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 Stacyville Community Nursing Home during CMS and state inspections, most recent first.
A resident with intact cognition and multiple diagnoses, including Parkinson’s disease and depression, was receiving lorazepam when an LPN failed to sign out a controlled dose at the time of administration, later assumed it had not been given, and administered a second dose, resulting in a double dose and a missing, unaccounted-for dose. Video footage showed an RN removing the resident’s lorazepam and taping it into another resident’s controlled drug card during a controlled drug count. The resident’s EHR lacked documentation of the medication error, and the controlled drug count sheet for the period was missing. Surveyors also observed two CMAs and an LPN conducting shift-change controlled drug counts without comparing bubble packs to the count sheets to verify the correct resident, medication, and count, despite policies requiring proper reconciliation and documentation of controlled substances and medication errors.
A resident with intact cognition and multiple diagnoses, including Parkinson's disease and depression, was prescribed lorazepam. An LPN failed to sign out a controlled dose when first administered, later assumed the dose had not been given, and administered a second dose, resulting in a double dose of lorazepam. The medication error, including assessment and follow-up, was not documented in the EHR, despite facility policy requiring documentation of medication errors and monitoring for adverse effects.
A resident with intact cognition and multiple medical conditions reported missing money on two occasions, informing staff each time. Although staff initiated an internal investigation, the facility did not report the allegations of misappropriation to the state authorities as required by policy and regulation.
A resident who elected to begin hospice care did not have a Significant Change Status Assessment (SCSA) MDS completed as required. Staff and administration confirmed that the assessment was not performed within the mandated 14-day period following the initiation of hospice services, despite facility awareness of the regulatory requirement.
A resident's MDS assessment was inaccurately completed, showing daily insulin injections during the lookback period despite no documentation of such administration in the clinical record. The error was attributed to incorrect coding by a previous MDS coordinator, and the facility lacked a specific policy for MDS accuracy, relying solely on the RAI Manual.
Two residents did not receive services as ordered by their physicians: one did not receive a prescribed GLP1 medication due to a missed pharmacy delivery, and another did not receive ordered PT because staff failed to notify the therapy group. Staff interviews confirmed both omissions and the absence of a facility policy for following physician orders.
The facility did not have an effective QAPI program in place, as evidenced by repeated deficiencies in Resident Rights, Pharmacy Services, and QAPI. The Business Office Manager attributed the ongoing ineffectiveness to challenges from previous management and the current management team's learning curve.
Staff removed an electric wheelchair from a resident with intact cognition and physician orders for its use, without obtaining a discontinuation order. The resident, who relied on the wheelchair for mobility due to Parkinson's disease and a history of falls, experienced a significant loss of independence and had to wait for staff assistance as a result.
The facility did not ensure that care plans were complete and individualized for four residents, omitting prescribed restorative nursing programs and failing to update plans after significant changes in mobility or fall risk. For example, a resident with Parkinson's disease continued to have incidents with an electric wheelchair without care plan revision, and two residents with restorative therapy orders did not have these interventions reflected in their care plans.
Several residents with limited ROM and mobility needs did not consistently receive prescribed restorative nursing programs, as care plans failed to address these needs and documentation showed restorative services were only provided sporadically. Staff interviews confirmed that restorative care was often missed due to staffing shortages, resulting in a failure to maintain or improve residents' functional abilities.
A resident received compounded topical medications when an LPN mixed Nystatin powder and Clotrimazole Betamethasone cream without a physician order, using estimated amounts. This practice was identified as outside professional standards and not within the nursing scope of practice, as confirmed by facility administration.
An LPN was found sleeping in the front lounge while on duty, as confirmed by a photo and interviews with two residents and a CNA. The LPN, who worked from afternoon to early evening, did not take a scheduled break. The facility's administrator stated that sleeping in the lounge is unacceptable.
The facility failed to ensure competent care for residents, as an LPN administered IV medications without proper certification, diagnosed a resident without authority, and used Snapchat for communication with hospital staff. Additionally, staff lacked training to manage erratic behaviors, highlighting deficiencies in staff competencies and communication protocols.
The facility failed to provide an RN for eight consecutive hours per day and did not designate a qualified RN as the DON. An LPN was improperly promoted to Interim DON and directed to perform tasks beyond her scope without proper training. The facility's administrative staff confirmed the lack of adequate RN staffing.
The facility failed to provide effective leadership by appointing an LPN as Interim DON without the required RN qualification, leading to inadequate training and improper medication administration. An RN felt uncomfortable administering morphine to a resident due to family objections and reported feeling degraded by the Interim DON. The facility also lacked a proper chain of command for addressing concerns.
The facility failed to maintain an effective QA program, resulting in insufficient RN coverage for 10 days out of 90. Despite having 51 staff members and efforts to recruit more, the facility's documentation lacked plans to address the nursing staff issue, contributing to inadequate RN coverage.
