Inspection Reports for New London Specialty Care
100 Care Circle Street, New London, IA, 526450136
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 4, 2025 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a pattern of both compliance and deficiencies, including substantiated complaints related to narcotic medication misappropriation in October 2025 and multiple issues with resident care, abuse prevention, and documentation in prior years. Deficiencies primarily involved medication management, resident safety, abuse prevention, and staff training. Several complaint investigations were substantiated, including drug diversion by staff and failures to prevent resident abuse, while most other complaints were unsubstantiated. The facility appears to have made improvements over time, with recent inspections showing fewer deficiencies compared to earlier reports.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
45 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 4, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction ending October 14, 2025, with certification effective November 24, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Oct 14, 2025
Visit Reason
The inspection was conducted as a result of a facility reported incident #2624801-I involving alleged misappropriation of narcotic pain medications and drug diversion.
Complaint Details
The complaint investigation was substantiated, with findings of drug diversion by Staff A, who was terminated due to the investigation results. The facility reported incident #2624801-I was the basis for the investigation.
Findings
The facility failed to ensure residents were free from misappropriation of narcotic pain medications for six residents reviewed. The investigation revealed narcotic medications were taped, wasted, and not properly documented, leading to drug diversion substantiated by staff interviews and narcotic log reviews. Additionally, the facility failed to ensure pharmacy services were consistently implemented to account for all narcotic medications and timely identify suspected drug diversion.
Deficiencies (2)
Failure to ensure residents were free from misappropriation of narcotic pain medications.
Failure to ensure pharmacy services were consistently implemented to account for all narcotic medications and timely identify suspected drug diversion.
Report Facts
Resident census: 45
Number of residents reviewed for misappropriation: 6
Date of survey completion: Oct 14, 2025
Date of report: Nov 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named as the staff involved in narcotic medication misappropriation and drug diversion | |
| Staff F | Licensed Practical Nurse (LPN) | Reported taped narcotics to Director of Nursing and provided witness statement |
| Staff B | Licensed Practical Nurse (LPN) | Queried about narcotics and tape on narcotic cards |
| Staff C | Licensed Practical Nurse (LPN) | Witness statement about taped narcotics |
| Staff H | Registered Nurse (RN) | Explained narcotic count and issues during interview |
| DON | Director of Nursing | Received reports and provided education on narcotic administration and diversion |
| ADON | Assistant Director of Nursing | Provided narcotic audit information and observations about taped narcotics |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
An annual recertification survey was conducted from March 17, 2025 to March 20, 2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
Investigation of facility reported incident #125336-M and complaints #124269-A and #125160-A conducted from December 12, 2024 to December 23, 2024.
Complaint Details
Investigation of complaints #124269-A and #125160-A and facility reported incident #125336-M with no deficiencies found.
Findings
The investigation resulted in no deficiencies. Findings for the reported incident and complaints will be sent to the facility at a later date under separate cover.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An annual recertification survey was conducted from May 28, 2024 to May 30, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
A complaint survey for complaint #115619-C was conducted from April 2, 2024 to April 3, 2024.
Complaint Details
Complaint #115619-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: Mar 16, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of compliance and plan of correction 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 March 16, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaints #109818-C, #109957-C, and #109986-C from February 20, 2023 to February 23, 2023.
Complaint Details
The visit was complaint-related involving investigation of three complaints (#109818-C, #109957-C, #109986-C).
Findings
The facility was found deficient in multiple areas including quality of care, nutrition/hydration status maintenance, respiratory/tracheostomy care, physician visits, and drug regimen management. Specific deficiencies involved failure to elevate a resident's legs as ordered, failure to implement weight loss interventions, improper oxygen administration, incomplete physician orders, and inappropriate use of antibiotics.
Deficiencies (5)
Facility failed to ensure one resident's legs were elevated as ordered, increasing risk of edema and discomfort.
Facility failed to implement weight loss interventions for one resident, resulting in malnutrition risk.
Facility failed to ensure oxygen was administered properly to a resident, increasing risk of respiratory complications.
Facility failed to ensure physician clarified orders for a resident, increasing risk of respiratory, urinary, and gallbladder complications.
Facility failed to ensure drug regimen was free from unnecessary drugs for one resident, including inappropriate antibiotic use.
