Inspection Reports for
Anamosa Care Center

1209 East Third Street, Anamosa, IA, 522051503

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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/year

Deficiencies per year

4 3 2 1 0
2020
2022
2023
2024
2025

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.

Occupancy over time

45 50 55 60 65 Jun 2020 Jan 2022 Mar 2024 Jun 2025

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Aug 26, 2025

Visit Reason
A complaint investigation for facility reported incident #2588231-I was conducted on August 25, 2025 to August 26, 2025.

Complaint Details
Investigation was related to incident #2588231-I and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: 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 Date: 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.

Deficiencies (2)
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).
Facility failed to provide sufficient nursing staff assistance in a timely manner for 2 out of 2 residents reviewed (Residents #32 and #47).
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
NameTitleContext
Staff CCertified Nurses Aide (CNA)Directed Resident #47 to be incontinent in bed and failed to complete required competency training
Director of NursingReported expectation for staff to take residents to bathroom before bed and confirmed call light response expectations
Staff BCertified Nurses Aide (CNA)Reported normal bedtime routine and call light response times
Staff DCertified Nurses Aide (CNA)Reported call light procedures and resident toileting care
Staff ECertified Nurses Aide (CNA)Reported on resident toileting care and call light response
Staff FCertified Nurses Aide (CNA)Helped Resident #32 after 21 minutes delay
Assistant Director of NursingADONReported completion of CNA competency training and call light response expectations

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: May 1, 2025

Visit Reason
The investigation of facility reported incident #127868-M was conducted from April 21, 2025 to May 1, 2025.

Complaint Details
Investigation of facility reported incident #127868-M; facility found in substantial compliance.
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.

Inspection Report

Re-Inspection
Deficiencies: 0 Date: 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.

Complaint Details
Complaint #122634-C was not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective August 6, 2024. Complaint #122634-C was not substantiated.

Report Facts
Complaint number: 122634

Inspection Report

Annual Inspection
Census: 60 Deficiencies: 4 Date: 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.

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.
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.

Deficiencies (4)
Failure to assess Resident #14 after spilling hot thickened coffee resulting in a second degree burn.
Failure to complete annual performance reviews for 5 of 5 nurse aides reviewed.
Failure to maintain sanitary conditions when staff used bare hand to clean top of pepper shaker before use.
Failure to maintain an effective pest control program as evidenced by presence of flies in the kitchen and dining areas.
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
NameTitleContext
Staff GLicensed Practical Nurse (LPN)Reported being nurse on duty during hot coffee spill incident
Staff ICertified Nurse Aide (CNA)Reported sitting with resident at time of hot coffee spill incident
Staff FCertified Nurse Aide (CNA)Had missing annual performance reviews
Staff BCertified Nurse Aide (CNA)Had missing annual performance reviews
Staff CCertified Nurse Aide (CNA)Had missing annual performance reviews
Staff DCertified Nurse Aide (CNA)Had missing annual performance reviews
Staff ECertified Nurse Aide (CNA)Had missing annual performance reviews
Director of NursingDirector of Nursing (DON)Reported annual reviews should be done yearly for CNAs
AdministratorAdministratorReported annual evaluations have not been consistently done
Staff ADietaryObserved using bare hand to clean pepper shaker
Staff JCookInterviewed regarding condiment container cleaning and fly problem
Staff KDietaryReported coffee and hot chocolate not being tempered prior to incident
Staff LLicensed Practical Nurse (LPN)Observed attempting to get flies away from resident
Staff MMaintenanceReported pest control spraying schedule and awareness

Inspection Report

Plan of Correction
Deficiencies: 0 Date: 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 Date: 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.

Complaint Details
Facility reported incident #118609-I was not substantiated. Findings for facility reported incident #117992-M will be sent separately.
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.

Deficiencies (1)
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
NameTitleContext
Staff ACertified Nurse AideNamed in deficiency for incomplete background check
Glen ShultzAdministratorSigned the report and provided explanation regarding background checks

Inspection Report

Plan of Correction
Deficiencies: 0 Date: 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 Date: 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.

Complaint Details
Complaint #113429-C was investigated during the survey and 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.

Deficiencies (2)
The facility failed to accurately code anticoagulant use on the Minimum Data Set (MDS) assessments for three residents.
The facility failed to report a major injury after a resident incurred a fracture.
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
NameTitleContext
Staff ACertified Nursing Assistant (CNA)Interviewed regarding Resident #13's fall and mobility
Director of NursingInterviewed regarding Resident #13's fall and injury
MDS CoordinatorAcknowledged coding practices for anticoagulant medications
AdministratorInterviewed about Resident #13's fall and injury reporting

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: 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.

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.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.

Inspection Report

Complaint Investigation
Census: 55 Deficiencies: 2 Date: 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.

Complaint Details
The complaints investigated (#97922 and #101277) were unsubstantiated as stated in the report.
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.

Deficiencies (2)
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
NameTitleContext
Staff ARegistered Nurse (RN)Worked the 'P' shift on 12/08/21 and was certified in CPR.
Staff BRegistered 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 NursingDirector of Nursing (DON)Interviewed regarding CPR certification and staffing.

Inspection Report

Abbreviated Survey
Census: 53 Deficiencies: 0 Date: 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 Date: Sep 8, 2020

Visit Reason
The inspection was conducted to investigate Complaints #88847 and #92381 during the period 9/2-9/8/2020.

Complaint Details
Complaints #88847 and #92381 were investigated and both were not substantiated.
Findings
Both complaints were investigated and found to be not substantiated.

Report Facts
Complaint numbers: 2

Inspection Report

Abbreviated Survey
Census: 56 Deficiencies: 0 Date: 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 Date: Jan 7, 2020

Visit Reason
The inspection was conducted to investigate complaints #87572-C and #87663-C.

Complaint Details
Complaints #87572-C and #87663-C were investigated and found not substantiated.
Findings
The complaints investigated were not substantiated according to the report.

Report Facts
Complaint numbers: 2

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