Inspection Reports for Community Memorial Health Center
231 North Eighth Avenue West, IA, 513460188
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 22, 2025, did not identify any deficiencies, reflecting certification of compliance. Earlier inspections showed a pattern of deficiencies related primarily to resident rights, abuse reporting, care planning, and timely interventions following incidents such as falls and abuse. Complaint investigations substantiated issues including failure to protect residents from abuse, inadequate supervision, and failure to ensure residents’ rights to self-determination regarding waking and dressing times. Enforcement actions such as staff suspension and retraining were noted, but fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent plans of correction accepted and no deficiencies cited in the latest survey.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
45 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 22, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective November 28, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 1, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction, the facility will be certified in compliance effective October 9, 2025.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Nov 25, 2025
Visit Reason
Investigation of Complaint #2635744-C conducted from November 24, 2025 to November 25, 2025 regarding resident self-determination and rights.
Findings
The facility failed to ensure residents' rights to self-determination were met, specifically in allowing residents to choose when to get dressed and awake. Observations and record reviews showed residents were awakened and dressed before their preferred time.
Complaint Details
Investigation of Complaint #2635744-C completed November 24-25, 2025. The complaint was substantiated as the facility failed to ensure residents' rights to self-determination in timing of awakening and dressing.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents' right to self-determination regarding timing of awakening and dressing. | E |
Report Facts
Resident census: 45
Residents reviewed: 5
Date survey completed: Nov 25, 2025
Correction date: Nov 28, 2025
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Oct 7, 2025
Visit Reason
The inspection was conducted as a result of complaint #2632277-C and facility reported incidents #1735845-1 and #1735847-1 to investigate allegations of abuse and ensure compliance with reporting requirements.
Findings
The facility failed to report an allegation of abuse within the required two-hour timeframe and did not maintain accurate resident records reflecting the incident. The investigation found deficiencies in reporting suspected abuse and maintaining resident-identifiable information and medical records.
Complaint Details
Complaint #2632277-C was investigated with no deficiency cited related to the allegation. Facility reported incidents #1735845-1 and #1735847-1 were cited for deficiencies. The complaint was not substantiated but deficiencies were found related to failure to report abuse and maintain records.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse within two hours as required by regulation. | Level D |
| Failure to maintain accurate resident records reflecting incidents involving residents. | Level D |
Report Facts
Resident census: 46
Complaint number: 2632277
Incident numbers: 1735845
Incident numbers: 1735847
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 30, 2024
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 with health requirements effective November 30, 2024, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 1
Nov 7, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and to investigate facility reported incident #123365-I from November 4 to November 7, 2024.
Findings
The facility failed to ensure bed hold notices were properly provided and signed by residents or their representatives for residents transferred to hospital or on therapeutic leave. The facility did not meet the requirement for bed hold policy notification for 2 residents reviewed, despite verbal confirmations lacking signatures.
Complaint Details
Facility reported incident #123365-I was investigated and found not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written bed hold notice before transfer and upon transfer for residents, lacking resident or representative signatures. | SS=D |
Report Facts
Residents reviewed: 2
Census: 49
Brief Interview for Mental Status (BIMS) score: 12
Brief Interview for Mental Status (BIMS) score: 7
Dates of audits: 8
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don | Director of Nursing | Responsible for retraining staff and conducting audits on bed hold policy compliance |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 30, 2024
Visit Reason
A revisit of the survey ending July 8, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective July 27, 2024.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
Jul 8, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #118773-C and a facility reported incident #119936-M from June 30, 2024 to July 8, 2024. The complaint #118773-C was substantiated.
Findings
The facility failed to protect one resident from physical abuse by staff, including an incident where Staff F slapped Resident #1. The facility also failed to report the abuse allegations timely and conduct a thorough investigation. The facility retrained staff on abuse prevention, reporting, and investigation procedures and suspended the involved employee.
Complaint Details
Complaint #118773-C was substantiated. The investigation revealed that Staff F slapped Resident #1 during care, and the facility failed to report the abuse timely to the Director of Nursing and conduct a thorough investigation. The facility suspended Staff F on 6/30/24 and retrained staff on abuse prevention and reporting.
