Inspection Reports for
Chautauqua Guest Home #3 (9th St.)
302 Ninth Street, Charles City, IA, 506163697
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
74% occupied
Based on a July 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 30, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, indicating acceptance of a credible allegation of substantial compliance and certification effective July 25, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification in compliance with health requirements effective July 25, 2025.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Jul 3, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to the treatment of residents with dignity and respect, specifically concerning Resident #13.
Complaint Details
The complaint investigation focused on Resident #13's treatment during meals. Staff A pulled a spoon from Resident #13's hand without verbal explanation. Staff and the administrator acknowledged this was inappropriate. Staff training records showed mandatory abuse reporter training completion.
Findings
The facility failed to ensure residents are treated with dignity and respect for Resident #13. Staff forcibly pulled a spoon from Resident #13's hand without explanation, which was acknowledged as inappropriate by staff and the administrator.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Staff forcibly pulled a spoon from Resident #13's hand without explanation, violating dignity and respect.
Report Facts
Residents Affected: 1
Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant / Certified Medication Aide | Acknowledged pulling spoon from Resident #13's hand without explanation |
| Staff B | Certified Nursing Assistant | Witnessed Staff A pulling spoon from Resident #13's hand and reported it should not have happened |
| Administrator | Registered Nurse / Bachelor of Science in Nursing | Acknowledged Resident #13 as a slow eater and that staff should not pull silverware away |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey with an investigation of complaint #128237-C from July 1 to July 3, 2025.
Complaint Details
Investigation of Complaint #128237-C did not result in a deficiency.
Findings
The facility was found not in compliance with resident rights requirements, specifically failing to ensure residents were treated with dignity and respect, as evidenced by staff forcibly pulling a spoon from Resident #13's hand during a meal. The complaint investigation did not result in a deficiency.
Deficiencies (1)
Failure to ensure residents are treated with dignity and respect, including forcibly pulling a spoon from Resident #13's hand during a meal.
Report Facts
Total census: 42
Resident #13's Brief Interview for Mental Status (BIMS) score: 99
Resident #13's July 2025 Documentation Survey Report: 0.25
Staff A Dependent Adult Abuse Mandatory Reporter Training completion date: Mar 1, 2024
Staff B Dependent Adult Abuse Mandatory Reporter Training completion date: Jan 24, 2023
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The document is a Plan of Correction submitted following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance with health requirements, leading to certification effective March 25, 2025. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's right to dignity and respect during personal care.
Complaint Details
Based on clinical record review, staff interview, and observation, the complaint regarding dignity and respect for Resident #3 was substantiated.
Findings
The facility staff failed to treat one resident with dignity and respect while providing personal care, as evidenced by improper positioning of the resident's clothing and undergarments. Staff acknowledged the issue and apologized during the observation.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Staff improperly positioned a resident's clothing and undergarments during personal care, compromising dignity.
Report Facts
Residents Affected: 1
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Mar 7, 2025
Visit Reason
The inspection was conducted due to a complaint (#126743) investigation from March 7, 2025 through March 13, 2025. The complaint was not substantiated.
Complaint Details
Complaint #126743 was investigated and found not substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 related to Resident Rights/Exercise of Rights. Staff failed to treat one resident with dignity and respect during personal care, specifically regarding appropriate clothing and positioning.
Deficiencies (1)
Failure to treat one resident with dignity and respect while providing personal cares, including inappropriate handling of clothing and positioning.
Report Facts
Total census: 44
Brief Interview for Mental Status (BIMS) score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed providing personal care to Resident #3 |
| Staff B | Certified Nursing Assistant (CNA) | Observed providing personal care to Resident #3 |
| Staff C | Registered Nurse (RN) | Observed providing personal care to Resident #3 and confirmed dignity issue |
| Director of Nursing | Responsible for periodic audits of staff knowledge regarding Resident Rights | |
| CQI Nurse | Responsible for periodic audits of staff knowledge regarding Resident Rights |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
Investigation of complaints #125135 and #125183 conducted from December 9, 2024 to December 10, 2024.
Complaint Details
Complaints #125135 and #125183 were investigated and found not substantiated.
Findings
The Chautauqua Guest Home #3 Nursing Home was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaints #125135 and #125183 were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
A complaint investigation for Complaint #123859-C was conducted on November 14, 2024.
Complaint Details
Complaint #123859-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as an annual health recertification survey for compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Chautauqua Guest Home #3 was found to be in compliance with the applicable federal requirements during the annual survey conducted from August 12 to August 15, 2024.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
Annual inspection survey conducted for regulatory compliance of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The inspection was conducted following an investigation for complaint #119457 from April 16, 2024 to April 18, 2024.
Complaint Details
Investigation was related to complaint #119457; the facility was found in substantial compliance.
Findings
The Chautauqua Guest House #3 Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective January 31, 2024, based on the acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 2
Date: Jan 18, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from January 16, 2024 to January 18, 2024.
Findings
The facility was found to be in substantial compliance overall, but deficiencies were identified related to failure to complete significant change Minimum Data Set (MDS) assessments within 14 days for two residents receiving hospice care, and failure to follow proper food safety and hand hygiene practices during meal service and food delivery.
