MercyOne Centerville Medical Center
One St Joseph Drive, Centerville, IA 52544 · Non profit - Church related · 19 certified beds · (641) 437-4111 Medicaid only — no Medicare
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.1% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.1% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.4% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.1% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.8% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 26.7% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.7% | 20.8% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 7.1% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.0% | 25.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.5% | 19.5% | 17.1% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 19 beds and averages 18.4 residents a day — about 97% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.06 hrs/resident/day on weekends vs 4.76 on weekdays — 15% thinner on weekends. RN hours go from 1.17 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2026-04-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, the facility failed to verify the dosage on a bottle of Morphine was correct when received from the pharmacy and failed to administer the correct dose of Morphine as ordered for one of four residents reviewed (Resident #1). The facility reported a census of 18 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 12 and had the following diagnoses: Diabetes Mellitus, Anxiety Disorder and COPD (Chronic Obstructive Pulmonary Disease). The MDS also identified Resident #1 to be totally dependent on staff for assistance with showers/baths, lower body dressing, putting on and removing footwear and required substantial/maximal assist with toileting, upper body dressing and personal hygiene. On [DATE] the Care Plan identified Resident #1 with the problem of risk of discomfort related to end of life process and directed the staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-28 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to inform residents/resident representatives in advance of the risks and benefits of psychotropic medications for 5 of 5 residents reviewed for medications (Residents #3, #4, #10, #14, #18). The facility reported a census of 19 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 7/11/25, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident took antipsychotics and antidepressant medications and listed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. The facility policy Gradual Dose Reduction and Use of Antipsychotics/Psychoactive Drugs revised 4/2023, stated staff would notify the resident/responsible party of the initiation, increase, or decrease of any psychoactive medications. The Order Summary Report listed the following orders:a. 5/13/25 sertraline (an antidepressant) 100 milligrams(mg) 1 tablet by mouth one time a day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on initial kitchen tour observation, facility policy review and staff interview, the facility failed to ensure the removal of out dated nutritional supplement drinks from a dry good storage area in the kitchen in order to prevent the service and resident consumption of an unsafe, expired food product. The facility reported a census of 19 residents. Findings include: On 8/25/25 at 10:51 AM, during an initial tour of the kitchen, observation revealed a total of 13 Glucerna, a type of nutritional shake supplement, creamy strawberry flavor in 8 ounce individual serve cartons an expiration date of July 2025. The expired Glucerna drink was located on a dry storage shelf in kitchen with other supplement drinks, including other non-expired Glucerna flavors. The Dietary Manager confirmed the Glucerna in the creamy strawberry flavor had expired the end of July 2025. ON 8/26/2025 at 9:22 AM, the Dietary Manager reported dietary staff had removed the out dated Glucerna. The Dietary Manager explained Staff C, Dietary Aide, went through the supplements and looked for out dated product…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to ensure staff dressed a resident in a dignified manner and utilized incontinent products appropriately for 1 of 2 residents reviewed for dignity (Resident #4). The facility reported a census of 19 residents.Findings include:The Minimum Data Set (MDS) assessment tool, dated 7/11/25, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident was dependent on staff for lower body dressing and toileting hygiene and listed her Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Scope of Service-Long Term Care Department, revised 5/2019, stated the facility would maintain respect for residents. A Care Plan entry, revised 8/1/23, stated the resident required extensive assistance with all activities of daily living (ADLs). A Care Plan entry, revised 4/14/24, stated the resident required extensive assistance with dressing. On 8/27/25 at 12:52 p.m., Staff A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, and staff interview, the facility failed to notify the State Long-Term Care Ombudsman of the hospitalization and discharge of residents for 2 of 2 residents sampled (Resident #3 and #23) with a hospitalization or discharge. The facility reported a census of 19 residents. Findings include:1.The Minimum Data Set (MDS) assessment for Resident #3, dated 6/23/25, identified the resident had diagnoses of chronic obstructive pulmonary disease and diabetes. The Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 (indicative no cognitive impairment).On 8/25/25 at 1:19 PM, the resident reported a recent hospitalization in July 2025.Review of the clinical MDS list for Resident #3 revealed a lack of an MDS to