Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Valley Vista For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents were not protected from abuse when one cognitively impaired, non-ambulatory resident who preferred to stay in common areas was reportedly placed in his room with the door closed by a CNA to avoid his vocalizations, keeping him there for an extended period despite his gestures indicating he wanted to leave, as corroborated by his roommate and an RN. In a separate incident, a resident with dementia and mood disorders was observed by an RN being kissed twice on the mouth and held around the waist by a female visitor later identified as a facility cook, and later seen walking hand-in-hand with her, while the same staff member had also sought to take another resident out overnight and obtain that resident’s medications without guardian consent. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation but did not address how residents would be protected during investigations, and the described events demonstrate failures to prevent unreasonable confinement and potential sexual exploitation.
A resident with cerebral palsy, severe intellectual disability, and a strong preference for staying in the common area was allegedly placed in his room with the door closed by a CNA to avoid hearing his vocalizations, and left there for an extended period despite his gestures indicating he wanted out. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted to leave the room. Although facility policy defined abuse to include involuntary seclusion and required reporting allegations to the State Agency within 2 hours, the DON and Administrator stated they were not informed, and there was no documentation that the allegation was reported to the State Agency as required.
A resident with cerebral palsy, severe intellectual disability, and severe cognitive impairment, who depended on staff for most ADLs and preferred to stay in the common area, was allegedly placed in his room with the door closed by a CNA so the CNA would not have to hear his vocalizations, and kept there for an extended period despite his apparent wish to leave. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted out, but the RN only mentioned the concern to the DON in passing. The DON and Administrator stated such allegations should be reported directly to them and that the alleged perpetrator should be separated from residents, yet there was no documentation that an abuse investigation was initiated or that the CNA was separated from residents, despite an abuse policy that defined abuse to include involuntary seclusion and required timely reporting and investigation.
Incomplete resident POA documentation was found for 7 of 7 residents reviewed when the EHR and paper chart did not contain the Iowa Statutory POA paperwork for residents listed as having an appointed POA. Staff A in Social Services and the DON acknowledged the missing legal documentation in the residents' records.
Incomplete POA documentation was found in multiple resident records after surveyors reviewed the EHR, paper charts, staff interviews, and a prior CMS-2567. Several residents were listed as having a designated POA, but the legal POA documents were not available in the records for review, and the DON and Social Services staff acknowledged the missing documentation and the repeat recordkeeping issue.
The facility did not update care plans for several residents to reflect current interventions, treatments, and preferences. Examples included outdated documentation of discontinued medications, lack of updates for wound care and nutrition interventions, and failure to note changes in code status, transfer needs, and hospice services. Staff interviews confirmed that care plans were not consistently revised as required by facility policy.
The facility failed to accurately complete MDS assessments for two residents, with one case involving unreported significant weight loss despite EHR documentation and another involving the omission of a serious mental illness diagnosis confirmed by PASRR. The MDS Coordinator acknowledged both errors, which were inconsistent with the 2024 RAI guidance.
A resident with end stage renal disease and diabetes did not consistently receive required pre and post dialysis assessments as ordered by the physician. Multiple dates were identified where these assessments were not documented, and facility leadership acknowledged the omissions. No policy was available to guide staff on the procedure for completing these assessments.
Two residents with complex medical needs did not have current nutrition progress notes or assessments readily accessible in the EHR, as required. The RD's documentation was inconsistently scanned or maintained on a personal jump drive, leading to gaps in the medical record and lack of timely access for staff.
Staff did not follow infection control protocols in two cases: an LPN administered an insulin injection to a resident without wearing gloves, and a medication aide assisted a resident on enhanced barrier precautions without wearing a required gown. Both staff members acknowledged the lapses, and the DON confirmed that facility policy requires proper PPE use during these procedures.
Two residents who enrolled in hospice care did not have Comprehensive MDS Assessments completed and transmitted within the federally required timeframe. In one case, the assessment was completed late, and in the other, it was not completed at all, as confirmed by staff review.
Several residents who required assistance with bathing did not consistently receive scheduled showers or bed baths, with some reporting missed care and dissatisfaction with the quality of hygiene provided. Audit records confirmed that on multiple days, most scheduled baths were not completed or documented, and care plans were not always updated to reflect residents' needs. Facility policy required support for ADLs, but inconsistent documentation and failure to follow procedures led to unmet hygiene needs.
The facility failed to provide adequate weekend staffing, resulting in delayed call light responses and unmet resident needs. Residents reported long wait times for assistance, with one waiting up to an hour and 45 minutes. Staff confirmed fewer CNAs on weekends, leading to incontinence and unmet needs. Grievance records showed complaints about long wait times, and audits were not conducted during weekends or nighttime. The administrator acknowledged staffing issues due to call-ins and no-shows.
Two residents reported incidents of disrespect and inadequate care. One resident was left on a bedpan for hours, causing discomfort, and felt uneasy with CNAs speaking in a foreign language during care. Another resident experienced delayed call light responses, leading to incontinence and embarrassment. The facility's dignity policy was not followed.
