Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Worth County Convalescent Center during CMS and state inspections, most recent first.
Staff failed to follow professional standards and physician orders in several areas, including wound care, LAL mattress use, and insulin administration. A resident with stage 3 pressure ulcers did not consistently receive ordered peri-wound skin prep and zinc spray during dressing changes, as observed when an RN completed a dressing change without applying the sprays and did not return after being questioned. Another resident at risk for pressure ulcers used a LAL mattress that was repeatedly observed set at 350 pounds, with no corresponding physician order, no care plan entry for the mattress, and no clear staff responsibility for checking settings. Multiple residents with diabetes received insulin from pens that lacked proper labeling and open dates, and an LPN repeatedly did not clean the pen port or prime the pen before administration, while also misunderstanding when priming was required; the DON later described correct labeling, dating, port cleaning, and priming procedures that were not followed.
Failure to Obtain Written Consent for Psychotropic Medications: The facility did not document written consent before starting psychotropic meds for four residents. Records showed no informed consent for antipsychotic, antidepressant, or anticonvulsant use for residents with diagnoses including dementia, stroke, depression, psychotic disorder, and impaired cognition. The DON and Administrator acknowledged that written consents should have been in the medical record.
Resident Trust Fund Accounting Deficit: The facility failed to maintain a full and separate accounting of resident trust funds when monthly bank paper statement fees were charged to the account but not reimbursed by the facility. The resident trust fund reconciliation showed a growing deficit owed by the facility, with interest credited only on the ending balance and not on the funds the facility owed. Four residents were affected, including residents who were cognitively intact and others with dementia, Alzheimer’s disease, stroke, quadriplegia, and other chronic conditions.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident’s care plan did not include the resident’s goal to return to the community, despite being cognitively intact and stating that goal during interview. Another resident’s care plan did not address DNR/code status, even though the face sheet and physician orders reflected DNR and the DON stated care plans should address code status.
Insulin Pen Administration Errors: Staff failed to clean insulin pen ports and prime the pens with two units before administering insulin to three residents. Observations showed an LPN administering Humalog or Lispro without priming the pen or cleaning the port, despite orders for blood sugar monitoring and scheduled insulin doses. The DON stated staff should clean the port with alcohol and prime the pen with two units each time before use.
Medication Labeling and Storage Deficiencies: Staff pre-poured medications for several residents, taped punctured Lorazepam doses back into a bubble pack, and kept multiple insulin pens without proper open-date labeling. An opened bottle of morphine sulfate was also found undated. The DON and an LPN acknowledged the improper medication handling and labeling.
Food storage temperatures were not properly monitored or documented. In the kitchen, multiple refrigerators and freezers had no temperature logs, and the chest freezer thermometer was buried under frozen food. The DM said staff were supposed to check the thermometer but it often got covered after deliveries, and dietary temperature sheets were no longer being used. The DON stated temperatures should be checked and recorded daily, but prior logs showed missing entries, no initials, and long gaps with no documented readings.
Failure to complete required TB screening for new hires: the facility did not follow its TB policy for multiple employees by allowing baseline testing to occur after hire, reading one TB test too early and another too late, and lacking updated TB documentation for a CNA on file. The DON stated TB tests read outside the 48- to 72-hour window are invalid, and the Administrator said she could not explain why one CNA lacked pre-employment TB testing and another CNA’s documentation could not be located.
A resident's credit card was used without authorization for multiple purchases, totaling over $300, after being kept in an unlocked dresser drawer. The resident, who had no cognitive impairment and required staff supervision for ADLs, was unaware the card was missing until notified by their financial POA. Facility staff were not aware the resident had a debit card, and the required comprehensive investigation was not conducted according to policy.
A resident with no cognitive impairment and multiple medical diagnoses experienced unauthorized charges on their debit card, which was kept in an unlocked dresser. The facility Administrator, after being notified by the resident's POA, failed to conduct a thorough investigation as required by policy, only interviewing the resident and family and not documenting when the card was last in the resident's possession. Staff were unaware of the card, and the Sheriff's office was notified.
