Inspection Reports for Odebolt Specialty Care
801 South Des Moines Street, Odebolt, IA, 514584867
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 10, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed pattern, with prior annual and complaint investigations identifying deficiencies related mainly to medication management, resident supervision, infection control, and care planning. Notable issues included a fall down basement stairs due to inadequate supervision, incomplete medication and care assessments, and lapses in infection prevention practices, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaint investigations were unsubstantiated, though some substantiated complaints involved resident safety and care concerns. The facility’s recent inspections suggest improvement, with the latest surveys showing compliance following earlier citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
33 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 10, 2025
Visit Reason
A complaint investigation was conducted for facility reported incident #2681826-I.
Complaint Details
Complaint investigation for incident #2681826-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
A complaint investigation for complaint #129302-C and facility reported incident #129319-I was conducted from June 17th, 2025 to June 24th, 2025.
Complaint Details
Investigation was related to complaint #129302-C and facility reported incident #129319-I; 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 6, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was certified in compliance with health requirements effective March 6, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 5
Date: Feb 17, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from February 17, 2025 to February 20, 2025.
Findings
The facility failed to accurately represent residents' medication use in Minimum Data Set (MDS) assessments for 3 residents, failed to provide comprehensive care plans related to high-risk medications for 2 residents, failed to maintain quality of care for 1 resident including proper assessment after ER visits, failed to provide adequate supervision to prevent accidents for 1 resident, and failed to maintain infection prevention and control for 1 resident with catheter care.
Deficiencies (5)
Failure to accurately record medication use in MDS assessments for Residents #2, #26, and #27.
Failure to develop and implement comprehensive care plans related to high-risk medications for Residents #26 and #27.
Failure to provide assessment and interventions necessary to maintain residents' highest practical physical well-being for Resident #7.
Failure to provide adequate nursing supervision to prevent accidents and injuries for Resident #5.
Failure to establish and maintain an infection prevention and control program for Resident #9.
Report Facts
Residents reviewed: 3
Census: 33
Residents reviewed: 5
Residents reviewed: 14
Residents reviewed: 1
Residents reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed confirming medication and care plan issues for Residents #26 and #27 |
| Director of Nursing (DON) | Interviewed regarding expectations for accurate MDS assessments and care plans, and verified progress notes and assessments for Resident #7 and Resident #9 | |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #5 and involved in fall incident |
| Staff C | Certified Nursing Assistant (CNA) | Observed and assisted with Resident #9 catheter care and infection control |
| Staff D | Certified Nursing Assistant (CNA) | Observed and assisted with Resident #9 catheter care and infection control |
| Administrator | Reported expectations for staff use of gait belts and infection control procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
Investigation of facility reported incident #124391-M and complaint #124397-C conducted from January 08, 2025 to January 13, 2025.
Complaint Details
Complaint #124397-C was investigated and resulted in no deficiencies.
Findings
The investigation resulted in no deficiencies. Findings for facility reported incident #124391-M will be sent to the facility at a later date under separate cover.
Report Facts
Incident number: 124391
Complaint number: 124397
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
A complaint investigation for complaint #122262-C was conducted from July 24, 2024 to July 25, 2024.
Complaint Details
Complaint #122262-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
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaints #121889-C and facility reported incident #121955-I from July 9 through July 11, 2024. Both complaints and incident were substantiated.
Complaint Details
Complaints #121889-C and facility reported incident #121955-I were substantiated. The incident involved Resident #1 falling down 13 basement stairs after wandering through an unsupervised kitchen door left propped open.
Findings
The facility failed to prevent an accident for a cognitively impaired resident who self-propelled in her wheelchair through an unsupervised, propped-open kitchen door and fell down 13 basement stairs, sustaining multiple injuries. The facility implemented corrective actions including door audits and staff education.
Deficiencies (1)
Failure to prevent an accident for 1 of 3 residents reviewed for wandering with cognitive impairments, resulting in a fall down 13 basement stairs in a wheelchair.
