Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Community Memorial Health Center during CMS and state inspections, most recent first.
A resident with advanced cognitive impairment was subjected to rough handling and forceful feeding by a CNA, as witnessed by another CNA. The incident was reported internally to the DON, but the required report to state authorities was not submitted within the mandated two-hour window, resulting in a delay of nearly two days.
A resident with significant cognitive and communication deficits was reportedly shaken and struck in the mouth by a CNA during feeding, as witnessed by another staff member. Although the incident was reported to the DON and to the state, there was no documentation of the event in the resident's medical record, contrary to facility expectations.
The facility failed to obtain signatures for bed hold notices for two residents transferred to hospitals. Despite verbal confirmations, the required signatures from residents or their representatives were not secured, contrary to facility policy.
A facility failed to investigate an alleged abuse incident involving a CNA and a resident with severe cognitive impairment. The CNA allegedly slapped the resident during care, but was allowed to continue working the shift, exposing other residents to potential abuse. The incident was not documented in the resident's progress notes, and the facility's initial investigation could not confirm the occurrence. The facility did not follow its policy to immediately separate the accused employee from residents, contributing to the deficiency.
The facility failed to have the Infection Preventionist (IP) present at quarterly Quality Assessment and Assurance (QAA) meetings, as required by their policy. The IP, a Registered Nurse, was working on the floor during these meetings and had not attended from January to May 2024. The Director of Nursing confirmed the IP's absence and noted that the IP was working towards certification but had not yet obtained it.
A resident with severe cognitive impairment was subjected to physical abuse by a CNA during incontinence care. The resident became agitated and combative, leading to the CNA slapping the resident on the thigh. The incident was reported by another CNA to the charge nurse and the DON. The facility's investigation revealed inconsistencies in staff accounts, and the incident was not documented in the resident's progress notes.
A resident with severe cognitive impairment was slapped by a CNA during care, and the incident was not reported to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The facility's policy mandates immediate reporting of abuse allegations, but the Director of Nursing was not reached immediately, leading to a delayed report to DIAL.
A resident with severe cognitive impairment was involved in an incident where a CNA slapped them during care. The incident was reported internally but was not documented in the resident's medical record, violating the facility's documentation policy. The Director of Nursing confirmed the lack of documentation, highlighting a failure to adhere to established procedures.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required two-hour timeframe for one resident. The incident involved a resident with Alzheimer's Disease, aphasia, and cognitive communication deficit, who was not able to be assessed with the Brief Interview for Mental Status (BIMS) due to being rarely or never understood. During a supper meal, a CNA was observed by another CNA to have forcefully fed the resident, hitting the resident's tooth with a spoon and shaking the resident while urging her to eat. The observing CNA reported the incident to the DON, and the staff member involved was sent home immediately. Despite the facility's policy requiring all allegations of abuse to be reported to the state within two hours, the self-report to DIAL was not submitted until nearly two days after the incident. Interviews with staff and review of facility records confirmed the delay in reporting. The administrator stated he believed the DON had submitted the report to the state office, but documentation showed otherwise.
Failure to Document Incident in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident following an incident involving alleged rough handling by a CNA during mealtime assistance. The resident, who had diagnoses of Alzheimer's Disease, aphasia, and cognitive communication deficit, was reportedly shaken and had her tooth struck by a spoon while being fed, as witnessed by another staff member. Although the incident was reported to the DON and a self-report was submitted to the state agency, a review of the resident's progress notes revealed no documentation of the incident in the medical record. The DON confirmed that she expected documentation of the incident to be present in the resident's chart, but it was missing.
Failure to Obtain Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for two residents. The first resident, who had diagnoses of heart failure, diabetes mellitus, and urinary retention, was transferred to a hospital on unpaid leave. Although verbal permission for bed hold authorization was obtained via phone, the required signature from the resident or their representative was missing. The resident returned to the facility after a few days. The second resident, with diagnoses of hypertension, bradycardia, and anemia, experienced multiple hospital transfers, both unpaid and paid. In each instance, verbal confirmation for bed hold was obtained, but the necessary signatures were not secured. The facility's policy required verification of room reservation within 24 hours of hospital admission, but the Director of Nursing confirmed that the facility did not send bed hold notices for signatures if verbal confirmation was received.
