Inspection Reports for Centerville Specialty Care
1208 East Cross Street, IA, 525443599
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 31, 2025, noted one deficiency but accepted the facility’s plan of correction and certified substantial compliance. Earlier inspections showed multiple deficiencies related to residents’ rights, quality of care including blood sugar management, accident hazards, menu adequacy, and infection prevention. Complaint investigations revealed some substantiated issues, including failure to ensure respectful treatment of a resident and inadequate catheter management, but most complaints were found unsubstantiated or resulted in substantial compliance findings. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with care quality and safety, with some corrective actions accepted but no clear pattern of sustained improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
38 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 31, 2025
Visit Reason
This document is a statement of deficiencies and plan of corrections following an inspection, indicating acceptance of credible allegation of substantial compliance and plan of correction.
Findings
The facility will be certified in compliance effective December 19, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and plan of correction
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 5
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual recertification survey of Centerville Specialty Care from December 2 to December 4, 2025.
Findings
The facility was found to have multiple deficiencies related to residents' rights to be informed and make treatment decisions, quality of care including blood sugar management, free of accident hazards, menu adequacy, and infection prevention and control. Corrective actions and education plans were outlined for nursing and dietary staff to address these issues.
Deficiencies (5)
Right to be Informed/Make Treatment Decisions - Facility failed to obtain medication consents for residents prior to medication initiation.
Quality of Care - Facility failed to ensure proper monitoring and notification of elevated blood sugar for residents.
Free of Accident Hazards/Supervision/Devices - Facility failed to prevent falls and ensure proper use of gait belts.
Menus Meet Resident Needs/Prep in Advance/Followed - Facility failed to provide correct portions of mechanical soft and pureed diets.
Infection Prevention and Control - Facility failed to implement infection prevention program properly, including PPE use and catheter care.
Report Facts
Census: 38
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Named in fall incident and gait belt use deficiency |
| Director of Nursing | Mentioned in relation to medication initiation and infection control findings | |
| Staff B | Cook | Mentioned in relation to food portioning and menu deficiency |
| Dietary Manager | DM | Mentioned in relation to menu and dietary portioning deficiency |
| Staff A | Physical Therapy Assistant (PTA) | Mentioned in infection control deficiency related to PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
The investigation was conducted in response to complaint #2582139-C from October 13, 2025 to October 15, 2025.
Complaint Details
Investigation of complaint #2582139-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A complaint investigation was conducted for Complaint #129325-C and facility reported incidents #129184-I and #129323-I from June 17, 2025 to June 25, 2025.
Complaint Details
Complaint #129325-C and facility reported incidents #129184-I and #129323-I were investigated and found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
A complaint investigation was conducted for facility reported incident #124765-I from January 6, 2025 to January 7, 2025.
Complaint Details
Incident #124765-I was not substantiated.
Findings
The facility was found to be in compliance and the incident #124765-I was not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 31, 2024.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 2
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey completed from 10/14/24 to 10/17/24.
Findings
The facility was found deficient in meeting nutritional needs of residents on pureed diets and in food procurement, kitchen sanitation, and food handling practices. Specific issues included incorrect portion sizes and textures served, inadequate kitchen sanitation, and food safety violations.
Deficiencies (2)
Menus did not meet nutritional needs of residents on pureed diets; incorrect portion sizes and textures served.
Food procurement, store, prepare, and serve sanitary requirements not met; inadequate kitchen sanitation and food handling observed.
Report Facts
Census: 36
Audits planned: 4
Audits planned: 2
Audits planned: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in findings related to food portioning, kitchen sanitation, and food handling |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #122478-C, #122486-C and a facility self-report #122524-I from August 21 to August 22, 2024.
Complaint Details
The investigation was based on complaints #122478-C, #122486-C and facility self-report #122524-I. The complaints and self-report were substantiated. The deficiency involved staff escalating interactions with Resident #1, including physical contact and pushing, which was not in line with facility policies on abuse prevention.
Findings
The facility was found to have failed to ensure that one resident (Resident #1) was treated with respect and dignity during interactions, as evidenced by staff behavior that escalated to physical contact. The complaints and self-report were substantiated, and the facility had corrected the deficiency from a prior non-compliance dated August 2, 2024.