Severity Breakdown
SS-D: 2
SS-O: 1
SS-E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to protect 1 out of 3 residents from physical abuse by staff. | SS-D |
| Facility failed to report an allegation of abuse within required timeframes and failed to conduct a thorough investigation. | SS-D |
| Facility failed to maintain resident-identifiable information confidentiality. | SS-O |
| Facility failed to maintain a quality assessment and assurance program including infection preventionist attendance at quarterly meetings. | SS-E |
Report Facts
Resident census: 50
Dates of incident: Apr 3, 2024
Dates of retraining: 4
Date of employee suspension: Jun 30, 2024
Dates of audit schedule: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 19, 2024
Visit Reason
A recertification survey was completed from October 30, 2023 to November 2, 2023, followed by a Federal Monitoring Survey conducted from December 11 to December 16, 2023. The document serves as a statement of deficiencies and plan of correction related to these surveys.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective January 19, 2024.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 19, 2024
Visit Reason
The document reports on a recertification survey completed from October 30, 2023 to November 2, 2023, and a Federal Monitoring Survey conducted from December 11 to December 16, 2023, related to facility compliance and certification.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective January 19, 2024.
Inspection Report
Monitoring
Census: 56
Deficiencies: 11
Dec 16, 2023
Visit Reason
A Federal Monitoring Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on December 16, 2023, following an Iowa Department of Inspection and Appeals survey on November 2, 2023.
Findings
The survey identified multiple deficiencies related to resident rights, comprehensive care planning, activities of daily living, bedrails, medication errors, respiratory care, infection prevention and control, and immunizations. The facility failed to ensure dignified dining experiences, proper care plan implementation, medication administration, and infection control practices among others.
Severity Breakdown
SS=D: 8
SS=E: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and respect during dining, including improper use of clothing protectors and delayed meal service. | — |
| Failure to develop and implement comprehensive, person-centered care plans including bed rail use for residents. | SS=D |
| Failure to provide necessary care and services to maintain or improve residents' abilities in activities of daily living, including providing assistive devices such as curved built-up spoons. | SS=D |
| Failure to ensure residents receiving restorative/Range of Motion services maintained or improved mobility, with inadequate documentation and follow-through. | SS=D |
| Failure to provide respiratory care including proper maintenance of equipment and correct oxygen dosage per physician orders. | SS=D |
| Failure to ensure proper use, assessment, and documentation of bed rails for residents at risk of entrapment. | SS=D |
| Failure to maintain medication error rates below 5%, including crushing medications without proper orders and failure to follow physician orders. | SS=D |
| Failure to properly label and store drugs and biologicals, including expired medications. | SS=D |
| Failure to establish and maintain an effective infection prevention and control program, including failure to ensure hand hygiene and proper isolation procedures. | SS=E |
| Failure to ensure infection preventionist had completed specialized training and met educational qualifications. | SS=F |
| Failure to ensure residents received influenza and pneumococcal immunizations according to CDC guidelines. | SS=D |
Report Facts
Survey Census: 56
Residents involved in dignity deficiency: 4
Medication error rate: 32.14
Residents assessed for side rail use: 56
Audits frequency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Zeller | Administrator | Signed the report on 1/5/2024 |
| Director of Nursing | Interviewed regarding staff interaction with residents during meals and restorative therapy program oversight | |
| Licensed Practical Nurse LPN1 | Licensed Practical Nurse | Interviewed regarding CPAP mask cleaning and medication administration |
| Registered Nurse RN1 | Registered Nurse | Observed medication administration and interviewed regarding medication orders |
| Restorative Aide RA | Interviewed and observed providing restorative care and exercises | |
| Infection Preventionist Nurse | Infection Preventionist | Named in infection prevention and control deficiency and training |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 4
Oct 30, 2023
Visit Reason
The inspection was conducted as an annual recertification survey of the facility from October 30, 2023 to November 2, 2023.
Findings
The facility failed to meet several federal requirements including coordination of PASARR assessments, updating resident care plans accurately, ensuring personal alarms function properly, and conducting a facility-wide assessment. Deficiencies were noted in care planning, medication management, accident prevention, and facility assessment policies.
Deficiencies (4)
| Description |
|---|
| Failed to incorporate specialized services into resident care with Level II PASARR for 1 out of 2 residents. |
| Failed to update resident care plans accurately for 4 of 13 reviewed residents. |
| Failed to ensure personal alarm sounded when a resident arose from the chair for 1 out of 1 resident reviewed. |
| Failed to have a facility-wide assessment updated for 2023 and lacked a policy on facility assessment or revision. |
Report Facts
Census: 50
Residents reviewed: 13
Residents with deficient care plans: 4
Residents with PASARR deficiency: 1
Residents with personal alarm deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan deficiencies, PASARR coordination, and personal alarm issues. |
| Administrator | Administrator | Interviewed regarding facility assessment policy and update. |
| Staff D | Licensed Practical Nurse (LPN) | Reported details about the personal alarm malfunction and fall incident. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 3, 2023
Visit Reason
A revisit of the survey ending August 22, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective August 31, 2023.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Aug 31, 2023
Visit Reason
The inspection was conducted as a result of investigations into complaints #110827-C, #112504-C, #108867-C, #113295-C, and a facility reported incident #112434-I from 8/15/23 to 8/22/23.