A resident with intact cognition reported an unpleasant interaction with an LPN, who responded dismissively when asked about dining area management. The LPN's tone upset the resident, and a CNA witnessed the LPN rolling her eyes at another resident requesting pain medication. These actions violated the facility's Residents' Rights, which require treating residents with respect and dignity.
A facility staff failed to follow professional standards when a RN drew up liquid morphine without a witness, and an LPN administered it to a resident without verifying the contents. This incident violated the facility's policy on controlled substances, which requires reconciliation at various stages. The resident involved had been assessed to receive opioid medication.
A facility failed to maintain suction equipment, leading to critical incidents involving two residents. One resident choked on peanut butter crackers, and the suction machine failed to operate, necessitating manual intervention. Another resident was unable to clear aspirations due to a malfunctioning suction machine with the wrong canister. These incidents highlight the facility's failure to ensure essential equipment was in safe operating condition.
The facility failed to report missing narcotics from the emergency narcotic lock box within the required 24-hour timeframe. A discrepancy was identified, but the facility did not report the missing narcotics to the Department until several days later. The Interim Administrator and the current Administrator acknowledged the delay, attributing it to their ongoing investigation process.
A resident with moderately impaired cognition experienced severe abdominal pain, but the facility failed to conduct a comprehensive assessment or document necessary interventions. Despite the resident's distress and elevated blood pressure, the initial evaluation lacked vital checks like bowel and lung sounds. This oversight did not align with the facility's policy for managing changes in a resident's condition.
A facility failed to ensure a safe environment when a nurse found a marijuana pipe and a Lasix bottle with unknown contents in a resident's drawer. The resident, with intact cognition, was told the items could be locked up or picked up by his daughter. The nurse did not confiscate the items and lacked the daughter's contact information. The clinical record did not document a physician's order for marijuana use or follow-up on the items.
A resident with intact cognition received another resident's medications due to a nurse's error in identity verification, leading to sedation and hospitalization. The nurse, unfamiliar with the residents, administered medications based on last names, not realizing the presence of two residents with similar names. The resident exhibited signs of sedation and was difficult to wake, prompting eventual hospitalization for further evaluation.
The facility did not have an RN on duty for eight consecutive hours on multiple occasions, as required by Federal Regulations. This deficiency was identified through a review of timesheets and schedules, and the Administrator acknowledged a misunderstanding regarding a waiver for RN coverage.
A facility failed to update a resident's PASRR to include new diagnoses of major depression disorder and unspecified psychosis. The resident's MDS assessment reflected these conditions, but the PASRR, dated over four years prior, did not. The oversight was identified during a survey, prompting the Administrator to submit the PASRR for review, which triggered a Level II review. The facility's policy lacked guidance on submitting new mental health diagnoses for PASRR review.
The facility failed to complete comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not include the use of bed rails, another's inaccurately addressed bladder incontinence instead of a urinary catheter, and a third resident's care plan lacked specific interventions, despite expectations for completion within 21 days of admission.
A facility failed to update a resident's care plan to include interventions for major depression disorder and unspecified psychosis, despite these diagnoses being documented in the resident's medical record. The care plan lacked necessary instructions and interventions, as identified during a record review and staff interview.
A resident with intact cognition expressed a desire to transfer to another facility, feeling like a prisoner. Despite her request, the care plan lacked interventions for her discharge, and the facility's policy did not guide staff on incorporating residents' wishes into discharge planning. The DON noted the resident required 24-hour care.
The facility did not have a qualified Infection Preventionist to oversee its infection prevention program. An RN, referred to as Staff A, had completed the required class but had not taken the certification test. The facility had 31 residents at the time.
A facility failed to ensure a resident received Olanzapine only for psychiatric or mood disorders upon admission. The resident, with intact cognition, was prescribed Olanzapine for dementia without disturbances, despite no prior use before hospitalization. The care plan lacked a comprehensive review for antipsychotic use, and the DON was unaware of the medication's use for dementia.
The facility failed to properly sanitize blood sugar meters and use barriers during blood sugar checks and insulin administration for three residents with diabetes. Staff did not clean the meters between uses, contrary to guidelines and manufacturer instructions, leading to deficiencies in infection control practices.
The facility failed to document education and consent for flu vaccinations for three residents. One resident received their last flu vaccine years ago, another never received it, and the third had no recent record. The Infection Preventionist did not document education on vaccine risks and benefits or the residents' decisions to accept or decline the vaccine, as required by the facility's program.
The facility inaccurately reported its Payroll Based Journal (PBJ) for licensed nursing staff, indicating a lack of 24/7 coverage, despite timecards showing continuous coverage. The Administrator acknowledged the error in submission, affecting a facility with 31 residents.