Report Facts
Number of residents present: 29
Number of stairs fallen: 13
Time of incident: 1855
Number of sutures: 7
Vital signs: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Cook | Found Resident #1 at bottom of basement stairs; acknowledged forgetting to close kitchen door |
| Staff D | Dietary Aide | Last saw Resident #1 at dining table; responsible for cleaning dining area and asked to close kitchen door |
| Staff A | Certified Nursing Assistant (CNA) | Involved in searching for Resident #1 and providing initial assessment and first aid |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 to nurse's station and participated in search |
| Staff E | Certified Nursing Assistant (CNA) | Participated in search and assisted Resident #1 after fall |
| Social Worker | Participated in search and assisted Resident #1 after fall; called 911 | |
| DON | Director of Nursing | Received call about missing resident, arrived during emergency response, conducted investigation and staff education |
| Administrator | Instructed staff to search for missing resident and coordinated response |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 4
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaint intakes #119308-C, #119511-I, and #119537-I.
Complaint Details
Complaint #119308-C was substantiated.
Findings
The facility was found not in compliance with multiple requirements including accuracy of resident assessments, quality of care related to skin assessments and diabetic ulcers, food procurement and sanitary preparation, and infection prevention and control practices related to catheter drainage bags.
Deficiencies (4)
Failed to complete a discharge Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed (Resident #31).
Failed to accurately complete skin assessments to prevent delay in treatment and decline in condition of a diabetic ulcer for 1 of 3 residents reviewed (Resident #21).
Failed to store and prepare food under sanitary conditions, including accumulation of food debris, dried liquid, and lime-like substance in kitchen and dishwashing areas.
Failed to provide appropriate infection prevention practices related to catheter drainage bags for 1 of 4 residents reviewed (Resident #8).
Report Facts
Resident census: 30
Diabetic ulcer measurements: 0.36
Diabetic ulcer measurements: 3.05
Diabetic ulcer measurements: 0.52
Diabetic ulcer measurements: 1.7
Diabetic ulcer measurements: 9.1
Diabetic ulcer measurements: 3.5
Diabetic ulcer measurements: 0.97
Diabetic ulcer measurements: 1.31
Diabetic ulcer measurements: 1.01
Diabetic ulcer measurements: 0.34
Diabetic ulcer measurements: 0.73
Diabetic ulcer measurements: 0.68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Verified Resident #31 did not have a discharge MDS completed |
| Director of Nursing | Director of Nursing (DON) | Reported expectation that MDS assessments be completed and turned in at appropriate times; also explained infection control expectations regarding catheter drainage bags |
| Staff C | Hospice Licensed Practical Nurse (LPN) | Reported assessment findings of new yellow ulcers on Resident #21's feet |
| MDS Nurse | MDS Nurse | Reported first learning of Resident #21's right toe ulcers on 2/28/24 and explained measurement issues |
| Dietary Manager | Dietary Manager (DM) | Reported expectations for sanitary kitchen conditions and noted cleaning deficiencies |
| Administrator | Administrator | Reported expectation that staff follow policy and professional practice regarding skin assessments |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
The inspection visit was conducted as an onsite revisit following a previous survey ending January 4, 2024, to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Odebolt Specialty Care Nursing Home was found to be in substantial compliance with the federal requirements as of February 19, 2024.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 6
Date: Jan 4, 2024
Visit Reason
The inspection was conducted due to complaint investigations of multiple intakes alleging deficiencies in resident rights, transfer and discharge requirements, quality of care, accident hazards, respiratory care, and physician supervision.
Complaint Details
The complaint investigation included intakes #112960-C, #113290-C, #113338-I, #113357-C, and #1176474-C. Complaints #112960-C, #113290-C, #113357-C, and #1176474-C were substantiated. Facility reported incident #113338-I was substantiated.
Findings
The facility was found non-compliant with multiple federal regulations including failure to treat residents with dignity and respect, failure to notify physicians timely about resident discharges, inadequate wound care, inadequate supervision leading to resident elopement, failure to provide adequate oxygen therapy, and lack of signed physician orders in clinical records.
Deficiencies (6)
Failure to treat residents with dignity and respect, including forcing residents to leave their rooms for meals against their wishes.
