Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Wapello Specialty Care during CMS and state inspections, most recent first.
Failure to Use EBP During Wound Care: An ADON and RN performed wound care and perineal care for a resident with a chronic pressure ulcer, MDRO, and indwelling Foley catheter without wearing gowns. The resident’s care plan directed staff to use EBP for high-contact care, but only gloves were used during the observed care.
The facility failed to ensure proper food labeling and sanitary meal service. Observations included undated food items and unsanitary practices by staff, such as using a handwashing sink for filling drinks and handling items without washing hands. These actions violated the facility's sanitation policy and the 2022 Food Code.
The facility failed to update care plans for two residents with severe cognitive impairments who exhibited wandering behaviors. One resident, diagnosed with dementia and delirium, frequently wandered into other residents' rooms without interventions in their care plan. Another resident, with schizophrenia and obsessive-compulsive behavior, intruded on others' privacy and took items from their rooms, but their care plan did not address this behavior. Staff confirmed these behaviors, and the Director of Nursing acknowledged the need for care plans to address these issues.
A resident with severe cognitive impairment experienced a delay in UTI treatment due to communication lapses in a facility. Despite symptoms of urgency and burning with urination, there was a delay in obtaining and processing a urine sample. Abnormal urinalysis results were not promptly communicated to the provider, leading to a delay in antibiotic treatment. The facility's policy on antibiotic stewardship was not followed, resulting in the resident receiving treatment several days after initial symptoms.
A resident with moderately impaired cognition and a psychosocial well-being problem did not receive their prescribed antipsychotic medication consistently due to pharmacy delivery issues and lack of backup supply. The facility's policy required timely administration of medications, but this was not followed, leading to a deficiency.
A resident with intact cognition and mobility impairments fell while being dressed by a CNA, who did not follow the care plan's instruction to assist with dressing while seated. The CNA momentarily let go of the gait belt, causing the resident to lose balance and fall, resulting in skin tears and abrasions. Interviews with staff confirmed that dressing while standing was unsafe, and the facility's policy required reviewing the care plan for special needs, which was not adhered to.
The facility failed to prevent abuse between residents, involving a resident with severely impaired cognition who exhibited inappropriate sexual behavior towards two female residents. Despite interventions like changing dining room seating and 1:1 supervision, the incidents continued, highlighting a significant deficiency in protecting residents from abuse.
The facility failed to report allegations of abuse within the required 2-hour timeframe for three residents. One incident involved a resident allegedly touching another resident's breast, and another incident involved a resident touching another's stomach. Both incidents were reported late, contrary to federal requirements and facility policy.
The facility failed to adequately supervise a resident with a history of inappropriate sexual behavior, leading to multiple incidents of resident-to-resident abuse. Despite interventions like 1:1 supervision, these measures were inconsistently implemented, resulting in several incidents where the resident inappropriately touched another resident.
Failure to Use EBP During Wound and Perineal Care
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) during wound care for a resident with a chronic stage 3 sacral pressure ulcer, multidrug-resistant organism (MDRO), neurogenic bladder, obstructive uropathy, and an indwelling Foley catheter. The resident’s MDS documented intact cognition, one or more unhealed pressure ulcers/injuries, and an indwelling catheter. The care plan, revised 10/10/25, identified the resident as at risk for infection related to the Foley catheter and directed staff to use EBP during high-contact care activities. During observation of wound care, the ADON and an RN performed perineal care and wound care while wearing gloves, but neither staff member wore a gown. They washed hands, sanitized the tray table, used gloves for care, and changed gloves and sanitized hands between tasks, but no gown was used during the wound care or perineal care. The ADON later acknowledged that a gown should have been worn to comply with EBP and stated the resident required EBP because of the chronic wound and indwelling catheter. The Administrator also acknowledged that EBP should have been used during the wound care and high-contact care activity.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items and did not maintain sanitary conditions during meal service. During an initial kitchen tour, several food items were found improperly labeled or undated, including an open package of cheddar cheese, smoked ham, homestyle chicken salad, and a bag of chicken fried steak in the freezer. These observations indicate a lack of adherence to food safety protocols regarding the storage and handling of food items. Additionally, during a lunch meal service, multiple unsanitary practices were observed. Staff B was seen picking up a key from the floor and then preparing drinks without washing hands, using an ice scoop that was improperly stored, and utilizing the handwashing sink for purposes other than handwashing, such as filling drinks. Staff B also wiped hands on their shirt before handling drinks and picked up items from the floor without washing hands. These actions were contrary to the facility's sanitation policy and the 2022 Food Code, which mandates that handwashing sinks be used exclusively for handwashing.
