Inspection Reports for Golden Age Care Center
1915 South 18th Street, IA, 525443199
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 29, 2025, included a Plan of Correction acknowledging prior deficiencies and outlining corrective actions, with certification of compliance effective December 17, 2025. Earlier inspections showed a pattern of deficiencies related mainly to medication management, resident care including wound treatment and restorative activities, and failure to notify physicians or representatives of changes in condition. Several complaint investigations were substantiated, particularly involving medication storage issues, wound care, and resident dignity, while others were found to be unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be addressing prior deficiencies through plans of correction, indicating some improvement over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
40 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 29, 2025
Visit Reason
This document is a Plan of Correction submitted by Golden Age Care Center following a prior inspection, indicating acceptance of substantial compliance and outlining corrective actions to achieve compliance by December 17, 2025.
Findings
The facility has accepted the allegation of substantial compliance and submitted a Plan of Correction to address deficiencies, with certification of compliance effective December 17, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of substantial compliance and Plan of Correction |
Report Facts
Compliance effective date: Dec 17, 2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 24, 2025
Visit Reason
A complaint investigation for complaints #2671174-C and facility reported incidents #2624960-I was conducted on November 24, 2025 to November 25, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaints #2671174-C and facility reported incidents #2624960-I. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Oct 21, 2025
Visit Reason
The inspection was conducted as a result of complaint #2594081-C and a facility reported incident #2646013-1 that occurred from October 20 to October 21, 2025.
Findings
The facility failed to keep all medications in a locked medication cart inaccessible to unauthorized staff and residents, resulting in a medication being left unattended and not administered properly to Resident #1. The investigation included staff interviews, record reviews, and policy reviews, confirming noncompliance with drug storage and administration protocols.
Complaint Details
Complaint #2594081-C was investigated and substantiated based on evidence including staff interviews, record reviews, and observation of medication storage and administration practices.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep all medications in a locked medication cart inaccessible to unauthorized staff and residents, resulting in medication storage and administration issues. | Level II |
Report Facts
Census: 40
Date of incident: Oct 11, 2025
Correction date: Dec 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrisha Smith | Administrator | Signed the report and plan of correction |
| Staff A | Licensed Practical Nurse (LPN) | Involved in medication administration and observed leaving medication unattended |
| Staff B | Certified Nursing Assistant (CNA) | Observed leaving Resident #1's room and denied seeing medications |
| Director of Nursing | Notified of the incident and interviewed regarding medication administration expectations |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 19, 2025
Visit Reason
The document is a plan of correction related to a prior inspection, indicating acceptance of substantial compliance and plan of correction for the facility.
Findings
The facility, Golden Age Care Center, is certified in compliance effective August 17, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and plan of correction. |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Jul 31, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of complaints #1767344 and #1767346 from July 28, 2025 to July 31, 2025.
Findings
The facility was found deficient in several areas including self-administration of medications, grievance handling, pressure ulcer treatment, medication error prevention, immunizations, and resident call system functionality. Deficiencies were supported by clinical record reviews, policy reviews, staff and resident interviews, and observations.
Complaint Details
The survey included investigation of complaints #1767344 and #1767346 which resulted in deficiencies.
Severity Breakdown
D: 5
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure thorough documentation of assessment for resident's ability to self-administer insulin. | D |
| Failure to establish and implement a grievance policy ensuring prompt resolution of resident grievances. | D |
| Failure to carry out interventions and ordered treatments to prevent and treat pressure ulcers. | D |
| Failure to ensure residents are free of significant medication errors, including omission of insulin. | D |
| Failure to offer pneumococcal immunizations to all eligible residents. | E |
| Failure to provide a properly functioning resident call system ensuring timely staff access. | D |
Report Facts
Resident census: 40
Residents reviewed for medication errors: 6
Residents reviewed for immunizations: 5
Residents reviewed for call system: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Saxton | Administrator | Signed the report and involved in grievance policy re-education |
| Director of Nursing | Director of Nursing | Involved in medication administration and immunization findings |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding resident self-administration of insulin |
| Staff G | Certified Medication Assistant (CMA) | Reported resident refusal of insulin and grievance process issues |
| Staff C | Registered Nurse (RN) | Discussed resident insulin and wound care treatments |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 4, 2025
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 found to be in substantial compliance and will be certified effective April 4, 2025, based on the Plan of Correction submitted.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Mar 19, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #126541-C, 127183-C, 127256-C, and a facility self-report #126314-I from March 12 to March 19, 2025.
Findings
The facility was found to have deficiencies related to activities of daily living and quality of care, specifically failing to provide restorative activities and appropriate assessments and interventions for residents, including Resident #3. Complaint #127183-C was substantiated.