Report Facts
Deficiencies cited: 5
Resident weight loss: 26.2
Resident weight loss percentage: 15
Oxygen flow rate: 2
Oxygen flow rate observed: 3
Sample size: 16
Meals refused: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated responsibility for elevating resident R138's legs and confirmed oxygen administration details. |
| Director of Nursing | Director of Nursing | Provided admission records, monitored orders, and education related to deficiencies. |
| Physician DR1 | Physician | Provided orders for oxygen administration and care for resident R136. |
| Physician DR2 | Physician | Provided orders related to resident R24's urinary tract infection and antibiotic use. |
| Nurse Practitioner | Nurse Practitioner | Verified incomplete physician orders and discussed care for resident R136. |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed about diet cards and resident R4's meal consumption. |
| Certified Nurse Aide 6 | Certified Nurse Aide | Stated responsibility for elevating resident R138's legs and awareness of care plan. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
An onsite revisit of the survey ending November 08, 2022 was conducted from February 6, 2023 to February 9, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 28, 2022.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 15
Date: Nov 8, 2022
Visit Reason
The inspection was conducted due to complaints regarding abuse, neglect, and inappropriate sexual behavior involving residents at the facility. The investigation focused on allegations of resident-to-resident abuse and staff failure to prevent and report such incidents.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, and failure to protect residents. The facility was found deficient in multiple areas related to resident safety and staff training.
Findings
The facility was found to have multiple deficiencies related to abuse, neglect, and failure to protect residents from harm. Several residents exhibited sexually inappropriate behaviors, and staff failed to adequately intervene or report incidents. Corrective actions and training plans were implemented to address these issues.
Deficiencies (15)
Failure to prevent and investigate allegations of abuse including physical, mental, psychosocial, sexual and verbal misappropriation.
Failure to maintain a safe environment free from resident sexual abuse by another resident.
Failure to fully investigate allegations of abuse and failed to prevent and protect residents from further potential abuse during the investigation.
Failure to report all allegations of abuse including physical, mental, psychosocial, sexual and verbal misappropriation immediately to their supervisor and the management and to report to DIA and/or local law enforcement within two hours if applicable.
Failure to educate staff timely on abuse, neglect, exploitation, and mistreatment and failure to provide documentation of training.
Failure to maintain documentation of staff education and training completion.
Failure to ensure staff competency in abuse prevention and reporting.
Failure to provide adequate supervision and monitoring of residents with inappropriate sexual behaviors.
Failure to ensure facility staff education on timely completion of training requirements.
Failure to maintain documentation of physical examinations for staff.
Failure to maintain documentation of TB testing and physical examinations for staff.
Failure to maintain documentation of staff training on infection control.
Failure to maintain documentation of staff training on resident rights.
Failure to maintain documentation of staff training on abuse, neglect, and exploitation.
Failure to maintain documentation of staff training on infection control.
Report Facts
Resident census: 36
Staff training audit frequency: 4
Staff supervision: 24
Number of residents assessed with MDS: 15
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Sep 8, 2022
Visit Reason
The inspection was conducted as a result of investigation of complaints #104616-C, #105387-C, #105415-C, and #107016-C from August 29, 2022 to September 8, 2022.
Complaint Details
Complaints #104616-C, #105387-C, #105415-C, and #107016-C were substantiated.
Findings
The facility was found to have deficiencies related to providing adequate assistance with bathing for dependent residents and failure to timely obtain and complete treatment orders to prevent and treat pressure ulcers for residents at risk or with existing pressure ulcers.
Deficiencies (2)
Failure to provide two showers/baths per week as scheduled for 3 of 3 residents reviewed, indicating inadequate assistance with bathing.
Failure to timely obtain and complete treatment orders and put interventions in place to prevent pressure ulcers for residents at risk or with pressure ulcers.
Report Facts
Census: 40
Residents reviewed: 3
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Buckland | Administrator | Signed the plan of correction on 10/21/22 |
| Staff A | Non-Certified Nurse Aid | Reported being the facility's shower aid recently unless in class |
| Staff B | Certified Nurse Aid | Reported filling in for showers to ensure completion |
| Director of Nursing | Reported expectation for residents to receive baths on scheduled days and education on skin issues | |
| Staff C | Licensed Practical Nurse (LPN) | Reported on wound care and treatment orders |
| Staff D | Non-Certified Nurse Aide | Reported working evening/night shift and noticing wounds on Resident #5 |
| Staff E | Registered Nurse (RN) | Reported on treatment supplies and ordering |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
Investigation of complaints #104616-C, #105387-C, #105415-C, and #107016-C on September 8, 2022.
