Inspection Report Summary
The most recent inspection on December 10, 2025, found the facility in compliance based on acceptance of a plan of correction. Earlier inspections showed a pattern of deficiencies related mainly to infection prevention and control, food handling, and care planning, with some issues involving abuse reporting and resident care. Complaint investigations were mostly unsubstantiated, though a few substantiated complaints involved failure to post required information and timely abuse reporting. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made improvements over time, addressing prior deficiencies through accepted plans of correction.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
49 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 10, 2025
Visit Reason
This document is a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance and plan of correction.
Findings
The facility, Spurgeon Manor, is certified in compliance effective September 26, 2025, based on acceptance of their plan of correction. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 3, 2025
Visit Reason
A complaint investigation for complaints #2654644-C was conducted from October 30, 2025 to November 3, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for complaints #2654644-C; facility found in substantial compliance.
Report Facts
Complaint number: 2654644
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 2
Sep 25, 2025
Visit Reason
The inspection visit was conducted as an annual recertification survey combined with an investigation of complaint #2569412-C from September 22 to September 25, 2025.
Findings
The facility was found deficient in food procurement and sanitary food handling practices, including improper thawing of meat and inadequate hand hygiene by staff. Additionally, the infection prevention and control program was not properly maintained, with failures in staff compliance with enhanced barrier precautions and hand hygiene protocols.
Complaint Details
The visit included investigation of complaint #2569412-C conducted from September 22 to September 25, 2025.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Food Procurement, Store, Prepare, Serve - Sanitary: Facility failed to properly thaw/defrost meat and serve food under appropriate sanitary conditions. | E |
| Infection Prevention & Control: Facility failed to maintain an infection prevention and control program, including failure to ensure use of enhanced barrier precautions and proper hand hygiene. | D |
Report Facts
Census: 49
BIMS score: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2025
Visit Reason
Investigation of facility reported incident #127697-I conducted from 6/30/25 to 7/1/25.
Findings
The investigation resulted in no deficiency, and the facility was found to be in substantial compliance.
Complaint Details
Investigation of facility reported incident #127697-I; no deficiencies found; facility in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 2025
Visit Reason
A complaint investigation for Complaint #124853-C was conducted from January 8, 2025 to January 9, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #124853-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 8, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of the facility's 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, resulting in certification effective November 8, 2024.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 2
Nov 7, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification survey from November 4, 2024 to November 7, 2024.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for residents, including repeated hospitalizations and high-risk medications, and failed to properly prevent and treat pressure ulcers in residents at risk. The facility submitted a Plan of Correction addressing these deficiencies.
Deficiencies (2)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan including repeated hospitalizations and high-risk medications for residents. |
| Failure to properly prevent and treat pressure ulcers for residents at risk, including failure to prevent an unstageable pressure ulcer to bilateral heels. |
Report Facts
Census: 49
Resident count reviewed for care plans: 15
Resident count reviewed for pressure ulcers: 1
Braden Score: 15
Dates of inspection: 2024-11-04 to 2024-11-07
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dr Tingle | Physician | Provided progress notes and new orders related to pressure ulcer treatment |
| MDS Coordinator | Reviewed and updated care plans to be person-centered and comprehensive | |
| ADON | Assistant Director of Nursing | Reported on care plan expectations and interventions for high-risk medications and pressure ulcers |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2024
Visit Reason
A complaint investigation for complaint #123740-C was conducted from October 8, 2024 to October 9, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #123740-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 15, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective August 15, 2024.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Aug 8, 2024
Visit Reason
The inspection was conducted as a result of investigations into Complaints #116959-C, #117816-C, and Facility Reported Incidents #122575-I from August 5 to August 8, 2024.
Findings
The facility failed to properly post past survey results and ombudsman information in an accessible area for residents, family members, and legal representatives. Complaints #116959-C and #117816-C were substantiated. The facility has since updated ombudsman postings and taken corrective actions to ensure accessibility of survey results and information.