Complaint Details
Complaint #127183-C was substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to provide restorative activity as planned for Resident #3. |
| Failure to ensure residents are appropriately assessed and provided interventions to maintain optimal health and well-being for 3 residents reviewed. |
Report Facts
Resident census: 38
Brief Mental Status (BIMS) score: 15
Number of residents reviewed: 3
Dates of restorative tasks frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Saxton | Administrator | Signed the initial comments and correction date |
| Staff C, Rehab Director | Interviewed regarding Resident #3's therapy services | |
| Assistant Director of Nursing (ADON) | Interviewed about restorative nursing tasks for Resident #3 | |
| Staff G | Registered Nurse | Documented progress notes and interviewed about Resident #3's groin area complaints |
| Staff H | Wound Nurse | Documented weekly skin assessments for Resident #3 |
| Staff F | Licensed Practical Nurse | Documented treatment orders for Resident #3 |
| Director of Nursing (DON) | Interviewed regarding complaint process and physician contact |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 25, 2024
Visit Reason
A complaint investigation for complaint #124079-C was conducted from November 21, 2024 to November 25, 2024.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint #124079-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 22, 2024
Visit Reason
An annual recertification survey was conducted from August 19, 2024 to August 22, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 8, 2024
Visit Reason
The visit was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and to review the facility's plan of correction based on a credible allegation of compliance.
Findings
The Golden Age Care Center Nursing Home was found to be in substantial compliance as of August 8, 2024, based on the department's acceptance of the facility's credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Jul 17, 2024
Visit Reason
The inspection was conducted based on investigation of complaint #122064-C and facility self-report #122082-L from July 15 to July 17, 2024. The complaint was substantiated.
Findings
The facility failed to notify the physician and resident's power of attorney (POA) upon discovery of a new blistered area on Resident #1's left foot and failed to obtain treatment orders for the wound. The blister grew in size and treatment orders were not obtained despite wound progression. The ARNP was not initially aware of the wound due to being on vacation. Resident #1 had multiple comorbidities contributing to skin issues.
Complaint Details
Complaint #122064-C was substantiated based on clinical record review, staff interviews, family interview, and provider interview.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify physician and resident representative of a change in condition (new blister on Resident #1's left foot). | SS=D |
| Failure to obtain treatment orders for a resident identified with new wounds. | SS=D |
Report Facts
Resident census: 38
Blister size initial: 6
Blister size initial width: 3.5
Blister size progression length: 8
Blister size progression width: 7.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in findings related to failure to notify physician and POA and failure to obtain treatment orders |
| Rose Saxton | Administrator | Signed the statement of deficiencies on 8/8/24 |
| Advanced Practice Nurse Practitioner | ARNP | Interviewed regarding awareness of Resident #1's wound and comorbidities |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 8, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on March 8, 2024.
Findings
The facility was found to be in substantial compliance based on acceptance of a credible allegation and plan of correction, resulting in certification effective March 8, 2024.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 4
Feb 8, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints #111301-C, #116489-C, and #116570-C.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity, failure to complete a criminal background check for a staff member, failure to serve diets at the appropriate consistency, and failure to implement adequate infection prevention and control measures including Legionella prevention.
Complaint Details
Complaint #111301-C, #116489-C, #116570-C were substantiated.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to treat resident with dignity; Resident #3 was moved abruptly to a feeding assistance table causing embarrassment and humiliation. | — |
| Failed to complete a criminal background check including record check evaluation for one staff member (Staff A). | SS=D |
| Failed to serve diets at the appropriate consistency for 5 residents on mechanical soft diet; diced chicken served instead of ground chicken. | SS=E |
| Failed to carry out infection control measures for Resident #21 during medication pass and failed to develop and implement a plan to prevent Legionella growth in water systems. | SS=F |
Report Facts
Resident census: 37
Residents on mechanical soft diet: 5
Staff members reviewed: 6
Residents observed during medication pass: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Assistant (CNA) | Named in deficiency for incomplete criminal background check |
| Staff F | Licensed Practical Nurse (LPN) | Named in infection control deficiency for improper eye care and sanitization |
| Staff J | Maintenance Assistant | Named in deficiency for lack of knowledge and implementation of Legionella prevention |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident dignity and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2023
Visit Reason
A complaint investigation was conducted for complaint #108825-C and facility reported incidents #109167-I, #111035-I, and #111072-I from February 22, 2023 to February 27, 2023.
Findings
The facility was found to be in substantial compliance following the complaint investigation and review of reported incidents.
Complaint Details
Complaint investigation for complaint #108825-C and facility reported incidents #109167-I, #111035-I, and #111072-I; facility found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 27, 2022
Visit Reason
A revisit of the survey, complaint and facility reported incident investigation ending August 29, 2022 was conducted from September 27, 2022 to September 29, 2022.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 09, 2022.