Complaint Details
Complaints #104616-C, #105387-C, #105415-C, and #107016-C were investigated and found to be credible with accepted plans of correction.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction following the complaint investigations, the facility will be certified in compliance effective October 19, 2022.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Nov 18, 2021
Visit Reason
An investigation of complaints #100238-C and #100658-C was conducted from 11/8/21 to 11/18/21 to determine compliance with regulations related to cardiopulmonary resuscitation (CPR) and resident safety.
Complaint Details
Complaint #100238-C and #100658-C were substantiated as the facility failed to provide timely CPR and failed to prevent falls as per care plans.
Findings
The facility was found noncompliant with CPR procedures, failing to perform CPR until EMS arrival for a resident in full code status, and lacking a CPR declaration page in a resident's clinical record. Additionally, the facility failed to follow care plans to prevent falls for residents. The facility provided education to staff and implemented corrective actions including audits, mock drills, and monitoring.
Deficiencies (3)
Personnel failed to provide basic life support, including CPR, to a resident requiring emergency care prior to EMS arrival.
Resident's clinical record lacked a CPR declaration page.
Facility failed to follow care plans to prevent further falls for residents.
Report Facts
Resident census: 37
Complaint investigation dates: Investigation conducted from 11/8/21 to 11/18/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse (LPN) | Reported performing CPR and involved in resident care during emergency |
| Staff F | Certified Nursing Assistant (CNA) | Reported resident rounds and involvement in emergency response |
| Director of Nursing | Director of Nursing (DON) | Reported educating staff on CPR policy and monitoring corrective actions |
Inspection Report
Renewal
Census: 31
Deficiencies: 5
Date: Aug 30, 2021
Visit Reason
The inspection was conducted as part of the Recertification Survey and Complaint investigations #91655, #92425, #94366, and #94656 from August 2, 2021 through August 30, 2021.
Complaint Details
Complaints #92425-C, #94366-C, and #94656-C were substantiated. Complaint #91655-C was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to meet professional standards of quality in comprehensive care plans, failure to provide ongoing activities support, incomplete assessments and follow-ups on changes of condition, improper placement and monitoring of feeding tubes, and inadequate infection prevention and control measures. The facility reported a census of 31 residents during the survey.
Deficiencies (5)
Failure to follow physician orders for residents, including incomplete documentation and failure to obtain blood draws as ordered.
Failure to provide ongoing activities support and meet interests for sampled residents.
Failure to complete assessments and follow-up on changes of condition for sampled residents.
Failure to properly place and monitor gastrostomy tubes according to professional standards.
Failure to establish and maintain an infection prevention and control program including proper PPE use and quarantine procedures.
Report Facts
Census: 31
Complaint investigations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Anderson | Named in relation to completion of infection control training. | |
| Staff J | Certified Nurse Aide | Mentioned as assisting with activities and coverage when activity director is absent. |
| Staff K | Certified Nurse Aide | Mentioned as assisting with activities and coverage when activity director is absent. |
| Staff A | Registered Nurse | Mentioned in relation to gastrostomy tube care and infection control observations. |
| Staff B | Certified Nurse Aide | Reported resident quarantine and COVID-19 related care. |
| Staff C | Certified Nurse Aide | Reported resident quarantine and COVID-19 related care. |
| Staff D | Housekeeper/Laundry Aide | Reported on resident admission and PPE setup. |
| Staff E | Housekeeper | Observed PPE compliance and room setup for isolation. |
| Staff F | Housekeeper | Observed PPE compliance and room setup for isolation. |
| Staff H | Licensed Practical Nurse | Reported resident activity participation and reminders. |
| Staff I | Licensed Practical Nurse | Reported resident activity participation and reminders. |
| Director of Nursing | Mentioned regarding attempts to locate documentation and infection control policies. | |
| Administrator | Mentioned regarding monitoring compliance and activity coverage. | |
| Nurse Consultant | Mentioned regarding resident care and infection control observations. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on December 1 - 2, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Routine
Census: 32
Deficiencies: 0
Date: Jun 25, 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.
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