The facility inaccurately documented MDS assessments for four residents, including incorrect coding of bed rails as restraints and failure to document opioid and anticoagulant medication administration. The DON and Administrator acknowledged these errors.
Failure to Prevent, Document, and Reconcile Controlled Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent a medication error for one resident, to document that error in the clinical record, and to follow professional standards for reconciling controlled substances. A resident with intact cognition and diagnoses including Parkinson’s disease, depression, and sleep apnea was receiving lorazepam, an antianxiety medication. On one occasion, an LPN did not sign out the controlled medication at the time of administration, later believed the dose had not been given, and administered another dose around 8:00 PM. When the LPN subsequently signed the controlled drug record, she realized a double dose had been given. The facility’s investigation also identified that another dose of lorazepam for this resident was missing and unaccounted for, and video footage showed an RN punching out the resident’s lorazepam and taping it into another resident’s controlled drug card during the controlled drug count. The resident’s EHR contained no documentation of the medication error, and the controlled drug count sheet for the relevant period was missing. Surveyors also observed ongoing failures in the controlled substance reconciliation process. During a shift-change controlled drug count, two CMAs conducted the count by having one staff member look at the bubble packs while the other read the counts from the controlled drug sheets, without comparing the bubble packs to the sheets to verify the correct resident, medication, and count. An LPN stood by observing this process, and all three staff confirmed this was their normal method for counting controlled drugs. The DON later confirmed that staff had completed the count incorrectly and that the facility’s policies required reconciliation of controlled substances upon receipt, administration, disposal, and at the end of each shift, as well as documentation of medication errors in the resident record and completion of a medication error form. Despite these policies, the medication error for the resident and the associated controlled drug discrepancies were not properly documented or reconciled.
Failure to Prevent and Document Significant Medication Error
Penalty
Summary
The facility failed to ensure a resident remained free from a significant medication error and failed to document the error and related assessment in the clinical record. The resident had intact cognition with a BIMS score of 15 and diagnoses including Parkinson's disease, depression, and sleep apnea, and was receiving an antianxiety medication. An incident investigation for missing controlled drugs documented that a nurse did not sign the controlled drug record at the time of administration, which led to a double dose of lorazepam being given to this resident. The nurse later returned to sign out the medication, believed the resident had not yet received it, and administered another dose around 8:00 PM before realizing the error when signing the controlled drug record. The resident's EHR contained no documentation of the medication error, no assessment, and no follow-up related to the incident. The DON confirmed that there was no information in the EHR documenting the medication error, assessment, or follow-up, despite the facility’s Medication Error-Incident Report Process policy directing that a medication error must be documented in the resident record and that residents must be monitored for any adverse effects caused by the error. The failure to document and assess the resident following the double administration of lorazepam constituted the deficiency identified by surveyors.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property within the required timeframe to the Iowa Department of Inspection, Appeals, and Licensing (DIAL). A resident with intact cognition and a history of renal insufficiency, stroke, and end stage renal disease reported missing money on two separate occasions, totaling over $300. The resident stated he informed staff each time money was missing from his room. Staff interviews confirmed that the missing money was reported internally to nursing and administrative staff, and an investigation was initiated by the facility. Despite the facility's policy requiring immediate reporting of all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation to the appropriate authorities, there was no evidence that the incidents involving the resident's missing money were reported to DIAL as required. The administrator acknowledged that neither the previous nor the current incidents of missing money were reported to DIAL, in violation of both facility policy and regulatory requirements.
Failure to Complete SCSA MDS Assessment After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment for a resident who elected to begin hospice care. According to the clinical census and health status notes, the resident's primary payer changed to hospice, and hospice services were initiated. The resident's representative signed a hospice election statement, confirming the start of hospice care. However, review of the MDS 3.0 Summary page in the electronic health record revealed that the required SCSA MDS assessment was not completed following the election of hospice services. Interviews with the MDS Coordinator and the Administrator confirmed that the facility was aware of the requirement to complete the SCSA within 14 days of the significant change, as outlined in the RAI manual. Both staff members acknowledged that the assessment was not completed for the resident after the initiation of hospice care. The RAI manual specifically requires an SCSA when a terminally ill resident enrolls in hospice while remaining in the facility, with a completion deadline of 14 days from the determination of the significant change.
Inaccurate MDS Assessment Due to Incorrect Medication Coding
Penalty
Summary
The facility failed to accurately document and submit a correct Minimum Data Set (MDS) assessment for one resident. The MDS assessment for this resident indicated a Brief Interview of Mental Status (BIMS) score of 13, reflecting intact cognition, and listed diagnoses of hypertension, diabetes, and obesity. The assessment also reported that the resident received insulin injections daily during the lookback period. However, a review of the clinical record revealed no documentation of insulin administration or any injections during that period. Interviews with the MDS coordinator confirmed that the previous coordinator had incorrectly coded the medication administration, and it was also noted that the facility did not have a policy in place for ensuring MDS accuracy and completion, relying instead on the RAI Manual.