Complaint Details
The visit included a complaint investigation and facility reported incident investigation.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 8
Aug 29, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints and facility-reported incidents between August 1, 2022 and August 29, 2022.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, protect residents' property, prevent abuse and neglect, properly investigate allegations of abuse, and ensure quality of care including medication administration and PASRR compliance. Several complaints were substantiated. The facility reported a census of 36 residents during the survey.
Complaint Details
Multiple complaints were investigated during the survey period. Several complaints were substantiated including complaints #93591-C, #94454-C, #95328-C, #96284-C, #96427-C, #102676-C, #102677-C, #103884-C, #104928-C, and facility reported incidents #99530-I and #104930-I. Some complaints were not substantiated. The facility lacked documentation for some complaints and investigations.
Deficiencies (8)
| Description |
|---|
| Failure to treat residents with dignity and respect, including incidents involving staff and residents. |
| Failure to protect resident property, including missing items and inadequate investigation of missing watches. |
| Failure to prevent verbal abuse and neglect by staff toward residents, including documented incidents and staff statements. |
| Failure to thoroughly investigate allegations of abuse and separate residents from alleged perpetrators. |
| Failure to ensure quality of care, including medication administration errors and failure to follow care plans. |
| Failure to coordinate PASRR assessments and update with new psychiatric diagnoses. |
| Failure to ensure residents are free from accident hazards, including inadequate supervision and removal of straws. |
| Failure to ensure residents are free from unnecessary psychotropic medications and proper documentation of PRN use. |
Report Facts
Complaint numbers substantiated: 9
Complaint numbers not substantiated: 2
Facility reported incidents substantiated: 2
Resident census: 36
Residents reviewed for dignity: 5
Residents reviewed for missing property: 1
Residents reviewed for abuse: 4
Residents reviewed for accidents: 6
Residents reviewed for psychotropic medication: 1
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 1
Nov 9, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on November 9-10, 2020, to assess compliance with CMS and CDC recommended practices related to COVID-19 reporting requirements.
Findings
The facility was found not to be in compliance with COVID-19 reporting requirements, specifically failing to notify residents, representatives, and families of confirmed COVID-19 cases within the required timeframe. Interviews confirmed the facility did not inform residents or staff testing positive for COVID-19.
Complaint Details
This visit was complaint-related, triggered by concerns about COVID-19 reporting. The facility was found non-compliant with notification requirements. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify residents, resident representatives, and/or family members of confirmed cases of COVID-19 as required by CMS and CDC guidelines. |
Report Facts
Facility Census: 33
COVID-19 Positive Residents: 28
COVID-19 Positive Staff: 19
Date of First COVID-19 Case: Oct 26, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Goodwin | Administrator designee | Signed the report on December 21, 2020. |
| Director of Nursing | Interviewed on 11/9/2020, stated inability to call or document calls since end of October regarding COVID-19 cases. |
Inspection Report
Abbreviated Survey
Census: 43
Deficiencies: 0
Sep 24, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from September 21 to 24, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 26, 2020
Visit Reason
A Focused Infection Control Survey and complaint #92774 was conducted by the Department of Inspection and Appeals on August 18 - 26, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices. Complaint #92774-C was not substantiated.
Complaint Details
Complaint #92774-C was not substantiated.
Inspection Report
Routine
Census: 47
Deficiencies: 0
Jun 23, 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.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 1
Feb 20, 2020
Visit Reason
The inspection was conducted as an annual health survey of the Golden Age Care Center to assess compliance with federal regulations, including review of complaints which were found not substantiated.
Findings
The facility failed to provide care consistent with professional standards to prevent pressure ulcers, as evidenced by Resident #3 developing a pressure ulcer. The facility did not implement adequate interventions to prevent the wound and failed to document the wound properly.
Complaint Details
Complaints #85762, #88859, and #89169 were investigated and found not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to provide care consistent with professional standards to prevent pressure ulcers, resulting in a pressure ulcer for Resident #3. |
Report Facts
Resident census: 49
Brief Interview for Mental Status (BIMS) score: 6
Braden Scale score: 14
Measurement of left heel wound: 3.5
Measurement of left heel wound: 4.2
Measurement of left hip bruise: 14
Measurement of left hip surgical incision: 17
Measurement of left hip surgical incision width: 0.5
Number of staples: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Applied skin prep to Resident #3's left heel and performed wound care |
| Staff B | Registered Nurse/Wound Nurse | Provided wound care, measured wound, and reported on wound documentation |
| Director of Nursing | Director of Nursing (DON) | Confirmed facility failed to implement interventions to prevent wound and provided interviews regarding wound care and documentation |
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