Inspection Reports for Iowa Veterans Home

1301 Summit St, Marshalltown, IA 50158, United States, IA, 50158

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Inspection Report Summary

The most recent inspection on December 16, 2025 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed mostly compliance, with a few isolated deficiencies related to medication management in May 2024 and wheelchair safety in November 2025. Inspectors cited issues primarily involving safe resident transportation and documentation for psychotropic medication use. A substantiated complaint in November 2025 identified a deficiency in wheelchair safety, while other complaint investigations were generally unsubstantiated or found the facility in substantial compliance. The inspection history suggests the facility has maintained a generally compliant record with some recent issues that are being addressed.

Deficiencies (last 6 years)

Deficiencies (over 6 years) 0.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

84% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 353 residents

Based on a November 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

330 360 390 420 450 Jan 2020 Jul 2020 Dec 2020 Jul 2021 Oct 2021 Mar 2025 Nov 2025

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Dec 16, 2025

Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, certifying substantial compliance effective December 5, 2025.

Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance with health requirements.

Report Facts
Certification effective date: Dec 5, 2025

Inspection Report

Complaint Investigation
Census: 353 Deficiencies: 1 Date: Nov 17, 2025

Visit Reason
The inspection was conducted as a result of complaint #129295-C, which triggered an investigation from September 8, 2025, to November 17, 2025.

Complaint Details
Complaint #129295-C was substantiated, resulting in a deficiency related to accident hazards and supervision for wheelchair safety.
Findings
The facility failed to ensure safe wheelchair transportation for two residents, resulting in a deficiency related to free of accident hazards and supervision. Observations and interviews confirmed staff did not apply foot pedals on wheelchairs during transport, posing safety risks.

Deficiencies (1)
Failure to ensure safe wheelchair transportation for residents, including not applying foot pedals on wheelchairs during transport.
Report Facts
Resident census: 353 Brief Interview for Mental Status (BIMS) score: 7 Dates of complaint investigation: September 8, 2025 to November 17, 2025

Employees mentioned
NameTitleContext
Staff BRegistered Nurse (RN)Observed and interviewed regarding wheelchair transportation practices
Nursing Services DirectorInterviewed about expectations for staff to apply foot pedals on wheelchairs

Inspection Report

Annual Inspection
Census: 352 Deficiencies: 0 Date: Mar 27, 2025

Visit Reason
The inspection was conducted as an annual recertification survey with an investigation of facility reported incidents #127413-I, #127535-I, and #127527-I from March 24, 2025 to March 27, 2025.

Findings
The Iowa Veterans Home was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The investigated incidents were not substantiated.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Nov 26, 2024

Visit Reason
A complaint investigation for complaint #124055-C was conducted from November 25, 2024 to November 26, 2024.

Complaint Details
Complaint #124055-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.

Report Facts
Complaint number: 124055

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Aug 8, 2024

Visit Reason
Investigation of complaint intakes #121475-C and #121586-I conducted from August 6, 2024 to August 8, 2024.

Complaint Details
Investigation of complaint intakes #121475-C and #121586-I.
Findings
The Iowa Veterans Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the complaint investigation.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Jun 10, 2024

Visit Reason
The document is a statement of deficiencies and plan of correction related to the Iowa Veterans Home Nursing Home's compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Findings
The Iowa Veterans Home Nursing Home is in substantial compliance based on acceptance of a credible allegation of substantial compliance and the submitted Plan of Correction. The facility will be certified in compliance effective May 31, 2024.

Inspection Report

Annual Inspection
Census: 339 Deficiencies: 1 Date: May 2, 2024

Visit Reason
The inspection was conducted as the facility's annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Complaint Details
Complaint #119410-C was unsubstantiated.
Findings
The Iowa Veterans Home was found not in compliance due to failure to provide documented rationale for psychotropic medication use beyond 14 days for Resident #87 and failure to perform periodic re-evaluation of the medication regimen. Complaint #119410-C was unsubstantiated.

Deficiencies (1)
Facility failed to provide a documented rationale on why Resident #87's PRN psychotropic medication needed continuation beyond 14 days and failed to perform periodic re-evaluation of the medication regimen.
Report Facts
Total Census: 339 Complaint Number: 119410

Employees mentioned
NameTitleContext
Staff BRN Nursing Service DirectorSpoke to Pharmacy Director regarding medication order duration for Resident #87
Staff ARegistered NurseDocumented telephone order for lorazepam on 4/30/24

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jun 20, 2023

Visit Reason
A complaint investigation was conducted for Complaint #113029-C on June 20-21, 2023.

Complaint Details
Complaint #113029-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Mar 2, 2023

Visit Reason
An annual recertification survey and investigation of multiple complaints and a facility reported incident were conducted from February 27, 2023 to March 2, 2023.

Complaint Details
The investigation included complaints #105237-C, #105837-C, #109466-C, #109533-C, #109682-C, #111307-C and facility reported incident #107533-I.
Findings
The facility was found to be in substantial compliance at the time of the survey.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jun 23, 2022

Visit Reason
A complaint investigation for Complaint #101469-C and a Facility-Self Reported Incident #103610-I was conducted from June 20, 2022 to June 23, 2022.

Complaint Details
Investigation was related to Complaint #101469-C and Facility-Self Reported Incident #103610-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.

Inspection Report

Routine
Census: 351 Deficiencies: 0 Date: Oct 18, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 10/13 to 10/18/2021 to assess compliance with CMS and CDC recommended practices for COVID-19.

Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. An investigation of a facility-reported incident #99601-I did not result in any deficiency.

Report Facts
Total Residents: 351

Inspection Report

Routine
Census: 350 Deficiencies: 0 Date: Sep 9, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 09/07/2021 to 09/09/2021 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.

Report Facts
Total census: 350

Inspection Report

Complaint Investigation
Census: 351 Deficiencies: 0 Date: Jul 19, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #97837 were conducted by the Department of Inspection and Appeals from 7/12/21 to 7/19/21.

Complaint Details
Complaint #97837 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #97837 was not substantiated.

Inspection Report

Annual Inspection
Deficiencies: 0 Date: May 20, 2021

Visit Reason
The inspection was conducted as a recertification survey and investigation of Facility Self-Reported Incidents #97364 and #97365 during 5/17-20/2021.

Findings
The facility was found in substantial compliance. Incident #97634 was not substantiated and incident #97365 was substantiated without a deficiency.

Inspection Report

Complaint Investigation
Census: 353 Deficiencies: 0 Date: Feb 23, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #92393 and #95977 was conducted by the Department of Inspections and Appeals from 2/8/21 to 2/23/21.

Complaint Details
Complaints #92393 and #95977 were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both complaints were not substantiated.

Inspection Report

Routine
Census: 363 Deficiencies: 0 Date: Dec 23, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 12/21/2020 through 12/23/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.

Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Inspection Report

Abbreviated Survey
Census: 394 Deficiencies: 0 Date: Aug 6, 2020

Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 8/5/2020 through 8/6/2020 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

Abbreviated Survey
Census: 388 Deficiencies: 0 Date: Jul 16, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 07/14/2020 through 07/16/2020 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

Routine
Census: 393 Deficiencies: 0 Date: Jun 18, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/17/2020 through 6/18/2020 to assess compliance with CMS and CDC recommended practices.

Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Report Facts
Total residents: 393

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Feb 27, 2020

Visit Reason
The inspection was conducted as a complaint investigation related to Incident #89597.

Complaint Details
Incident #89597 was investigated and found not substantiated.
Findings
The complaint investigation found that Incident #89597 was not substantiated according to Code of Federal Regulations (42CFR) Part 483, Subpart B-C.

Inspection Report

Complaint Investigation
Census: 428 Deficiencies: 2 Date: Jan 22, 2020

Visit Reason
Investigation of Complaint #87671-C conducted December 31, 2019-January 22, 2020 resulted in the following deficiencies related to resident rights and smoking restrictions.

Complaint Details
Complaint #87671-C investigated from December 31, 2019 to January 22, 2020. The complaint was substantiated with findings related to residents' rights and smoking restrictions.
Findings
The facility failed to ensure residents' rights to a dignified existence, self-determination, and communication, specifically restricting residents' rights to smoke and moving residents due to smoking concerns. Resident #5 was moved and restricted from leaving the unit without supervision, and multiple smoking incidents and violations were documented. The facility had a census of 428 residents at the time of inspection.

Deficiencies (2)
Facility failed to ensure residents' rights without interference, coercion, discrimination, or reprisal, specifically restricting residents' rights to smoke and moving Resident #5 to another unit with restrictions.
Facility failed to develop and implement a comprehensive person-centered care plan for residents who smoke or use smokeless products, including Resident #1 and Resident #14.
Report Facts
Census: 428 Resident cigarettes per day: 6 Resident cigarettes per day: 3 Resident cigarettes per hour: 4 Resident cigarettes per day: 10 Resident cigarettes per day: 2 Resident cigarettes per day: 6 Resident cigarettes per day: 1 Resident cigarettes per day: 3 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 1 Resident cigarettes per day: 3 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6 Resident cigarettes per day: 6

Employees mentioned
NameTitleContext
Staff JRegistered Nurse (RN)Documented smoking assessments and incidents related to Resident #5 and Resident #14.
Staff MSocial WorkerMet with Resident #5 to discuss smoking incidents and restrictions.
Staff ORegistered Nurse (RN)Documented calls and observations related to Resident #5 smoking incidents.
Staff FSecurityObserved and reported smoking incidents and searched Resident #5's belongings.
Staff GNursing SupervisorConfirmed smoking privileges revocation and communicated with Resident #7.
Staff KCertified Medication Aide (CMA)Monitored Resident #14's smoking and medication compliance.
Staff LNurse ClinicalWorked with Resident #14 and monitored smoking room.
Staff SRegistered Nurse (RN)Documented smoking incidents and interactions with Resident #7.
Staff ELicensed Practical Nurse (LPN)Educated Resident #7 about smoking safety and monitored smoking room.
Staff BNursing SupervisorDocumented removal of smoking privileges for Resident #7.
Staff ADirector of Nursing (DON)Provided resident education regarding smoking incidents.
Staff FRegistered Nurse (RN)Reported smoking incidents and searched Resident #7's room.
Staff HLicensed Practical Nurse (LPN)Educated Resident #7 about smoking safety.
Staff CResidential Treatment Worker (RTW)Observed smoking room and monitored residents.
Staff DRegistered Nurse (RN)Observed Resident #1 smoking and documented assessments.
Staff NNursing Services Director (NSD)Communicated with Resident #7 about smoking privileges.
Staff FNursing SupervisorContacted and discussed smoking restrictions with Resident #5.
Staff LNurse ClinicalCalled supervisor regarding Resident #14 smoking incident.
Staff JRegistered Nurse (RN)Monitored Resident #14 and documented smoking incidents.

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