Findings
The facility failed to provide adequate assessment and timely intervention for a resident who experienced an unwitnessed fall resulting in a right femoral neck fracture. Staff failed to complete range of motion assessments, neurologic checks, and follow-up assessments after the fall. Staff A, LPN was terminated due to failure to assess and falsification of documentation. The facility updated its Fall Prevention and Response Policy and retrained staff accordingly.
Complaint Details
Complaint #110827-C was substantiated; complaints #108867-C, #112504-C, and #113295-C were not substantiated. Facility reported incident #112434-I was substantiated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide adequate assessment and timely intervention for a resident after an unwitnessed fall, including failure to complete range of motion and neurologic checks. | G |
Report Facts
Complaint numbers investigated: 4
Facility reported incident: 1
Census: 44
Dates of investigation: From 8/15/23 to 8/22/23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in failure to assess resident after fall and falsification of documentation |
| Staff B | Certified Nursing Assistant (CNA) | Responded to floor alarm and found resident on floor |
| Staff C | Licensed Practical Nurse (LPN) | Responded to resident's pain, arranged transfer to hospital |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding fall response and staff expectations |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 21, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective October 21, 2022.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 1
Oct 21, 2022
Visit Reason
This inspection was a revisit following a prior survey ending August 2, 2022, to assess correction of deficiencies related to bowel/bladder incontinence care.
Findings
The facility failed to provide complete and appropriate incontinence care to prevent urinary tract infections for 2 of 3 residents observed, with staff failing to perform proper hand hygiene during care. Policies on handwashing and peri care were updated and staff retrained prior to the revisit.
Deficiencies (1)
| Description |
|---|
| Failure to provide complete and appropriate incontinence care to prevent urinary tract infections for residents #3 and #6, including failure of staff to perform hand hygiene before, during, and after care. |
Report Facts
Census: 57
Residents observed with deficient care: 2
Residents observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Failed to perform hand hygiene during incontinence care for Resident #6 |
| Staff B | Certified Nursing Assistant (CNA) | Failed to perform hand hygiene during incontinence care for Resident #3 |
| Staff C | Registered Nurse (RN) | Handled supplies after Staff B without intervening on hand hygiene |
| Director of Nursing | Provided expectations on hand hygiene and oversaw policy updates and audits |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 14
Jul 25, 2022
Visit Reason
A re-certification survey and investigation of self report #101435-I and complaint #106345-C were conducted from 7/25/22 to 8/2/22. The visit was complaint-related and included substantiation of both the self report and complaint.
Findings
The facility was found to have multiple deficiencies including failure to accurately reflect residents' advanced directive elections, failure to follow Medicare coverage requirements for skilled services, failure to conduct background checks prior to hiring, failure to properly coordinate PASARR assessments, inadequate comprehensive care plans, quality of care issues including failure to assess and intervene timely for changes in condition, failure to prevent accidents and falls, inadequate infection control, and failure to properly label oxygen tubing. Staff retraining and audits were planned or completed for many areas.
Complaint Details
Self report #101435-I and complaint #106345-C were both substantiated.
Deficiencies (14)
| Description |
|---|
| Failure to assure resident/representative's advanced directive elections were accurately reflected in the resident's record for 1 resident (Resident #7). |
| Failure to follow Medicare coverage requirements for skilled services for 2 of 3 residents reviewed (Residents #6 and #35). |
| Failure to obtain evaluation by Department of Criminal Investigation prior to hire for 1 of 5 current employees (Staff A). |
| Failure to refer 1 resident with negative Level I PASRR result for appropriate evaluation and determination (Resident #37). |
| Failure to revise and update care plans to include opioid medication usage and side effects and oxygen usage in 1 of 14 sampled residents (Resident #45). |
| Failure to provide adequate assessment and timely intervention for change in condition for 2 of 2 residents reviewed (Residents #104 and #3). |
| Failure to ensure resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents for 1 of 6 residents reviewed (Resident #104). |
| Failure to provide restorative therapy for 3 of 14 residents reviewed (Residents #3, #7, and #34). |
| Failure to provide adequate supervision and assistance devices to prevent accidents for Resident #104 who sustained injuries from a fall. |
| Failure to ensure resident with urinary incontinence receives appropriate catheterization and removal assessment (Resident #19). |
| Failure to label oxygen tubing for Resident #45 and failure to retrain staff on appropriate labeling. |
| Failure to assure psychotropic medication changes were implemented after dose reduction order for 1 of 5 residents reviewed (Resident #37). |
| Failure to ensure food safety requirements including proper storage and labeling of opened food items. |
| Failure to maintain infection prevention and control program including hand hygiene and isolation procedures. |
Report Facts
Census: 55
Residents reviewed: 14
Residents reviewed: 6
Residents reviewed: 3
Employees reviewed: 5
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 6
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 6
Residents reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Employee with incomplete background check prior to hire. |
| Staff G | Registered Nurse | Staff involved in care of resident #19 and retrained on peri care. |
| Staff H | Certified Nursing Assistant | Staff involved in care of resident #19 and retrained on peri care. |
| Director of Nursing | Director of Nursing | Named in multiple findings including advanced directive, care plans, audits, and retraining. |
| Staff F | Certified Nurse Assistant | Reported restorative therapy sessions and staffing problems. |
| Staff K | Certified Nursing Assistant | Reported on night resident fell and did not remember checking alarm. |
| Staff R | Certified Nursing Assistant | Reported on night resident fell and went to hospital. |
| Staff O | Registered Nurse | Former Director of Nursing, involved in fall incident. |
| Staff C | Licensed Practical Nurse | Removed soiled dressing and applied new dressing to resident wound. |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 8
Jul 29, 2021
Visit Reason
A recertification survey was completed from 7/26/21 to 7/29/21 to assess compliance with federal regulations following a prior inspection.
