The most recent inspection on March 21, 2025, cited deficiencies related to professional standards of care, fall prevention, medication and respiratory supply storage, and the facility’s water management plan for Legionella risks. Earlier inspections showed a pattern of issues with medication administration, care planning, infection control, and communication, with several substantiated complaints over time. Prior reports noted deficiencies in medication management, resident supervision, infection prevention, and documentation, including some related to respiratory care and emergency communication. Complaint investigations were mostly substantiated when deficiencies were found, including a notable case involving inadequate respiratory suctioning that contributed to a resident’s death. The facility’s inspection history shows ongoing challenges with clinical care and safety practices, with recent findings continuing some previously identified themes.
Deficiencies (last 6 years)
Deficiencies (over 6 years)6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
129630
2020
2021
2022
2023
2024
2025
Census
Latest occupancy rate41 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The Centers for Medicare and Medicaid Services conducted a comparative Federal Monitoring Survey from 3/17/25 through 3/21/25, including investigation of 1 Facility Reported Incident and 1 complaint.
Findings
Deficiencies were cited related to failure to meet professional standards of care for 1 of 5 residents, inadequate supervision to prevent falls for 1 of 3 residents, improper storage of respiratory supplies for 2 residents, and failure to ensure proper medication storage and administration including insulin pen handling. The facility also failed to maintain an effective water management plan for Legionella risks.
Complaint Details
One complaint was investigated as part of the survey. The complaint involved issues with blood sugar monitoring and physician notification for a resident. The complaint was substantiated as evidenced by cited deficiencies.
Severity Breakdown
Level D: 3Level E: 1Level F: 1
Deficiencies (5)
Description
Severity
Facility failed to provide services meeting professional standards of quality of care for 1 of 5 residents related to blood sugar monitoring and physician notification.
Level D
Facility failed to adequately supervise residents to prevent falls for 1 of 3 residents, including failure to investigate falls and ensure safe environment.
Level E
Respiratory supplies for 2 residents were not properly stored, risking infection.
Level D
Facility failed to ensure medications were stored and administered according to accepted professional principles, including improper handling of an insulin pen.
Level D
Facility failed to have an effective water management plan to address Legionella risks, potentially affecting all residents.
An annual recertification survey and investigation of complaint #122797-C, and facility reported incident #124901-I, were conducted from February 24, 2025 to February 27, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaint #122797-C was conducted during the visit.
A recertification survey and investigation of complaint #122797-C and incident #124901-I was conducted from February 24, 2025 to February 27, 2025, followed by a Federal Monitoring Survey from March 17 to March 21, 2025.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility was certified in compliance with health requirements effective April 24, 2025.
Complaint Details
Investigation of complaint #122797-C and incident #124901-I was completed during the survey period.
A complaint investigation for complaint #120790-C was conducted from July 16, 2024 to July 18, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #120790-C was investigated and the facility was found to be in substantial compliance.
Inspection Report Plan of CorrectionDeficiencies: 0May 8, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective May 7, 2024.
The inspection was conducted as an investigation of complaints #118015-C and #119293-C, and a self-report #119878-I, related to medication administration and pharmaceutical services at the facility.
Findings
The facility failed to ensure residents received medications per physician orders, specifically for Resident #1, resulting in medication administration errors and delays in pharmacy ordering and receiving medications. The complaint #118015-C was substantiated, while complaint #119293-C and self-report #119878-I were not substantiated.
Complaint Details
Complaint #118015-C was substantiated. Complaint #119293-C was not substantiated. Self-report #119878-I was not substantiated.
Deficiencies (2)
Description
Facility failed to ensure residents received medications per physician orders, including incomplete administration of Tamiflu and Albuterol nebulizer treatments for Resident #1.
Facility failed to provide pharmaceutical services to meet the needs of Resident #1, including delays and errors in ordering and receiving medications.
Report Facts
Resident census: 42Medication doses ordered vs received: 15Medication doses administered: 9Medication doses missed: 8Correction date: May 7, 2024
Employees Mentioned
Name
Title
Context
Director of Nursing
Director of Nursing (DON)
Stated on 4/17/24 that she would look into medication availability issues and confirmed medication ordering procedures
Inspection Report Plan of CorrectionDeficiencies: 0Jan 4, 2024
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction for surveys ending November 20, 2023 and December 21, 2024, leading to certification of compliance effective January 4, 2024.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted for prior surveys, resulting in certification of compliance.
Report Facts
Survey end dates: Surveys ending November 20, 2023 and December 21, 2024 referenced in Plan of Correction
Inspection Report Plan of CorrectionDeficiencies: 0Jan 4, 2024
Visit Reason
The document certifies the facility in compliance based on acceptance of a credible allegation of substantial compliance and Plan of Correction for surveys ending November 20, 2023 and December 21, 2024.