Failure to Follow Physician Orders for Medication and Therapy
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with diagnoses of hypertension, diabetes, and obesity, the Treatment Administration Record did not show documentation that Ozempic, a GLP1 medication, was administered as ordered on 4/4/25. Progress notes indicated the medication was expected from the pharmacy that evening, but there was no further documentation confirming its receipt or administration. Staff interviews confirmed the medication was missed because it did not arrive from the pharmacy, and the facility lacked a policy related to following physician orders. For another resident with diagnoses of hypertension, depression, and dementia, a physician ordered physical therapy (PT) evaluation and treatment after the resident expressed a desire to use the therapy bike. However, the clinical record did not show that PT was provided following the order. Staff interviews revealed that nursing staff are responsible for notifying the contracted therapy group of new orders, but the order for PT was missed and not communicated, resulting in the therapy not being initiated.
Ineffective QAPI Program and Ongoing Deficiencies
Penalty
Summary
The facility failed to maintain an effective quality assurance (QA) program to support the provision of quality care for its residents. A review of facility records and staff interviews revealed that the facility received deficiencies in Resident Rights, Pharmacy Services, and Quality Assurance and Performance Improvement (QAPI) during a complaint survey. The survey investigation found that these deficient practices persisted during a subsequent complaint and revisit investigation. The Business Office Manager, who was responsible for monitoring the QAPI program, stated that the program remained ineffective due to issues with previous management and the ongoing learning curve of the current management staff.
Failure to Honor Resident's Right to Self-Determination in Wheelchair Use
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and to follow physician orders regarding the use of an electric wheelchair. The resident, who had intact cognition as indicated by a BIMS score of 13 and diagnoses including Parkinson's disease, anxiety, and repeated falls, was care planned and had a physician's order to use an electric wheelchair at the lowest speed with close staff supervision. Despite these orders and interventions, staff removed the resident's electric wheelchair without first obtaining a physician's order to discontinue its use. As a result, the resident reported a significant negative impact on his mobility and independence, stating that he could no longer get around and had to wait for staff assistance, which he disliked. The resident acknowledged occasionally hitting walls but denied causing injury to himself or others. The facility's Residents' Rights form affirms the right to reasonable accommodation unless it endangers health or safety, but there was no documentation that the resident's use of the wheelchair posed such a risk at the time it was taken away.
Failure to Maintain Complete and Accurate Care Plans for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate care plans tailored to the individual needs of four residents. For two residents with documented functional limitations and restorative nursing recommendations, their care plans did not address the prescribed restorative programs, despite clinical records indicating scheduled exercise, range of motion (ROM), and ambulation interventions. These omissions were confirmed by both clinical documentation and facility administration. Another resident, who had a history of Parkinson's disease, anxiety, and repeated falls, experienced multiple incidents involving unsafe operation of an electric wheelchair. Despite documented staff observations, family communication, and a physician's directive to restrict wheelchair speed and provide close supervision, the care plan was not revised after the resident's electric wheelchair was removed. The resident reported significant changes in mobility and independence following this removal, but the care plan did not reflect these changes or new interventions. A fourth resident with upper extremity ROM limitations and a moderate fall risk, as indicated by assessment tools and restorative nursing recommendations, also had a care plan that failed to address both her restorative program and her risk for falls. The facility's own review confirmed these omissions in the care plans for two residents, and documentation showed that the care plans did not reflect the residents' current needs or prescribed interventions.
Failure to Provide Consistent Restorative Services for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative services to residents with limited range of motion (ROM) and mobility needs, as evidenced by gaps in the delivery and documentation of restorative nursing programs for three residents. For one resident with functional limitations in both lower extremities and dependent on a wheelchair, the care plan did not address her prescribed restorative program, and flow records showed restorative exercises were only documented on a few days each month, with no indication of services being offered or provided on other days. Another resident, who used a walker and wheelchair and had intact cognition, also had a prescribed restorative program that was not reflected in the care plan, and documentation showed restorative services were provided infrequently, with large gaps in the records. This resident reported that restorative exercises were only performed when staff availability allowed. A third resident with upper extremity ROM limitations and moderate fall risk was similarly affected. Her care plan did not address her restorative program, and flow records indicated restorative services were documented on only a few days each month, with no evidence of services being offered or provided on other days. Staff interviews confirmed that restorative programs were inconsistently implemented, often depending on CNA availability and staffing levels. Staff acknowledged that restorative care was not always completed due to staffing issues, and the ADON could not confirm whether restorative tasks were performed as assigned when CNAs were reassigned to other duties. The lack of consistent restorative care and documentation for these residents, despite identified needs and prescribed programs, demonstrates a failure by the facility to maintain or improve residents' highest level of functioning. The deficiency was identified through observation, clinical record review, and staff interviews, with a total facility census of 27 residents at the time of the survey.