Deficiencies in Care Plans for Wandering Behaviors
Penalty
Summary
The facility failed to update care plans for two residents exhibiting wandering behaviors, leading to deficiencies in addressing these behaviors. Resident #39, with a severe cognitive impairment and diagnosed with non-Alzheimer's dementia, amnesic disorder, and delirium, displayed daily wandering behavior. Despite multiple observations of the resident attempting to enter other residents' rooms and being redirected by staff, the care plan did not include any focus area or interventions for wandering behavior. Interviews with staff, including a CNA and LPN, confirmed the resident's wandering into other rooms, and the Director of Nursing acknowledged the need for the behavior to be care planned. Resident #6, also with a severe cognitive impairment and diagnosed with schizophrenia, restlessness, agitation, and obsessive-compulsive behavior, displayed daily wandering behavior and intruded on the privacy of others. Although the care plan addressed the risk for elopement and wandering that intrudes on others' privacy, it did not address the resident's behavior of taking other residents' property. Behavior notes documented multiple incidents where the resident entered rooms and took items, such as phones and a tablet, which were later returned. Staff interviews confirmed the resident's behavior of taking items and the use of stop signs to prevent entry into certain rooms. The facility's policy on comprehensive, person-centered care plans requires the incorporation of identified problem areas and the development of targeted interventions. However, the care plans for both residents failed to adequately address the specific behaviors observed, leading to deficiencies in managing the residents' wandering and intrusive behaviors. The Director of Nursing confirmed the need for these behaviors to be addressed in the care plans, acknowledging past complaints from family members about Resident #6's behavior.
Delayed Treatment for UTI Due to Communication Lapses
Penalty
Summary
The facility failed to ensure prompt treatment for a urinary tract infection (UTI) for a resident who was severely cognitively impaired. The resident had been experiencing symptoms of urgency and burning with urination, which were noted in the progress notes. A physician ordered a urinalysis (UA) with culture on the same day, but there was a delay in obtaining and processing the urine sample. The sample was collected the following day, and the results indicated abnormal findings suggestive of a UTI. Despite the abnormal urinalysis results, there was a delay in communicating these findings to the provider. The facility awaited the culture and sensitivity (C&S) results to guide treatment, which took several days. During this period, the resident continued to experience discomfort and frequent urination with little output. The bacteriology report eventually revealed a significant presence of Pseudomonas aeruginosa, but there was further delay in the provider reviewing the results and issuing a new order for antibiotics. The resident did not receive the prescribed antibiotic, Cipro, until several days after the initial symptoms were reported and the UA was ordered. The facility's policy on antibiotic stewardship required that lab results and the current clinical situation be communicated to the prescriber as soon as available, which was not adhered to in this case. The delay in treatment was attributed to a lack of timely communication and follow-up with the provider, as well as inadequate documentation of actions taken by the nursing staff.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medication was available and administered per physician order for a resident with moderately impaired cognition and a psychosocial well-being problem. The resident was prescribed Aripiprazole, an antipsychotic medication, to be taken at bedtime for Borderline Personality Disorder. However, the medication was not consistently available, as documented in the resident's progress notes. The medication was not available from 7/16/24 to 7/29/24, with only partial administration on certain days. The facility's records showed that the medication was ordered multiple times, but there were delays in receiving it from the pharmacy. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed issues with the pharmacy's delivery schedule and stock availability. The ADON explained that the pharmacy delivered every night except Sunday and closed early on Saturdays, which could delay medication availability until Tuesday. The DON confirmed that the facility did not have a backup supply of the medication and was still waiting for delivery slips from the pharmacy. The facility's policy on administering medications, which was revised in 2019, stated that medications should be administered in a safe and timely manner, as prescribed, but this was not adhered to in this case.