Findings
The facility was found to be in substantial compliance and will be certified effective January 4, 2024, based on the Plan of Correction submitted.
The inspection was conducted following an investigation of a facility-reported incident #117429-I from December 12 to December 21, 2023, to determine if the complaint was substantiated regarding failure to notify physician and family of a resident's change in condition.
Findings
The facility was found to have failed to notify the physician and family of a significant change in condition for one resident, including increased pain and a sternal wound. The resident experienced inadequate pain management and lack of timely assessment and intervention, resulting in a substantiated deficiency related to quality of care and notification of changes.
Complaint Details
Complaint #117429-I was substantiated. The facility failed to notify the physician and family of a resident's significant change in condition and failed to provide adequate pain management and assessment.
Deficiencies (2)
Description
Failure to notify physician and family of a resident's significant change in condition including increased pain and sternal wound.
Failure to provide adequate assessment and timely intervention for pain management for one resident.
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #115149-C and #116718-C, with complaint #116718-C substantiated.
Findings
The facility failed to maintain a home-like environment due to a strong offensive urine odor throughout the facility, failed to communicate necessary information during an emergency hospital transfer, failed to accurately complete assessments, failed to develop and update baseline and comprehensive care plans appropriately, failed to meet professional standards for catheter orders, failed to provide appropriate incontinence care, and failed to maintain proper infection prevention and control practices including hand hygiene.
Complaint Details
Complaint #116718-C was substantiated.
Severity Breakdown
SS=E: 1SS=D: 8
Deficiencies (9)
Description
Severity
Facility repeatedly had a strong offensive urine odor throughout the facility.
SS=E
Failed to communicate necessary information to receiving facility during emergency transfer of Resident #44.
SS=D
Failed to accurately complete MDS assessments reflective of resident status for Residents #12 and #23.
SS=D
Failed to complete a baseline care plan including catheter care for Resident #45.
SS=D
Failed to develop a comprehensive care plan addressing risk factors and interventions for skin impairment and pressure ulcers for Resident #12.
SS=D
Failed to update care plan after Resident #22 attempted to leave the facility.
SS=D
Failed to have a physician's order for a resident admitted with a foley catheter (Resident #45).
SS=D
Failed to provide appropriate incontinence care for Resident #27, including incomplete cleansing and improper glove and hand hygiene use.
SS=D
Failed to maintain proper hand hygiene and standard precautions during care of Residents #27 and #34.
SS=D
Report Facts
Deficiency count: 9Resident census: 43
Employees Mentioned
Name
Title
Context
Staff A
MDS Coordinator
Acknowledged and verified MDS assessment inaccuracies and care plan deficiencies
Director of Nursing
Director of Nursing
Acknowledged missing transfer documentation, care plan expectations, and hand hygiene standards
Staff B
Certified Nurse Aide
Observed failing to perform proper hand hygiene and infection control during resident care
Staff C
Non-Certified Aide
Observed failing to perform proper hand hygiene and infection control during resident care
Staff D
Certified Nurse Aide
Observed failing to perform proper hand hygiene and infection control during resident care
Inspection Report Plan of CorrectionDeficiencies: 0Aug 9, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction and will be certified in compliance effective August 9, 2023.
The inspection was conducted as a result of investigations into complaints #113175-C, #112685-C, and #112616-C from August 1 to August 8, 2023. The complaints were substantiated and related to controlled substance record-keeping and medication administration.
Findings
The facility failed to maintain accurate and complete records of controlled substances, including lack of staff signatures on narcotic counts and inconsistent reconciliation of medications. Multiple discrepancies were found in narcotic counts for medication carts and individual residents, indicating poor compliance with pharmacy service procedures.
Complaint Details
Complaints #113175, #112685, #112628, and #112616 were substantiated following investigation from August 1 to August 8, 2023.
Deficiencies (1)
Description
Failure to ensure drug records are in order and accurate, including lack of staff signatures on controlled substance counts and failure to reconcile medications consistently.
Report Facts
Census: 41Complaints investigated: 4
Employees Mentioned
Name
Title
Context
Director of Nursing
Director of Nursing (DON)
Reported completion of facility investigations and narcotic count discrepancies.
Staff A
Registered Nurse (RN)
Documented medication administration and provided a typed recount statement regarding narcotic counts.
Staff B
Certified Medication Aide (CMA)
Administered tramadol and involved in medication discrepancy.
Staff C
Certified Medication Aide (CMA)
Reported on narcotic count practices and shift procedures.
Staff D
Licensed Practical Nurse (LPN)
Reported narcotic count concerns and interactions with DON.