A facility failed to document a resident's code status by not having an Iowa Physician Orders for Scope of Treatment (IPOST) form or a physician's order for a Do Not Resuscitate (DNR) status. Despite the resident's documented DNR status in their care plan, the absence of the IPOST form and physician's order meant the resident would be treated as a full code in an emergency. The Director of Nursing expected all residents to have a completed IPOST form.
A resident with multiple wounds did not receive consistent wound care as prescribed, with treatments often undocumented or incomplete over several months. Interviews revealed staff inconsistencies in treatment application, and the DON admitted to lapses in documentation. Facility policies requiring immediate documentation were not followed, leading to a deficiency in wound care management.
The facility failed to assist two residents with shaving, as they were only shaved on shower days despite their requests for more frequent shaving. One resident, with Parkinson's and no cognitive impairment, reported the facility often lacked razors, affecting his grooming. Another resident, with moderate cognitive impairment, also expressed dissatisfaction with the infrequent shaving schedule. The facility's policy aimed to promote cleanliness and skin care, but the practice did not meet residents' needs.
A resident with a history of stroke and hemiplegia reported shoulder pain after a CNA moved him too quickly during care, causing his shoulder to hit the wall. Despite the resident's report, no assessment or medical evaluation was conducted. Staff involved did not report the incident to management, and the facility's pain management policy was not followed, leading to a deficiency in care.
A resident with mobility issues was pushed in a wheelchair without foot pedals by a CNA, contrary to facility policy. The resident was barefoot, with a wrap around her calves, exposing her toes. The CNA claimed management instructed not to use foot pedals due to skin issues, but the DON stated no such directive was given. The facility's policy requires foot pedals for safety during wheelchair transport.
A facility failed to maintain infection control standards by not using PPE during high-contact care for a resident on enhanced barrier precautions. An RN was observed without a gown or gloves while handling the resident's wound vac tubing and bed sheet, contrary to the facility's protocol requiring PPE for residents with wounds or medical devices. Interviews confirmed the expectation for PPE use, indicating a breach in procedure.
A resident with a history of congestive heart failure and other conditions was admitted to the hospital with pressure ulcers that were not accurately documented by the LTC facility. Despite previous documentation of skin issues, daily skilled assessments failed to note these concerns. Staff interviews revealed inconsistencies in skin assessments and communication with physicians, leading to a deficiency in pressure ulcer care.
The facility failed to prevent the deterioration of pressure ulcers in two residents. One resident, admitted with a Stage 2 ulcer, experienced worsening conditions due to inadequate documentation and implementation of care plans, including the use of an air mattress and regular repositioning. Another resident, with Stage 3 ulcers, was not repositioned as needed, and the clinical record lacked detailed wound documentation. The facility's DON confirmed the lack of necessary documentation and adherence to care plans.
The facility failed to complete prescribed treatments for two residents, leading to deficiencies in care. One resident with a stage 2 pressure ulcer did not receive several wound care treatments and medications as ordered. Another resident with pressure ulcers also missed multiple wound care treatments. The facility's DON confirmed that treatments were expected to be completed as per the MAR and TAR instructions, but the lack of documentation indicated they were not performed.
A resident with a history of aggressive behavior was involved in multiple altercations with other residents, resulting in injuries. Despite having a care plan, the resident's behavior was not adequately managed, leading to a deficiency in supervision and safety. Facility staff acknowledged the need for increased supervision to prevent further incidents.
The facility failed to maintain proper infection control practices when animal feces was observed on a couch in the rehab dining room, an area accessible to residents and used for conferences. The Regional Director of Operations and the Administrator acknowledged the issue, citing past problems with dogs and the possibility of the facility's cats being responsible. The facility's policy mandates environmental cleaning and disinfection.
A resident was taken to an outside appointment wearing only a shirt and briefs, with a blanket wrapped around her, leading to feelings of embarrassment and a violation of her dignity. Staff failed to ensure she was appropriately dressed, and the facility's policy on maintaining resident dignity was not followed.
The facility failed to meet professional standards in medication administration and following physician orders for three residents. Eye drops for one resident were administered outside the scheduled time frames, ACE bandages were not applied daily for another resident, and a laxative mixture was left unattended with a third resident. The Director of Nursing and Administrator acknowledged these deficiencies.
The facility failed to ensure that residents received at least two baths or showers per week. Three residents, including those with conditions such as morbid obesity, cellulitis, hemiplegia, stroke, arthritis, and non-Alzheimer's dementia, did not have adequate documentation of showers or baths being provided or offered. The facility's policy on maintaining proper hygiene was not consistently followed.