Failure to notify physician timely about resident discharge and failure to document reasons for discharge.
Failure to provide adequate wound care and documentation for a resident with a wound vacuum.
Failure to provide adequate supervision resulting in resident elopement.
Failure to provide adequate oxygen therapy and monitoring, resulting in resident found unresponsive with oxygen saturation of 45% and empty oxygen tank.
Failure to maintain signed physician orders in clinical records for multiple residents.
Report Facts
Deficiencies substantiated: 4
Residents reviewed: 5
Residents reviewed: 15
Oxygen saturation: 45
Oxygen saturation: 17
Oxygen saturation: 12
Oxygen saturation: 88
Oxygen saturation: 96
Oxygen saturation: 91
Oxygen liters: 3
Oxygen liters: 10
Oxygen liters: 8
Oxygen liters: 60
Wound measurements: 16.3
Wound measurements: 7.1
Wound measurements: 3.1
Wound measurements: 4
Wound measurements: 2.2
Wound measurements: 2.2
Wound measurements: 1.4
Wound measurements: 1.1
Wound measurements: 0.5
Wound measurements: 1.9
Wound measurements: 13.5
Wound measurements: 7.4
Wound measurements: 2.6
Wound measurements: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Named in resident dignity and respect finding and oxygen therapy failure |
| Staff B | Certified Nurse Aide | Named in resident dignity and respect finding and elopement incident |
| Staff F | Licensed Practical Nurse | Named in wound care and oxygen therapy findings |
| Staff I | Licensed Practical Nurse | Named in wound care findings |
| Staff D | Licensed Practical Nurse | Named in resident elopement and oxygen therapy findings |
| Staff G | Certified Nurse Aide | Named in oxygen therapy failure |
| Staff N | Director of Nursing | Named in resident elopement and oxygen therapy findings |
| Staff M | Former Administrator | Named in resident discharge and elopement findings |
| Staff L | Former Director of Nursing | Named in resident discharge and elopement findings |
| Staff K | Regional Director | Named in oxygen therapy and physician order findings |
| Resident #2's Representative | Named in resident discharge and elopement findings | |
| Resident #9's physician | Named in oxygen therapy findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
The document is a plan of correction submitted by the facility following a prior inspection to address cited deficiencies and achieve compliance.
Findings
The facility was found to be in compliance based on acceptance of their credible allegation of compliance and plan of correction, effective January 31, 2023.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 5
Date: Jan 19, 2023
Visit Reason
The inspection was conducted as a recertification health survey and investigation of complaint #107965, which was found to be unsubstantiated.
Complaint Details
Complaint #107965 was investigated and found to be unsubstantiated.
Findings
The facility failed to notify the provider of medications not received by Resident #14 after hospital discharge and failed to administer four different medications for six consecutive days. The facility also failed to follow physicians' orders for medication administration related to blood pressure parameters for Resident #14. Additional findings included failure to coordinate PASARR assessments and failure to provide accurate dialysis assessments for Resident #14.
Deficiencies (5)
Failure to notify provider of medications not received by Resident #14 after hospital discharge.
Failure to administer four different medications to Resident #14 for six consecutive days after hospital discharge.
Failure to follow physicians' orders for medication administration related to blood pressure parameters for Resident #14.
Failure to coordinate PASARR assessments and resubmissions for Residents #13, #15, and #23.
Failure to provide accurate and complete dialysis assessments for Resident #14.
Report Facts
Census: 27
Medication administration failures: 4
Dialysis hospitalizations: 2
Dialysis assessments: 1
Dialysis treatments missed documentation: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and achieve compliance certification.
Findings
The facility was found to have deficiencies but submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective October 28, 2022.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaints (#100313-C, #107050-C, #107422-C, #105515-I, and #107178-I) related to resident care and staffing issues at Odebolt Specialty Care.
Complaint Details
Complaints #100313-C and #107050-C were not substantiated. Complaint #107422-C was substantiated. Facility reported incident #105515-I was substantiated. Facility reported incident #107178-I was not substantiated.