The facility failed to update care plans with fall interventions for four residents who experienced falls. Despite multiple incidents, no new interventions were documented, leaving the residents at ongoing risk.
A facility failed to investigate an injury of unknown origin for a resident with dementia, resulting in extensive bruising. The facility did not follow its abuse and neglect policy, failed to interview all staff and residents, and did not document the investigation. The resident required substantial assistance with daily activities and had a history of dementia and other medical conditions.
Failure to Follow Wound Care Orders, LAL Mattress Parameters, and Insulin Pen Standards
Penalty
Summary
The deficiency involves multiple failures to follow professional standards of practice and physician orders for wound care, low air loss (LAL) mattress use, and insulin administration. One resident with two stage 3 pressure ulcers on both buttocks had physician orders for licensed nursing staff to clean the wounds with wound cleanser, use skin prep to the peri-wound area, apply collagen powder, and cover with bordered gauze on specified days, as well as to apply a zinc spray to the peri-wound area with dressing changes and daily. During an observed dressing change, the RN removed intact dressings, cleansed the wounds, applied collagen powder, and covered them with bordered gauze, but did not apply the ordered skin prep spray or zinc spray to the peri-wound area. When questioned afterward, the RN stated they believed the sprays were only done with morning and night dressing changes and did not return to complete the ordered treatment. The resident reported that staff were supposed to check the dressings every day shift and apply spray, but that this was rarely done and that primarily one LPN applied the spray. The DON confirmed that the RN should have completed the entire ordered treatment, including the sprays, and that nursing staff should perform treatments as ordered and according to the schedule. Another deficiency involved the use and management of a LAL mattress for a resident who was cognitively severely impaired, dependent on staff for most ADLs, always incontinent, and at risk for pressure ulcers. The resident’s care plan did not address the use of a LAL mattress, and the physician orders contained no order for a LAL mattress or its settings. Multiple observations over several days showed the resident either in bed or out of bed with the LAL mattress consistently set at 350 pounds. When interviewed, an LPN stated they did not know who was responsible for checking the LAL mattress settings and thought it might be housekeeping. The Administrator stated that if a resident was on hospice, hospice should monitor to ensure the LAL mattress was on the correct setting. The facility did not provide a policy for the Drive LAL mattress. Additional deficiencies were identified in insulin administration practices for several residents with diabetes mellitus. For one resident who was cognitively intact and independent with ADLs, orders included blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals. Observation showed the resident checked their own blood sugar and reported a value of 184 to an LPN. The Humalog pen used had no pharmacy label, no open date, and only a handwritten first name and dose on the lid. The LPN did not clean the pen port before attaching the needle, did not prime the pen with two units, and then dialed and administered 12 units. For another cognitively intact resident with diabetes, orders included blood sugar checks before meals and at bedtime and Humalog 8 units three times a day. Observation showed the LPN obtained a blood sugar of 116 and used a Humalog pen that lacked a proper label and open date, with only handwritten initials and dose on the lid. Again, the LPN did not clean the port or prime the pen before dialing and administering 8 units. A further observation of insulin administration for another resident showed the same LPN preparing to administer 12 units of insulin from a pen that had no open date written on it. The LPN had already attached the needle and drawn up the dose without priming the pen or cleaning the port. In a subsequent interview, the LPN stated they believed priming was only necessary when the pen was first opened and described their procedure as simply screwing on the needle and dialing the required amount, without mentioning port cleaning. The LPN acknowledged that insulin pens should be dated when opened. The DON stated that insulin pens should be labeled with the resident’s name, not used if not dated or labeled, the port should be cleaned with alcohol before attaching the needle, and the pens should be primed with two units before each use. The facility did not provide a policy for the use of insulin pens, although existing policies required that physician orders be followed as written and that wound care procedures include applying prescribed medications to the wound or wound area if ordered.
