Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at State Center Specialty Care during CMS and state inspections, most recent first.
Failure to follow the approved pureed diet menu and post accurate substitutions. Dietary staff served pureed meals without the bread listed on the menu, substituted green beans for corn, and did not update the dining room menu when ice cream sundaes were unavailable. The CDM and dietary staff acknowledged the menu board was inaccurate and that the pureed meal portions were prepared using the regular menu measurements without adjusting for puree consistency.
A resident’s care plan was not revised to match the resident’s current transfer status. The resident was observed being transferred with a standing mechanical lift and 2 staff, and the MDS showed intact cognition, substantial/maximal assist for ambulation and transfers, and diagnoses including kidney failure, prior femur fracture, schizophrenia, muscle weakness, unsteadiness on feet, and lymphedema. Although care plan notes reflected use of a standing mechanical lift for ADLs, the ADL intervention still directed transfer with assist of one using a front wheeled walker. The DON acknowledged the care plan should include the standing mechanical lift.
Failure to assess and follow up on a groin rash. A resident with intact cognition and diagnoses including Parkinson’s disease, seizure disorder, and anxiety disorder had a groin rash noted on admission and an order for nystatin powder for candidal intertrigo, but the documentation lacked details such as size, color, pain, itching, discomfort, or infection. The care plan did not address the rash, and there were no additional assessments of the area until the resident later reported ongoing itching and burning; staff also stated the groin excoriation was pretty bad and had not been photographed.
A resident with a G-tube and continuous enteral feeding was observed lying flat in bed while the feed was running, despite orders and the care plan directing the head of bed be elevated to 30 degrees during and after feeding. CNA staff did not correct the positioning, one CNA did not know how to verify the angle, and an RN confirmed the need for 30-degree elevation but also did not know how to measure it.
Failure to notify a resident's representative after the resident voiced suicidal thoughts and a plan. A resident with intact cognition, anxiety disorder, and encephalopathy stated she would use Visine on her food as a method of self-harm, and a 1:1 was started. The progress notes did not document that the resident's representative was notified, and the DON acknowledged the lack of documentation. The resident said staff did not ask if she wanted her representative contacted, though she preferred that they had.
The facility failed to ensure call lights were within reach for two residents, compromising their safety and care. One resident, at risk for falls, was observed multiple times with the call light out of reach while seated in a recliner. Despite acknowledging the risk, the resident preferred to manage independently. Another resident, requiring assistance with mobility, also had the call light out of reach and admitted to being at risk for falls. The staff did not consistently ensure the call light was accessible, contrary to facility policy.
A facility failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) to a resident 48 hours before the end of skilled services, as required by Medicare regulations. The resident received Medicare benefits for skilled services but was not informed of potential liability for continued services through the necessary SNF ABN (CMS form 10055). This oversight occurred due to a change in staff, affecting one of three residents reviewed for liability and appeal notices.
A facility failed to include a resident in quarterly interdisciplinary team meetings to discuss care plan revisions. The resident, with intact cognitive function and multiple diagnoses, recalled attending only one meeting and expressed a desire to attend more. Staff interviews revealed a lack of documentation and communication regarding these meetings, and the administrator could only provide evidence of two meetings. The facility's policy required notification and record-keeping for care conferences, which was not adequately followed.
A resident with multiple health conditions was left with medication unattended at their bedside by a CMA, despite not being approved to self-administer. The resident was cognitively intact but had not taken the medication when observed. Facility policy requires staff to observe medication administration, which was not followed.
A resident with multiple diagnoses, including cerebral infarction and diabetes, did not receive a prescribed topical treatment for a wart due to medication unavailability. The treatment was not administered for nearly a month, and the resident reported toe pain. The DON acknowledged the lapse and mentioned a process for handling unavailable medications, but there was no documentation of alerts to the provider or pharmacy.
A CMA in the facility failed to follow proper infection control practices during medication administration, including neglecting hand hygiene before and after glove use and handling medications. The CMA was observed administering various medications to residents without adhering to hand hygiene protocols and improperly handling a dropped Amlodipine tablet. The DON confirmed that these actions were against the facility's infection control policy.
A facility failed to ensure a clean environment for a resident and in the kitchen storage area. A resident's room was cluttered with papers, clothing, and open food items, and the resident reported no housekeeping assistance since arrival. In the kitchen storage, crumbs, debris, and possible mice droppings were observed. The facility's cleaning policy requires regular cleaning and alertness to rodent activity.
