Inspection Reports for Mechanicsville Specialty Care

104 East Fourth Street, Mechanicsville, IA, 523060430

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Inspection Report Summary

The most recent inspection on October 1, 2025, found the facility to be in substantial compliance following a plan of correction. Prior inspections showed deficiencies related mainly to resident rights and dignity, including issues with urinary catheter care and tube feeding protocols, as well as food safety and documentation of resident funds and care plans. Complaint investigations were generally unsubstantiated, with one substantiated facility-reported incident involving food safety in August 2024. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility’s record shows some recurring themes in resident dignity and care practices, with recent inspections indicating efforts toward correction and compliance.

Deficiencies (last 5 years)

Deficiencies (over 5 years) 2.6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

41% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2020
2022
2023
2024
2025

Census

Latest occupancy rate 29 residents

Based on a September 2025 inspection.

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

Census over time

20 25 30 35 40 45 Jun 2020 Jul 2020 Apr 2022 Sep 2023 Aug 2024 Sep 2025

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Oct 1, 2025

Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey ending September 4, 2025, related to facility compliance.

Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification effective September 25, 2025.

Report Facts
Survey end date: Sep 4, 2025 Certification effective date: Sep 25, 2025

Inspection Report

Annual Inspection
Census: 29 Deficiencies: 2 Date: Sep 4, 2025

Visit Reason
The inspection was conducted as an annual recertification survey of the facility from September 2, 2025 to September 4, 2025.

Findings
The facility was found to have deficiencies related to resident rights and dignity, specifically involving failure to maintain dignity with urinary catheter bags, and deficiencies in tube feeding management and protocols. The facility failed to provide proper care and education to staff regarding these issues.

Deficiencies (2)
Resident #2's urinary catheter drainage bag was left uncovered and not kept in a dignity bag as required.
Facility failed to administer the correct amount of water flush before tube feeding for Resident #2.
Report Facts
Census: 29 BIMS score: 9 Tube feeding water flush amount: 70 Tube feeding water flush amount: 30 Tube feeding water flush amount: 40 Tube feeding water flush amount: 30

Employees mentioned
NameTitleContext
Director of NursingDirector of Nursing (DON)Reported expectations regarding catheter drainage bags and tube feeding protocols
Staff CCertified Nurse Aide (CNA)Reported catheter bags placement on 9/4/25
Staff BLicensed Practical Nurse (LPN)Administered tube feeding and flushed water on 9/3/25 and 9/4/25

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Dec 17, 2024

Visit Reason
A complaint investigation for complaint #123766-C was conducted from December 16, 2024 to December 17, 2024.

Complaint Details
Complaint #123766-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Aug 31, 2024

Visit Reason
The document is a statement of deficiencies and plan of correction indicating acceptance of a credible allegation of compliance for certification.

Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, resulting in certification effective August 31, 2024.

Inspection Report

Annual Inspection
Census: 34 Deficiencies: 2 Date: Aug 8, 2024

Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #117374-C and facility reported incidents #122511-I.

Complaint Details
Facility reported incident #122511-I was substantiated.
Findings
The facility was found to have deficiencies related to resident rights and dignity, including failure to treat a resident with respect and dignity, and food safety violations involving cross contamination and improper food handling practices.

Deficiencies (2)
Failure to treat a resident with respect and dignity, including incidents of verbal abuse and improper handling of resident's rights.
Failure to prevent exposure for cross contamination during meal service and failure to follow safe food handling practices.
Report Facts
Census: 34 Census: 33

Employees mentioned
NameTitleContext
Staff ARegistered Nurse (RN)Named in resident rights deficiency related to treatment of Resident #7
Staff BCertified Nurses Aid (CNA)Named in resident rights deficiency related to treatment of Resident #7
Staff CCookNamed in food safety deficiency related to cross contamination and food handling
Staff DDietary AidNamed in food safety deficiency related to food thermometer handling
Staff ECertified Nurses Aid (CNA)Reported upset of Staff A regarding Resident #7
Director of Nursing (DON)AdministratorProvided statements and investigation information related to resident rights deficiency

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Oct 19, 2023

Visit Reason
The document certifies the facility in compliance based on acceptance of a credible allegation of substantial compliance and the submitted Plan of Correction.

Findings
The facility was found to be in substantial compliance, leading to certification effective October 19, 2023. No specific deficiencies or severity levels are detailed in the report.

Inspection Report

Annual Inspection
Census: 37 Deficiencies: 8 Date: Sep 25, 2023

Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of substantiated complaints #109369-C, #109751-C, and #110764-C from September 25 to September 28, 2023.

