Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Zearing Health Care, Llc during CMS and state inspections, most recent first.
A resident with Huntington’s disease and methadone therapy experienced a medication-related emergency after the facility did not clarify the Narcan order on admission, did not have Narcan immediately available, and had staff who lacked access and training for the Medbank. The resident later became cyanotic and unresponsive, was transferred to the ER, and the hospital documented acute respiratory failure and opioid intoxication. The record also showed inaccurate measurement of titrated liquid methadone doses, with staff using a syringe that could not accurately measure odd mL doses.
Failure to Reassess Unsafe Smoking and Prevent Repeated Burn Injuries: Residents with dementia, Huntington’s disease, chorea, and impaired motor function were identified as unsafe smokers requiring supervision, a smoking apron, and a clothes pin, but their care plans and records did not reflect timely updated smoking assessments or new interventions after repeated cigarette burns. One resident sustained multiple burns to the abdomen, thighs, hands, chest, and groin with incomplete documentation, another had repeated burns to the clavicle, hand, and finger, and a third repeatedly leaned forward while smoking and kept burning herself despite staff prompts and supervision.
Two residents experienced delayed response to significant weight loss. One resident with dementia, Huntington’s disease, dysphagia, and aspiration pneumonia had progressive weight loss, but the chart lacked timely notification of the MD/family and included paper weights that were not entered into the EMR or shared with the RD. Another resident with Huntington’s disease and dysphagia lost weight over several weeks; although the RD recommended a house supplement, nursing staff did not start it as ordered, and the NP reported the facility did not notify her about the weight loss.
Staff destroyed controlled substances without a second witness, left discontinued narcotics in medication carts, and used inconsistent methods to track and dispense Methadone and Clonazepam. Records showed mismatched MARs and controlled drug logs, negative balances, and a practice of taping unused half tablets back into medication cards instead of disposing of them.
Failure to assess and document a left heel blister. A resident with DM and diabetic nephropathy had a blister identified on the back of the left heel after a shower, but the record lacked skin assessments, interventions, treatment, and MD notification. The care plan did not include the heel impairment, and the DON reported no skin sheets or skin assessments were completed because the skin nurse was not aware of the area. During observation, the resident had sandals with a heel strap and a Band-Aid on the left heel, and said the strap rubbed the area.
A resident with Huntington's disease, dementia, and total bowel/bladder incontinence was treated for a UTI with Cipro and had an order for a follow-up UA after treatment. Although the MAR directed staff to recheck the UA, the record showed staff were waiting for physician direction on straight catheter use, and there was no documentation that the UA was obtained or that the order was clarified. The PCP expected the follow-up UA to be completed, and the ADON could not find documentation that it was rechecked.
A facility failed to obtain informed consent for psychotropic meds with black box warnings for 5 of 5 residents reviewed. Residents included individuals with intact cognition and others with severe cognitive impairment, with active orders for antidepressants, antipsychotics, and antianxiety meds such as sertraline, mirtazapine, clonazepam, Lexapro, clozapine, lorazepam, trazodone, Paxil, risperidone, and bupropion. The EHR lacked psychotropic consent documentation, and the DON stated she did not have informed consents.
The facility failed to develop complete, person-centered care plans for three residents with repeated falls and behavioral issues. Staff reported that the residents intentionally got themselves out of bed or put themselves on the floor, but the care plans only addressed general fall risk, noncompliance, or behavioral concerns and did not document the specific floor-lowering behavior. The residents had diagnoses including Huntington’s disease, dementia, depression, and progressive neurological conditions, and the DON stated falls and behaviors were expected to be documented with assessments and neuro checks when indicated.
Improper Glove Use During Food Preparation and Meal Service: A DM and a DA/Cook wore the same gloves while handling food and nonfood items during meal prep and service. The DM touched utensils, pans, bread, plates, bowls, and crackers without changing gloves or performing hand hygiene, and the DA/Cook handled bread, condiments, meat, and a knife while making sandwiches. The DM acknowledged the improper glove use and stated utensils should have been used for the crackers and gloves changed after touching nonfood items.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was honored.
A medication error occurred when an RN administered oral medications intended for one resident to another with severe cognitive impairment, resulting in the recipient experiencing lethargy and decreased responsiveness. The error was discovered during documentation, and the facility's policy requiring verification of the correct resident was not followed.