Complaint Details
Complaints #116959-C and #117816-C were substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to properly post past survey results and ombudsman information in an accessible area. |
Report Facts
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator revealed expectations for survey results and ombudsman information accessibility and was involved in observations and interviews. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 13, 2023
Visit Reason
The document is a plan of correction related to a credible allegation of compliance survey conducted at Spurgeon Manor Nursing Home.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the credible allegation of compliance as of 10/12/23.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 2
Oct 12, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey combined with the investigation of complaints #114131 and #114618.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements, specifically regarding timely updates to care plans for residents and deficiencies in infection prevention and control practices, including inadequate cleaning and disinfecting of shared glucometers.
Complaint Details
Complaint #114131 was substantiated; Complaint #114618 was not substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update Care Plans in a timely manner for residents, including missing information on medications that increase bleeding risk and lack of updates after hospital stays. | SS=D |
| Infection Prevention and Control program deficiencies, including failure to properly clean and disinfect shared glucometers according to manufacturer instructions and facility policy. | SS=D |
Report Facts
Census: 42
Complaint numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed using and cleaning the glucometer improperly during the survey |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for staff cleaning and care plan revisions |
| Administrator | Administrator | Explained expectations for timely care plan revisions |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 3, 2023
Visit Reason
This document is a plan of correction related to a survey of Spurgeon Manor Nursing Home to address compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements as of 2/28/23, with no deficiencies cited in this report.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Feb 16, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from February 14 to 16, 2023, following investigation of facility reported incidents #107928 and #109461. The visit was complaint-related to investigate allegations of abuse and neglect.
Findings
The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified related to failure to develop and implement abuse/neglect policies, failure to report alleged abuse timely, and failure to assess residents for injury following abuse allegations. The facility submitted a Plan of Correction to address these issues.
Complaint Details
The complaint investigation was triggered by allegations of abuse involving Resident #2. The facility failed to report the abuse allegations timely to the state agency and failed to assess the resident for injuries. The complaint #107928 was substantiated; complaint #109461 was not substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to develop and implement abuse/neglect policies including training, coordination with QAPI, reporting crimes, posting employee rights, and preventing retaliation. |
| Failure to report alleged abuse within required timeframes to the Iowa Department of Inspections and Appeals (IDIA). |
| Failure to assess resident for injury following allegation of abuse and failure to document such assessments. |
| Failure to follow facility policy for reporting alleged abuse, including improper use of text messaging instead of direct calls. |
| Failure to educate and re-educate staff on abuse prevention and reporting policies. |
Report Facts
Total Residents: 45
Incident Dates: Incidents occurred on 12/3/22 and were investigated during the survey
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant involved in abuse incident and reporting | |
| Staff B | Licensed Practical Nurse involved in abuse incident and reporting | |
| Staff C | Staff member who reported the incident and communicated with leadership | |
| Director of Nursing | DON | Involved in abuse policy enforcement and reporting procedures |
| Assistant Director of Nursing | ADON | Conducted assessments and involved in abuse reporting |
| Staff D | Certified Nursing Assistant | Reported concerns of abuse to charge nurse |
| Staff E | Registered Nurse | Reported allegations to management |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 8, 2022
Visit Reason
An annual recertification survey and investigation of complaints #98400-C, #101858-C, and #98836-C were conducted from 2022-07-05 to 2022-07-08.
Findings
Complaint #98836-C was substantiated, while complaints #98400-C and #101858-C were not substantiated. The facility was found to be in substantial compliance.
Complaint Details
Complaint #98400-C was not substantiated. Complaint #98836-C was substantiated. Complaint #101858-C was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 12, 2021
Visit Reason
An investigation of Facility Report #96261-M was completed from 3/11/2021 to 4/12/2021.
Findings
The investigation resulted in no deficiencies. Results from the investigation will be sent under separate cover at a later date.
Complaint Details
Investigation of Facility Report #96261-M was completed with no deficiencies found.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 7
Mar 25, 2021
Visit Reason
An annual recertification health survey was conducted from March 8, 2021 to March 25, 2021 to assess compliance with federal regulations and facility policies.
Findings
The survey identified multiple deficiencies including failure to ensure all employees had completed required criminal background and abuse registry checks, inadequate coordination of PASARR assessments, failure to follow bathing assistance plans, inadequate quality of care including failure to perform CPR during a cardiac arrest, and failure to prevent accidents such as skin tears. The facility reported a census of 46 residents during the survey.