Improper Compounding of Topical Medications by Nursing Staff
Penalty
Summary
Facility staff failed to follow professional standards of practice by allowing a Licensed Practical Nurse (LPN) to compound, or mix together, treatment ointments and creams prior to application for a resident. Specifically, the LPN mixed Nystatin powder and Clotrimazole Betamethasone cream on two separate occasions, basing the amounts on estimation rather than precise measurement. The resident's clinical record did not contain a physician order authorizing the compounding of these treatments. Another LPN identified this practice as unacceptable and redirected the staff member involved. The facility administrator confirmed that compounding these medications was not in accordance with acceptable practice and was outside the scope of practice for nursing staff.
LPN Found Sleeping on Duty
Penalty
Summary
The facility failed to ensure that a licensed nurse was awake and capable of rendering nursing services during a shift, as required. On the evening of January 22, 2024, Staff C, an LPN, was observed sleeping in the front lounge of the facility. This was confirmed by multiple sources, including a photograph showing Staff C reclined in a chair with her eyes closed, and interviews with residents and staff. Resident #12, with intact cognition, reported seeing Staff C asleep, while Resident #9, also with intact cognition, attempted to speak with Staff C during this time. Staff C was later escorted out of the building by another staff member. The incident was further corroborated by a written statement from Staff E, a CNA, who witnessed Staff C sleeping while on duty. A review of Staff C's time card indicated she worked from 1:52 PM to 6:29 PM on the day in question. An email from the Administrator noted that Staff C did not take a scheduled break and emphasized that sleeping or meditating in the lounge area is unacceptable. The facility reported a census of 28 residents at the time of the incident.
Incompetent Staff and Inappropriate Communication Methods
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for residents, as evidenced by several deficiencies. An LPN administered intravenous medications via a peripherally-inserted central catheter (PICC) to a resident without having the necessary Iowa-approved certification. This resident, who had a history of wound infection and pulmonary embolism, received antibiotics through a central line, but the LPN's certification from the Mayo Clinic was not recognized by the Iowa Board of Nursing. The facility's failure to ensure that the LPN had the proper certification for IV therapy in Iowa led to this deficiency. Additionally, the facility's staff demonstrated a lack of understanding of their professional scope of practice. An LPN diagnosed a resident with a transient ischemic attack (TIA) without being present in the facility or having the authority to make such a diagnosis, which is outside the scope of practice for nurses. This action was based on a previous physician's statement and was confirmed through a video recording. Furthermore, the facility staff used an unsecured social media platform, Snapchat, to communicate with hospital staff about residents' conditions, which is inappropriate and breaches confidentiality protocols. The facility also failed to provide adequate training for managing residents with erratic behaviors or suspected drug use. An LPN reported that the facility management did not educate her on handling such situations, indicating a gap in staff training and preparedness. This lack of training and inappropriate communication methods contributed to the overall deficiency in ensuring competent care for residents.
Failure to Provide RN Coverage and Designate Qualified DON
Penalty
Summary
The facility failed to comply with federal regulations by not providing a Registered Nurse (RN) for eight consecutive hours per day. This deficiency was identified through a review of staffing calendars, time cards, and staff interviews, which revealed multiple dates where the facility did not meet the required RN coverage. The facility's administrative staff confirmed the lack of adequate RN staffing in an email communication. Additionally, the facility did not designate a RN as the Director of Nursing (DON), which is another requirement under federal regulations. The facility employed an LPN, referred to as Staff B, as an Interim DON, which is outside the scope of practice for an LPN. Staff B was initially hired as a part-time charge nurse and later promoted to the Interim DON position. During her tenure, she was directed by the Provisional Administrator and the Board of Directors to perform tasks beyond her scope, such as flushing PICC lines, without proper training. Staff B was eventually terminated for failing to adhere to nursing standards of practice.
Leadership and Training Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide effective leadership by not adhering to Federal Regulations and state rules, specifically by not having a Registered Nurse (RN) designated as the Director of Nursing (DON). Instead, the provisional Administrator appointed a Licensed Practical Nurse (LPN) as the Interim DON, despite knowing she did not possess the required RN qualification. This decision was made without ensuring a proper chain of command for addressing concerns related to the DON. The facility, which had a census of 28 residents, also failed to provide adequate training for the Interim DON, as evidenced by an email where she reported receiving only 2.5 shifts of training from an actual nurse. In one incident, a Registered Nurse (RN) drew up a dose of liquid Morphine for a resident without a witness and took it to the Administrator's office. After a dispute, the Interim DON administered the medication to the resident without direct knowledge of the syringe contents. The RN felt uncomfortable with the situation, especially since the resident's family continuously denied the administration of morphine. Additionally, the RN reported feeling degraded by the Interim DON, which affected her confidence. An audio recording revealed a discussion where the RN was advised to show confidence in front of families and to report non-clinical concerns about the Interim DON to the Administrator.
