Inspection Reports for Timely Mission Nursing Home
109 Mission Drive, IA, 504241206
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 15, 2025, found the facility certified in compliance based on acceptance of a credible allegation of compliance and plan of correction. Prior inspections showed a pattern of deficiencies related mainly to documentation and provision of specialized rehabilitative services, resident assessments, and food safety practices. Complaint investigations in recent years included substantiated findings for failure to provide required therapy services and issues with resident property and notifications, while most other complaints were unsubstantiated. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility’s inspection history shows some recurring issues but also periods of substantial compliance and corrective actions accepted by inspectors.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
33 residents
Based on a November 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 15, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility was certified in compliance effective December 12, 2025, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted as a result of complaint #2666379-C from November 13 to November 17, 2025, to investigate deficiencies related to specialized rehabilitative services at Timely Mission Nursing Home.
Complaint Details
Complaint #2666379-C was investigated from November 13 to November 17, 2025, and was substantiated with a deficiency found related to failure to provide specialized rehabilitative services.
Findings
The facility failed to ensure provision of required physical and occupational therapy services for Resident #1 following an ankle fracture, as documented by missing clinical records and lack of therapy on admission. The facility acknowledged the deficiency and outlined plans for corrective actions including prior authorization processes for Medicare Advantage residents.
Deficiencies (1)
Failure to provide or obtain specialized rehabilitative services as required by federal regulations.
Report Facts
Resident census: 33
Deficiency count: 1
Dates of complaint investigation: November 13 to November 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #1's clinical record lacked documentation of physical and occupational therapies on day of admission |
| Administrator | Facility Administrator | Stated expectation that staff follow physician orders for therapies and ensure residents receive ordered therapies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An annual recertification survey was conducted from June 23, 2025 to June 25, 2025.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
An investigation of complaints #124573-C, #124578-C, #124579-C and a facility self-reported incident #124609-I was conducted from November 6, 2024 to November 13, 2024.
Complaint Details
Investigation involved multiple complaints and a self-reported incident; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 18, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status following a survey.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective August 18, 2024. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
The inspection was the facility's annual recertification survey conducted from July 29, 2024 to August 1, 2024, to assess compliance with federal regulations.
Findings
The facility failed to ensure that Significant Change Minimum Data Set (MDS) assessments were completed within 14 days for two residents discharged from hospice care and failed to provide appropriate treatment and documentation for pressure ulcers in one resident. The facility reported a census of 30 residents during the inspection.
Deficiencies (2)
Failure to complete Significant Change MDS assessments within 14 days for residents discharged from hospice care.
Failure to provide treatment and services consistent with professional standards to promote healing and prevent infection for residents with pressure ulcers, including inadequate documentation and lack of physician orders.
Report Facts
Census: 30
Deficiencies cited: 2
Braden Scale scores: 21
Dates of wound treatment orders: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported facility does not have a policy for MDS and provided information about wound care and incident reports | |
| MDS Coordinator | Reported facility follows RAI Manual but had not done MDS completion when residents go on or off hospice | |
| Staff A | Licensed Practical Nurse (LPN) | Reported wounds are measured on bath days and documented |
| Staff B | Certified Nursing Assistant (CNA) | Stated she did not recall being passed report about encouraging Resident #1 to reposition |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 17, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for Timely Mission Nursing Home.
Findings
The facility was certified in compliance effective September 17, 2023, based on acceptance of the credible allegation and Plan of Correction.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 4
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of complaints #113490-M and #113493-A from 08/14/23 to 08/17/23.
Complaint Details
The visit included investigation of complaints #113490-M and #113493-A. The facility was found to have failed to notify the Long Term Care Ombudsman of a resident transfer, and the social worker was not receiving all resident transfer data. Substantial compliance was achieved by June 2023.
Findings
The facility was found deficient in several areas including failure to notify the Long Term Care Ombudsman of resident transfers, inaccurate Minimum Data Set (MDS) assessments, failure to employ a qualified dietary manager, and improper food safety practices. The facility reported a census of 28 residents during the survey.
Deficiencies (4)
Failure to notify the Long Term Care Ombudsman of a resident transfer to the hospital.
Failure to accurately document and submit resident Minimum Data Set (MDS) assessments for 2 of 5 residents reviewed.
Failure to employ a qualified director of food and nutrition services.
Failure to ensure food items were dated, covered, and labeled properly, leading to potential food contamination.
Report Facts
Census: 28
Residents reviewed: 5
Residents with inaccurate MDS: 2
Date of MDS for Resident #21: 2023
Date of MDS for Resident #23: 2023
Date of hospital transfer for Resident #3: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Manager | Named in findings related to food handling and safety violations. |
| Administrator | Provided information on policies and staff qualifications related to findings. | |
| Social Services Director | Notified the Office of the State Ombudsman of resident transfers. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 20, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective June 20, 2022.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Timely Mission Nursing Home, certifying compliance based on acceptance of the facility's credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective May 7, 2022, based on the acceptance of their credible allegation of compliance and plan of correction. No specific deficiencies are listed in this document.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 3
Date: May 5, 2022
Visit Reason
A health comparative Federal Monitoring Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on May 5, 2022, following an Iowa Department of Inspections and Appeals survey conducted April 11-April 14, 2022.
