Inspection Reports for Anamosa Care Center
1209 East Third Street, IA, 522051503
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 26, 2025 found the facility in substantial compliance with no deficiencies cited. Earlier inspections identified deficiencies related to resident dignity and timely nursing assistance, quality of care including injury assessment and staff performance reviews, and administrative issues such as background checks and accurate reporting. Complaint investigations were generally unsubstantiated, with the facility found in substantial compliance in all recent complaint-related inspections. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history shows some recurring themes around resident care and staffing, but recent findings suggest improvement in addressing prior deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
55 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 26, 2025
Visit Reason
A complaint investigation for facility reported incident #2588231-I was conducted on August 25, 2025 to August 26, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to incident #2588231-I and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 7, 2025
Visit Reason
The document is a Plan of Correction submitted by the facility following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification in compliance effective June 30, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with no specific deficiencies detailed in this document.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 2
Jun 12, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 9, 2025 to June 12, 2025.
Findings
The facility was found deficient in treating residents with dignity and respect, specifically failing to assist Resident #47 to the restroom and instead directing staff to leave the resident incontinent in bed. Additionally, the facility failed to provide sufficient nursing staff assistance in a timely manner for two residents reviewed, including delayed response to call lights.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to treat 1 out of 1 resident reviewed with dignity by telling them to be incontinent in bed after they asked to use the restroom (Resident #47). | SS=D |
| Facility failed to provide sufficient nursing staff assistance in a timely manner for 2 out of 2 residents reviewed (Residents #32 and #47). | SS=D |
Report Facts
Census: 55
Deficiencies cited: 2
Call light response time: 15
Resident Brief Interview for Mental Status (BIMS) score: 5
Resident BIMS score: 2
Minutes delay: 35
Minutes delay: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nurses Aide (CNA) | Directed Resident #47 to be incontinent in bed and failed to complete required competency training |
| Director of Nursing | Reported expectation for staff to take residents to bathroom before bed and confirmed call light response expectations | |
| Staff B | Certified Nurses Aide (CNA) | Reported normal bedtime routine and call light response times |
| Staff D | Certified Nurses Aide (CNA) | Reported call light procedures and resident toileting care |
| Staff E | Certified Nurses Aide (CNA) | Reported on resident toileting care and call light response |
| Staff F | Certified Nurses Aide (CNA) | Helped Resident #32 after 21 minutes delay |
| Assistant Director of Nursing | ADON | Reported completion of CNA competency training and call light response expectations |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 1, 2025
Visit Reason
The investigation of facility reported incident #127868-M was conducted from April 21, 2025 to May 1, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey. The results of incident #127868-M will be sent at a later date under a different cover letter.
Complaint Details
Investigation of facility reported incident #127868-M; facility found in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 1, 2024
Visit Reason
A revisit of the survey ending July 25, 2024 and investigation of complaint #122634-C was conducted from August 31, 2024 to September 1, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective August 6, 2024. Complaint #122634-C was not substantiated.
Complaint Details
Complaint #122634-C was not substantiated.
Report Facts
Complaint number: 122634
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 4
Jul 25, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #121264-C and facility reported incident #120752-I from July 22 to July 25, 2024.
Findings
The facility was found deficient in quality of care related to failure to assess a resident after a hot liquid spill causing a second degree burn, failure to complete annual performance reviews for nurse aides, failure to maintain sanitary food service conditions, and failure to maintain an effective pest control program.
Complaint Details
The visit included investigation of complaint #121264-C and facility reported incident #120752-I regarding failure to assess a resident after a hot liquid spill causing injury.
Severity Breakdown
SS=G: 1
SS=E: 2
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to assess Resident #14 after spilling hot thickened coffee resulting in a second degree burn. | SS=G |
| Failure to complete annual performance reviews for 5 of 5 nurse aides reviewed. | SS=E |
| Failure to maintain sanitary conditions when staff used bare hand to clean top of pepper shaker before use. | SS=D |
| Failure to maintain an effective pest control program as evidenced by presence of flies in the kitchen and dining areas. | SS=E |
Report Facts
Resident census: 60
Burn measurement: 12.7
Burn measurement: 7.6
Blister measurement: 2.4
Blister measurement: 1.2
Burn measurement: 3.1
Number of nurse aides reviewed: 5
Mental Status Score: 4
Mental Status Score: 13
Resident count at observed food safety incident: 1
Date of plan of correction completion: Aug 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse (LPN) | Reported being nurse on duty during hot coffee spill incident |
| Staff I | Certified Nurse Aide (CNA) | Reported sitting with resident at time of hot coffee spill incident |
| Staff F | Certified Nurse Aide (CNA) | Had missing annual performance reviews |
| Staff B | Certified Nurse Aide (CNA) | Had missing annual performance reviews |
| Staff C | Certified Nurse Aide (CNA) | Had missing annual performance reviews |
| Staff D | Certified Nurse Aide (CNA) | Had missing annual performance reviews |
| Staff E | Certified Nurse Aide (CNA) | Had missing annual performance reviews |
| Director of Nursing | Director of Nursing (DON) | Reported annual reviews should be done yearly for CNAs |
| Administrator | Administrator | Reported annual evaluations have not been consistently done |
| Staff A | Dietary | Observed using bare hand to clean pepper shaker |
| Staff J | Cook | Interviewed regarding condiment container cleaning and fly problem |
| Staff K | Dietary | Reported coffee and hot chocolate not being tempered prior to incident |
| Staff L | Licensed Practical Nurse (LPN) | Observed attempting to get flies away from resident |
| Staff M | Maintenance | Reported pest control spraying schedule and awareness |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 16, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance, certifying the facility in compliance effective March 22, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Mar 21, 2024
Visit Reason
The inspection was conducted following investigations of two facility reported incidents (#118609-I and #117992-M) between March 11, 2024 and March 21, 2024.