Complaint Details
Complaint #109751-C was substantiated as part of this inspection.
Findings
The facility was found deficient in several areas including accounting and records of personal funds, Medicaid/Medicare coverage and liability notices, notice of bed hold policy before transfer, accuracy of assessments, development and implementation of comprehensive care plans, and food safety and nutrition services. Specific deficiencies involved failure to maintain proper resident funds accounting, failure to provide timely and accurate beneficiary notices, failure to provide bed hold notices, inaccurate coding of assessments, incomplete care plans especially related to pressure ulcers and hospice care, and failure to maintain safe food temperatures and proper food handling.

Deficiencies (8)
Failure to set up resident funds over $50 in an interest bearing account and failure to provide quarterly balance statements for resident funds.
Failure to inform Medicaid-eligible residents in writing about coverage and changes in services and charges.
Failure to provide notice of bed hold policy and return before transfer for 2 of 2 residents reviewed.
Failure to accurately code Minimum Data Set (MDS) assessments for hospice services for 1 of 2 residents reviewed.
Failure to develop and implement comprehensive person-centered care plans including measurable objectives and timeframes for 1 of 13 residents reviewed with a pressure ulcer.
Failure to meet professional standards of quality for physician insulin orders and administration for 1 of 2 residents observed.
Failure to provide food at appropriate temperatures and failure to serve palatable, attractive pureed food.
Failure to procure food from approved or considered satisfactory sources and failure to discard food after expiration dates.
Report Facts
Census: 37 Resident funds balance: 111.72 Deficiencies cited: 8 MDS BIMS score: 14 MDS BIMS score: 15 Temperature range: 41 Temperature range: 135

Employees mentioned
NameTitleContext
Staff ARegistered Nurse (RN)/MDS CoordinatorObserved and administered insulin to Resident #15; involved in medication administration deficiency.
Staff BLicensed Practical Nurse (LPN)Reported transition from insulin pens to vials and issues related to insulin administration.
Staff CDietary ManagerObserved food temperatures and food service deficiencies; involved in food safety and handling.
Staff DRestorative AideObserved Resident #36's heel boots related to pressure ulcer care.
Staff ECertified Medication Aide (CMA)Reported awareness of Resident #36's pressure ulcer and medication directions.
Director of Nursing (DON)Director of NursingReported expectations for insulin administration and pressure ulcer care; involved in audits and education.
Business Office Manager (BOM)Business Office ManagerReported on resident funds handling and deposits; involved in accounting deficiency.
Social Service CoordinatorSocial Service CoordinatorReported on beneficiary notices and veteran status documentation.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Apr 22, 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 April 22, 2022, based on acceptance of the credible allegation of compliance and plan of correction.

Inspection Report

Annual Inspection
Census: 29 Deficiencies: 1 Date: Apr 4, 2022

Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #100482-C and Facility Self-Reported Incident #92983-I.

Complaint Details
Complaint #100482-C was not substantiated. Facility Self-Reported Incident #92983-I was not substantiated.
Findings
The facility was found deficient in infection prevention and control practices, specifically failing to ensure proper placement of indwelling catheter tubing off the floor for one resident. The complaint and self-reported incident were not substantiated. A plan of correction was submitted addressing staff education and procedural improvements.

Deficiencies (1)
Failure to follow proper infection control practices by not ensuring indwelling catheter tubing was kept off the floor for resident #26.
Report Facts
Resident census: 29 Brief Interview for Mental Status (BIMS) score: 15 Urine culture colony forming units: 100000 Antibiotic dosage: 250

Employees mentioned
NameTitleContext
Staff BLicensed Practical Nurse (LPN)Observed leaving Foley catheter tubing on floor
Staff ATemporary Nurse Aide (TNA)Repositioned catheter tubing off the floor
Staff CCertified Nurse Aide (CNA)Interviewed regarding catheter tubing placement
Staff DRestorative Aide (RA)Interviewed regarding catheter tubing placement
Director of Nursing (DON)Director of NursingObserved catheter tubing left on floor and interviewed about infection control practices

Inspection Report

Abbreviated Survey
Census: 29 Deficiencies: 0 Date: Jul 15, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections 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.

Report Facts
Total residents: 29

Inspection Report

Abbreviated Survey
Census: 30 Deficiencies: 0 Date: Jun 16, 2020

Visit Reason
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.

Report Facts
Total residents: 30

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Feb 27, 2020

Visit Reason
The inspection was conducted as a recertification survey combined with an investigation of Complaint #84931.

Complaint Details
Complaint #84931 was investigated and found not substantiated.
Findings
The facility was found to be in substantial compliance at the time of the survey, and Complaint #84931 was not substantiated.

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