Failure to Prevent Unreasonable Confinement and Sexual Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including unreasonable confinement and sexual exploitation, as required by its abuse policy. For one resident with cerebral palsy, severe intellectual disability, a BIMS score of 1/15, and dependence on staff for mobility and ADLs, staff and resident interviews indicated that a CNA placed the resident in his room and closed the door so she would not have to hear his vocalizations. The resident was described in the care plan and by staff as preferring to be in the common area near the nurses’ station, watching people and making his needs known through gestures and vocalizations. A CNA reported that on a specific day she observed another CNA put the resident in his room and close the door, and that the resident remained in the room for 45 minutes to an hour despite his preference to be out of the room. The resident’s cognitively intact roommate corroborated that staff sometimes shut the door when the resident wanted out of the room, and confirmed that the resident liked to be in the common area. The RN familiar with the resident stated that he did not like to be in his room and that staff understood his wishes through his grunting and pointing. She acknowledged that another CNA had reported to her that a CNA placed the resident in his room and closed the door, and that the roommate had activated the call light, after which the CNA entered, the resident pointed toward the door indicating he wanted out, and the CNA told him she would be back in a minute and then closed the door. The RN stated she relayed this information to the DON “in passing,” but there was no indication that this allegation was formally reported or investigated at the time. The deficiency also includes an incident of alleged sexual exploitation involving another resident with non-Alzheimer’s dementia, anxiety, depression, and a BIMS score of 8/15. A staff RN reported that she entered the resident’s room to administer medication and observed a female visitor with a child present kiss the resident twice on the mouth while holding him around the waist, and later saw them walking down the hall holding hands. The RN later learned the visitor was a facility cook who knew the resident prior to admission and had also requested to take another resident out overnight and obtain that resident’s medications without guardian permission. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation and required timely reporting and investigation, but did not specify how residents would be protected during an investigation, and the events described show that residents were subjected to alleged unreasonable confinement and potentially exploitative physical contact by a staff member/visitor.
Failure to Report Allegation of Involuntary Seclusion to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse, specifically involuntary seclusion, to the State Agency for one resident. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most activities of daily living, and had a BIMS score of 1/15 indicating severely impaired cognition. Care plan entries documented that the resident liked to spend time in the common area watching TV, listening to music, and people watching, and that he could express basic needs through body language and simple verbalizations. The facility’s Abuse Policy defined abuse to include involuntary seclusion and required reporting to the State Agency within 2 hours, along with a timely and thorough investigation. On a day when Staff A CNA was documented as providing care to the resident, Staff E CNA reported that the resident was making vocalizations and that Staff A placed him in his room and closed the door so she would not have to hear him, leaving him there for 45 minutes to an hour despite his preference to be in the common area. Staff E stated she reported this to Staff F RN, and the resident’s roommate confirmed that staff sometimes shut the door when the resident wanted out of the room. Staff F initially denied knowledge of such actions but then acknowledged that Staff E had reported that Staff A placed the resident in his room and closed the door, and that the roommate had activated the call light. The DON and Administrator both stated that such an incident should have been reported as an allegation of abuse and investigated, but neither had received a report of this allegation. The facility lacked documentation that the allegation was reported to the State Agency prior to 2/25/26, contrary to its abuse reporting policy.
Failure to Investigate Alleged Involuntary Seclusion and Protect Resident During Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of abuse and to ensure resident safety during the investigation for one resident with severe cognitive impairment. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most ADLs, and did not ambulate. The resident’s MDS and care plan documented that he preferred to spend time in the common area watching TV, listening to music, and people watching, and that he communicated basic needs through body language and limited verbalizations. On a February day shift, Staff A CNA was documented as providing multiple ADL cares to the resident. Staff E CNA later reported that on a Saturday, Resident #7 was making vocalizations and Staff A placed him in his room and closed the door so she would not have to hear him, keeping him there for 45 minutes to an hour despite his preference to be out of the room. Staff E stated she reported this to Staff F RN, and that the resident’s roommate was present at the time. Resident #8, the roommate, stated that at times Resident #7 wanted out of the room and staff shut the door, and confirmed that Resident #7 liked to be in the common area. Staff F RN acknowledged that Resident #7 did not like to be in his room and communicated his wishes by grunting and pointing, and, after further questioning, confirmed that Staff E had reported to her that Staff A placed the resident in his room and closed the door, with the roommate activating the call light. Staff F believed the incident occurred a couple of weeks before it was reported to her and stated she only mentioned it to the DON “in passing.” Staff A denied closing the door against the resident’s wishes and stated she could interpret some of his gestures, and did not think she had cared for him that weekend. The DON and Administrator both stated that such an allegation should be reported to them, that residents should be free from abuse, and that they would have separated the alleged perpetrator from residents and reported and investigated the allegation. The facility’s abuse policy defined abuse to include involuntary seclusion and required timely reporting and thorough investigation, but did not specify how to protect residents during an investigation. The facility lacked documentation that any investigation was carried out or that residents were separated from Staff A prior to February 25.
