Inspection Reports for
Mechanicsville Specialty Care
104 East Fourth Street, Mechanicsville, IA, 523060430
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
74% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
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 survey to assess compliance with regulatory requirements related to resident dignity and feeding tube care.
Findings
The facility failed to provide dignity in care for one resident by not keeping the urinary catheter drainage bag covered. Additionally, the facility failed to administer the correct amount of water flush before tube feeding for the same resident.
Deficiencies (2)
F 0550: The facility failed to honor the resident's right to dignity by not keeping the urinary catheter drainage bag covered for Resident #2.
F 0693: The facility failed to administer the correct amount of water flush before tube feeding for Resident #2, providing less than the ordered 70 milliliters.
Report Facts
Residents reported in census: 29
Water flush amount ordered: 70
Water flush amount administered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in the finding related to incorrect water flush administration for tube feeding |
| Staff C | Certified Nurse Aide (CNA) | Named in the finding related to catheter bag dignity care |
| Director of Nursing | Director of Nursing (DON) | Reported expectations regarding catheter bag care and water flush administration |
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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported expectations regarding catheter drainage bags and tube feeding protocols |
| Staff C | Certified Nurse Aide (CNA) | Reported catheter bags placement on 9/4/25 |
| Staff B | Licensed 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
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in resident rights deficiency related to treatment of Resident #7 |
| Staff B | Certified Nurses Aid (CNA) | Named in resident rights deficiency related to treatment of Resident #7 |
| Staff C | Cook | Named in food safety deficiency related to cross contamination and food handling |
| Staff D | Dietary Aid | Named in food safety deficiency related to food thermometer handling |
| Staff E | Certified Nurses Aid (CNA) | Reported upset of Staff A regarding Resident #7 |
| Director of Nursing (DON) | Administrator | Provided statements and investigation information related to resident rights deficiency |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Aug 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the treatment of Resident #7 by nursing staff, specifically concerning respect and dignity during care interactions.
Complaint Details
The complaint involved Resident #7 alleging disrespectful and undignified treatment by Staff A, RN, including verbal abuse and refusal to honor requests for emergency care. The complaint was substantiated based on staff statements, resident interviews, and clinical record review.
Findings
The facility failed to treat Resident #7 with respect and dignity during an interaction with a nurse, resulting in verbal altercations and the resident being sent to the emergency room. The investigation included staff and resident interviews and review of clinical records.
Deficiencies (2)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Staff verbally mistreated Resident #7, including telling her she was at the facility to die and not respecting her requests.
Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, including respecting privacy, preferences, and treating cognitively impaired residents with sensitivity.
Report Facts
Residents present: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in findings related to disrespectful treatment of Resident #7 |
| Staff B | Certified Nurses Aid (CNA) | Witnessed and reported interactions involving Resident #7 and Staff A |
| Administrator | Provided policy and statements regarding expectations for resident dignity | |
| Director of Nursing | DON | Conducted interview with Resident #7 and involved in investigation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Aug 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to treat a resident with respect and dignity during an interaction with nursing staff.
Complaint Details
The complaint investigation focused on Resident #7's treatment by nursing staff, including disrespectful behavior, verbal abuse, and failure to honor her requests for emergency care. The resident was cognitively intact with a BIMS score of 13. The investigation included multiple staff statements and resident interviews confirming the issues. The physician ordered the resident sent to the emergency room after the incident.
Findings
The facility failed to treat Resident #7 with dignity and respect, as evidenced by staff interactions where the resident was yelled at, called vulgar names, and was not allowed to go to bed or the emergency room as requested. The facility also failed to prevent cross contamination during meal service and did not follow safe food handling practices.
Deficiencies (2)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Staff yelled at Resident #7, called her vulgar names, and did not respect her wishes to go to bed or to the emergency room.
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards. Staff left serving utensils in food, did not cover food items, and failed to sanitize thermometers between uses, risking cross contamination.
Report Facts
Residents present: 34
Residents present: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in multiple findings related to disrespectful treatment and verbal abuse of Resident #7 |
| Staff B | Certified Nurses Aid (CNA) | Witnessed and reported Staff A's behavior and interactions with Resident #7 |
| Staff C | Cook | Observed leaving serving utensils in food and failing to wash hands before plating food |
| Staff D | Dietary Aid | Observed using thermometer without sanitizing between food items |
| Administrator | Provided policy information and expectations regarding resident dignity and food safety | |
| Director of Nursing (DON) | Provided statements and investigation information regarding Resident #7 |
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
Routine
Census: 37
Deficiencies: 3
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds management, bed hold notices for hospital transfers, and professional standards of care including medication administration.