indicate the resident discharged to the hospital with an anticipated return or reentry to the facility in the month of July 2025.On 8/28/25, review of Progress Notes for Resident #3 revealed the following:a. A progress note, titled Health Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to complete required Minimum Data Set (MDS) assessments for 2 of 16 residents reviewed (Residents #3 and #7). The facility reported a census of 19 residents.Findings include:1. Resident #7's electronic health record (EHR) MDS list, reviewed on 8/28/25, documented her 7/24/25 quarterly MDS was in progress. The facility MDS Transmission Policy and Procedure, revised 3/2015, stated the facility would ensure accurate completion and submission of federally required assessments including quarterly, discharge, and reentry assessments. On 8/27/25 at 1:50 p.m., the MDS Coordinator stated she was aware she did not complete the MDS assessments very well lately and said she did not get enough time for this. She stated she found one that was due “last month” that was not completed. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated staff should complete MDS assessments in the appropriate time frames. 2.The MDS assessment for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interview, the facility failed to ensure the care plan identified diuretic (a medication which reduced fluid in the body) and antidepressant medications and failed to address the risk of skin impairment for a resident with a history of skin breakdown for 2 of 16 residents reviewed for care plans (Residents #10 and #17). The facility reported a census of 19 residents.Findings include:1. The Minimum Data Set (MDS) assessment tool dated 7/21/25, listed diagnoses for Resident #10 which included anxiety, osteoarthritis (inflammation of the bone and joints), asthma, chronic obstructive pulmonary disease, or chronic lung disease (diseases which can cause shortness of breath/difficulty breathing). The MDS stated the resident received diuretic and antidepressant medications and listed her BIMS(Brief Interview for Mental Status) score as 14 out of 15, indicating intact cognition. The facility policy Comprehensive Care Plans, effective 7/2025, stated Care Plans would include skin conditions and medications. The August 2025 Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident and family interview, staff interview, hospice staff interview, and review of facility policy, the facility failed to ensure staff revised a resident's care plan to include hospice services within 7 days after the completion of a significant change in condition comprehensive assessment and failed to include hospice professional staff in the care planning process for 1 of 1 sampled residents reviewed for hospice services (Resident #2). The facility staff failed to include resident/family in the participation and development of their care plan for 1 of 1 residents reviewed for care planning participation (Resident #15). The facility reported a census of 19 residents. Findings include:1.The Minimum Data Set (MDS) significant change in condition assessment for Resident #2, dated 4/8/25, and the quarterly MDS assessment, dated 7/9/25, identified a facility admission date of 10/6/2014, indicating the resident received hospice services, and identified diagnoses of major depressive disorder, edema (fluid retention), unspecified joint pain, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure nursing staff provided personal hygiene assistance to a dependent resident in a timely manner after an episode of bowel and urine incontinence for 1 of 1 resident's sampled (Resident #15) with a reported concern of delayed assistance in care. The facility reported a census of 19 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #15, dated 8/16/25, identified diagnoses of hemiplegia (paralysis on one side of the body) following cerebral infarct (stroke), hypomagnesemia (low magnesium level) and obstructive sleep apnea (difficulty breathing or loss of breath when asleep). The MDS assessment included a Brief Interview Mental Status (BIMS) score of 14 out of 15 (indicative of a mild cognitive impairment) and assessed the resident was dependent on staff for toileting hygiene, dressing and transfers, and required maximum assistance for personal hygiene. The Care Plan for Resident #15, last revised 8/25/25, revealed the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to provide sufficient activities for 3 of 3 residents reviewed for activities (Residents #5, #6, and#18). The facility reported a census of 19 residents. Findings include: 1. The annual Minimum Data Set (MDS) assessment tool, dated 5/13/25, listed diagnoses for Resident #5 which included heart failure, anxiety, and depression. The MDS stated the following activities were very important to the resident: books, newspapers, being around animals, news, group activities, favorite activities, going outside for fresh air, and religious practices. The MDS listed the resident’s Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Long Term Care (LTC) Resident Activities, effective 1/2025, stated the facility would provide an on-going person centered activity program. An 8/15/25 Care Plan entry stated the resident would continue to attend activities twice per day. On 8/25/25 at 11:40 a.m., Resident #5 stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2025-08-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to adequately assess areas of skin impairment for 1 of 3 residents reviewed for skin concerns (Resident #4) and failed to document care planning and collaboration and communication with Hospice services for 1 of 1 residents reviewed receiving end-of-life care (Resident #2). The facility reported a census of 19 residents.Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 7/1125, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident was at risk for developing pressure ulcers and listed Brief Interview for Mental Status (BIMS) score 9 out of 15, indicating moderately impaired cognition. The untitled facility policy, dated 2025, stated residents were reassessed on a quarterly basis or sooner if their physical status changed. a. A 3/21/25 Health Status Note stated (staff) removed the resident’s sock and found a bandage over a 0.5 centimeter x 0.5 cm area with erythema(redness) which measured 10 cm x 9…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, policy review, and staff interview, the facility failed to wear appropriate personal protective equipment (PPE) during personal cares for 2 of 2 residents (Residents #1 and#13) reviewed on Enhanced Barrier Precautions (EPB) and failed to clearly identify/carry out the correct level of infection control precautions for 1 of 1 residents reviewed for Transmission Based Precautions (Resident #3). The facility reported a census of 19 residents. Findings include:1. The Minimum Data Set (MDS) assessment tool, dated 7/15/25, listed diagnoses for Resident #13 which included arthritis, heart failure, and hypertension. The MDS stated the resident had 1 unstageable pressure ulcer and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The undated facility policy Enhanced Barrier Precautions, directed staff to carry out enhanced barrier precautions during high contact resident care activities such as wound care and catheter care. The policy directed staff to wear a gown and gloves. An 8/19/25 Health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #2). The facility reported a census of 19 residents. Findings include:On 8/28/2025 at 8:52 AM, the Director of Nursing (DON) reported that it was the responsibility of the Infection Preventionist to ensure the residents got their immunizations.On 8/28/2025 at 8:54 AM, the Infection Preventionist (IP) reported she had worked in her role at the facility for 11 years. The IP reported the facility followed CDC guidelines when offering immunizations to residents. The IP reported the DON and nursing staff were responsible for ensuring residents were offered and received immunizations. Review of CDC guidelines, dated 10/2024, revealed the following recommendations:Administer Prevnar 20 (PVC20), Prevnar 21 (PVC21), or Vaxneuvance (PVC15) for all adults 50 years or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, policy review, and staff interview the facility failed to follow infection control measures to prevent cross contamination during food service for 1 of 2 meals observed. The facility reported a census of 18 residents. Finding include: Observation of the noon meal service on 5/13/2024 at 11:50 AM revealed the following concerns: A. Staff D (Cook), did not wear gloves and handled buns with bare hands which she then served to residents. B. Staff D sneezed on her right arm while she held a plate of food in her left hand. She did not wash her hands then served the plate to a resident. A review of the facility provided policy titled Hand Hygiene revised on January, 2017 documented the following procedure: hands shall be washed before handling food, after sneezing, coughing, or blowing the nose. On 5/16/2024 at 10:27 AM, the Director of Food and Nutritional Services stated in the above situation staff should discard the food, wash their hands, and prepare a new plate of food for the resident.
- Potential for harm · D2024-05-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to maintain accurate advance directive records for 2 of 16 residents reviewed (Residents #8 and #9). The facility reported census of 18. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had diagnoses of Coronary Artery Disease, Hemiplegia, and Cerebrovascular Accident (CVA). The MDS documented the resident scored 13 on a Brief Interview for Mental Status (BIMS) exam, which is indicated cognitively intact. Record review, on [DATE] at 02:15 PM, revealed the resident's chart did not contain the Iowa Physician's Orders for Scope of Treatment (IPOST). During an interview on [DATE] at 12:32 PM The DON looked in the chart unable to find the IPOST. The DON stated they would try to locate it. During an interview on [DATE] at 12:20 PM The DON stated she obtained a new IPOST. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 entered the facility on [DATE] and was admitted to Hospice Care on [DATE]. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, policy review, and staff interview, the facility failed to utilize a gait belt in order to ensure a safe transfer for 1 of 6 transfers observed (Resident #1). The facility reported a census of 18 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 3/16/24, listed diagnoses for Resident #1 which included a history of falling, anxiety disorder, and diabetes. The MDS stated the resident required substantial/maximal assistance for toilet transfers and listed the Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. An 8/4/23 Post Fall Huddle Form/Variance stated staff heard the resident yell and found her sitting the floor next to her bed. 12/6/23 Health Status Notes stated staff heard the resident yelling and found her prone (on her stomach) on the floor near the bed. The resident bled from a laceration (cut) on the left forehead, transferred to the ER, and received 4 stitches. A 12/6/23 Post Fall Huddle Form/Variance stated staff heard the resident yelling and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IA
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 16E728. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.