Findings
The facility was found to have insufficient nursing staff to meet resident needs, resulting in delayed call light responses and inadequate care. Medication administration deficiencies were also identified, including failure to accurately reconcile controlled substances and narcotic counts. Several residents reported concerns about staffing shortages and care delays.
Deficiencies (2)
Insufficient nursing staff to provide timely care and respond to call lights promptly.
Failure to establish a system to accurately reconcile controlled medications and maintain proper records.
Report Facts
Resident census: 31
Deficiencies cited: 2
Call light response audit frequency: 5
Medication reconciliation audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported staffing shortages and care issues |
| Staff B | Certified Nursing Assistant (CNA) | Reported staffing shortages and care issues |
| Staff C | Certified Nursing Assistant (CNA) | Reported staffing shortages and care issues |
| Staff D | Licensed Practical Nurse (LPN) | Reported staffing shortages and medication administration issues |
| Staff E | Certified Nursing Assistant (CNA) | Reported staffing shortages and care issues |
| Staff F | Certified Nursing Assistant (CNA) | Reported staffing shortages and care issues |
| Staff G | Certified Nursing Assistant (CNA) | Reported staffing shortages and care issues |
| Staff H | Licensed Practical Nurse (LPN) | Reported staffing shortages and medication administration issues |
| Staff I | Certified Nursing Assistant / Certified Medication Aide (CNA/CMA) | Reported medication administration issues |
| Staff J | Licensed Practical Nurse (LPN) | Reported medication administration issues |
| Staff K | Licensed Practical Nurse (LPN) | Reported medication administration issues |
| Director of Nursing | Director of Nursing (DON) | Verified staffing shortages and medication administration issues |
| MDS Coordinator | MDS Coordinator | Reported staffing and medication administration issues |
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 5
Date: Sep 7, 2021
Visit Reason
A recertification health survey was conducted from 09/07/21 to 09/13/21 to assess compliance with federal regulations and to follow up on previously identified deficiencies.
Findings
The facility was found deficient in several areas including comprehensive resident assessments, development and implementation of comprehensive care plans, food procurement and sanitation, quality assurance and performance improvement meetings, and infection prevention and control. Deficiencies were corrected by the Regional Director of Clinical Services and other staff by specified correction dates.
Deficiencies (5)
Failure to conduct comprehensive assessments of residents' functional capacity and needs.
Failure to develop and implement comprehensive care plans addressing respiratory deficits and other needs.
Failure to procure, store, prepare, and serve food in a sanitary manner preventing foodborne illness.
Failure to maintain a quality assessment and assurance committee and hold required quarterly meetings.
Failure to establish and maintain an infection prevention and control program including screening of staff and visitors and use of PPE.
Report Facts
Resident census: 26
Number of residents reviewed for comprehensive assessments: 16
Number of residents reviewed for care plans: 16
Number of QAPI meetings missed: 3
COVID-19 positivity rate: 5.2
Screening log entries: 638
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynn Simpson | Administrator | Signed plan of correction and involved in deficiency corrections |
| Director of Nursing | Provided statements regarding resident care and QAPI meetings | |
| Regional Director of Clinical Services | Educated staff and corrected deficiencies | |
| Dietary Services Manager | Updated cleaning schedules and corrected food sanitation deficiencies | |
| Administrator | Reeducated staff on screening and PPE use |
Inspection Report
Abbreviated Survey
Census: 24
Deficiencies: 2
Date: Jun 11, 2020
Visit Reason
A COVID-19 focused infection control survey was conducted to determine compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility failed to maintain a sanitary environment to prevent pathogen transmission for 5 of 24 residents in isolation and lacked current infection control policies aligned with national standards. Observations included lack of signage, PPE, and proper handling of isolation protocols.
Deficiencies (2)
Failure to maintain sanitary environment and infection control for residents in isolation, including lack of signage, PPE availability, and use of ineffective disinfectants.
Facility policies and procedures for infection control were outdated and not aligned with current COVID-19 guidance.
Report Facts
Residents reviewed: 24
Residents with infection control deficiencies: 5
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