Failure to Obtain Written Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care by not obtaining written consent before starting psychotropic medications for four sampled residents. The facility policy stated residents or representatives have the right to be informed in advance of the risks and benefits of proposed care or treatment. Review of records showed no documentation of informed consent for the use of psychotropic medications for Resident #3, Resident #4, Resident #5, and Resident #30. Resident #3 had severe cognitive impairment, dementia, psychotic disorder, and stroke, and was ordered Quetiapine Fumarate and Divalproex Sodium for mood disorders beginning 10/16/24, but no informed consent from the resident or family was found. Resident #4 was cognitively intact and had depression, muscle wasting and atrophy, and wound infection; Aripiprazole and Sertraline were ordered on 08/15/24, but no consent was located. Resident #5 was cognitively intact with dementia, depression, and stroke; Sertraline was ordered on 03/04/24 and Quetiapine Fumarate on 07/11/25, with no consent documented. Resident #30 had moderately impaired decision-making, Alzheimer’s disease, stroke, depression, and non-traumatic brain dysfunction; Seroquel 50 mg at bedtime was started on 12/16/25, and the electronic chart contained no consents or education on risks and benefits. The DON and Administrator stated that written consents should have been in the medical record.
Resident Trust Fund Accounting Deficit
Penalty
Summary
The facility failed to establish and maintain a system that provided a full and complete separate accounting of residents’ personal funds entrusted to the nursing home. Monthly personal funds reconciliation showed an accumulating reimbursement deficit in the resident trust fund account because monthly bank charges for a paper statement fee were not reimbursed by the facility. The resident trust fund account review from February 2025 through January 2026 showed a $2.00 monthly fee charged each month, no entries showing reimbursement for those bank charges, and a running balance of money owed by the facility that reached $84.00. Interest was credited monthly based on the ending account balance, which did not include the funds the facility owed to the account. This affected four of 12 sampled residents: Resident #3, Resident #4, Resident #7, and Resident #12. Resident #3 had diagnoses including hypertension, diabetes, stroke, dementia, quadriplegia, seizure disorder, traumatic brain injury, and psychotic disorder. Resident #4 was cognitively intact and had anemia, hypertension, and GERD. Resident #7 was cognitively intact and had heart failure, hypertension, urinary tract infection, diabetes, dementia, and anxiety disorder. Resident #12 was not cognitively screened and had hypertension, diabetes, Alzheimer’s disease, and depression. During interview, the Administrator stated the facility kept a running tally of the bank statement fees charged to the resident trust fund and that the residents were not responsible for those bank fees, but the account had last been reconciled and reimbursed sometime the prior year.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for two sampled residents. Facility policies stated that care plans should be individualized, include resident goals and desired outcomes, and address the resident’s stated preference and potential for future discharge, including a desire to return to the community. The interdisciplinary team was responsible for developing a comprehensive care plan within seven days of completion of the resident assessment. For Resident #34, the admission MDS showed the resident was cognitively intact and required partial assistance with showering, bathing, and putting on footwear, with setup assistance for most other ADLs; diagnoses included heart failure, chronic lung disease, and kidney failure. The resident’s care plan was revised but did not address the resident’s wish to discharge to the community. During interview, the resident stated the goal was to return to the community and to be able to do things outside the facility. For Resident #29, the care plan did not address code status or the preference for life-saving measures. The face sheet showed DNR, the quarterly MDS showed cognitive skills intact with no behaviors and diagnoses of stroke, depression, and hemiparesis/hemiplegia, and physician orders included DNR. The DON, who was also the MDS/care plan coordinator, stated the care plans should address the resident’s code status.
