Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 St Anthony Senior Services during CMS and state inspections, most recent first.
A cognitively impaired, non-verbal resident with Alzheimer’s disease and total dependence for ADLs was being assisted by two CNAs with evening toileting and dressing using a mechanical lift when the resident became agitated and combative. One CNA reported that the other CNA appeared irritated, raised her voice, continued care despite the resident’s resistance, and, while the reporting CNA was holding both of the resident’s hands to calm him, struck the resident’s face with an open hand, causing a cut to the lip and a scratch to the cheek. A nurse later documented fresh facial injuries consistent with this account, and subsequent notes recorded healing scratches and bruising, demonstrating that the resident was not kept free from physical abuse by staff as required by the facility’s abuse policy.
A resident with severely impaired cognition, dementia, depression, and psychotic disorder did not have a Level 2 PASRR evaluation submitted after a new delusional disorder diagnosis and the start of Seroquel. The record showed only an earlier Level 1 PASRR for major depressive disorder, with no later PASRR updates despite the added mental health diagnosis and antipsychotic medication; the DON acknowledged the PASRR had not been updated.
Incorrect Transcription of Psychotropic Medication End Dates: Two residents with severe cognitive impairment had written Lorazepam orders with limited durations, but the EMR listed the same orders as indefinite. The DON acknowledged the mismatch between written orders and electronic orders and stated she needed to figure out how to change the end date; she also acknowledged the discrepancy could result in residents receiving unnecessary psychotropic medications.
Improper Catheter Care Infection Control: A CNA failed to follow proper infection control practices during perineal and catheter care for a resident with a urinary catheter and irritated, reddened skin. The CNA placed washcloths in the sink, used one for perineal care, and then used the same washcloth to cleanse the catheter tubing. The DON stated washcloths for this care should never be placed in the sink, and the IP said staff knew not to do this.
A resident with a history of repeated falls and neurological impairment experienced multiple falls resulting in serious injuries, including a head laceration and hip fracture, due to the facility's failure to consistently implement and follow effective fall prevention interventions and supervision as outlined in the care plan. Staff did not always monitor the resident after meals, left her unattended during transfers, and failed to ensure timely or effective use of safety equipment, leading to preventable accidents and a decline in the resident's condition.
The facility failed to ensure proper food storage and labeling, with open and undated food items found in the kitchen. Additionally, staff did not follow hand hygiene practices during meal service, as observed with Staff J and Staff K, who served residents without sanitizing hands between tasks. The facility's policies require food to be labeled and dated, and staff to maintain hand hygiene to prevent contamination and illness.
A facility failed to accurately verify and document a resident's advanced directive, resulting in a discrepancy between the resident's documented DNR status and the physician's orders. The resident was not listed on the Full Code list, and visual indicators for code status were missing. Staff interviews and observations confirmed the inconsistency, and the DON acknowledged the expectation for accurate records.
A facility failed to include a resident's urinary tract infections (UTIs) in their care plan, despite the resident's history of UTIs and physician orders for treatment. The care plan lacked necessary interventions to prevent or monitor the condition, contrary to facility policy requiring comprehensive care plans. The omission was confirmed by the MDS Coordinator.
A facility failed to accurately account for Schedule II medications, resulting in a missing dose of Ativan for a resident with complex needs. Staff inconsistencies in counting procedures and a lack of specific orientation on medication management contributed to the deficiency.
Failure to Protect Cognitively Impaired Resident From Physical Abuse During Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a staff member during provision of evening care. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, heart failure, and stroke, and required complete assistance with ADLs, including two-person assistance and a stand-up mechanical lift for toileting. Care plans documented impaired cognition, poor comprehension, impaired communication, episodes of sudden mood and behavior changes, and a tendency to become resistive or combative with care. Staff were directed in the care plan to use calm approaches, diversion, nonpharmacological interventions, and to intervene as necessary to protect the safety and rights of the resident and others. On the evening of 3/12/2026, two CNAs (Staff A and Staff B) assisted the resident with bedtime care in the bath house, including changing clothes and toileting with a mechanical lift. According to progress notes and Staff B’s written and verbal statements, the resident became agitated and aggressive while staff attempted to change his clothes, hitting and elbowing Staff A. Staff B reported that Staff A appeared irritated, had a temper, raised her voice, and continued trying to change the resident’s clothes despite his agitation, rather than stopping or changing approach. After transferring the resident to the toilet with the mechanical lift, Staff A removed the resident’s pants and socks and began putting on new socks while Staff B, standing to the resident’s left, held both of the resident’s hands to calm him. Staff B stated that at this point the resident was no longer aggressive. Staff B reported that while she was holding both of the resident’s hands, she saw Staff A bring up her right hand and with an open hand strike the resident in the face, causing an immediate cut to the right upper lip and a scratch to the right cheek. Staff B denied that the resident hit his face or hands on the wall and stated she was present in the bathroom for the entire interaction. A nurse (Staff C) assessed the resident shortly after the report and observed a 3 cm scratch under the right eye/cheek and a 1–0.5 cm cut to the lip with fresh blood. Subsequent progress notes over the following days documented the evolution and healing of facial injuries, including scratches and bruising to the right cheek and lower lip. In interviews, Staff A denied intentionally striking the resident and initially attributed a “smack” sound to the resident’s arm contacting the wall, but later stated, “I don’t know the time I hit him,” and could not explain how the resident sustained the facial abrasion and lip injury. The facility’s investigative conclusion stated that there was some degree of staff-to-resident contact, whether a swiping motion or open-handed slap/hit, resulting in the resident’s facial injuries, in violation of the facility’s abuse policy that prohibits residents from being subjected to abuse by anyone.