Findings
The facility failed to properly manage resident funds by not placing amounts over $50 in interest-bearing accounts and not providing quarterly statements. The facility also failed to provide written bed hold notices for residents transferred to hospitals. Additionally, the facility did not have physician insulin orders matching insulin administration and failed to follow manufacturer safety directions for insulin use.
Deficiencies (3)
F 0568: The facility failed to set up resident funds over $50 in an interest bearing account and failed to provide quarterly balance statements for 1 of 4 residents sampled. Resident #25 had a balance of $111.72 not in an interest bearing account.
F 0625: The facility failed to provide written bed hold notices for 2 of 2 residents discharged to the hospital (Residents #32 and #139).
F 0658: The facility failed to have physician insulin orders that matched insulin administration and failed to follow manufacturer directions for insulin use for 1 of 2 residents observed (Resident #15).
Report Facts
Resident census: 37
Resident fund balance: 111.72
Residents affected: 4
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Reported on resident funds management and account handling | |
| Administrator | Reported expectations for resident funds and bed hold notices | |
| Staff A | Registered Nurse (RN)/MDS Coordinator | Observed administering insulin and stopped for incorrect insulin use |
| Staff B | Licensed Practical Nurse (LPN) | Reported on insulin administration practices and transition from pens to vials |
| Director of Nursing (DON) | Reported expectations for insulin administration and physician orders |
Inspection Report
Routine
Census: 37
Deficiencies: 8
Date: Sep 28, 2023
Visit Reason
Routine inspection of Mechanicsville Specialty Care to assess compliance with regulatory requirements including resident funds management, Medicare beneficiary notices, bed hold notices, resident assessments, care planning, medication administration, food service, and food safety.
Findings
The facility had multiple deficiencies including failure to properly manage resident funds, incomplete Medicare beneficiary notices, lack of bed hold notices for hospital transfers, inaccurate coding of hospice care in assessments, incomplete care plans for pressure ulcers, mismatched insulin orders and administration practices, serving food at inappropriate temperatures, and unsafe food handling practices.
Deficiencies (8)
F 0568: The facility failed to set up resident funds over $50 in an interest bearing account and failed to provide quarterly balance statements for 1 of 4 residents sampled.
F 0582: The facility failed to correctly fill out and serve beneficiary notices of Medicare non-coverage for 3 of 3 residents reviewed.
F 0625: The facility failed to provide written bed hold notices for 2 of 2 residents discharged to the hospital.
F 0641: The facility failed to accurately code hospice care on multiple Minimum Data Set assessments for 1 of 2 residents reviewed.
F 0656: The facility failed to develop a care plan addressing pressure reduction interventions for a chronic left heel pressure ulcer for 1 of 13 residents reviewed.
F 0658: The facility failed to have physician insulin orders that matched insulin administration and failed to follow manufacturer directions for insulin use for 1 of 2 residents observed.
F 0804: The facility failed to provide food at appropriate temperatures and failed to serve pureed food that was attractive in appearance.
F 0812: The facility failed to discard expired food and leftovers after 3 days, prevent cross contamination during meal service, and serve meals on time.
Report Facts
Resident census: 37
Resident funds balance: 111.72
Food temperature: 129
Food temperature: 128
Food temperature: 132
Insulin dosage: 4
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
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN)/MDS Coordinator | Observed and administered insulin to Resident #15; involved in medication administration deficiency. |
| Staff B | Licensed Practical Nurse (LPN) | Reported transition from insulin pens to vials and issues related to insulin administration. |
| Staff C | Dietary Manager | Observed food temperatures and food service deficiencies; involved in food safety and handling. |
| Staff D | Restorative Aide | Observed Resident #36's heel boots related to pressure ulcer care. |
| Staff E | Certified Medication Aide (CMA) | Reported awareness of Resident #36's pressure ulcer and medication directions. |
| Director of Nursing (DON) | Director of Nursing | Reported expectations for insulin administration and pressure ulcer care; involved in audits and education. |
| Business Office Manager (BOM) | Business Office Manager | Reported on resident funds handling and deposits; involved in accounting deficiency. |
| Social Service Coordinator | Social Service Coordinator | Reported 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
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Observed leaving Foley catheter tubing on floor |
| Staff A | Temporary Nurse Aide (TNA) | Repositioned catheter tubing off the floor |
| Staff C | Certified Nurse Aide (CNA) | Interviewed regarding catheter tubing placement |
| Staff D | Restorative Aide (RA) | Interviewed regarding catheter tubing placement |
| Director of Nursing (DON) | Director of Nursing | Observed 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.
Viewing
Loading inspection reports...