Insulin Pen Administration Errors
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system free from significant medication errors when staff did not prime insulin pens before administering insulin to three sampled residents. The report states the facility also did not provide a policy for administration of insulin or the use of insulin pens. Resident #2 had orders for blood sugar checks twice daily and Humalog insulin 12 units three times daily with meals; on 2/25/26, staff documented a blood sugar of 184 and insulin administration, and during observation LPN A did not clean the port, did not prime the pen with two units, dialed the pen to 12 units, and administered the insulin in the resident’s right arm. Resident #11 had orders for blood sugar checks before meals and at bedtime and Humalog insulin pen 8 units three times daily; on 2/25/26, staff documented a blood sugar of 154 and insulin administration, and during observation LPN A obtained a blood sugar of 116 but again did not clean the port or prime the pen before dialing to 8 units and administering insulin in the resident’s abdomen. Resident #7 had orders for blood sugar checks twice daily and Lispro insulin 12 units twice daily with meals; on 2/26/26, staff documented a blood sugar of 128 and insulin administration, and during observation LPN A did not clean the port or prime the pen before dialing to 12 units and allowing the resident to administer the insulin to the lower right abdomen. LPN A stated the port should have been cleaned with alcohol and that new insulin pens were primed with two units, but after that the pens were not primed; the DON stated staff should clean the insulin ports with an alcohol wipe and prime the insulin pen with two units each time before use.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and stored properly, as shown by multiple medication handling errors involving insulin pens, pre-set medications, taped-in tablets, and an undated opened bottle of morphine sulfate. During observation, staff had pre-poured medications into paper cups for three residents, and an LPN acknowledged the medications should not have been preset. The facility also had no policy provided for insulin pens, and several insulin pens for five residents were found with handwritten resident identifiers and dose markings but no date when opened. The DON stated the insulin pens should have been labeled with the resident’s name, date opened, and expiration date. In addition, a resident’s Lorazepam bubble pack contained seven punctured doses that had been taped back into the card, and the LPN stated the medication should have been destroyed by two nurses rather than taped in. Another resident had an opened bottle of Morphine Sulfate that was undated; the bottle had been filled by the pharmacy and later opened, but the facility had no policy for how long it could be used after opening. The LPN stated the morphine should have been dated when opened, and the DON stated the insulin pens should not have been used if they were not dated when opened because there was no way to know how long they had been opened.
Food Storage Temperatures Not Properly Monitored
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not properly monitor food storage temperatures. During observation in the kitchen, the chest freezer, two stand-up freezers, two large 2-door refrigerators, and one stand-up refrigerator were missing refrigerator or freezer temperature logs. The chest freezer thermometer was buried beneath frozen food items and had to be dug out by the DM. The facility policy required potentially hazardous foods to be kept out of the temperature danger zone, refrigerators to be maintained at 41 degrees or lower, freezers at 0 degrees, and food temperatures to be checked and recorded regularly. During interview, the DM stated kitchen staff were supposed to look at the thermometer, but after truck deliveries it would get shoved around and covered up. The DM also stated dietary staff did not currently have temperature check sheets and had stopped using them because they were not filled out consistently, although she said she would ask dietary aides if they checked temperatures and that the Dietician checked the thermometers monthly. The Activities Coordinator, who helped in the kitchen, stated kitchen staff should always check and record refrigerator and freezer temperatures. The DON stated temperature checks should be completed daily and recorded by dietary staff. Review of the prior year’s logs showed multiple months with missing entries, no initials, and repeated temperatures that did not vary by one degree, including months with no logs provided and February 2026 with no documented readings until the 22nd.
Failure to Complete Required TB Screening for New Hires
Penalty
Summary
The facility failed to follow its Employee Screening for Tuberculosis (TB) Policy and Procedure by not completing required TB screening for six of 10 employees prior to employment. The policy stated that each newly hired employee must complete a 2-step TB test prior to offer of employment and prior to duty assignment, with baseline testing, individual risk assessment, and symptom evaluation completed before entering the facility. Review of Human Resources and TB records showed that a CNA had TB baseline established 2 days after hire, a dietary employee 11 days after hire, and a nursing assistant 5 days after hire. Another RN’s first-step TB test was read in less than 48 hours, and a second RN’s first-step TB test was read over 72 hours later, outside the stated reading window. Additional record review showed that one CNA hired on 11/13/25 did not have TB baseline established until 1/11/26, 59 days after hire, and another CNA hired on 12/18/25 had only a prior baseline from another facility dated 5/26/22 with no updated TB test on file at the current facility. During interview, the DON stated that TB tests read outside the 48 to 72 hour window are invalid and must be retaken. The Administrator stated that annual tests completed previously by new hires are good for up to one year prior to the date of hire at this facility, that TB tests must be read between 48 and 72 hours after injection, and that she was not sure why one CNA did not have a TB test completed and on file before starting work, while another CNA’s documentation could not be found.