Failure to Update PASRR After New Mental Health Diagnosis and Antipsychotic Use
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for Resident #12 after the resident developed additional mental health diagnoses and was started on antipsychotic medication. The clinical record showed a diagnosis of delusional disorder with an effective date of 9/27/23, and a physician order dated 4/3/25 directed Seroquel 25 mg at bedtime for dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and delusional disorders. The record also showed the resident had been on Seroquel at different dosages since 9/27/23. The Minimum Data Set documented severely impaired cognition with a BIMS score of 03, and the care plan identified use of an antipsychotic medication for symptoms of delusional disorder, insomnia, and depression. A Level 1 PASRR completed on 3/29/23 documented major depressive disorder and antidepressant use, but the clinical record showed no additional PASRR evaluations after that date. Survey review found no Level 2 PASRR evaluation submitted after the new mental health diagnosis and antipsychotic medication were added, and the DON acknowledged that the resident's PASRR had not been updated.
Incorrect Transcription of Psychotropic Medication End Dates
Penalty
Summary
The facility failed to accurately transcribe written physician orders for psychotropic medications into the electronic medical record for 2 of 3 residents reviewed, Resident #5 and Resident #62. Resident #5 had diagnoses of dementia, stroke, and heart failure, with a BIMS score of 3 indicating severe cognitive impairment. The care plan noted psychotropic medication use for mild cognitive impairment with behaviors including restlessness, agitation, and being inappropriate toward female staff. A written physician order for Lorazepam 2 mg/ml directed 0.25 ml by mouth every 4 hours as needed for 3 months, but the electronic clinical physician order listed the same medication and dose with an end date of indefinite. Resident #62 had diagnoses of dementia, stroke, and depression, and also had a BIMS score of 3 indicating severe cognitive impairment. The care plan stated the resident used antidepressant and antipsychotic medication to manage symptoms of depression, anxiety, and unwanted behavior secondary to depression and dementia. A written physician order for Lorazepam 2 mg/ml directed 0.5 ml by mouth every 6 hours as needed for 90 days, but the electronic clinical physician order listed the same medication and dose with an end date of indefinite. During interview, the DON stated the facility kept a spreadsheet to track Lorazepam orders needing reordering and acknowledged that the electronic orders should match the written physician orders, but said she did not know how to change the end date. The DON also acknowledged that the discrepancy could result in residents receiving unnecessary psychotropic medications.
Improper Catheter Care Infection Control
Penalty
Summary
The facility failed to follow proper infection control practices during catheter care for one resident who had a urinary catheter and observed irritated, reddened skin. During observation, a CNA performed hand hygiene and donned PPE, assisted the resident to the toilet, gathered supplies, placed two washcloths in the sink, and allowed the sink to fill with water. The CNA then removed a washcloth from the sink, folded it into fourths, and used it to provide perineal care to the resident's penis. The same washcloth was then used to cleanse the tubing of the resident's urinary catheter. When asked about the care, the CNA stated nothing should have been done differently and acknowledged that placing washcloths in the sink was not right. The DON stated washcloths used for perineal or catheter care should never be placed in the sink and said a basin should be used instead. The IP reported that placing washcloths in the sink before perineal or catheter care increased the risk of infection and stated staff had been educated not to do this.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate nursing supervision and implement effective interventions to prevent falls for a resident with a known history of repeated falls and high fall risk. The resident, who had progressive neurological conditions, hypertension, and depression, experienced eight falls over several months. Despite being assessed as requiring partial to moderate assistance with mobility and transfers, the resident was frequently left unattended or allowed to self-transfer, particularly when returning to her room after meals. The care plan included interventions such as encouraging the resident to use the call light, ensuring appropriate footwear, moving her room closer to the nurse's station, and providing additional call lights, but these measures were inconsistently implemented or ineffective. Multiple incidents documented that staff did not always follow the care plan or facility policy. For example, the resident was left alone on the toilet, not provided with a gait belt during transfers, and staff failed to consistently monitor her movements after meals. The use of a floor mat alarm was delayed due to equipment compatibility issues, and when it was eventually implemented, it was later removed because it was not functioning properly and the resident or her husband would move it out of the way. There was a lack of additional interventions during the period when the floor mat alarm was unavailable. Staff interviews revealed that the resident was known to be impulsive and quick, often leaving the dining room unassisted, and staff were not always able to anticipate or intercept her movements in time to prevent self-transfers. The resident sustained significant injuries as a result of these falls, including a laceration to the forehead requiring emergency care and a left hip fracture that necessitated surgical intervention. Documentation showed that staff education following falls was often verbal and not formally recorded, and there was confusion among staff regarding the implementation and timing of interventions such as auto-lock brakes and alarms. The facility also experienced staff turnover and use of agency staff, which may have contributed to inconsistent supervision and adherence to the care plan. The cumulative effect of these actions and inactions resulted in the resident suffering repeated falls, injuries, and ultimately a decline in health following the final fall and subsequent surgery.