Findings
The facility failed to complete a required Significant Change in Status Assessment for one resident and failed to develop comprehensive care plans addressing specific medication usage and side effects for another resident. Additional deficiencies included improper insulin pen use, failure to maintain nutritional parameters, expired medications in medication carts, improper food temperature monitoring, and inadequate documentation for therapeutic diets and feeding assistance.
Deficiencies (8)
| Description |
|---|
| Failed to complete a required Significant Change in Status Assessment for Resident #31. |
| Failed to develop comprehensive care plans addressing antipsychotic, antianxiety, diuretic, and anticoagulation medication usage and side effects for Resident #5. |
| Failed to meet professional standards of quality in insulin pen preparation and administration for Resident #7. |
| Failed to maintain acceptable nutritional parameters for Resident #31, including weight loss and inadequate dietary interventions. |
| Expired medications found in medication carts; failure to properly store and check medication expiration dates. |
| Failed to properly monitor and record food temperatures during meal service. |
| Failed to have signed physician orders for therapeutic diets for Resident #25 and failed to properly document feeding assistance. |
| Failed to ensure food safety and proper labeling/storage of opened food packages. |
Report Facts
Census: 61
Residents reviewed for care plans: 16
Residents reviewed for insulin pen administration: 2
Residents reviewed for nutritional parameters: 1
Residents reviewed for therapeutic diet orders: 1
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Mar 1, 2021
Visit Reason
The inspection was conducted as a result of an investigation of Incident #96021-I, which was substantiated. The visit focused on ensuring resident safety and supervision to prevent elopement.
Findings
The facility failed to provide adequate supervision for Resident #1, who exited the facility unsupervised, resulting in immediate jeopardy to resident health and safety. The wanderguard device was found not working, and staff failed to properly respond to the door alarm. The facility reported a census of 67 residents at the time of inspection.
Complaint Details
The visit was complaint-related due to Incident #96021-I, which was substantiated following investigation from 2/23/21 to 3/1/21.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure each resident received adequate supervision to prevent elopement, as Resident #1 exited unsupervised and the facility failed to respond properly to an activated door alarm. | Immediate Jeopardy |
Report Facts
Census: 67
Residents identified with wanderguards: 10
Resident #1 BIMS score: 5
Date of Resident #1 MDS assessment: Dec 23, 2020
Date of Potential Elopement Assessment: Jan 10, 2020
Distance from nursing facility to assisted living: 100
Survey date: Mar 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Simons | Administrator | Signed the initial comments section of the report |
| Staff A | Certified Nursing Assistant (CNA) | Observed resident and escorted Resident #1 back to nursing home |
| Staff B | Certified Nursing Assistant (CNA) | Observed Staff A pushing Resident #1 and assisted resident into recliner |
| Staff C | Certified Nursing Assistant (CNA) | Last saw Resident #1 before elopement and assisted with wanderguard device |
| Staff D | Registered Nurse (RN) | Responded to door alarm and investigated wanderguard failure |
| Director of Nursing | Director of Nursing (DON) | Reviewed and updated wandering resident policy and wanderguard activation procedures |
| RN | Registered Nurse | Re-educated on door alarms and wanderguard procedures on 2/19/21 |
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Dec 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from December 21 - 23, 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.
Inspection Report
Abbreviated Survey
Census: 67
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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.
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