Deficiencies (1)
Failure to ensure each resident was treated with respect and dignity while interacting with Resident #1.
Report Facts
Census: 40
Complaints investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in findings related to inappropriate physical interaction with Resident #1. |
| Staff C | Housekeeping Supervisor | Provided interview details about the incident involving Resident #1. |
| Staff D | Housekeeper | Witnessed and described interactions between Staff A and Resident #1. |
| Staff E | Housekeeper | Witnessed and described interactions between Staff A and Resident #1. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance effective August 2, 2024, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as a result of complaints #120070-C, #120181-C, #121268-C, and #121820-C from July 25, 2024 to August 1, 2024. Complaint #120070-C was substantiated.
Complaint Details
Complaint #120070-C was substantiated based on clinical record review and staff interviews indicating failure to properly manage catheter removal and voiding for Resident #5, and failure to conduct required neurological assessments for Resident #6.
Findings
The facility failed to ensure residents were appropriately assessed and provided interventions to maintain optimal health and well-being for 2 of 4 residents reviewed. Specific issues included improper catheter management and failure to monitor neurological assessments as required.
Deficiencies (1)
Failure to ensure residents receive treatment and care in accordance with professional standards, specifically related to catheter management and neurological assessments.
Report Facts
Resident census: 45
Brief Mental Status (BIMS) score: 15
Complaint numbers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Named in findings related to catheter removal and neurological assessments |
| Staff A | Registered Nurse | Interviewed regarding care of Resident #5 and catheter voiding concerns |
| Staff D | Certified Nurse Aide | Interviewed regarding Resident #5 catheter removal day |
| Staff F | Involved in neurological evaluations and vital sign recordings for Resident #6 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
A complaint investigation for Complaint #116406-C was conducted from March 26, 2024 to March 28, 2024.
Complaint Details
Complaint #116406-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: Oct 9, 2023
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 9, 2023.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 5
Date: Sep 18, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of a Facility Reported Incident #115431-I.
Complaint Details
Facility reported incident #115431-I was unsubstantiated.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable, and homelike environment; inadequate housekeeping and maintenance; failure to meet professional standards of medication administration; failure to provide adequate bathing care; failure to ensure safe administration of medications; failure to provide adequate supervision and assistance devices to prevent accidents; and failure to ensure call lights were accessible to residents.
Deficiencies (5)
Failure to maintain a safe, clean, comfortable, and homelike environment including housekeeping and maintenance issues such as rust on toilet riser, stained flooring, and strong odors.
Failure to meet professional standards of medication administration for 3 of 7 residents reviewed, including medication errors and improper insulin administration.
Failure to provide adequate bathing care for dependent residents, with some residents not receiving showers or baths as needed.
Failure to ensure the facility remained free of accident hazards and provide adequate supervision and assistance devices to prevent accidents.
Failure to ensure call lights were accessible and within reach of residents in bed or confined to a chair.
Report Facts
Census: 51
Residents reviewed for housekeeping deficiency: 3
Residents reviewed for medication administration: 7
Residents reviewed for bathing care: 3
Residents reviewed for accident hazards: 24
Residents reviewed for call light accessibility: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Named in medication administration deficiencies including improper insulin administration and medication errors. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding facility maintenance issues and bathing care deficiencies. |
| Staff C | Licensed Practical Nurse (LPN) | Prepared insulin injections and involved in medication administration. |
| Staff B | Certified Nursing Aide (CNA) | Reported issues related to bathing equipment. |
| Staff E | Corporate Nurse Consultant (CNC) | Discussed bathing care and facility cleanliness. |
| Staff F | Certified Medication Assistant (CMA) | Reported lack of shower chair availability. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 12, 2023
Visit Reason
A complaint investigation for complaints #112121-C and #112328-C was conducted from May 4, 2023 to May 12, 2023.