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as well as adequate hand hygiene during meal service. During an observation in the main kitchen, it was noted that there were two open and undated bags of pasta and graham cracker crumbs. Staff I, the Food and Service Director, acknowledged the expectation that food should be dated, labeled, and sealed after opening, which was not adhered to in this instance. The facility's Food Storage Guidelines policy, revised in December 2024, mandates that unused foods be identified, labeled, and dated to prevent contamination or spoilage. Additionally, the facility did not ensure that staff followed proper hand hygiene practices during lunch service. Staff J was observed serving residents without sanitizing hands between tasks, such as plating food, touching utensils, and handling residents' food and drink items. Similarly, Staff K also failed to sanitize hands between serving residents, touching various surfaces and residents' items. The Director of Nursing and Staff I both stated the expectation for staff to sanitize hands between serving residents, as outlined in the facility's Infection Prevention and Control policy, which emphasizes the importance of hand hygiene to prevent foodborne illnesses and communicable diseases.
Failure to Verify and Document Resident's Advanced Directive
Penalty
Summary
The facility failed to accurately verify and document a resident's advanced directive choice, leading to a discrepancy between the resident's documented code status and the physician's orders. The resident's dashboard indicated a Do Not Attempt Resuscitation (DNR) status, while the Iowa Physician Orders for Scope of Treatment (IPOST) initially documented Cardio Pulmonary Resuscitation (CPR) and later DNR. Additionally, the Order Summary Report confirmed a physician's order for DNR. However, the resident was not listed on the Full Code list at the nurse's station, and the visual indicators for code status, such as a star on the name tag, a red band on the bed or wheelchair, and a purple chart, were not present. Interviews with staff revealed that the facility's protocol for identifying full code residents was not followed for this resident, as evidenced by the absence of the required visual indicators. The Director of Nursing confirmed the inconsistency between the physician's order and the IPOST, acknowledging the expectation for records to be accurate and consistent. The facility's policy on advanced directives mandates that changes to a resident's choices be documented, included in the care plan, and communicated to staff, which was not adhered to in this case.
Failure to Include UTI Management in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of urinary tract infections (UTIs). The resident, diagnosed with Non-Alzheimer's Dementia and frequently incontinent of urine, had experienced UTIs twice since admission. Despite physician orders for Macrobid and Cefurixine to treat the UTIs, the resident's care plan did not include these diagnoses, treatments, or any interventions to prevent or monitor the condition. The facility's policy requires care plans to include measurable objectives and time frames to address the resident's medical, nursing, mental, and psychosocial needs, which was not adhered to in this case. The MDS Coordinator confirmed the omission of the UTIs from the care plan during an interview.
Failure in Accurate Accounting of Schedule II Medications
Penalty
Summary
The facility failed to ensure an accurate accounting of Schedule II controlled medications for a resident, leading to a missing dose of Ativan. The resident in question, who was rarely understood and required substantial assistance with daily activities, had a care plan that included administering medication as ordered and monitoring for side effects and effectiveness. However, discrepancies in the medication count were discovered, indicating a failure in the facility's medication management practices. On the morning of January 3rd, a Licensed Practical Nurse (LPN) discovered that the number of Ativan syringes did not match the expected count. The resident's controlled substance record showed that 50 syringes were accounted for after a delivery on December 31st, but only 42 syringes remained after being used seven times. Staff interviews revealed inconsistencies in the counting process, with some staff members admitting to not verifying the number of syringes in each bundle, leading to the missing dose. Further investigation showed that staff were not consistently following the facility's policy on narcotic medication management, which required narcotic counts to be conducted at shift change by both the oncoming and outgoing nurses. The Director of Nursing confirmed that agency staff were oriented on processes and expectations, but the orientation checklist lacked specific reference to the counting and verification of Schedule II medications. This oversight contributed to the failure in maintaining accurate medication records.
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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 Carroll
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Park Nursing & Rehab Center Of Carroll | 0.4 mi | ★★★★★ | 1 | 0 |
| Accura Healthcare Of Carroll | 2 mi | ★★★★★ | 18 | 0 |
| Accura Healthcare Of Lake City, Llc | 15.4 mi | ★★★★★ | 8 | 0 |
| Thomas Rest Haven | 16 mi | ★★★★★ | 9 | 0 |
| Twilight Acres | 19.4 mi | ★★★★★ | 24 | 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.