Deficiency in RN Coverage Due to Ineffective QA Program
Penalty
Summary
The facility failed to maintain an effective quality assurance program, which resulted in insufficient nursing staff coverage. Specifically, the facility did not schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 10 days out of a 90-day period. This deficiency was identified during a Recertification, Complaint, and Incident survey. The facility had a census of 28 residents at the time of the survey. The facility's Quality Assurance Performance Improvement (QAPI) meeting minutes and Quality Improvement Plan of Action forms lacked documentation and plans addressing the nursing staff issue. Despite having 51 staff members and efforts to recruit more, the facility's documentation did not reflect any progress or plans related to resolving the nursing staff deficiency. This lack of documentation and planning contributed to the facility's failure to provide adequate RN coverage, as required.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect, as evidenced by an incident involving a resident with intact cognition, as indicated by a BIMS score of 15. The resident reported an interaction with an LPN, Staff C, who responded unpleasantly when the resident inquired about the management of the dining area. The LPN's dismissive tone and statement that managing the dining area was not her responsibility upset the resident. Additionally, a CNA, Staff E, witnessed Staff C rolling her eyes at another resident who requested pain medication, further indicating a lack of respect and dignity in interactions with residents. This behavior was contrary to the facility's Residents' Rights form, which mandates that residents be treated with respect and dignity.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice in the administration of medication for one resident. A Registered Nurse (RN), identified as Staff A, drew up a dose of liquid morphine, Roxanol, in a 1 milliliter syringe without a witness present, which is against the facility's Controlled Substances policy. This policy requires reconciliation of controlled substances upon receipt, administration, and at the end of each shift. Staff A then took the syringe to the Administrator's office, where after a dispute, the Interim Director of Nursing (DON)/Licensed Practical Nurse (LPN), identified as Staff B, took the syringe and administered the medication to the resident without direct knowledge of the syringe's contents. The incident involved Resident #1, who had been assessed to receive opioid medication as per their Minimum Data Set (MDS) assessment.
Failure to Maintain Suction Equipment Leads to Resident Incidents
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically the suction machines, which led to critical incidents involving two residents. Resident #2, who had a do not resuscitate (DNR) status, experienced a choking incident on peanut butter crackers. During the emergency, the suction machine failed to operate, and staff had to resort to manual methods such as the Heimlich maneuver and finger sweeps, which were unsuccessful. Despite efforts from multiple staff members, including maintenance personnel, the suction machine could not be made operational in time to assist the resident effectively. In another incident, Resident #1 was reported to be drowning in her aspirations due to a malfunctioning suction machine. An investigation revealed that the machine was equipped with the wrong canister, preventing it from creating the necessary suction. This issue was identified by a nurse consultant, highlighting a critical oversight in equipment maintenance and readiness. These incidents underscore the facility's failure to ensure that essential medical equipment was in proper working order, directly impacting resident safety and care.
Delayed Reporting of Missing Narcotics
Penalty
Summary
The facility failed to report missing narcotics from the emergency narcotic lock box within the required 24-hour timeframe. A discrepancy was identified on January 15, 2025, but the facility did not report the missing narcotics to the Department of Inspections, Appeals and Licensing until January 23, 2025, at 11:51 AM. During an interview on January 23, 2025, the Interim Administrator and the current Administrator acknowledged the delay in reporting, attributing it to their ongoing investigation process. The facility had a census of 28 residents at the time of the incident.
Inadequate Assessment and Intervention for Resident's Change in Condition
Penalty
Summary
The facility failed to provide adequate assessments and interventions for a resident following a change in condition. The resident, who had a moderately impaired cognition with a BIMS score of 9, experienced severe right-side abdominal pain while sitting at the breakfast table. Despite the resident's clear signs of distress, including grimacing, labored breathing, and elevated blood pressure, the initial assessment did not include a comprehensive evaluation such as checking bowel sounds, lung sounds, or other vital signs. The resident had a history of ileus and still had his appendix, which were relevant to his condition. The facility's policy required thorough assessments and documentation every shift for residents with a change in general condition until they were stable. However, the documentation failed to meet these guidelines, as it did not include necessary assessments or interventions. The facility's administrator confirmed the expectation for staff to assess and document for three days or until the resident was asymptomatic following a condition change. The lack of comprehensive assessment and documentation in this case represents a deficiency in the facility's adherence to its own policies and procedures.
