Inspection Reports for
Community Memorial Health Center

The facility was found to have multiple deficiencies including failure to accommodate resident bathing preferences, failure to refer a resident for PASRR Level II evaluation, improper catheter care leading to potential UTI risk, inaccurate transcription of psychotropic medication orders, and failure to use Enhanced Barrier Precautions during catheter care.

The facility failed to ensure residents' rights to self-determine their dressing and waking times for 5 residents with dementia. Staff routinely dressed residents early in the morning without their consent, despite severe cognitive impairments and care plans emphasizing resident choice. The Administrator and Director of Nursing acknowledged the issue and indicated a policy to start getting residents up at 6 a.m. unless otherwise requested.

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.

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.

The complaint investigation was substantiated as the facility failed to report the abuse allegation timely and failed to document the incident in the resident's records. Staff A was involved in the abuse and was sent home immediately. The Director of Nursing was expected to have submitted the report but did not do so within the required timeframe.

The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 2 hours as required and failed to document the incident in Resident #1's medical records. Staff A was found to have roughly handled Resident #1 during supper, which was witnessed and reported by Staff B. Staff A was sent home immediately after the incident.

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.

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.

The facility failed to ensure that bed hold notices were signed by residents or their representatives for 2 of 2 residents reviewed, despite verbal confirmations being obtained. The facility policy allowed verbal confirmation without obtaining signatures.

Facility reported incident #123365-I was investigated and found not substantiated.

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.

The complaint investigation was triggered by an allegation that Staff F, a CNA, slapped Resident #1 on the upper left leg during incontinence care on 4/3/24. The facility failed to report the allegation to the Iowa Department of Inspections & Appeals and Licensing within 2 hours and allowed the CNA to continue working the rest of her shift. The facility investigation was inconclusive about the incident occurrence. Immediate Jeopardy was identified due to failure to separate the alleged abuser from residents during the investigation. The Immediate Jeopardy was removed after the facility suspended the CNA and provided staff education.

The facility failed to protect Resident #1 from physical abuse when a CNA slapped the resident during care. The facility also failed to timely report the abuse allegation to the Iowa Department of Inspections & Appeals and Licensing within 2 hours, failed to separate the alleged abuser from residents during the investigation, and failed to document the incident in the resident's medical record. The facility's Infection Preventionist also failed to attend quarterly Quality Assurance meetings.

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.

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.

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.

The facility failed to incorporate specialized services from PASRR Level II into resident care plans, failed to update care plans to reflect current resident conditions and medication usage, failed to ensure personal alarms functioned properly to prevent falls, and failed to update the facility-wide assessment for 2023.

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.

Complaint #110827-C was substantiated; complaints #108867-C, #112504-C, and #113295-C were not substantiated. Facility reported incident #112434-I was substantiated.

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.

The investigation was complaint-related, focusing on the fall of Resident #1. The complaint was substantiated as the facility failed to assess the resident properly after the fall, leading to actual harm (hip fracture).

The facility failed to complete a thorough assessment including range of motion and neurologic checks after the resident's unwitnessed fall, resulting in delayed identification of a right femoral neck fracture. Staff failed to follow fall response protocols, and the responsible nurse was terminated for lack of assessment and falsification of documentation.

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.

Self report #101435-I and complaint #106345-C were both substantiated.

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.

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.

The visit was complaint-related due to Incident #96021-I, which was substantiated following investigation from 2/23/21 to 3/1/21.

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.