Staff E
Licensed Practical Nurse (LPN)
Reported narcotic count practices and verification issues.
Assistant Director of Nursing
Assistant Director of Nursing (ADON)
Reported on narcotic count completion and observations.
The inspection was conducted as a result of an investigation of multiple complaints and facility-reported incidents related to respiratory and tracheostomy care and suctioning at Fonda Specialty Care.
Findings
The facility failed to ensure that a resident requiring respiratory care, including tracheostomy suctioning, received care consistent with professional standards. Specifically, the facility did not provide required suctioning for Resident #2, leading to respiratory distress and ultimately the resident's death. Staff interviews confirmed the resident's need for suctioning and availability of suction equipment, but suctioning was not performed timely.
Complaint Details
The complaint #111171-C was substantiated. The investigation included review of multiple complaints (#108529-C, #108838-C, #108860-C, #109201-C, #109263-C, #110210-C, #110798-C, #111030-C, #111171-C, #111173-C) and facility-reported incidents (#108385-I and #111450-I) conducted from February 23, 2023 to March 8, 2023.
Deficiencies (1)
Description
The facility failed to provide required suctioning for a resident needing respiratory care including tracheostomy suctioning, resulting in inadequate care.
Report Facts
Facility census: 43Date of survey completion: Mar 8, 2023
Employees Mentioned
Name
Title
Context
Jennifer Blair
Administrator
Signed the Plan of Correction on 03/22/2023
Staff A
LPN (licensed practical nurse)
Interviewed and confirmed Resident #2's communication and suctioning needs
Interviewed and confirmed Resident #2's suctioning needs
Staff C
RN (registered nurse)
Interviewed and confirmed Resident #2's suctioning needs and procedure
Staff D
CNA
Interviewed and described Resident #2's condition and suctioning needs
Staff E
CNA
Interviewed and confirmed Resident #2's communication about suctioning needs
Staff F
CNA
Interviewed and described Resident #2's condition and suctioning needs
Staff G
LPN
Interviewed and described events around Resident #2's decline and suctioning
Staff H
CMA/CNA
Interviewed and confirmed Resident #2's communication about suctioning needs
Staff I
ADON (assistant director of nursing)
Interviewed and confirmed nursing expectations for suctioning Resident #2
Staff J
RN
Interviewed and confirmed Resident #2's suctioning needs and availability of suction machine
Inspection Report Plan of CorrectionDeficiencies: 0Nov 17, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective November 17, 2022.
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #107528-C, #107895-C, and #108394-C from October 17, 2022 to October 24, 2022.
Findings
The facility failed to complete a comprehensive admission assessment within 14 days for one resident, failed to develop a complete baseline care plan for a new admission, failed to provide adequate bathing assistance for dependent residents, failed to provide treatments and care as ordered by physicians, failed to ensure proper food temperatures and food safety, failed to maintain infection prevention and control practices, and failed to ensure proper documentation and administration of psychotropic medications. The facility also had deficiencies related to resident transfer supervision and COVID-19 infection control.
Complaint Details
Complaints #107528-C and #108394-C were substantiated. Complaint #107895-C was not substantiated.
Deficiencies (11)
Description
Failed to complete admission Minimum Data Set (MDS) assessment within 14 days for Resident #145.
Failed to develop and implement a complete baseline care plan for Resident #145.
Failed to provide bathing assistance per resident preference for Residents #9, #39, and #3.
Failed to provide treatments and interventions as ordered by physicians for Residents #33 and #21.
Failed to ensure food was served at proper temperatures and maintain food safety standards.
Failed to establish and maintain an infection prevention and control program, including proper use of PPE and hand hygiene.
Failed to ensure psychotropic medications were limited to 14 days unless properly documented and renewed.
Failed to ensure adequate RN coverage for required hours and days.
Failed to ensure proper supervision and assistance during resident transfers, resulting in falls and injuries.
Failed to properly document and administer influenza and pneumococcal vaccinations for residents.
Failed to ensure COVID-19 infection control measures, including signage and PPE use, were properly implemented.
Administered medications and tube feeding to Resident #145 and provided statements regarding tracheostomy care.
Staff I
Licensed Practical Nurse (LPN)
Confirmed admission MDS for Resident #145 had not been completed.
Staff C
Certified Nursing Assistant (CNA)
Observed transferring Resident #39 using Sit-To-Stand lift and assisted with resident care.
Staff J
Registered Nurse (RN)
Removed old dressing and applied new dressing for Resident #6 and #11.
Staff A
Activities Director
Observed not wearing gloves and failing to use sanitizer during COVID-19 outbreak.
Staff B
Certified Medication Aide (CMA)
Failed to perform hand hygiene during medication administration.