A resident with moderate cognitive impairment and Huntington's disease was allegedly prevented from smoking by an RN and an LPN, leading to distress. The incident was not reported immediately as required by facility policy. Staff A and Staff B witnessed the event and wrote statements, but these were not promptly delivered to the Administrator. The Administrator learned of the incident a week later through a staffing agency, highlighting a delay in reporting the abuse allegation.
A resident with moderate cognitive impairment and Huntington's disease was allegedly abused by an RN and an LPN, but the incident was not reported to the administration. Despite staff witnessing the event and writing statements, the alleged abuser continued working for a week. The facility's policy for immediate reporting and preventive measures was not followed, leading to a deficiency.
Failure to Clarify Emergency Overdose Orders, Maintain Narcan Access, and Accurately Dose Methadone
Penalty
Summary
The facility failed to clarify and implement an emergency overdose medication order on admission, failed to maintain available stock of emergency medication, failed to provide staff with access or training for the automated medication storage system, and failed to accurately measure and administer titrated liquid methadone doses for one resident. The resident had a BIMS score of 14, was functionally independent, and had Huntington’s disease. The care plan documented methadone therapy with black box warning instructions to monitor for respiratory depression and sedation and to use a device that could accurately measure and deliver the prescribed dose. The resident was admitted with orders that included methadone and Narcan for emergency use if the resident became unarousable. The clinical record lacked documentation that staff clarified the Narcan IV order on admission, and the MARs lacked documentation of the Narcan order. When the resident later became cyanotic, unresponsive to sternal rubs, and had shallow respirations with low blood pressure, staff notified the family and physician, and the physician ordered transfer to the ER and Narcan if available. The note documented the facility did not stock Narcan at that time. The resident was transferred to the ER and the hospital discharge summary documented acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, unresponsiveness, elevated troponin, and opioid intoxication without complication. The report also documented problems with access to the Medbank and with methadone dosing. Staff A reported she did not have a code or password for the Medbank until later and did not know how to enter it or whether it contained Narcan. The DON reported she did not clarify the Narcan order because she was unfamiliar with methadone and Narcan and stated the facility did not administer IV medications. The pharmacy policy required staff to review the E-kit list, contact the prescriber, document the order, and obtain the six-digit code to open the E-kit. In addition, the resident’s methadone oral concentrate was titrated in odd doses, and the controlled drug record documented administration errors, including 4.0 ml instead of 4.2 ml and repeated doses of 3.8 ml instead of the ordered 4.1 ml. Staff B stated the syringe measured in 0.2 increments and sometimes could not measure odd dosages accurately, and the DON acknowledged concerns with the methadone administration and documentation.
Failure to Reassess Unsafe Smoking and Prevent Repeated Burn Injuries
Penalty
Summary
The facility failed to complete and update smoking assessments for residents who smoked and had repeated burn injuries, and it failed to implement new interventions after the existing smoking precautions were ineffective. Resident #6 had moderately impaired cognition, dementia, Huntington’s disease, functional limitations, and a safe smoking assessment that stated she did not smoke safely, lacked the fine motor skills to hold a cigarette securely, and required constant supervision, a smoking apron, and a clothes pin. Her care plan did not include the apron and clothes pin interventions identified in the smoking assessment. She sustained multiple cigarette burns over time, including burns to the abdomen, thigh, hands, chest, and groin area, with several skin assessments lacking the degree of burn and some records lacking physician, family, or treatment documentation. The record also lacked additional smoking assessments or safety interventions after several of the burn घटनाएं occurred. Resident #8 had severely impaired cognition, dementia, Huntington’s disease, chorea, and functional limitations, and her safe smoking assessment also stated she did not smoke safely, lacked the fine motor skills to hold a cigarette securely, and required supervision, a smoking apron, and a clothes pin. Her care plan included supervision, a smoking apron, a clothes pin, and smoking in designated areas, but she sustained repeated cigarette burns, including burns to the right clavicle, left hand knuckle, and left index finger. The clinical record lacked documentation of a Silvadene treatment on one burn, and the smoking record lacked additional smoking assessments or safety interventions after the burns. During observation, she was seen smoking with exposed skin around the neck and clavicle area, and she dropped the cigarette to the ground while staff were not fully attentive. Resident #9 had moderately impaired cognition, dementia, Huntington’s disease, chorea, and tobacco use, and her safe smoking assessment stated she did not smoke safely, lacked the fine motor skills to hold a cigarette securely, and required supervision, a smoking apron, and a clothes pin. Her family refused a vape and wanted cigarettes continued. Staff documented that she leaned significantly forward while smoking, could not maintain an upright position, kept burning herself with the cigarette, and required repeated prompts to sit upright. Staff also documented concern that she could burn herself or fall face forward onto the concrete. The facility policy required smoking assessments to be re-evaluated quarterly, after significant physical or cognitive changes, and whenever staff deemed necessary, but the record showed no updated smoking assessments after the repeated burn-related events for these residents.
