Southeast Iowa Healthcare Center

In the surveyor’s words

From the most serious findings on record at Southeast Iowa Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Jul 1, 2026

  Based on observations, record review, hospital record review, facility investigative file review, employee file review staff interviews and policy review the facility failed to prepare and serve the recommended therapeutic meal in a form designed to safely meet the resident's needs and according to physician orders for 1 of 3 residents reviewed (Resident #1). This resulted in Resident #1 choking on a peanut butter and jelly uncrustable, she became unconscious, CPR was initiated, the resident gained consciousness and was sent to the hospital. She was found to have a pneumothorax. Resident #1 was given an improper textured diet when she asked for a snack; she was ordered to receive a puree diet. The facility reported a census of 50 residents. […]

• No harm, potential for more than minimal, isolatedF568Jan 8, 2026

  Based on clinical record review, list of residents with personal accounts maintained by the facility, facility policy review, resident and staff interview, the facility failed to provide quarterly personal account statements to 1 of 1 residents sampled (Resident #1). The facility reported a census of 50 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #1, dated 12/18/25, revealed an admission date of 12/30/24. The Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicated Resident #1 had a moderate cognitive impairment. During an interview on 1/5/26 at 10:25 AM, Resident #1 reported the facility assisted her in managing her money. Resident #1 reported she had not received a quarterly statement, and she had not requested a statement. […]

• No harm, potential for more than minimal, isolatedF641Jan 8, 2026

  Based on staff interview, clinical record review, and facility policy review, the facility failed to ensure accurate information reflected current resident status for 2 of 2 residents (Resident #3 and Resident #4) reviewed for quarterly assessments. The facility report a census of 50. Findings include: 1. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/16/25, under Section O. Special Treatments, Procedures, and Programs; Subcategory: Respiratory Treatments, documented in F1. that Resident #3 required an invasive mechanical ventilator while a resident at the facility. Review of the assessment under Section N. Medications; Subcategory: Insulin, documented that Resident #3 received insulin injection on 1 of the 7 days during the look back period. […]

• No harm, potential for more than minimal, isolatedF658Jan 8, 2026

  Based on observation, record review, staff interviews, and the manufacturer's instructions, the facility failed to use the manufacturer approved needle to inject the insulin for 1 of 1 residents reviewed for insulin administration (Resident #15). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 with intact cognition based on a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS list of diagnoses included diabetes mellitus, and indicated Resident #15 received insulin injections 7 out of 7 days. Review of the Physician Orders revealed an order for Admelog U-100 Insulin (Lispro) solution- give 6 units subcutaneous with meals. […]

• No harm, potential for more than minimal, isolatedF677Jan 8, 2026

  Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to provide assistance with nail care for 1 of 2 residents sampled (Resident #42). The facility reported a census of 50 residents. Findings include:Review of Resident #42's Minimum Data Set (MDS) assessment, dated 11/13/25, revealed an admission date of 9/18/2020. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicated a moderate cognitive impairment. The list of diagnoses included schizophrenia (a mental health disorder causing a causing a disconnect with reality), diabetes and chronic obstructive pulmonary disease. […]