Findings
The facility was found not in compliance with federal regulations related to abuse/neglect policies, specifically failing to process a complete background check for one staff member. Incident #118609-I was not substantiated. The facility must develop and implement policies to prevent abuse, neglect, and exploitation, and ensure proper background checks are completed.
Complaint Details
Facility reported incident #118609-I was not substantiated. Findings for facility reported incident #117992-M will be sent separately.
Deficiencies (1)
| Description |
|---|
| Failure to process a complete background check as required by the state of Iowa for 1 out of 1 record reviewed (Staff A, Certified Nurse Aide). |
Report Facts
Census: 59
Date of background check: Mar 18, 2023
Date research completed: Mar 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in deficiency for incomplete background check |
| Glen Shultz | Administrator | Signed the report and provided explanation regarding background checks |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 29, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective June 29, 2023.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 2
Jun 15, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included investigation of Complaint #113429-C, which was not substantiated.
Findings
The facility failed to accurately code anticoagulant use on the Minimum Data Set (MDS) assessments for three residents, and failed to report a major injury after a resident incurred a fracture. The complaint was not substantiated. Deficiencies were identified related to accuracy of assessments and additional notification requirements.
Complaint Details
Complaint #113429-C was investigated during the survey and was not substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to accurately code anticoagulant use on the Minimum Data Set (MDS) assessments for three residents. | SS=D |
| The facility failed to report a major injury after a resident incurred a fracture. | SS=D |
Report Facts
Residents reviewed for MDS accuracy: 3
Facility census: 54
Resident reviewed for injury reporting deficiency: 1
Date of correction: Jun 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #13's fall and mobility |
| Director of Nursing | Interviewed regarding Resident #13's fall and injury | |
| MDS Coordinator | Acknowledged coding practices for anticoagulant medications | |
| Administrator | Interviewed about Resident #13's fall and injury reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 27, 2023
Visit Reason
A complaint investigation was conducted for multiple complaints and facility self-reported incidents from April 24, 2023 to April 27, 2023.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation covered Complaints #104922-C, #105397-C, #109164-C, #109207-C, #109620-C and Facility Self-Reported Incidents #102000-I and #104932-I. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Jan 6, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and Complaint Investigation of complaints #97922 and #101277 completed from 1/3-6/2022. Both complaints were found to be unsubstantiated.
Findings
The facility failed to ensure a staff member certified in CPR was present during the entire overnight shift on 12/08/21, and failed to ensure residents did not receive foods to which they had allergies, intolerances, or preferences. The facility reported a census of 55 residents during the inspection.
Complaint Details
The complaints investigated (#97922 and #101277) were unsubstantiated as stated in the report.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a staff member certified in Cardiopulmonary Resuscitation (CPR) was present for the complete evening/overnight shift on 12/08/21. |
| Failure to ensure residents did not receive foods they had allergies to, as evidenced by one resident not receiving appropriate food accommodations. |
Report Facts
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Worked the 'P' shift on 12/08/21 and was certified in CPR. |
| Staff B | Registered Nurse (RN) | Listed as CPR certified staff; was not observed on schedule between 10:00 PM and 6:00 AM on 12/08/21. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding CPR certification and staffing. |
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 0
Nov 18, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 53
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 8, 2020
Visit Reason
The inspection was conducted to investigate Complaints #88847 and #92381 during the period 9/2-9/8/2020.
Findings
Both complaints were investigated and found to be not substantiated.
Complaint Details
Complaints #88847 and #92381 were investigated and both were not substantiated.
Report Facts
Complaint numbers: 2
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/15/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 7, 2020
Visit Reason
The inspection was conducted to investigate complaints #87572-C and #87663-C.
Findings
The complaints investigated were not substantiated according to the report.
Complaint Details
Complaints #87572-C and #87663-C were investigated and found not substantiated.
Report Facts
Complaint numbers: 2
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