Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Zearing Health Care, Llc during CMS and state inspections, most recent first.
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.
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 July 2026) and official state health department websites.