A resident with intact cognition and independent in ADLs reported that an overnight CNA made disrespectful comments, telling her to "sit her ass down" and that the situation was none of her business. The resident stated it did not affect her, but the incident was reported, and the staff member was suspended pending investigation. The facility's policy requires residents to be treated with dignity and respect at all times.
Failure to Follow and Post Accurate Pureed Diet Menu
Penalty
Summary
The facility failed to follow the approved menu for residents on a pureed diet and failed to post accurate menu substitutions. The facility had 3 residents requiring pureed diets. The dietitian-approved cycling lunch menu for the pureed diet included king ranch chicken, pinto beans, corn, and a wheat roll, while the posted regular menu in the dining room listed the same meal with an ice cream sundae for dessert. During lunch meal service, dietary staff prepared pureed chicken, green beans, and pinto beans, but did not add bread to the pureed diets as listed on the menu. Staff also substituted green beans for corn and used the same measurements directed by the menu without adjusting for the pureed consistency, despite having a pureed chart available. Staff acknowledged they did not have ice cream for the sundae dessert and had not updated the dining room menu to reflect the substitution. The Certified Dietary Manager and dietary staff acknowledged the menu board was not accurate and that residents would have seen a posted dessert that was not offered. The Administrator also acknowledged the facility did not post the food substitutions. The facility policy stated residents on pureed diets should receive the same items as the regular diet, with correct portions of pureed food, and that bread and butter may be added to the mixture if bread is not pureed separately.
Care plan not updated for current transfer method
Penalty
Summary
The facility failed to revise Resident #11’s care plan to reflect the resident’s current transfer status. On 1/20/25, Resident #11 was observed being transferred to the restroom with a standing mechanical lift and 2 staff, and later that same morning was observed being transferred from the toilet to the wheelchair with a standing mechanical lift. The resident’s MDS assessment identified a BIMS score of 15, indicating intact cognition, and noted substantial/maximal assistance was required for ambulation and transfers, with use of a walker or wheelchair for mobility. The assessment also listed kidney failure, history of femur fracture, schizophrenia, muscle weakness, unsteadiness on feet, and lymphedema. Resident #11’s care plan conference progress notes dated 2/26/25, 5/20/25, 8/20/25, and 12/3/25 indicated the resident used a standing mechanical lift for transfers with ADLs. However, the care plan focus related to ADLs still included an intervention directing transfer with assist of one using a front wheeled walker. On 1/21/26, the DON stated the resident used the standing mechanical lift for security due to increased anxiety and fear with transfers and acknowledged the care plan should include the standing mechanical lift. The facility’s Comprehensive Person-Centered Policy stated that assessments are ongoing and care plans are revised as information about residents and their conditions change.
Failure to Assess and Follow Up on Groin Rash
Penalty
Summary
The facility failed to assess and follow up on a groin rash for one resident reviewed for skin concerns. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, and documented diagnoses including Parkinson’s disease, seizure disorder, and anxiety disorder. The resident required substantial to maximal assistance with toileting hygiene. The facility policy for skin tears, abrasions, and minor breaks directed staff to assess the wound and surrounding skin for swelling, redness, drainage, and tissue healing progress. On admission, the resident was noted to have a rash to the groin, but the documentation did not include the size, color, or any signs or symptoms of pain, itching, discomfort, or infection. The January 2026 MAR included an order for nystatin powder to the groin three times daily for candidal intertrigo. The care plan did not include information related to the groin rash, and the facility lacked additional assessments of the area from the admission note until the resident reported on 1/20/26 that he had an itchy groin since before admission and that the itching had not improved. The next day, he stated his groin still burned. Staff later stated the resident came in with a pretty bad excoriation in his groin and that powder was applied, but the area was not photographed, and the DON stated the skin concerns were monitored weekly.
Failure to Maintain Required Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to maintain the head of bed elevated during enteral feedings for Resident #40, who had a gastrostomy tube and an order for tube feeding at 65 milliliters per hour. The resident’s MDS listed an entry date of 1/15/26, and the physician order dated 1/16/26 directed head of bed elevation to 30 degrees during feedings. The care plan initiated 1/16/26 identified tube feeding as a focus and directed staff to keep the head of bed elevated 30 degrees during and for 30 minutes after tube feeding. During observation on 1/21/26, Resident #40 was found in bed with the head of bed only slightly elevated and her body lying flat under the elevated portion of the bed while the feeding was running at 65 milliliters per hour. Staff C, a CNA, stated the resident was repositioned at least every two hours but did not address the head of bed position. Staff D, a CNA, stated the resident should be sitting up higher and did not know how to determine whether the head of bed was at 30 degrees. Staff A, an RN, stated the feed would need to be paused while the resident was repositioned and confirmed the head of bed should be at 30 degrees, but also did not know how to measure that degree. The DON later stated tape had been added to the wall so staff would know where to adjust the head of bed elevation for tube feeding.