Delayed Weight Loss Monitoring and Nutrition Interventions
Penalty
Summary
The facility failed to implement weight loss interventions in a timely manner for two residents with significant nutritional decline. One resident had dementia and Huntington’s disease, required substantial to maximal assistance with eating, and had documented swallowing problems, including food or liquid loss from the mouth, pocketing food, and coughing or choking during meals or with medications. The resident was on a mechanically altered and therapeutic diet and had a care plan for impaired nutritional status with interventions including dietitian consultation, speech therapy if swallowing issues were suspected, nutritional supplements between meals, and supervision during meals. For that resident, the record showed progressive weight loss over several months, including a 5.3% loss in one month and a 17.4% loss over three months. The chart also documented an aspiration pneumonia hospitalization and a discharge weight of 95.7 lbs. The record lacked documentation that the physician or family were notified of the 5.3% one-month weight loss, and the facility’s paper weight forms showed additional weights that were not entered into the EMR. The dietitian reported she only had access to EMR weights, was not notified of reweights, and did not see the paper weights. The second resident had Huntington’s disease, required supervision or touching assistance with eating, and had a care plan for aspiration risk related to dysphagia. The resident lost 7.7% of body weight over three months, and the dietitian recommended a house supplement to promote weight stability. The physician order was signed several days later, but nursing staff did not start the supplement as ordered, and the resident lost additional weight afterward. The NP stated she expected supplements to begin within 24 hours and reported the facility did not fax or call her about the weight loss. The ADON acknowledged the supplement had not been started and stated the facility had communication and process problems related to the dietitian and the weight-loss form.
Controlled substance destruction and medication reconciliation failures
Penalty
Summary
The facility failed to have two staff members present when controlled substances were destroyed for four residents. Staff C destroyed multiple narcotic medications in the drug buster without a witness, including Methadone for a resident with Huntington’s disease and intact cognition, Adderall for another resident with Huntington’s disease and intact cognition, Clonazepam for a resident whose hospitalization had ended the medication order, and Lorazepam for a resident with severe cognitive impairment who was receiving hospice care. The controlled drug records documented the destructions, but the report states they were completed without the required second staff member present. The record also showed problems with controlled substance dispensing and reconciliation. For one resident receiving Methadone for pain related to Huntington’s disease, the controlled drug record was not updated when the order changed from tablets to oral solution, and staff documented a negative balance and later adjusted the remaining amount in the bottle. Staff described difficulty measuring the liquid medication because of the bottle stopper and said they sometimes had to dump the medication into a cup and measure it with a syringe, while the record reflected inconsistent amounts remaining. The facility also left discontinued or expired controlled medications in medication carts. Clonazepam for one resident remained in the cart after the resident returned from the hospital and after the discharge summary directed it to be stopped, and Lorazepam for another resident remained in the cart after the order was discontinued. For a different resident receiving Clonazepam 0.25 mg BID, the pharmacy label and controlled drug record did not match the MAR, and staff described a practice of breaking tablets, taping the unused half back into the medication card, and later counting those taped pieces during narcotic counts. Staff and leadership acknowledged that discontinued narcotics were not always removed promptly and that the facility’s practice included leaving half tablets taped back into the card for later use.
Failure to Assess and Document Left Heel Blister
Penalty
Summary
The facility failed to complete and document appropriate assessments and interventions for Resident #7 after a blister was identified on the back of the left heel. Resident #7’s MDS showed intact cognition, partial/moderate assistance needed with putting on and taking off footwear, independence with transfers and ambulation, and diagnoses including diabetes mellitus with diabetic nephropathy. The care plan addressed diabetes and directed staff to monitor, document, and report signs and symptoms of infection to open areas, as well as refer to podiatry for foot care needs. The clinical record documented that Resident #7 received a shower and a blister to the back of the left heel was identified from her sandals, but the record lacked skin assessments, interventions, treatment, and physician notification for the blistered area. The care plan also lacked information about the left heel skin impairment. The DON reported she could not locate physician notification and stated the skin nurse was not aware of the area, so no skin sheets or skin assessments were completed. During observation, Resident #7 had sandals with a strap around the back of the heels and a Band-Aid on the left heel, and she stated the strap rubbed the back of her heel and that the area came and went.