Failure to Follow Fall Risk Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan fall risk interventions for a resident, leading to a fall incident. The resident, who had intact cognition and required substantial assistance for mobility and dressing, fell while being dressed by a CNA. The care plan specified that the resident required assistance with dressing while sitting down, but during the incident, the CNA was dressing the resident while he was standing, which was against the care plan instructions. The incident occurred when the CNA was dressing the resident for bed, and the resident lost balance and fell backward into a closet, resulting in multiple skin tears and abrasions. The CNA admitted to letting go of the gait belt momentarily, which led to the resident losing balance. The resident reported that the staff member did not use a gait belt and that the dressing was usually done while he was seated, which was not followed during the incident. Interviews with other staff members, including another CNA and an LPN, confirmed that dressing a resident while standing was not a safe practice due to their unsteadiness. The facility's policy on assessing falls directed staff to review the resident's care plan for any special needs, which was not followed in this case. The Director of Nursing also acknowledged that changing a resident's clothing while standing was not appropriate, indicating a lapse in following established protocols.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse between residents, specifically involving three residents with varying degrees of cognitive impairment. Resident #1, who had severely impaired cognition, exhibited socially inappropriate sexual behavior on multiple occasions. Despite interventions such as changing dining room seating and implementing 1:1 supervision, Resident #1 continued to engage in inappropriate touching of female residents, including Resident #2 and Resident #7. These incidents were documented in progress notes and incident reports, indicating repeated failures to prevent such behavior effectively. Resident #2, also with severely impaired cognition, was a victim of Resident #1's inappropriate behavior. On multiple occasions, Resident #1 was observed attempting to lift Resident #2's shirt and touch her inappropriately. Despite immediate actions taken to separate the residents and notify family members, the incidents continued to occur, highlighting a lack of effective monitoring and intervention. Resident #7, who had intact cognition, was another victim of Resident #1's inappropriate behavior. Although Resident #7 denied that Resident #1 actually touched her, staff witnesses reported seeing Resident #1 attempt to fondle her breast. The facility's failure to prevent these incidents, despite being aware of Resident #1's behavior and implementing various interventions, constitutes a significant deficiency in protecting residents from abuse.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe for three residents. The first incident involved Resident #1 allegedly touching Resident #7's right breast in the dining room. The incident occurred on 11/12/23 at 12:00 PM, but the facility became aware of it on 11/13/23 and reported it at 3:45 PM. Staff A, a CNA, and Staff B, an LPN, admitted they did not realize the need to report the incident immediately. The second incident involved Resident #1 touching Resident #2's stomach on top of her shirt in the facility's lobby. This incident occurred on 11/16/23 at 4:20 PM, but the facility became aware of it on 11/17/23 and reported it at 7:55 PM. Both incidents were not reported within the required 2-hour timeframe as per federal requirements and the facility's policy on recognizing signs and symptoms of abuse/neglect. During interviews, staff members confirmed their failure to report the incidents promptly. The ADON acknowledged that allegations of abuse should be reported within 2 hours of the incident. The facility's policy, dated 4/21, mandates that all personnel report any signs and symptoms of abuse/neglect to their supervisor or the director of nursing services immediately. The policy also requires investigating and reporting any allegations within the timeframe required by federal requirements. The failure to adhere to these policies led to the deficiency noted in the report.
Inadequate Supervision Leading to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adequately supervise a resident with a history of socially inappropriate sexual behavior, leading to multiple incidents of resident-to-resident abuse. Resident #1, who had severely impaired cognition as indicated by a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, was involved in several incidents where he inappropriately touched Resident #2. Despite interventions such as seating Resident #1 away from female residents and providing 1:1 supervision, these measures were not consistently implemented or effective in preventing further incidents. On one occasion, Resident #1 was observed rubbing Resident #2 with his hand up her shirt. Another incident occurred when Resident #1 touched Resident #2's stomach on top of her shirt. The final reported incident involved Resident #1 attempting to lift Resident #2's shirt while she was waiting for breakfast. In each case, staff intervened to separate the residents, but the supervision was insufficient to prevent these occurrences. Interviews with staff revealed inconsistencies in the implementation of 1:1 supervision. Some staff reported that the 1:1 supervision was not always maintained due to staffing issues, and there were instances where the assigned staff would disappear. The facility's policy on safety and supervision emphasized the need for individualized, resident-centered approaches and consistent communication and implementation of interventions, which were not adequately followed in this case.
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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 Wapello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azria Health Prairie Ridge | 4.9 mi | ★★★★★ | 19 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 14.2 mi | ★★★★★ | 0 | 0 |
| New London Specialty Care | 15.4 mi | ★★★★★ | 6 | 0 |
| Colonial Manors Of Columbus Community | 16.8 mi | ★★★★★ | 0 | 0 |
| Southeast Iowa Regional Medical - Klein Center | 18.4 mi | ★★★★★ | 2 | 1 |
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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.