Failure to Notify Resident Representative of Suicidal Thoughts
Penalty
Summary
The facility failed to contact a resident's representative after the resident voiced suicidal thoughts and described a plan for self-harm. Resident #1 had a BIMS score of 15 on the MDS, indicating intact cognition, and had diagnoses including anxiety disorder and encephalopathy. The care plan noted a history of making comments about being dead and a goal to resolve thoughts of being better off dead or harming herself. Progress notes documented that the resident stated she would put Visine on her food because she had seen that if ingested it would cause a heart attack within 15 minutes and could not be traced. A 1:1 was initiated, but the progress notes did not document that the resident's representative was notified. The DON stated the representative would be contacted when there was a change in condition and acknowledged the notes lacked documentation that she had offered to contact the representative. The resident stated staff did not ask whether she wanted her representative contacted when the 1:1 was initiated, though she preferred they would have done so. The facility policy directed staff to promptly notify the resident representative of changes in the resident's medical, mental, or psychosocial condition unless otherwise instructed by the resident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #28, who had intact cognitive function and was at risk for falls, was observed multiple times seated in a recliner with the call light positioned behind the television and out of reach. Despite acknowledging the risk of not having the call light accessible in case of an emergency, the resident expressed reluctance to bother staff and preferred to manage independently. The Director of Nursing confirmed that call lights should be accessible to residents, aligning with the facility's policy that mandates call lights be within easy reach when residents are in bed or confined to a chair. Similarly, Resident #13, who also had intact cognition and required moderate assistance with mobility, was observed seated in a recliner with the call light attached to the wall at the head of the bed, out of reach. The resident reported occasionally moving the call light to make it more accessible but admitted to being at risk for falls and sometimes feeling weak. Despite this, the staff did not consistently ensure the call light was within reach when the resident was in the recliner. These observations highlight the facility's failure to adhere to its policy of ensuring call lights are accessible, thereby compromising resident safety and care.
Failure to Provide Timely SNF ABN Notice
Penalty
Summary
The facility failed to comply with Federal Regulations regarding Medicare billing practices by not providing a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) to a resident 48 hours before the end of skilled services. This deficiency was identified for one of the three residents reviewed for liability and appeal notices. The resident in question received Medicare benefits for skilled services from June 6 to June 26, 2024, but was not informed of the potential liability for continued skilled services through the required SNF ABN (CMS form 10055). The facility's policy, dated April 2021, mandates that the admissions coordinator or business office manager notify the resident in writing if Medicare may not cover certain skilled services, explaining the potential liability for non-covered services. However, due to a change in staff, the ABN was not completed timely or accurately for the resident. The facility had a census of 35 residents at the time of the survey.
Failure to Include Resident in Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly interdisciplinary team meetings were conducted with the inclusion of the resident to discuss changing goals and revisions to the care plan for one of the two residents reviewed. The resident, who had a documented Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognitive function, had diagnoses including cerebral infarction, cancer, diabetes, pain, and anxiety disorder. The care plan, initiated on December 15, 2023, included an intervention to review resident choices quarterly and as needed. However, the resident recalled attending only one care conference meeting and expressed a desire to attend more, indicating a lack of communication regarding the scheduling of these meetings. Interviews with staff revealed that the responsibility for ensuring care conference meetings for quarterly review and MDS updates had recently been assigned to a new staff member, who was unsure of the previous process and could not locate documentation to verify past meetings. The administrator was only able to provide documentation for two care conferences, one in December 2023 and another in August 2024, and acknowledged the expectation that the resident should have been included in quarterly reviews. The facility's policy required the social services director or designee to notify residents of care conferences and maintain records of such notices, but this was not adequately followed, leading to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident diagnosed with multiple conditions including diabetes, seizure disorder, schizophrenia, and depression. The resident, who was cognitively intact with a BIMS score of 14, was observed with two clear medication cups containing various pills left at their bedside. The resident was not approved to self-administer medications, yet the Certified Medication Aide (CMA) had left the medications unattended, assuming the resident would take them independently. The CMA had set up the resident's medications in two separate cups due to the quantity and administered other forms of medication such as nasal spray, inhaler, and eye drops before leaving the room. The resident was found lying in bed, appearing to be asleep, and later confirmed that they were not ready to take the medications. The facility's policy requires that medications should not be left unattended and that staff should observe residents taking their medications, which was not followed in this instance.