Failure to Maintain a Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident when a nurse discovered a marijuana pipe and a medication bottle labeled Lasix with unknown contents in the resident's drawer. The resident, who had intact cognition and reported moderate pain, was informed by the nurse that the items could either be locked up or picked up by his daughter. The resident cooperatively stated he would not smoke there and was unsure why the items were brought. The nurse did not confiscate the items and notified another staff member, but did not have the resident's daughter's contact information to arrange for the items' removal. The clinical record lacked documentation of a physician's order for marijuana use, notification to the physician about the items, or any follow-up on what happened to the items after the initial discovery.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to administer the correct medications to a resident, leading to significant medication errors. On the specified date, a resident with intact cognition, as indicated by a BIMS score of 13, received medications intended for another resident. These medications included Benztropine mesylate, Atorvastatin, Clozapine, Cranberry, Flomax, Senokot, and Sertraline, none of which were prescribed to the resident. The error occurred when an agency nurse, unfamiliar with the residents, administered the wrong medications, mistaking the resident's identity due to similar names. Following the administration of the incorrect medications, the resident exhibited signs of sedation and was difficult to wake. The staff noted the resident's unusual behavior, such as sleeping in a chair and not responding to attempts to wake him. Despite these observations, the nurse delayed notifying the on-call doctor and did not take immediate action. Eventually, the resident was sent to the hospital due to increased respiratory rate and other concerning symptoms, where he was admitted for further evaluation. Interviews with staff and documentation revealed that the nurse did not verify the resident's identity properly and failed to follow the facility's medication administration policy, which includes the five rights of medication administration. The incident highlighted a lapse in communication and adherence to protocols, as the nurse relied on last names without realizing the presence of two residents with similar names. The facility's documentation and staff interviews confirmed the medication error and the subsequent hospitalization of the resident.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to comply with Federal Regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours per day. A review of RN timesheets and schedules revealed that the facility did not have an RN on duty on several specific dates between January and July 2024. The facility had a census of 31 residents during this period. The deficiency was identified through a review of time cards, schedules, and staff interviews. During an interview, the Administrator admitted that the facility mistakenly believed they had a waiver for RN coverage, which led to the absence of an RN for the required hours on the specified dates.
Failure to Update PASRR for New Diagnoses
Penalty
Summary
The facility failed to submit a new Pre-admission Screening and Resident Review (PASRR) for a resident when new diagnoses were documented in the medical record. The resident's Minimum Data Set (MDS) assessment included diagnoses of depression and psychotic disorder. However, the current PASRR, dated over four years prior, did not reflect these diagnoses. The resident's medical diagnoses included major depression disorder and unspecified psychosis not due to a substance or known physiological condition, which were not updated in the PASRR. During an interview, the Administrator reported submitting the PASRR for review only after the oversight was identified, which then triggered the need for a Level II review. The facility's policy lacked specific instructions on when to submit new mental health diagnoses for PASRR review.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to accurately complete comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #9, with intact cognition and diagnoses including arthritis and stage 3 pressure ulcers, used bed rails as a physical restraint. However, the care plan did not include the use of bed rails, despite the resident's ability to get in and out of bed independently with them. Both the Interim DON and the Administrator acknowledged that the care plan should have included bed rails, but the facility lacked a care plan policy. Resident #25, also with intact cognition, used a urinary catheter, but the care plan inaccurately addressed her as having bladder incontinence, directing staff to use disposable briefs and clean the peri-area with each incontinence episode. The Interim DON and the Administrator confirmed that the care plan should have addressed the use of a urinary catheter. Resident #28, with intact cognition, expressed feeling neglected and likened her experience to living in a jail. Her care plan lacked specific interventions for her care and treatment needs, and both the DON and the Administrator expected a comprehensive care plan to be completed within 21 days of admission, which was not done.
Failure to Revise Care Plan for Resident with Depression and Psychosis
Penalty
Summary
The facility failed to revise the care plan for Resident #11, who had documented diagnoses of major depression disorder and unspecified psychosis. The Minimum Data Set (MDS) assessment for the resident included these diagnoses, yet the current care plan lacked instructions and interventions related to these conditions. This deficiency was identified during a record review and staff interview, where it was noted that the care plan did not reflect the necessary interventions to address the resident's mental health needs. The facility had a census of 31 residents at the time of the survey.
Failure to Implement Discharge Planning for Resident
Penalty
Summary
The facility failed to implement discharge planning upon admission for a resident who expressed a desire to transfer to a different facility. The resident, who was admitted with intact cognition as indicated by a BIMS score of 13, reported feeling like a prisoner and expressed her wish to leave the facility. Despite her request, the care plan lacked a comprehensive review and interventions to facilitate her discharge to another facility. Additionally, the facility's Deaths/Discharges policy did not provide instructions on incorporating residents' wishes and goals into discharge planning. The Director of Nursing noted that the resident required 24-hour care due to her inability to care for herself at home.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to provide a qualified Infection Preventionist to oversee its infection prevention and control program. During an interview, the Administrator revealed that a Registered Nurse (RN), identified as Staff A, had completed the necessary class but had not yet taken the certification test. In a subsequent interview, Staff A confirmed that she had taken the class but had not completed the test. The facility reported a census of 31 residents at the time of the survey.