Complaint Details
Complaint investigation for complaints #112121-C and #112328-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 12, 2023
Visit Reason
A revisit of the survey ending February 16, 2023 was conducted from May 4, 2023 through May 12, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 17, 2023.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 4
Date: Feb 16, 2023
Visit Reason
The inspection was conducted as a result of investigation of multiple complaints and facility-reported incidents concerning resident care and safety at Centerville Specialty Care.
Complaint Details
Complaints #108491-C, #109045-C, #109588-C, #109770-C, #109816-C, #110729-C, #110800-C and facility reported incidents #100898-I and #110836-I were investigated. Complaints #108491-C, #109816-C, #110729-C and #110800-C were substantiated. Facility reported incidents #100898-I and #110836-I were substantiated.
Findings
The facility was found to have deficiencies related to resident participation in care planning, notification of changes in condition, prevention and treatment of pressure ulcers, accident hazards and supervision, and other care and safety issues. Several residents were identified as being affected by these deficiencies, including Resident #1, #4, and #9. The facility failed to meet regulatory requirements in multiple areas, including communication with residents and families, care planning, and environmental safety.
Deficiencies (4)
Right to participate in planning care was not met; residents and responsible parties were not included in care plan development and revisions.
Failure to notify resident and responsible party of changes in condition and injury.
Failure to provide treatment and services to prevent pressure ulcers and promote healing.
Failure to ensure resident environment was free of accident hazards, including unsafe placement of beds near heaters and unsecured doors.
Report Facts
Census: 46
Deficiencies cited: 4
Resident scores: 8
Resident scores: 3
Resident scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chanda Willingham | Registered Nurse (RN), Director of Nursing (DON) | Named in relation to findings on resident care, notification, and pressure ulcer treatment. |
| Natasha Blackburn | Administrator | Named in relation to facility administration and communication regarding deficiencies and corrective actions. |
| Heather Wells | Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) | Named in relation to wound care education and in-service training. |
| Teri Garr | Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Coordinator | Named in relation to care plan conference and family notification. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
An onsite revisit survey was conducted with an investigation of complaints 105381-C and 106778-C from 8/15/22 to 8/24/22, for the recertification survey and investigation of multiple intakes conducted on 7/5/22 - 7/9/22.
Complaint Details
The visit included investigation of complaints 105381-C and 106778-C and multiple intakes (#101173-C, #103171-C, #103248-C, #105298-C, and #105395-I).
Findings
All deficiencies identified in the prior investigations have been corrected and the facility is in compliance with all regulations surveyed effective 8/3/22. A discretionary denial of payment for new admissions was effectuated from 8/9/22 to 8/15/22.
Report Facts
Denial of Payment Duration: 7
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 13
Date: Jul 7, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints and facility-reported incidents.
Findings
The report details multiple deficiencies related to medication administration, resident rights, food service, infection control, call light response, and quality of care. Corrective actions and plans of correction were provided for each deficiency.
Deficiencies (13)
Failure to provide education to nursing staff regarding medication administration and self-administration.
Failure to honor resident food choices and preferences.
Failure to complete call light audits and respond timely to call lights.
Failure to provide and document advance directives appropriately.
Failure to provide education to nursing staff regarding completion of physician orders and medication administration.
Failure to provide adequate supervision to prevent abuse and neglect.
Failure to provide education to nursing staff regarding infection control and COVID-19 testing.
Failure to provide adequate staffing to meet resident needs.
Failure to provide palatable meals and maintain proper food temperatures.
Failure to maintain dish machine temperatures and proper sanitation.
Failure to maintain proper garbage disposal and refuse management.
Failure to maintain accurate and complete medical records and medication administration records.
Failure to provide adequate pest control measures.
Report Facts
Resident census: 63
Plan of correction completion dates: Jul 25, 2022
Number of call light audits: 4
Number of glucose checks: 3
Number of audits: 2
Number of residents: 63
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A Focused Infection Control Survey and Complaint #94395 were conducted by the Department of Inspection and Appeals on November 16 - 18, 2020.
Complaint Details
Complaint #94395-C was not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Complaint #94395-C was not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
A Focused Infection Control Survey and Facility Reported Incident #90800 were conducted by the Department of Inspection and Appeals on September 21 - 24, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices. Facility Reported Incident #90800-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Jun 15, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey and complaint investigation (#91253) conducted by the Department of Inspection and Appeals from June 15 to 17, 2020, to assess compliance with CMS and CDC recommended infection control practices.