Incomplete Resident POA Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible resident medical records for 7 of 7 residents reviewed because the EHR did not provide Iowa Statutory Power of Attorney (POA) documentation for residents identified as having an appointed POA. Review of the EHR for Resident #1, #4, #5, #6, #7, #8, and #9 showed each resident had a designated POA, but the legal documentation identifying the appointed POA was not available in the records for review. During interviews, Staff A, Social Services, reviewed the residents' records and acknowledged that the EHR and facility paper chart did not provide the legal POA documentation for these residents. Staff A and Staff B, DON, later acknowledged the same recordkeeping failure for Resident #1, #4, #5, #6, #7, #8, and #9.
Incomplete POA Documentation in Resident Records
Penalty
Summary
The facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in a repeat deficiency on the current complaint survey. Review of the EHR for Residents #1, #4, #5, #6, #7, #8, and #9 showed each had a designated POA, but the records did not contain the Iowa Statutory POA documentation for review. During interview, Social Services staff reviewed the resident records and acknowledged that the legal documentation identifying each resident's appointed POA was not provided in either the EHR or the paper chart. Review of the facility's prior CMS-2567 recertification report dated 8/14/25 showed a deficiency for failing to maintain complete and readily accessible resident medical records for 2 of 3 residents reviewed, and the DON and Social Services staff acknowledged the same failure to provide complete and readily accessible medical records, including POA documentation, for the residents reviewed on the current survey.
Failure to Timely Update Resident Care Plans to Reflect Current Conditions and Interventions
Penalty
Summary
The facility failed to update and revise resident care plans in a timely manner to reflect current conditions and interventions for five residents. For one resident with diabetes and end stage renal disease, the care plan continued to list a discontinued topical numbing cream, despite documentation in the progress notes and treatment administration record that the intervention had been stopped due to patient complaints. The MDS Coordinator acknowledged that the care plan did not reflect the current medicated cream in use. Another resident with multiple diagnoses, including diabetes, heart failure, and a colostomy, had a care plan that listed negative pressure wound therapy (NPWT) and a weight goal that did not match the resident's current weight trend. The NPWT had been discontinued, and the registered dietitian acknowledged that the nutrition care plan had not been updated to reflect the resident's actual weight. Similarly, a resident with severe cognitive impairment and multiple comorbidities had a care plan that did not include a physician-ordered protein supplement for wound healing, nor did it reflect the resident's current weight trend, despite documentation in the electronic health record. Additional deficiencies included a resident with a stage 3 pressure ulcer whose care plan did not reflect her refusal to use a chair cushion or alternative interventions, and another resident whose care plan did not accurately reflect her current code status, transfer needs, or hospice services. Staff interviews confirmed that care plans were not consistently updated to reflect changes in health status, interventions, or resident preferences, despite facility policy requiring ongoing assessment and timely revision of care plans.
Inaccurate MDS Assessments for Weight Loss and Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit accurate information on the Comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment did not accurately reflect a significant weight loss of 10% or more over the previous six months, as documented in the electronic health record (EHR). The MDS recorded the resident's weight and indicated no significant weight loss, despite EHR documentation showing a decrease from 272 pounds to 235 pounds over the relevant period. The MDS Coordinator acknowledged that the weight loss section was incorrectly answered and that the resident was on a physician-prescribed weight loss regimen. For another resident, the MDS assessment failed to accurately report the presence of a serious mental illness as determined by the PASRR Level II screening. Although the EHR and PASRR documentation confirmed a diagnosis of bipolar disorder, the MDS incorrectly indicated that the resident did not have a serious mental illness. The MDS Coordinator confirmed that the relevant section of the MDS was answered incorrectly, contrary to the guidance provided in the 2024 Resident Assessment Instrument (RAI).
Failure to Complete Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to consistently complete required pre and post dialysis assessments for a resident with end stage renal disease and diabetes, as directed by current physician orders. Review of the electronic health record and monthly Treatment Administration Records revealed multiple dates where no pre and post dialysis assessments were documented, including several specific days across April, May, July, and August. During interviews, the resident was unable to recall if staff obtained vital signs before dialysis, though believed blood pressures were taken upon return. The Administrator and DON acknowledged the lack of dialysis assessments on the identified dates. Additionally, the facility was unable to provide a policy outlining the procedure for completing pre and post dialysis assessments.