Failure to obtain ordered follow-up UA after UTI treatment
Penalty
Summary
The facility failed to obtain a follow-up urinalysis after completion of an antibiotic for a urinary tract infection as ordered by the physician for Resident #5. Resident #5 had a BIMS score of 11, was dependent on staff for transfers to the toilet and toileting hygiene, and was documented as always incontinent of bowel and bladder. The resident also had diagnoses of Huntington's disease and non-Alzheimer's dementia. The care plan lacked documentation regarding urinary incontinence or risk for UTIs. A new order was received to obtain a UA with C&S if indicated, and the UA was obtained via sterile technique. The culture was positive for E. coli, and the resident was started on Cipro 500 mg twice daily for 10 days with an order to recheck a UA in 14 days. The MAR directed staff to recheck the UA, but the record documented staff were waiting for direction from the physician about using a straight catheter to obtain the specimen, and there was no documentation that clarification was received or that the UA was obtained. The PCP stated she had ordered the antibiotic and wanted the UA rechecked to ensure the UTI was resolved, and the ADON could not locate documentation that the UA was rechecked per the physician order.
Missing informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications with black box warnings for 5 of 5 residents reviewed. Resident #1 had a BIMS score of 15 with diagnoses of depression and cerebral palsy and was receiving sertraline, mirtazapine, and clonazepam; the EHR lacked documentation of psychotropic consents. Resident #3 had a BIMS score of 15 with a diagnosis of anxiety and was receiving Lexapro, and the EHR also lacked psychotropic medication consent documentation. Resident #2 had severely impaired cognitive skills for daily decision making and diagnoses of Huntington’s disease, dementia, and depression; active orders included clozapine and lorazepam, but the EHR lacked informed consents for psychotropic drug use. Resident #4 had a BIMS score of 14 with diagnoses of Huntington’s disease, dementia, and anxiety and had active orders for clozapine, trazodone, and Paxil, with no informed consent documentation. Resident #10 had severely impaired cognitive skills for daily decision making and diagnoses of Huntington’s disease, dementia, and depression; active orders included risperidone, bupropion, and lorazepam, and the EHR lacked informed consents. The Administrator stated medications were done via telehealth with Iowa City so the family and/or resident received information, and the DON stated she did not have informed consents for psychotropic medications. The facility also lacked a policy related to informed consents for psychotropic drug use.
Care Plans Did Not Reflect Residents’ Intentional Floor-Lowering Behavior
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for 3 of 4 residents reviewed for falls. Staff reported that each of the three residents had a history of putting themselves on the floor, but the care plans did not reflect that behavior. The residents involved were identified as having significant cognitive and neurological conditions, including Huntington’s disease, progressive neurological conditions, dementia, and depression, and each had documented falls and care refusal or behavioral symptoms in the medical record. For Resident #2, staff stated she tries to get out of bed, rolls herself out of bed, does not use the call light, and has a mattress and pads on the floor because of the behavior. Her care plan addressed fall risk, dementia, high-risk medications, unsteady gait, and behavioral issues, but it did not document that she gets herself out of bed and falls. For Resident #10, staff stated she rolls herself out of bed when she wants up and does not use the call light. Her care plan addressed fall risk related to choreatic movement and noted the bed on the floor with a fall mat, but it did not document that she purposely rolled herself out of bed. For Resident #29, staff and the Administrator stated he was noncompliant, put himself on the floor on purpose, and had told the Administrator he did so because he did not want to lose hospice and massages. His care plan addressed noncompliance with the call light and attempts to perform his own care that ended in falls, but it did not document that he put himself on the floor intentionally. The DON stated she expected staff to document all falls and behaviors with vital signs and assessment, including neuro checks when indicated, and the facility policy stated all falls, whether witnessed or unwitnessed, must be assessed, managed, and documented promptly, accurately, and consistently.