Deficiencies (7)
| Description |
|---|
| Failure to assure all employees had completed Iowa criminal background and abuse registry checks prior to working. |
| Failure to coordinate PASARR assessments and refer residents with possible serious mental disorders for evaluation. |
| Failure to follow the plan of care for bathing assistance and respect resident preferences. |
| Failure to provide quality care including failure to perform CPR during a resident's cardiac arrest. |
| Failure to ensure residents received timely interventions and notification of physician for condition changes. |
| Failure to prevent accidents and injuries including failure to remove defective equipment and prevent skin tears. |
| Failure to properly administer psychotropic medications and monitor residents for side effects. |
Report Facts
Census: 46
Staff sample: 5
Residents reviewed: 12
Residents reviewed: 46
Resident #21 MDS assessment date: Jan 20, 2021
Resident #37 last PASRR date: Jul 7, 2014
Resident #47 MDS assessment date: Oct 1, 2020
Resident #21 Fall Risk Assessment score: 75
Resident #21 shower refusals: 3
Resident #21 showers received: 5
Resident #24 call light response time: 15
Resident #21 call light response time: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in deficiency related to background check completion and failure to perform CPR |
| Staff P | Licensed Practical Nurse (LPN) | Named in deficiency related to knowledge of resident status and medication administration |
| Staff Q | RN (Hospice Director) | Named in deficiency related to hospice care and CPR expectations |
| Staff M | Hospice RN | Named in deficiency related to hospice care and resident death |
| Staff D | Certified Nursing Assistant (CNA) | Named in deficiency related to resident injury and skin tear incident |
| Staff H | Physical Therapy | Named in deficiency related to electrical stimulation treatment and skin injury |
| Staff G | Maintenance | Named in deficiency related to equipment repair and maintenance |
| Staff E | Registered Nurse (RN) | Named in deficiency related to wound care and injury reporting |
| Staff C | Licensed Practical Nurse (LPN) | Named in deficiency related to wound care and resident observation |
| Staff I | Registered Nurse (RN) | Named in deficiency related to wound observation |
| Staff F | Environmental Specialist | Named in deficiency related to equipment maintenance |
| Staff N | Activities Coordinator | Named in deficiency related to equipment maintenance reporting |
| Staff J | Certified Nurse Assistant (CNA) | Named in deficiency related to resident observation and medication administration |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Aug 11, 2020
Visit Reason
A focused COVID-19 infection control survey and investigation of Complaint #88023-C, #89768-C, and Facility Reported Incident #87171-I was conducted ending 08/11/2020.
Findings
The investigation found that Complaint #88023-C, #89768-C, and Facility Reported Incident #87171-I were not substantiated. Deficiencies were identified related to failure to report alleged abuse within required timeframes and infection control practices, including failure to follow infection control procedures and annual review requirements.
Complaint Details
Complaint #88023-C was not substantiated. Complaint #89768-C was not substantiated. Facility Reported Incident #87171-I was not substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 24 hours for one resident who reported missing valuables. |
| Failure to follow infection control practices to prevent and reduce the risk of spreading infection and disease, including failure to conduct an annual review of the infection prevention and control program. |
Report Facts
Census: 44
Date of survey completion: Aug 11, 2020
Correction date: Sep 3, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Registered Nurse | Reported filling out missing belongings form and involvement in missing rings incident |
| Staff G | Licensed Practical Nurse | Reported completing missing item report and searching for missing rings |
| Staff K | Certified Nursing Assistant | Reported observations about resident wearing rings and behaviors related to missing items |
| Staff D | Licensed Practical Nurse | Reported information about missing rings incident and training |
| Staff E | Certified Medication Assistant | Reported missing belongings and observations about resident's rings and bruises |
| Staff F | Physician | Met with administrator to review PPE needs |
| Staff A | Registered Nurse | Observed performing blood sugar test and infection control practices |
| Staff M | Housekeeper | Observed wearing mask and goggles |
| Staff N | Dietary Cook | Observed serving food wearing mask and hairnet |
| Staff B | Certified Nursing Assistant | Reported on isolation gown use and resident care |
| Staff O | Certified Nursing Assistant | Assisted resident and observed infection control practices |
| Staff C | Registered Nurse | Reported on isolation signage and resident precautions |
Inspection Report
Routine
Census: 46
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections 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.
Report Facts
Total census: 46
Loading inspection reports...