Incomplete and Inaccessible Nutrition Documentation in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for two residents reviewed for nutrition. For one resident with diabetes and end stage renal disease, the electronic health record (EHR) lacked nutrition documentation for over nine months, with the last dietary assessment dated several months prior to the most recent care plan revision. The care plan required quarterly registered dietitian (RD) consultations and monitoring for malnutrition, but the required documentation was not present in the EHR. For another resident with severe cognitive impairment, Alzheimer's disease, and other comorbidities, the EHR similarly lacked current nutrition documentation, with the last nutrition risk assessment completed several months before the most recent care plan update. This resident's care plan included interventions for a mechanically altered diet and history of weight loss, but the supporting RD documentation was missing from the EHR. Interviews with the DON revealed uncertainty about the RD's charting process and an inability to locate current RD documentation in the EHR. The DON later found that some RD progress notes had been scanned into the EHR, but this process was not consistent or timely. The RD confirmed that nutrition-related entries were kept on a personal jump drive and that the process of printing and sending notes to the facility had not been routinely completed for an unknown period. As a result, staff did not have timely access to up-to-date nutrition assessments and progress notes for these residents.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection control standards in two separate incidents. In the first instance, a Licensed Practical Nurse administered an insulin injection to a resident without wearing gloves. The nurse later acknowledged the omission and confirmed awareness of the requirement to use gloves during such procedures. The Director of Nursing also stated that staff are expected to always wear gloves when administering insulin injections, as outlined in the facility's policy on glove use during invasive procedures. In the second incident, a Certified Medication Aide entered the room of a resident on enhanced barrier precautions, wearing only gloves and not a gown, and provided hands-on assistance by repositioning the resident. The aide admitted that a gown should have been worn in addition to gloves for this type of care, as the resident required both due to being on enhanced barrier precautions. The Director of Nursing confirmed that the expectation is for staff to use both gown and gloves for hands-on care with residents on enhanced barrier precautions, in accordance with facility policy.
Failure to Complete Timely MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change in condition for two residents who were admitted to hospice care. For one resident, the electronic health record documented hospice enrollment, but the Significant Change MDS assessment was not completed within the required timeframe, as the assessment was finalized 20 days after hospice admission. For the second resident, there was no evidence that a Significant Change MDS assessment was completed at all following hospice enrollment, as verified by the MDS Coordinator during a review of the resident's records. According to the 2024 Resident Assessment Instrument (RAI) Manual and the facility's own policy, a comprehensive assessment is required within 14 days of a significant change in a resident's status, such as enrollment in hospice care. The failure to complete and transmit these assessments as required was identified through clinical record review, staff interview, and policy review, and involved two residents out of a census of 54.
Failure to Provide Consistent Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide consistent bathing and assistance with activities of daily living (ADLs) for several residents over a four-day period. Clinical record reviews and resident interviews revealed that multiple residents who required substantial or maximal assistance with bathing did not consistently receive scheduled showers or bed baths. One resident, who was cognitively intact and required two staff for bathing, reported missing multiple showers over a two-month period, resulting in feelings of being unclean. Another resident with moderate cognitive impairment primarily performed sink baths independently, expressing dissatisfaction with the quality of staff-assisted showers and noting that staff often did not wash his hair or ensure he was clean. A third resident, bedbound after a medical procedure, reported not always receiving scheduled bed baths and sometimes refused care when staff attempted to use wet wipes instead of soap and water, preferring to wait for staff who would provide care according to her preferences. Audit sheets for the month indicated significant lapses in the completion of scheduled baths and showers. On several days, the majority of residents scheduled for bathing did not receive their baths, and there was no documentation of make-up baths on subsequent days. In one instance, a single staff member was assigned an unusually high number of baths in one shift and documented that all assigned residents refused, with no evidence that the required protocol for repeated offers and nurse notification was followed. The Assistant Director of Nursing confirmed the accuracy of the audit sheets and acknowledged the lack of records for completed baths on the specified days. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, including regular bathing, in accordance with their care plans. However, care plans were not always updated to reflect current bathing needs, and documentation practices were inconsistent. The failure to provide scheduled bathing and to follow established procedures for refusals and documentation resulted in unmet hygiene needs for several residents.
Inadequate Weekend Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate staffing on weekends, leading to delayed responses to call lights and unmet resident needs. Interviews with residents and staff revealed that the facility had fewer staff on weekends, resulting in longer wait times for call light responses. Residents reported waiting over 15 minutes, and in one case, up to an hour and 45 minutes for assistance. Staff confirmed that the facility operated with at least one less Certified Nurse Aide (CNA) on weekends, and management or office staff who typically assisted during the week were not available on weekends. This staffing shortage led to residents experiencing incontinence and unmet needs due to delayed assistance. The facility's grievance records showed complaints about long wait times for call light responses, particularly on weekends. One resident reported waiting 30-45 minutes for assistance and had to wheel themselves to the nurse's station without oxygen. The facility's call light audits were conducted during daytime hours on weekdays, not addressing the weekend or nighttime issues. The administrator acknowledged the staffing issues, citing frequent call-ins and no-shows as contributing factors. Despite having more staff hired and rotating them on weekends, the facility continued to receive complaints about call light response times.