Failure to Ensure Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident received an antipsychotic medication, Olanzapine, only for diagnoses related to psychiatric or mood disorders upon admission. The resident, who had intact cognition as indicated by a BIMS score of 13, was admitted without documentation of psychiatric or mood disorders. An order for Olanzapine was made for the resident related to dementia without behavioral, psychotic, or mood disturbances. The resident's history and physical records lacked documentation of prior antipsychotic medication use before hospitalization. The care plan did not include a comprehensive review or interventions for the use of antipsychotic medication. The Director of Nursing was unaware that the resident was receiving an antipsychotic medication for dementia and had not taken it before admission to the facility.
Inadequate Sanitization of Blood Sugar Meters
Penalty
Summary
The facility failed to adequately sanitize the blood sugar meter and use a barrier during blood sugar checks and insulin administration for three residents. Resident #25, with intact cognition and a diagnosis of diabetes, was observed having their blood sugar checked by a Certified Medication Aide who did not clean the blood sugar meter after use. The aide placed the meter back in the medication cart without sanitizing it, despite the requirement to clean the device between each resident. Resident #10, who had moderately impaired cognition and diabetes, also received insulin and blood sugar monitoring without proper sanitization of the equipment. A Registered Nurse used a Kleenex as a barrier and failed to clean the blood sugar meter after use, placing it back in the cart without disinfection. This practice was repeated for Resident #26, who had modified independence for cognition and diabetes. The nurse again used a Kleenex as a barrier and did not clean the meter after use, returning it to the medication cart without sanitization. The Assure Prism Glucose Manufacturer's Quality Assurance/Quality Control Reference Manual and CDC guidelines emphasize the importance of cleaning and disinfecting blood glucose meters between uses to prevent the transmission of bloodborne pathogens. The facility's failure to adhere to these guidelines and the manufacturer's instructions for cleaning and disinfecting the blood sugar meters after each use led to the identified deficiencies.
Failure to Document Vaccination Education and Consent
Penalty
Summary
The facility failed to have a system in place for residents to decline vaccinations if desired, affecting three out of four residents reviewed. Resident #16's immunization history showed he received his last influenza vaccine on 10/22/21, while Resident #5's history indicated he never received an influenza vaccine. Resident #20's records showed they last received an influenza vaccine on 11/26/12. The facility's administrator reported that the Infection Preventionist (IP) did not obtain written documentation confirming that Residents #16, #5, and #20 were educated about the risks and benefits of the influenza vaccine. Additionally, the IP failed to document the residents' choices to receive or decline the vaccine. The facility's Influenza Vaccine Program requires documentation in the resident's medical record to include education about the vaccine's benefits and potential side effects, as well as whether the resident received the vaccine or the reason for not receiving it.
Inaccurate PBJ Reporting for Nursing Coverage
Penalty
Summary
The facility failed to accurately report the Payroll Based Journal (PBJ) for licensed nursing staff during the second quarter of fiscal year 2024. The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week. However, a review of the nursing timecards for the same period showed that the facility did have licensed nurse coverage 24 hours a day, seven days a week. During an interview, the Administrator admitted to submitting the PBJ incorrectly regarding the 24-hour nursing coverage, despite the facility maintaining the required coverage. The facility reported a census of 31 residents at the time of the deficiency.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document and submit the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their records. Resident #9's MDS inaccurately coded bed rails as a physical restraint, despite the resident's ability to get in and out of bed independently. The Interim Director of Nursing (DON) and the Administrator both acknowledged that the bed rails should not have been coded as restraints. Similarly, Resident #3's MDS also incorrectly indicated the use of bed rail restraints, which did not meet the definition of a restraint according to the Resident Assessment Instrument (RAI) Manual. For Resident #20, the MDS assessment failed to document the administration of morphine, an opioid medication, during the look-back period, despite records showing its administration. The Interim DON and the Administrator confirmed that morphine should have been coded on the MDS. Additionally, Resident #29's MDS did not reflect the administration of Eliquis, an anticoagulant medication, during the look-back period, although the Medication Administration Record (MAR) indicated its use. The DON and the Administrator acknowledged that Eliquis should have been coded on the MDS.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stacyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Saint Ansgar | 7.5 mi | ★★★★★ | 0 | 0 |
| Faith Lutheran Home | 10.8 mi | ★★★★★ | 0 | 0 |
| Osage Rehab And Health Care Center | 10.9 mi | ★★★★★ | 33 | 0 |
| Riceville Family Care And Therapy Center | 12.6 mi | ★★★★★ | 5 | 0 |
| St Marks Living | 18.1 mi | ★★★★★ | 6 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.