' and was very vulgar to residents. The incidents were not reported immediately by all staff, with one CNA stating she delayed reporting due to having to work regularly with Staff F. The residents involved had significant cognitive and behavioral challenges, including diagnoses such as non-Alzheimer's dementia, anxiety disorder, chronic kidney disease, non-traumatic brain dysfunction, irritability, anger, and hypertension. Their care plans specifically directed staff to use gentle communication, reassurance, and emotional support. Despite these directives and facility policy prohibiting verbal abuse, staff failed to adhere to appropriate standards of conduct, resulting in residents being subjected to disparaging and derogatory language.
Failure to Timely Report Suspected Verbal Abuse Incidents
Penalty
Summary
Staff failed to timely report three separate incidents of potential verbal abuse involving residents with severe cognitive impairment. In one incident, a CNA was reported to have used vulgar and aggressive language toward a resident with non-traumatic brain dysfunction, irritability, and severely impaired cognition, telling him to sit down and calling him derogatory names. Another incident involved the same CNA calling a resident with non-Alzheimer's dementia and severe cognitive impairment a derogatory name multiple times. A third incident occurred when the CNA responded to a resident's complaint about hot water during a shower by telling her to 'shut the f*** up,' after which the resident was observed crying and expressing distress. Despite witnessing or being aware of these incidents, staff members did not immediately report the potential abuse to administrative staff. One CNA delayed reporting the incidents involving two residents until a later situation arose, citing the need to work regularly with the alleged perpetrator. Another CNA admitted to not reporting repeated verbal abuse toward a resident, despite recognizing it as inappropriate. The facility's policy required staff to report suspected abuse without fear of reprisal and to refer such concerns to the administrator for action, but this procedure was not followed in these cases.
Failure to Timely Separate Alleged Abuser from Residents
Penalty
Summary
The facility failed to promptly separate residents from an alleged perpetrator of abuse after an incident was reported. On 4/1/25, a staff member from housekeeping reported to the DON that a CNA was speaking loudly and disrespectfully to a resident in the memory care common area. Further investigation revealed that another CNA witnessed the same CNA loudly telling a resident that she knew how to do her job, and also observed the CNA continuing to shower a different resident with water the resident stated was too hot. Despite these reports, the CNA in question continued to work on 4/3/25, and the meeting to address the situation was not scheduled until 4/4/25. Facility policy requires that staff intervene and remove alleged abusers from contact with residents until an investigation is complete. However, the CNA accused of mistreatment was not immediately removed from resident care duties following the initial allegation. The DON confirmed that the CNA worked after the complaint was made and that she was not aware of any prior behaviors. The delay in separating the alleged perpetrator from residents did not align with the facility's stated procedures for protecting residents during abuse investigations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment did not exit the facility without staff knowledge. On July 26, 2024, a resident left a group while walking from an activity area to the memory care unit without the staff supervising noticing. The resident exited through an unlocked, unalarmed door to an unsecured courtyard area and walked on the sidewalk to a location approximately 100 yards from a large pond. A staff member saw the resident from a window and went outside to assist her back to the building. The resident was estimated to be outside, unsupervised, for approximately ten minutes. The resident involved had a severe cognitive impairment, as indicated by a score of 7 out of 17 on the Brief Interview for Mental Status. The resident was independent with mobility using a walker but required supervision when ambulating more than 50 feet with two turns. The resident's diagnoses included non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency. An Elopement Risk tool dated June 13, 2024, identified the resident with a total score of 52, indicating a low risk for elopement. At the time of the incident, the resident was attending a group activity in the general common area. The activity was conducted by the Administrator and the Activity Director, with several residents, including those from the memory care halls, attending. At the end of the activity, the memory care residents were supposed to be escorted back to their households. However, the Administrator did not realize the resident had left the group and veered back into the front lobby area. The resident was later observed through a window, heading east between the B and C buildings, and was immediately escorted back inside without injury.
Removal Plan
- Exit door where Resident #1 exited is now locked at all times and requires keypad access for egress.
- Memory Care residents have been escorted and supervised by designated employee(s) for all programming outside of the memory care.
- All residents have been evaluated for elopement risk.
- Residents identified to be at risk for elopement living in a non-secured unit have had an electronic wandering protection device placed and care plans have been updated.
- Residents identified to be at risk for elopement living in a secured unit will have an electronic wandering protection device placed.
- Elopement Prevention policy has been developed and approved.
- All staff have been educated on new Elopement Prevention policy.
- Additional electronic wandering protection devices were ordered through RF Technologies.
- Daily checks of resident electronic wandering protection devices to ensure that they are in place and operational are already being completed by nursing staff.
- Weekly door checks to be completed weekly.
- Elopement drills to be completed weekly.
Food Temperature and Quality Deficiencies
Penalty
Summary
The facility failed to provide food at a safe temperature in two of the seven households reviewed, specifically in Heritage House and Cobblestone House. Observations revealed that the Food Service/Dietary Manager did not ensure that food temperatures were checked before serving meals. On one occasion, Staff A, a dietary staff member, began plating the noon meal without checking the food temperatures, which led to the chicken salad being served at 46 degrees and the mechanical soft chicken at 127 degrees, both of which are outside the safe temperature range. The facility's policy requires hot foods to be held above 140 degrees, and cold foods should not exceed 41 degrees, which was not adhered to in this instance. Additionally, Resident #90, who has intact cognition and eats independently, reported dissatisfaction with the quality and temperature of the food. The resident stated that the food often tasted cold, vegetables were overcooked, and meats were difficult to chew. During an observation, the resident expressed displeasure with the taste and texture of the broccoli, describing it as overcooked and water-soaked. The resident also noted that the chicken was dry and the chicken noodle soup lacked substance. The resident expressed a desire for fresh food, indicating that the quality of food had not improved since a new company took over food services.
Medication Administration Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper supervision of medication administration for two residents, leading to medication being left unattended. Resident #7, who had moderately impaired cognition, was observed to have a white pill left on a table in a common area. Staff A, a Dietary Aide, found the pill and informed Staff C, a CNA, who then notified Staff B, an RN. Staff B confirmed that the pill belonged to Resident #7, as she was the only resident sitting at that table. Staff B admitted to feeling frazzled and not following the usual procedure of discarding the pill, instead returning it to Resident #7, who then took it. Interviews revealed that this was not an isolated incident, as pills had been found on tables before, and the practice of leaving medications on tables varied depending on the nurse and the resident's cognitive status. Resident #61, who also had moderate cognitive impairment, was left with a medication cup containing various pills and a bottle of eye drops without direct supervision. Staff D, an LPN, placed the medication in front of Resident #61 and continued to pass medications to other residents. The facility's policy did not support leaving medications with residents at the dining room table, yet it was noted that many residents preferred this practice. The Interim DON stated that nurses were expected to supervise residents while they took their medications, which was not adhered to in this case. The facility's Medication Administration Policy outlined that medications should be administered following specific rights and recorded accurately. Self-administration of drugs required a physician's order and an assessment documented in the EHR. However, the care plan for Resident #61 lacked focus and interventions for self-administration, and the MAR did not document self-administration. These oversights contributed to the deficiencies observed in the medication administration process for both residents.
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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 Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Azria Health Prairie Ridge | 13.6 mi | ★★★★★ | 19 | 0 |
| Henderson County Ret Center | 14.2 mi | ★★★★★ | 0 | 0 |
| New London Specialty Care | 14.6 mi | ★★★★★ | 6 | 0 |
| West Point Care Center Inc | 15.9 mi | ★★★★★ | 4 | 0 |
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