Failure to Ensure Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by incidents involving two residents. Resident #13, who has intact cognition and requires assistance with activities of daily living due to a stroke and hemiplegia, reported being left on a bedpan for 3-4 hours, causing discomfort and pain. The resident also expressed distress over two CNAs speaking in a language he did not understand while providing care, which made him feel uncomfortable and rushed. Despite reporting these issues to the Administrator, the resident felt that the situation was not adequately addressed, as the Administrator did not recall being informed about the prolonged use of the bedpan. Resident #40, who has moderate cognitive impairment, reported that staff did not respond to call lights in a timely manner, resulting in incontinence and feelings of embarrassment and shame. The facility's policy on Quality of Life-Dignity, which emphasizes the importance of treating residents with dignity and respect, was not adhered to in these instances. The Director of Nursing acknowledged the expectation for timely response to call lights to assist residents with toileting, highlighting a failure in meeting this standard.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to have an Iowa Physician Orders for Scope of Treatment (IPOST) form for one of the residents, which is a medical order form that records residents' treatment wishes in the event of a medical emergency. The resident in question had a documented Code Status of Do Not Resuscitate (DNR) in their Admission Narrative Bundle/Baseline Care Plan. However, upon review, the facility's IPOST book and the resident's electronic record lacked the IPOST form and a physician's order for the code status. A registered nurse confirmed that in the absence of an IPOST form or physician's order, the resident would be treated as a full code, meaning cardiopulmonary resuscitation would be performed. The Director of Nursing stated that there was an expectation for all residents to have a completed IPOST form in the IPOST book.
Inconsistent Wound Care Documentation and Treatment
Penalty
Summary
The facility failed to adhere to professional standards of nursing care, specifically in the area of wound care for one resident. The resident, who had intact cognition and was at risk for pressure ulcers, had multiple wounds including a stage 3 pressure ulcer and moisture-associated skin damage. The care plan required specific treatments and dressings to be applied as prescribed by the wound care ARNP, but these were not consistently documented or completed over several months. Interviews with the resident revealed inconsistencies in the treatment application, with staff not always following the prescribed method. The Treatment Administration Record (TAR) showed numerous instances where treatments were not recorded as completed, spanning from June to September. The Director of Nursing (DON) acknowledged that some treatments might not have been completed and admitted to forgetting to document treatments in the TAR. The facility's policy required immediate documentation of services provided, which was not adhered to in this case. The Administrator and DON both stated expectations for staff to document treatments immediately after completion and to follow prescribed orders. However, the review of the facility's policies and interviews indicated a failure to meet these expectations, leading to the deficiency in wound care management for the resident.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to assist residents with shaving, as observed in two residents. Resident #27, diagnosed with Parkinson's disease and muscle weakness, had no cognitive impairment and expressed a desire to be shaved more frequently than the current schedule of twice a week on shower days. The resident reported that the facility was often out of razors, and on one occasion, did not receive a scheduled shower or shave. Documentation on the resident's shower sheet confirmed the lack of razors as a reason for not shaving. Resident #40, with a diagnosis of Non-Alzheimer's Disease and moderate cognitive impairment, also expressed dissatisfaction with the frequency of shaving, which was limited to shower days. Observations over several days showed the resident with facial hair and confirmed that shaving had not occurred as desired. The facility's policy, revised in February 2018, stated that shaving should promote cleanliness and skin care, but the Director of Nursing indicated that shaving was expected on shower days and more frequently if requested by residents.
Failure to Assess and Address Resident's Shoulder Pain
Penalty
Summary
The facility failed to accurately assess and provide intervention for a resident who reported shoulder pain. Resident #13, who had a history of stroke and hemiplegia, required substantial assistance with activities of daily living. The resident reported that a CNA, Staff D, moved him too quickly during care, causing his shoulder to hit the wall and resulting in pain. Despite the resident's report of pain and the incident, no assessment or medical evaluation was conducted on the resident's shoulder. Interviews with staff revealed inconsistencies in the handling of the incident. Staff D admitted to moving the resident by his sore shoulder but denied slamming him into the wall. Staff E, a CMA, was informed by the resident about the incident but did not recall specific details about the resident's pain or whether Tylenol was administered. Neither Staff D nor Staff E reported the incident to the charge nurse or management, and there was no documentation of an assessment in the resident's electronic health record. The facility's Administrator was unaware of the incident until the survey. The facility's policy on pain management and assessment, which requires a multidisciplinary approach to alleviate pain, was not followed. The lack of communication and failure to assess the resident's shoulder pain led to a deficiency in providing appropriate care according to the resident's needs and preferences.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency in accident prevention and supervision. The resident, who had orthopedic conditions and mobility issues, was observed being pushed in a wheelchair without foot pedals by a CNA. The resident was barefoot, with a wrap around her calves, leaving her toes exposed. This occurred despite the facility's policy requiring the use of foot pedals for safety during wheelchair transport. The CNA reported being instructed by management not to use foot pedals for this resident due to skin issues on her legs, although the Director of Nursing (DON) stated that no such directive was given by current management. The DON confirmed the expectation that foot pedals should be used for safety when pushing residents in wheelchairs. The facility's policy emphasizes maintaining an environment free of accident hazards and providing adequate supervision and assistive devices to prevent accidents.