Complaint Details
Complaint #91253-C was substantiated.
Findings
The facility was found not in substantial compliance with CMS and CDC recommended COVID-19 infection control practices, including failure to implement effective screening, proper hand hygiene, and appropriate use of personal protective equipment (PPE) by staff. The complaint was substantiated.
Deficiencies (1)
Failure to implement CMS and CDC recommended infection control practices to control the spread of COVID-19, including ineffective screening, improper hand hygiene, and inadequate PPE use.
Report Facts
Census: 50
Staff sample size: 50
Correction date: Jul 23, 2020
Date survey completed: Jun 17, 2020
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 4
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as an annual health survey to assess compliance with federal regulations and evaluate the facility's care and infection control practices.
Findings
The facility was found deficient in several areas including accuracy of resident assessments, development and implementation of comprehensive care plans, and infection prevention and control practices. Specific issues included inaccurate MDS assessments, incomplete care plans for residents, and failure to follow infection control protocols.
Deficiencies (4)
Accuracy of Assessments - The assessment failed to accurately reflect the resident's status for 1 of 15 sampled residents.
Develop/Implement Comprehensive Care Plan - The facility failed to develop and implement a comprehensive person-centered care plan for 1 of 15 sampled residents.
Care Plan Timing and Revision - The facility failed to update the care plans for 2 of 2 sampled residents.
Infection Prevention & Control - The facility failed to establish and maintain an infection prevention and control program, including failure to follow infection control techniques and annual review.
Report Facts
Residents sampled: 15
Residents with care plan issues: 3
Residents with infection control issues: 2
Census: 49
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted due to reported incidents involving falls and safety concerns for residents at Centerville Specialty Care.
Complaint Details
The investigation was triggered by complaints related to falls and inadequate use of safety devices for Residents #1 and #2. Resident #1 fell from a shower chair without the safety belt secured, and Resident #2 tipped her wheelchair due to lack of a footboard, sustaining serious injuries.
Findings
The facility failed to provide adequate supervision and use of safety devices to prevent falls for two residents, resulting in serious injuries including a femur fracture and a cervical fracture. Staff failed to secure a safety strap on a shower chair and did not use a footboard on a wheelchair as required by care plans.
Deficiencies (2)
Failure to secure safety strap around Resident #1 in shower chair, resulting in fall and femur fracture.
Failure to use footboard on wheelchair for Resident #2, resulting in wheelchair tipping and cervical fracture.
Report Facts
Census: 52
Falls: 30
Incident date: Oct 7, 2019
Incident date: Dec 10, 2019
Incident date: Jan 7, 2020
Resident #2 death date: Jan 10, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Aide | Involved in transferring Resident #1 and failed to secure safety belt |
| Staff B | Nurse Aide | Assisted with Resident #1 transfer and witnessed fall |
| Staff C | Licensed Practical Nurse | Responded to Resident #1 fall and provided assessment |
| Staff D | Licensed Practical Nurse | Provided follow-up care for Resident #1 after fall |
| Staff E | Licensed Practical Nurse | Worked during Resident #2 falls and added footboard intervention |
| Staff F | Therapy Supervisor | Consulted on wheelchair interventions for Resident #2 |
| Staff G | Licensed Practical Nurse | Responded to Resident #2 fall and provided immediate care |
| Staff I | Nurse Aide | Reported footboard disappearance for Resident #2 |
| Staff J | Nurse Aide | Unaware of footboard for Resident #2 |
| Staff K | Nurse Aide | Unaware of footboard for Resident #2 |
| Director of Nursing | Director of Nursing | Provided expectations for safety belt use and responded to incidents |
| Administrator | Administrator | Reprimanded staff for failure to use safety belt |
| Advanced Registered Nurse Practitioner | ARNP | Provided medical assessment and hospice care for Resident #2 |
Report
Dec 4, 2025
Report
Oct 17, 2024
Report
Aug 22, 2024
Report
Aug 1, 2024
Report
Sep 18, 2023
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