Deficiencies (2)
Failure to complete significant change MDS assessments within 14 days for 2 residents receiving hospice care.
Failure to practice proper hand hygiene and cover food during meal service and food delivery for 5 residents.
Report Facts
Census: 39
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook | Observed failing to follow proper hand hygiene and food safety practices during meal service | |
| Director of Nursing (DON) | Expressed expectation for timely completion of MDS assessments | |
| MDS Coordinator | Interviewed regarding MDS assessment completion and hospice admission procedures | |
| Dietary Manager | Interviewed regarding expectations for glove changes and infection control |
Inspection Report
Routine
Census: 39
Deficiencies: 2
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and food handling practices at the facility.
Findings
The facility failed to complete significant change Minimum Data Set (MDS) assessments within 14 days for residents admitted to hospice care and failed to follow proper food handling and hygiene practices during meal service.
Deficiencies (2)
F0637: The facility failed to complete a significant change MDS assessment within 14 days of hospice admission for 2 of 2 residents reviewed.
F0812: The facility failed to cover food items during room tray delivery and did not practice proper hand hygiene during meal service for 5 residents observed.
Report Facts
Census: 39
Residents affected: 2
Residents affected: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was certified in compliance effective October 6, 2023, based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident rights violations, infection control issues, and improper care practices at the facility.
Complaint Details
The complaint investigation substantiated that staff disrespected Resident #1 by yelling and forcibly taking her to her room, used a dirty commode for Resident #2, and failed to maintain cleanliness and dignity for Resident #10. Infection control lapses were also confirmed with unsanitized commodes and Foley catheter bags contacting the floor.
Findings
The facility failed to respect resident rights by staff yelling at and forcibly taking a resident to their room, used a dirty commode for toileting a resident, and allowed a resident to lie on a dirty mattress without repeating peri-care. Additionally, infection control lapses were noted with unsanitized commodes and Foley catheter bags contacting the floor, increasing infection risk.
Deficiencies (2)
F 0550: The facility failed to honor residents' rights to dignity and respect, including staff yelling at Resident #1 and taking her to her room against her wishes. Staff used a dirty commode for Resident #2 and did not repeat peri-care after Resident #10 laid on a dirty mattress.
F 0880: The facility failed to implement an effective infection prevention program by not sanitizing commodes after each use and allowing Foley catheter bags to rest on the floor, risking urinary tract infections for Residents #2 and #6.
Report Facts
Residents Affected: 3
Census: 39
Residents Sampled for Infection Control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in findings for yelling at Resident #1 and forcibly taking her to her room |
| Staff F | Licensed Practical Nurse (LPN) | Intervened during incident involving Resident #1 and Staff G |
| Staff A | Certified Nursing Assistant (CNA) | Observed pushing dirty commode for Resident #2 and handling Foley catheter bag |
| Staff B | Certified Nursing Assistant (CNA) | Reported commodes must be cleaned after each use |
| Staff D | Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Reported expectations for commode cleaning and catheter bag care |
| Director of Nursing | Director of Nursing (DON) | Reported policy on catheter bag care and commode cleaning |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey combined with investigations of complaints #111814-C, #113546-C, and #113568-C conducted from September 18 to September 21, 2023.
Complaint Details
Complaints #111814-C, #113546-C, and #113568-C were substantiated based on observations, clinical record reviews, policy reviews, and staff/resident interviews indicating violations of resident rights and infection control standards.
Findings
The facility was found to be in substantial compliance overall, but deficiencies were identified related to resident rights violations including staff yelling at residents and failure to use clean commodes, as well as infection control issues such as failure to sanitize commodes and prevent cross contamination. Staff were reeducated and corrective actions were planned and implemented.
Deficiencies (2)
Staff failed to treat Resident #1 with respect and dignity by yelling at the resident and taking her to her room against her wishes; failure to use a clean commode for Resident #2; failure to repeat peri-care after Resident #10 was laid on a dirty mattress.
Failure to establish and maintain an infection prevention and control program including failure to sanitize commodes after each use and prevent cross contamination when Resident #6's Foley catheter bag contacted the floor.
Report Facts
Total Residents: 39
BIMS score: 14
BIMS score: 15
BIMS score: 15
Incident date: 52523
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Involved in incident with Resident #1 and documented statements regarding the incident |
| Staff G | Certified Nursing Assistant (CNA) | Involved in incident with Resident #1, yelled at resident, suspended pending investigation |
| Director of Nursing | Director of Nursing | Performed periodic observations and reeducation of staff regarding resident rights and infection control |
| Administrator | Administrator | Reported Staff G was disrespectful toward Resident #1 and expected staff to follow resident rights |
| Staff A | Certified Nursing Assistant (CNA) | Observed and reported on commode cleaning and resident care |
| Staff B | Certified Nursing Assistant (CNA) | Observed and reported on commode cleaning and resident care |
| Staff C | Certified Nursing Assistant (CNA) | Reported on commode cleaning and resident dignity |
| Staff D | Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Reported expectations for commode disinfection and cleaning schedules |
| Staff H | Certified Nursing Assistant (CNA) | Observed verbal exchanges between Resident #1 and staff |
| Staff J | Certified Nursing Assistant (CNA) | Reported Resident #1's comments about Staff G |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident rights violations, dignity issues, and infection control concerns at the facility.