Infection Control Breach in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards by not using personal protective equipment (PPE) during high-contact care activities for a resident on enhanced barrier precautions (EBP). The resident, who had a surgical wound and a Foley catheter, was observed in their room with a sign indicating EBP and PPE supplies available outside the door. Despite this, a registered nurse (RN) was seen in the resident's room without wearing a gown or gloves. The RN lifted the resident's bed sheet and touched the wound vac tubing without performing hand hygiene, subsequently touching her own clothing. Interviews with staff revealed that the protocol for residents on EBP requires wearing a gown, gloves, and mask during direct care activities, especially when handling wounds, bedding, or medical devices. The facility's policy, revised earlier in the year, mandates the use of EBP for residents with wounds or indwelling medical devices during high-contact care activities. The Director of Nursing confirmed the expectation for staff to wear PPE when in contact with the resident or their environment, highlighting a clear deviation from established procedures in this instance.
Deficiency in Pressure Ulcer Documentation and Care
Penalty
Summary
The facility failed to accurately document and assess pressure ulcers for a resident, leading to a deficiency in pressure ulcer care. The resident, who had a medical history of congestive heart failure, generalized weakness, osteoporosis, and hypertension, was admitted to the hospital with a decubitus ulcer on the buttocks. The facility's records showed inconsistencies in documenting the resident's skin condition, with daily skilled charting indicating no open areas or skin issues, despite previous documentation of skin concerns. Interviews with staff revealed a lack of consistent skin assessments and documentation. A registered nurse reported conducting weekly skin assessments and noted open skin areas on the resident's lower legs, but not on the heels. However, daily skilled assessments failed to document these issues. A CNA reported notifying a nurse about the resident's red and potentially opening skin on the buttocks, but this was not reflected in the skilled assessments. The Assistant Director of Nursing and the Director of Nursing both acknowledged that skin concerns should be documented and communicated to physicians, but this was not consistently done. The facility's policy on wound documentation required thorough assessment and documentation of pressure injuries, but this was not adhered to in the case of the resident. The hospital's progress notes indicated the resident had stage 2 decubitus ulcers on the buttocks and unstageable wounds on the lower legs and heels, which were not properly documented or addressed by the facility. This lack of accurate documentation and follow-up contributed to the deficiency in pressure ulcer care for the resident.
Failure to Prevent Deterioration of Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from deteriorating for two residents. Resident #1, who had a history of pressure ulcers, was admitted with a Stage 2 pressure ulcer on the coccyx. Despite having a care plan that included interventions such as using an air mattress and turning the resident side to side, the clinical record lacked documentation of weekly skin measurements and the application of the air mattress upon admission. The resident's condition worsened, with the development of a Stage 2 pressure ulcer on the left buttock, indicating a lack of effective pressure ulcer management. Resident #8, who returned from an acute care hospital with a diagnosis of pressure ulcers, was documented to have two Stage 3 pressure ulcers on the sacral and buttock regions. The resident's care plan included a pressure-reducing device and a turning schedule, but there was no documentation of a strict turning schedule being implemented. Observations revealed that the resident was not repositioned as frequently as needed, and the clinical record lacked detailed documentation of the wound's size and description, which is crucial for monitoring and treatment. The facility's Director of Nursing confirmed that the clinical records for both residents lacked necessary documentation, such as weekly skin measurements and adherence to a strict turning schedule. The facility's policy required accurate documentation of wound assessments and treatments, including changes in condition and response to treatment, which was not consistently followed. This lack of documentation and adherence to care plans contributed to the deterioration of pressure ulcers in both residents.
Failure to Complete Prescribed Treatments for Residents
Penalty
Summary
The facility failed to adhere to professional standards of nursing care by not completing prescribed treatments and dressings for two residents. Resident #1, who had a stage 2 pressure ulcer and other medical conditions such as anemia and malnutrition, did not receive several treatments as ordered. The Medication Administration Record (MAR) and Treatment Record (TAR) indicated multiple instances where treatments were not completed, including the application of wound dressings and administration of medications. These omissions occurred over several months, despite clear instructions on the MAR and TAR. Resident #8, diagnosed with conditions including anemia, hypertension, and pressure ulcers, also experienced lapses in care. The MAR and TAR documented that wound care treatments were not completed on several occasions. These treatments were crucial for the resident's wound healing process, yet they were missed repeatedly over two months. The facility's Director of Nursing and Assistant Director of Nursing confirmed that the treatments were expected to be completed as per the MAR and TAR instructions. The facility's policy on wound treatment documentation required that treatments be documented at the time of completion. However, the failure to check the boxes on the MAR and TAR indicated that the treatments were not performed. This lack of adherence to the facility's policy and the prescribed treatment plans contributed to the deficiency identified by the surveyors.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of residents from a particular resident who had verbal and physical altercations with others. Resident #4, who has a history of hypertension, insomnia, and depression, was involved in incidents on multiple occasions, including a physical altercation with Resident #3. Despite having a care plan in place that included interventions such as one-on-one supervision and behavior monitoring, Resident #4 continued to exhibit aggressive behavior. On one occasion, Resident #4 became agitated when attempting to access the bathroom, leading to a physical altercation with Resident #3. The incident resulted in Resident #3 sustaining injuries, including abrasions and bruising. The facility's progress notes and incident reports documented Resident #4's ongoing agitation and inability to be redirected, highlighting the need for increased supervision and intervention to prevent further incidents. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that Resident #4 required increased supervision due to previous altercations and threats of aggression. The facility's failure to adequately supervise and manage Resident #4's behavior resulted in a deficiency in ensuring a safe environment for all residents, as outlined in the facility's Resident Rights Policy.