Failure to Administer Ordered Treatment Due to Medication Unavailability
Penalty
Summary
The facility failed to provide treatment to a resident as per the physician's order. Resident #28, who has intact cognitive function and diagnoses including cerebral infarction, cancer, diabetes, pain, and anxiety disorder, was supposed to receive a topical salicylic acid treatment for a wart on her toe. The treatment was ordered to start on October 24, 2024, and be applied daily. However, the treatment was not administered from October 24, 2024, to November 21, 2024, due to the medication being unavailable. The resident reported experiencing pain in her toe, rated at 2 or 3 on a scale of 10, and mentioned that staff had looked at it but no treatment was provided. The Director of Nursing (DON) acknowledged the lapse in treatment and indicated that there was a process in place for when medication is unavailable, which involves notifying the provider to get an alternative order or to hold the treatment. However, there was no documentation of any alerts to the provider or pharmacy about the unavailability of the medication until much later.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed in multiple instances involving a Certified Medication Aide (CMA), identified as Staff A. On several occasions, Staff A did not perform hand hygiene before donning gloves or after removing them, which is a critical step in preventing cross-contamination and infection. Specifically, Staff A was observed administering Timolol eye drops, Amlodipine tablets, Fluticasone nasal spray, Stiolto Respimat inhaler, and Refresh eye drops to various residents without adhering to proper hand hygiene protocols. Additionally, Staff A was seen touching multiple items with gloved hands before administering medications, further increasing the risk of contamination. In one instance, Staff A dropped a resident's Amlodipine tablet on the medication cart and proceeded to pick it up with an ungloved hand, placing it back into the medication cup and administering it to the resident without discarding it and obtaining a new one. The Director of Nursing (DON) confirmed that the facility's policy requires staff to perform hand hygiene before and after each medication pass and to dispose of any dropped medication per policy. The facility's policy on administering medications, revised in April 2019, mandates adherence to established infection control procedures, including handwashing and the use of gloves.
Deficiencies in Cleanliness and Sanitation in Resident Room and Kitchen Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in both a resident's room and the kitchen storage area. Resident #28, who has intact cognition and is at risk for falls, was observed in a cluttered room with piles of paper, books, clothing, and open food items scattered around. Despite expressing a desire for assistance with cleaning and organization, the resident reported that no housekeeping had been done since their arrival, and they had been taking their own trash out. The Maintenance Supervisor acknowledged the need for work in the resident's room and confirmed that housekeeping was supposed to be on a rotating schedule. In the kitchen's dry storage room, surveyors observed visible crumbs, debris, and an open package of rodent poison on the floor, along with what appeared to be mice droppings along the baseboard. The Kitchen Manager admitted that the storage room should have been clean and mentioned that the issue with mice had been resolved months ago. The facility's policy on cleaning and disinfecting residents' rooms, revised in August 2013, requires regular cleaning and disinfection of floors and tabletops and mandates that personnel remain alert for evidence of rodent activity.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who had intact cognition and was independent with activities of daily living, reported that the overnight CNA made disrespectful comments, telling her to "sit her ass down" and that the situation was none of her business. This incident was documented in an Incident Report and an Incident, Accident, and Unusual Occurrence Note, both dated the same day. The resident informed the nurse of the comments, but stated that it did not affect her or hurt her feelings because she believed she was in the right. The facility's Dignity Policy Statement, dated February 2021, mandates that residents be treated with dignity and respect at all times, which was not adhered to in this instance. The facility's Administrator confirmed the expectation for staff to treat residents with dignity and respect. Despite the resident's assertion that she was not affected by the comments, the incident was reported to the Department of Inspections Appeals and Licensing (DIAL), and the staff member involved was suspended pending investigation.
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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 State Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Zearing Health Care, Llc | 11.7 mi | ★★★★★ | 9 | 0 |
| Iowa Veterans Home | 12.4 mi | ★★★★★ | 6 | 0 |
| Southridge Specialty Care | 13.1 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Marshalltown | 13.1 mi | ★★★★★ | 14 | 0 |
| Story Medical Senior Care | 13.5 mi | ★★★★★ | 6 | 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.