Staff D
Housekeeping Staff
Not wearing gown or gloves while cleaning resident rooms.
Staff E
Registered Nurse (RN)
Handled oxygen tubing for Resident #17 without gloves or gown.
Staff F
Certified Nursing Assistant (CNA)
Assisted Resident #19 who tested positive for COVID-19.
Staff G
Certified Nursing Assistant (CNA)
Assisted Resident #19 who tested positive for COVID-19.
Director of Nursing
Director of Nursing
Commented on improper positioning of resident during Sit-To-Stand transfer.
Administrator
Administrator
Provided statements regarding MDS completion, care plans, vaccination refusals, and COVID-19 infection control.
Regional Nurse Consultant
Regional Nurse Consultant
Confirmed lack of RN coverage and vaccination status for residents.
Dietary Manager
Dietary Manager
Provided statements regarding food temperatures, sanitation, and meal service.
Staff J
Registered Nurse (RN)
Removed old dressing and applied new dressing for Resident #6 and #11.
Inspection Report Plan of CorrectionDeficiencies: 0Sep 24, 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 September 24, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
The inspection was conducted as a result of investigations into multiple complaints and facility reported incidents between August 16 and August 24, 2022.
Findings
The facility was found to have deficiencies related to reasonable accommodations, safe and clean environment, professional standards, ADL care, increase/prevent decrease in range of motion, medication errors, and infection prevention and control. Several residents were affected, and staff were re-educated on various protocols.
Complaint Details
The inspection resulted from investigation of complaints #100324-C (unsubstantiated), #102967-C (substantiated), #102969-C (unsubstantiated), #103169-C (unsubstantiated), #104416-C (unsubstantiated), #104741-C (unsubstantiated), #104455-C (substantiated), #104709-C (substantiated), #105398-C (substantiated), and facility reported incidents #100951-I (unsubstantiated), #103320-I (unsubstantiated).
Deficiencies (7)
Description
Reasonable Accommodations Needs/Preferences not met for Resident #12 regarding call light accessibility.
Safe/Clean/Comfortable/Homelike Environment not maintained; Resident #1's trash can was full and wheelchair had food/debris.
Services Provided did not meet Professional Standards; Resident #1 lacked a physician's order for oxygen use.
ADL Care Provided for Dependent Residents was inadequate; bathing assistance not consistently provided for Residents #2 and #4.
Increase/Prevent Decrease in Range of Motion not met; restorative nursing care not fully provided for Residents #1 and #2.
Residents were not free of significant medication errors; Resident #1 had medication ordering and administration errors.
Infection Prevention and Control program deficiencies; failure to prevent infection for Resident #1 with oxygen and Residents #2 and #11 with incontinence care.
Report Facts
Census: 44Complaints investigated: 9Facility reported incidents investigated: 2Residents reviewed for bathing assistance: 4Residents audited for call light use: 3Residents audited for oxygen order compliance: 3Residents audited for bathing completion: 3Residents audited for ADL care: 3Residents reviewed for medication errors: 3Residents assessed for infection control: 3
The inspection was conducted as a complaint investigation related to an elopement incident involving Resident #1, as identified during investigations of Self-Report #91418-I and Complaint #91458-C.
Findings
The facility failed to adequately supervise residents at risk for elopement, specifically Resident #1 who eloped from the building on 6/13/21. The care plan did not identify or have sufficient interventions to prevent elopement. The resident was found outside the facility after removing an air conditioner from a window and leaving the building. The facility implemented corrective actions including securing windows and door alarms.
Complaint Details
The complaint investigation was related to an elopement incident involving Resident #1. The self-report #97594-I was substantiated, while complaint #98828-C was not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Facility failed to adequately supervise residents at risk for elopement, resulting in Resident #1 eloping from the building.
The inspection was conducted as the facility's annual survey from January 25, 2021 to January 28, 2021 to assess compliance with federal regulations.
Findings
The facility was found deficient in ensuring residents' rights to dignity and respect, specifically related to staff speaking Spanish while providing care, which made some residents uncomfortable. The facility planned corrective actions including staff education and monitoring.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to provide care with dignity and respect as evidenced by staff speaking Spanish to residents during care, causing discomfort to residents.
SS=D
Report Facts
Census: 38
Employees Mentioned
Name
Title
Context
Administrator
Interviewed on January 28, 2021 regarding staff communication with residents
Investigation of Complaint #84882-C and #83540-C, and a COVID-19 Focused Infection Control Survey conducted from 11/4 to 11/9/2020.
Findings
No deficiencies were found during the complaint investigations or the COVID-19 Focused Infection Control Survey. Both complaints were not substantiated, and the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #84882-C was not substantiated. Complaint #83540-C was not substantiated.
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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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