Failure to Prevent Misappropriation of Resident's Credit Card
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's credit card, which was used without authorization by either the resident or the resident's financial guardian. The card was used for multiple unauthorized purchases over several months, totaling $348.23. The resident, who had no cognitive impairment and required staff supervision for activities of daily living, kept the card in a purse inside an unlocked dresser drawer in their room. There were no records indicating when the card was last in the resident's possession or when it was discovered missing. The resident only became aware of the missing card after being informed by their financial power of attorney. The facility's policy required immediate and thorough investigation of financial exploitation, including interviews with all staff and residents, but the Administrator only interviewed the resident and their family. Staff members were unaware that the resident had a debit card, and the facility did not have surveillance cameras. The Administrator was notified of the unauthorized charges by the resident's financial POA and subsequently reported the incident to law enforcement. The investigation by the Sheriff's office was ongoing at the time of the report.
Failure to Investigate and Document Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to follow its policy regarding the investigation and documentation of an alleged misappropriation of a resident's funds. After being notified by a resident's Financial Power of Attorney (POA) about unapproved charges on the resident's debit card, the Administrator only interviewed the resident and the family, without interviewing other staff or residents as required by policy. There was no documentation regarding when the debit card was last in the resident's possession or when it was discovered missing. The facility's policy required a thorough investigation, including interviews with all staff and residents and written statements from involved parties, but these steps were not completed. The resident involved had no cognitive impairment and required supervision for activities of daily living, with diagnoses including anxiety, major depression, unsteadiness, diabetes, and stroke. The resident kept the debit card in a purse inside an unlocked dresser drawer. Bank statements showed multiple unauthorized charges over several months, totaling $348.23. Staff interviewed were unaware the resident had a debit card, and the Sheriff's office was notified of the missing card. The facility census at the time was 27.
Failure to Update Care Plans with Fall Interventions
Penalty
Summary
The facility failed to update and revise the care plans with fall interventions for four residents who had experienced falls. Resident #1 had multiple falls, including one with a head laceration, but no new interventions were documented after each fall. The care plan for Resident #1 was not updated to reflect these incidents and lacked specific steps to prevent future falls. Resident #2 experienced falls while using the toilet and sliding out of a wheelchair, but no new interventions were documented in the care plan after these incidents. The care plan remained unchanged despite the falls, and there was no evidence of steps taken to prevent reoccurrences. Resident #3 and Resident #4 also experienced falls, but their care plans were not updated with new interventions. Resident #3 had abrasions and bruising from a fall, and Resident #4 fell while transferring from the toilet to a wheelchair without assistance. The facility's failure to update care plans with appropriate fall interventions contributed to the ongoing risk of falls for these residents.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin when a resident was found to have extensive bruising across the abdomen, perineal area, and legs. The facility did not implement its abuse and neglect policy, as it failed to interview all staff working at the time, did not interview other residents, and did not provide complete and thorough documentation of the investigation. This affected one of four sampled residents, with a facility census of 27. The resident involved had a history of dementia, myeloma in remission, vitamin D deficiency, and gastroesophageal reflux disease. The resident was dependent on a wheelchair for mobility and required substantial assistance with daily activities. The resident's medical record showed no entries regarding bruising or assessments from the physician or nurse practitioner around the time the bruising was discovered. Interviews with staff revealed that the bruising was first noted on 3/2/24, but no formal investigation was conducted. The Director of Nursing (DON) and Administrator did not document their observations or interviews with staff. The facility's incident reports did not include any report on the injury of unknown origin. Additionally, the facility did not provide specific training on resident care or abuse and neglect upon hire, and no measurements of the bruising were documented.
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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 Grant City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Ayr Health Care Center | 18.2 mi | ★★★★★ | 6 | 0 |
| Clearview Home | 18.3 mi | ★★★★★ | 2 | 0 |
| Pine View Manor Inc | 19.5 mi | ★★★★★ | 1 | 0 |
| Bedford Specialty Care | 20.9 mi | ★★★★★ | 0 | 0 |
| Maryville Living Center | 25.5 mi | ★★★★★ | 5 | 0 |
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