Improper Glove Use During Food Preparation and Meal Service
Penalty
Summary
The facility failed to use gloves correctly to prevent cross contamination during food preparation and meal service. During kitchen observations, the Dietary Manager donned gloves and used the same gloved hands to touch a ladle, a pan containing rolls, and a container used to hold soup and rolls before placing the contents into a food processor and pureeing the food. With the same gloves still on and without hand hygiene, she handled a package of bread, removed the bread, tore it up, placed it into the food processor, and continued preparing the soup for reheating. Later, the Dietary Manager continued wearing the same gloves without hand hygiene while grabbing plates and bowls, arranging them for service, removing soup from the oven, moving rolls on the pan, and returning the pan to the oven. A Dietary Aide/Cook also donned gloves and made sandwiches while touching the outside of the bread package, bread, mayonnaise jar, bologna slices, peanut butter jar, and knife. The Dietary Manager then used the same gloved hands to grab crackers from a container after the lid was removed, and placed them on plates with soup. She acknowledged she should have used tongs for the crackers and changed gloves after touching non-food items, and stated the same for the Dietary Aide/Cook. The Administrator acknowledged the concerns, and the facility's glove use and meal service policy stated that utensils should be used to serve food and that gloves may be worn during food preparation only for single-task items.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Medication Administration Error Due to Failure to Follow Five Rights
Penalty
Summary
A medication administration error occurred when a Registered Nurse (RN) gave oral medications intended for one resident to another resident. The RN prepared medications for a resident with moderately impaired cognition and diagnoses including non-Alzheimer's dementia, Huntington's disease, anxiety, and difficulty walking. However, the RN mistakenly administered these medications—clonazepam and hydroxyzine—to a different resident who had severe cognitive impairment, was dependent in all activities of daily living, and also had diagnoses of non-Alzheimer's dementia and Huntington's disease. The error was identified approximately ten minutes later when the RN attempted to document the administration in the electronic Medication Administration Record and noticed the photo did not match the individual who received the medication. The resident who received the incorrect medications was assessed and initially showed no adverse reactions, with vital signs within normal limits. However, later assessments noted lethargy, decreased interactivity, and audible chest congestion. The resident's responsiveness fluctuated, with periods of alertness and interaction returning over the following days. The resident also experienced delayed swallowing and decreased appetite during the monitoring period. The incident was documented in the facility's records, and the staff followed the facility's protocol for assessment and monitoring. The facility's policy on medication administration requires staff to follow the five rights of medication administration, including verifying the right resident using two identifiers and administering medications as ordered by the physician. Staff interviews confirmed that the RN was aware of these requirements and had received education on the five rights. Despite this, the RN failed to follow the policy, resulting in the administration of medications to the wrong resident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner involving a resident with moderate cognitive impairment and Huntington's disease. The incident occurred when the resident attempted to go outside for a smoke break after the designated time. Staff D, an RN, and Staff E, an LPN, allegedly grabbed the resident and prevented her from going outside, causing the resident to become upset and exhibit behaviors. Staff A and Staff B, both CNAs, witnessed the incident and wrote statements, but these statements were not immediately delivered to the Administrator. Staff B reported the incident within 24 hours, but due to the involvement of both nurses on duty, there was no one to report to at the time. The facility's policy requires immediate reporting of abuse allegations to the charge nurse, who must then report to the Administrator or a designated representative. The policy also mandates reporting to the Iowa Department of Inspections and Appeals within two hours of the allegation. However, the Administrator only became aware of the incident a week later when contacted by Staff A's staffing agency. This delay in reporting violated the facility's policy and state regulations, as the staff did not report the incident immediately, and the statements were not promptly reviewed by the Administrator.
Failure to Report and Act on Alleged Abuse Incident
Penalty
Summary
The facility staff failed to report an alleged abuse incident involving a resident with moderate cognitive impairment and Huntington's disease. On the day of the incident, a Certified Nurse Aide (CNA) witnessed a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) physically restraining the resident when she attempted to go outside to smoke. Despite writing statements about the incident, the CNA and another staff member did not ensure these statements reached the facility administration. Consequently, the alleged abuser continued to work with the resident and other residents for approximately seven days after the incident. The facility's policy requires immediate reporting and preventive measures upon allegations of abuse, but these were not followed. The Administrator only became aware of the situation a week later when contacted by the CNA's staffing agency. During this period, the alleged abuser continued to work multiple shifts, as evidenced by timecard records. This failure to report and act promptly resulted in a deficiency, as the facility did not separate the alleged abuser from the resident or other residents, contrary to their abuse prevention policy.
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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 Zearing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hubbard Care Center | 9.6 mi | ★★★★★ | 6 | 0 |
| State Center Specialty Care | 11.7 mi | ★★★★★ | 11 | 0 |
| Rolling Green Village Care Center | 13.1 mi | ★★★★★ | 2 | 0 |
| Story Medical Senior Care | 13.2 mi | ★★★★★ | 6 | 0 |
| Bethany Life | 15.5 mi | ★★★★★ | 17 | 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 August 2026) and official state health department websites.