Complaint Details
The investigation was complaint-driven, focusing on allegations of staff disrespect and improper care practices. The complaint was substantiated with findings of staff yelling, improper use of dirty commodes, and infection control lapses.
Findings
The facility failed to respect resident rights by staff yelling at and forcibly taking a resident to their room, using a dirty commode for toileting, and failing to repeat peri-care after a resident laid on a dirty mattress. Additionally, infection control lapses were noted with unsanitized commodes and Foley catheter bags contacting the floor, increasing infection risk.
Deficiencies (2)
F 0550: The facility failed to honor residents' rights to dignity and respect by staff yelling at Resident #1, forcibly taking her to her room against her wishes, using a dirty commode for Resident #2, and not repeating peri-care after Resident #10 laid on a dirty mattress.
F 0880: The facility failed to implement an effective infection prevention program by not sanitizing commodes after each use and allowing Foley catheter bags to rest on the floor, increasing risk of urinary tract infections for Residents #2 and #6.
Report Facts
Residents affected: 3
Residents affected: 2
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in findings for yelling at Resident #1 and forcibly taking her to her room |
| Staff F | Licensed Practical Nurse (LPN) | Intervened during incident involving Resident #1 and Staff G |
| Staff A | Certified Nursing Assistant (CNA) | Observed pushing dirty commode for Resident #2 and Foley catheter care for Resident #6 |
| Staff B | Certified Nursing Assistant (CNA) | Reported commodes must be cleaned after each use |
| Staff D | Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Reported expectations for commode cleaning and catheter bag care |
| Director of Nursing | Director of Nursing (DON) | Reported policy on catheter bag care and commode cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
A complaint investigation was conducted for complaints #108397-C, #108463-C, and #108466-C on October 24 to October 25, 2022.
Complaint Details
Complaint investigation for complaints #108397-C, #108463-C, and #108466-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective July 29, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
The inspection visit was conducted as part of the facility's annual recertification survey and investigation of complaint #99665-C from July 25, 2022 to July 28, 2022.
Complaint Details
Complaint #99665-C was investigated and found to be not substantiated.
Findings
The facility was found to be in substantial compliance with all deficiencies as of July 29, 2022. One deficiency was cited for failure to properly dispose of garbage and refuse, specifically for uncovered trash cans that were heaping full during multiple observations.
Deficiencies (1)
Facility failed to cover garbage cans with tight fitting lids when not in use; trash cans were heaping full and uncovered during multiple observations.
Report Facts
Census: 39
Dates of inspection: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding trash can policy and observations of uncovered trash cans |
Inspection Report
Renewal
Census: 42
Deficiencies: 0
Date: Mar 22, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification and State Licensure survey of the facility.
Findings
The facility was found to be in compliance with Medicare Conditions of Participation and Iowa Administrative Code requirements.
Inspection Report
Routine
Census: 46
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from November 22 - 24, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Date: Sep 28, 2020
Visit Reason
The inspection was conducted as an investigation of Complaints #87669-C and #92831-C, which ended on 09/28/2020. Both complaints were substantiated, and a COVID-19 Focused Infection Control Survey was conducted in conjunction with the complaint investigation.
Complaint Details
Complaint #87669-C was substantiated. Complaint #92831-C was substantiated.
Findings
The facility was found to be in non-compliance with CMS and CDC recommended practices for COVID-19 infection control. Deficiencies included failure to ensure resident environment was free of accident hazards, inadequate supervision and assistance devices to prevent accidents, improper use of a gait belt during resident transfer, and failure to follow proper infection prevention and control procedures including PPE use.
Deficiencies (2)
The facility failed to follow the plan of care for a resident who sustained a fall while in a Lumex lift, including inadequate supervision and assistance devices to prevent accidents.
The facility failed to use proper Personal Protective Equipment (PPE) for infection control to mitigate transmission of COVID-19 virus with one resident.
Report Facts
Total residents: 46
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Failed to apply gait belt properly and did transfer with one assist instead of two |
| Staff B | Certified Nursing Assistant (CNA) | Observed in resident room without mask covering mouth |
| Staff C | Certified Nursing Assistant (CNA) | Observed in resident room with face mask below nose |
| Staff D | Certified Nursing Assistant (CNA) | Observed in resident room with face mask below chin |
| Staff E | Certified Nursing Assistant (CNA) | Observed in resident room with no face mask or face covering |
| Administrator | Confirmed and verified staff are expected to follow facility protocol for wearing PPE | |
| Director of Nursing | Involved in infection control education and audits | |
| Assistant Administrator | Involved in infection control education and audits | |
| CEO/President | Involved in infection control education and audits |
Inspection Report
Routine
Census: 48
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from June 15-16, 2020 to assess 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.
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