Complaint Details
The visit was complaint-related, investigating allegations regarding loss of personal property and failure to provide required notifications and assessments related to bed hold policies and bedrails. The complaint was substantiated based on findings.
Findings
The facility failed to ensure one resident's personal property was kept free from loss when two bras were sent to the laundry and never returned. The facility also failed to ensure required bed hold notifications were provided to residents or their representatives for two sampled residents transferred out of the facility. Additionally, the facility failed to assess risk and obtain informed consent for bedrails for four sampled residents.
Deficiencies (3)
Facility failed to ensure one resident's personal property was kept free from loss when two bras were sent to the laundry and never returned.
Facility failed to ensure required bed hold notifications were provided to residents or their representatives for two sampled residents transferred out of the facility.
Facility failed to assess risk and obtain informed consent for bedrails for four sampled residents.
Report Facts
Survey Census: 22
Sample Size: 17
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Sanders | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Named in findings related to missing bras and bed hold notification failures | |
| Social Services Director | Named in findings related to missing bras and bed hold notification failures | |
| Assistant Administrator | Interviewed regarding grievance listing of missing bras | |
| Licensed Practical Nurse (LPN) | Interviewed regarding bed hold notification procedures |
Inspection Report
Annual Inspection
Census: 24
Deficiencies: 3
Date: Apr 14, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #98391-C, #98159-C, and #100939-C from April 11 to April 14, 2022.
Complaint Details
Complaints #98391-C, #98159-C, and #100939-C were investigated and all were found not substantiated.
Findings
The facility was found deficient in several areas including accuracy of resident assessments, coordination of PASARR and assessments, and food safety requirements. Observations included lack of documentation for bedrail restraints, expired PASRR approval, and multiple food items stored without proper labeling or expiration dates.
Deficiencies (3)
Failure to complete accurate Minimum Data Set (MDS) resident assessments for restraints, including lack of documentation for bedrail restraints for residents #17 and #18.
Failure to resubmit a Preadmission Screening and Resident Review (PASARR) after a 180 day short stay approval expired for resident #5.
Failure to ensure food was labeled with dates after opening, labeled with product after removing from original package, discarded after product expiration date, and maintain clean and sanitizable cutting boards for food preparation.
Report Facts
Census: 24
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/MDS Coordinator | Interviewed regarding coding of bedrail use and MDS completion | |
| Social Services Coordinator | Interviewed regarding PASRR approval status for resident #5 | |
| Dietary Manager | Responsible for disposal of expired food items and cutting boards |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Date: Sep 28, 2020
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey related to infection prevention and control practices during a COVID-19 outbreak.
Complaint Details
The visit was complaint-related focusing on infection control practices and COVID-19 reporting. The facility failed to notify the family of the active COVID-19 status of residents and staff for Resident #1.
Findings
The facility failed to maintain proper infection control practices for 4 of 6 residents reviewed during a COVID-19 outbreak, including improper use of PPE, failure to perform hand hygiene, failure to isolate residents properly, and failure to encourage mask use among residents. Additionally, the facility failed to notify the family of the active COVID-19 status of residents and staff for one resident sampled.
Deficiencies (2)
Failure to maintain proper infection control practices including improper PPE use, failure to perform hand hygiene, and failure to isolate residents properly during a COVID-19 outbreak.
Failure to notify family of active COVID-19 status of residents and staff in the facility.
Report Facts
Residents testing positive for COVID-19: 22
Resident census: 24
Residents reviewed for infection control: 6
Residents with infection control failures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in multiple infection control failures including improper PPE use and hand hygiene. |
| Staff B | Housekeeper | Named in infection control failure related to cleaning equipment that could not be disinfected properly. |
| Staff C | Licensed Practical Nurse | Named in infection control observations and interviews regarding nebulizer treatments and PPE use. |
| Staff D | Infection Preventionist | Reported facility did not have a hand held nebulizer policy and infection control practices. |
| Staff E | Certified Nursing Assistant (CNA) | Named in infection control failures related to hand hygiene and water mug handling. |
| Staff G | Certified Nursing Assistant (CNA) | Reported on resident mask use and infection control practices. |
| Staff H | Certified Nursing Assistant (CNA) | Named in failure to perform hand hygiene when delivering meals and assisting residents. |
| Staff J | Social Services | Involved in family notification process; reported family was not fully informed of COVID status. |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding infection control practices, resident census, and family notification. |
| Administrator | Facility Administrator | Reported on family notification procedures and involvement. |
Inspection Report
Routine
Census: 29
Deficiencies: 0
Date: Jun 17, 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: 29
Report
Nov 17, 2025
Report
Jun 25, 2025
Report
Aug 1, 2024
Report
Aug 17, 2023
Viewing
Loading inspection reports...