Infection Control Lapse Due to Animal Feces in Resident Area
Penalty
Summary
The facility failed to maintain proper infection control practices when animal feces was observed on a couch in the rehab dining room. This area is accessible to residents and is also used as a conference room and by families. The Regional Director of Operations acknowledged the feces and mentioned past issues with people bringing in dogs and not cleaning up after them. The Administrator suggested the feces could have been from one of the facility's two cats. The facility's Infection Prevention and Control Program policy, dated 12/1/23, mandates environmental cleaning and disinfection, and requires all staff to report cleanliness issues outside their scope to the appropriate department.
Resident Taken to Appointment Without Proper Clothing
Penalty
Summary
The facility failed to promote resident dignity when a resident was taken to an outside appointment wearing only a shirt and briefs, with a blanket wrapped around her. The resident, who had intact cognition and required assistance with dressing due to conditions such as a stroke and hemiplegia, reported feeling naked and embarrassed upon arrival at the appointment. The resident stated that she normally goes to appointments fully dressed and had appropriate clothing in her drawers at the facility. Staff interviews revealed that the resident was bundled in a blanket, and the driver did not check if she was dressed appropriately. Additionally, a CNA mentioned that the resident did not have any pants that fit her at the time, and another staff member confirmed that it was not unusual for the resident to wear a t-shirt above her brief without pants. Upon arrival at the doctor's office, the resident's brief was found to be open and not taped closed, prompting the clinic staff to provide her with surgical pants. The facility's policy on promoting and maintaining resident dignity directs staff to groom and dress residents according to their preferences and maintain their privacy. The Director of Nursing stated that if a resident did not have proper clothing for an outside appointment, staff should follow up with the charge nurse or the DON for direction. The facility's failure to ensure the resident was appropriately dressed for her appointment resulted in a violation of her dignity and self-respect.
Medication Administration and Physician Orders Not Followed
Penalty
Summary
The facility failed to provide services that met professional standards regarding medication administration and following physician orders for three residents. For Resident #3, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and lymphedema, eye drops were administered outside the scheduled time frames on multiple occasions. The Medication Administration Record (MAR) showed that the eye drops were given either too early or too late, contrary to the facility's policy and physician orders. The Director of Nursing acknowledged that medications should not be administered outside the prescribed time frames without physician notification and permission. Resident #6, who had diagnoses including diabetes mellitus and schizophrenia, required ACE bandages to be applied daily to her lower extremities for edema. However, the Treatment Administration Record (TAR) lacked documentation of the ACE bandages being applied on several dates in February and March 2024. During an observation, the resident confirmed that the wraps were not applied as ordered, and the Director of Nursing confirmed that treatments should be completed as per physician orders. For Resident #17, who had diagnoses including stroke, hemiplegia, and aphasia, a Certified Medication Assistant (CMA) left a mixture of PEG 3350 (a laxative) with the resident unsupervised. The resident had an order for the laxative to be administered twice daily. The CMA acknowledged leaving the medication unattended, and the Administrator confirmed that medications should not be left in a resident's room without a physician's order for self-administration. The facility's policy on medication administration requires that medications be administered as ordered by the physician and in accordance with professional standards.
Failure to Provide Required Baths/Showers
Penalty
Summary
The facility failed to ensure that residents received at least two baths or showers per week, as required. This deficiency was identified for three residents. Resident #14, who had diagnoses including morbid obesity and cellulitis of the groin, required staff assistance for bathing. The electronic health record (EHR) for Resident #14 lacked documentation of showers or baths being provided or offered in the past 30 days, and the Director of Nursing (DON) could only verify three instances of showers or refusals in March 2024. The DON acknowledged that Resident #14's showers were not scheduled in the EHR. Resident #17, who had diagnoses including hemiplegia and stroke, also required staff assistance for bathing. The EHR for Resident #17 showed that the resident had only five showers between February 19, 2024, and March 19, 2024, with no documentation of additional showers being offered. Similarly, Resident #18, who had diagnoses including arthritis and non-Alzheimer's dementia, required extensive assistance for bathing. The EHR for Resident #18 revealed that the resident had only four showers in the same 30-day period, with no documentation of additional showers being offered. The facility's policy stated that residents should be assisted with bathing to maintain proper hygiene, but this was not consistently followed for these residents.
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 135 citations issued within 25 miles in the last 12 months — 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 Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Park Centre | 0.7 mi | ★★★★★ | 4 | 0 |
| Newton Village Health Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Accura Healthcare Of Newton East, Llc | 1.1 mi | ★★★★★ | 25 | 0 |
| Traditions Memory Care Of Newton | 1.6 mi | ★★★★★ | 2 | 0 |
| Mayflower Home | 17.2 mi | ★★★★★ | 1 | 0 |
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.