Failure to Investigate Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving a Certified Nurse Aide (CNA) and a resident. On April 3, 2024, a nurse learned that a CNA allegedly slapped a resident on the leg during incontinence care. Despite this allegation, the facility allowed the CNA to continue working the scheduled night shift and to work unattended with other residents, exposing them to potential abuse. This incident was not documented in the resident's progress notes, and the facility's initial investigation was unable to confirm or deny the occurrence of the incident. The resident involved in the incident had a history of Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. During the incident, the resident became agitated and combative, swinging and kicking at the staff. According to staff statements, the CNA slapped the resident on the thigh and later expressed regret for the action. The charge nurse was informed of the incident, and an attempt was made to contact the Director of Nursing (DON), but the call was not answered, and no further immediate action was taken to separate the CNA from the residents. The facility's policy on abuse prevention and investigation requires immediate measures to prevent further potential abuse, such as suspending the accused employee or segregating them from residents. However, these measures were not implemented promptly, as the CNA continued to work the remainder of the shift. The facility's failure to separate the alleged abuser from residents and to document the incident in the resident's progress notes contributed to the deficiency identified by the surveyors.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to include the Infection Preventionist (IP) in their quarterly Quality Assessment and Assurance (QAA) meetings, as required by their policy. A review of the Quality Assurance Process Improvement (QAPI) sign-in sheets for the months of January through May 2024 revealed the absence of the IP's signature, indicating non-attendance. An interview with the Director of Nursing (DON) confirmed that the IP, a Registered Nurse, was typically working on the floor during these meetings and had not attended them. Additionally, the DON mentioned that the IP was in the process of obtaining her certification but had not yet completed it. This oversight is contrary to the facility's policy, which mandates the Administrator to ensure compliance with federal, state, and local regulatory requirements for the QAPI program.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two CNAs and a resident with severe cognitive impairment. The resident, diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, became agitated and combative during incontinence care. According to staff statements, one of the CNAs, identified as Staff F, slapped the resident on the thigh after the resident began swinging and kicking. This incident was reported by Staff E, who witnessed the event, to the charge nurse and subsequently to the Director of Nursing (DON). The facility's investigation into the incident revealed discrepancies in the accounts provided by the involved staff. Staff E reported the slap to the charge nurse immediately after the incident, while Staff F's account did not acknowledge the slap. The facility's policy on abuse prevention clearly states that all residents have the right to be free from abuse, including physical abuse such as slapping. However, the facility's documentation, including the resident's progress notes, lacked any record of the incident, and the administrator could not confirm or deny the occurrence of the incident after their investigation.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment, diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction. During incontinence care, the resident became agitated and combative, leading to a Certified Nursing Assistant (CNA) slapping the resident on the thigh. The incident was initially reported to the charge nurse, who instructed the reporting to the Director of Nursing (DON). However, the DON was not reached immediately, and the incident was only reported to DIAL several hours later. The facility's policy mandates that all allegations of abuse be reported immediately to the charge nurse and subsequently to the Administrator or designated representative. Furthermore, the policy requires that such allegations be reported to DIAL within two hours. Despite these guidelines, the report was delayed, as the DON did not respond to the initial call or text message, and the incident was not reported to DIAL until later in the morning. This delay in reporting constitutes a deficiency in adhering to the facility's abuse prevention and reporting policy.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident diagnosed with Alzheimer's Disease, anxiety disorder, and non-traumatic brain dysfunction, who exhibited severe cognitive impairment. An incident occurred where two CNAs attempted to provide incontinence care, and the resident became agitated, resulting in one CNA slapping the resident on the thigh. This incident was reported internally, but the resident's progress notes lacked documentation of the event, which is a violation of the facility's Charting and Documentation policy. The facility's policy mandates that all services provided, progress toward care plan goals, and any changes in the resident's condition, including incidents, should be documented in the medical record. However, the incident involving the resident was not recorded, as confirmed by the Director of Nursing. This omission indicates a failure to adhere to the established documentation procedures, which are crucial for effective communication among the interdisciplinary team regarding the resident's care and condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hartley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Home | 7.9 mi | — | 0 | 0 |
| Aspire Of Sutherland | 14.6 mi | — | 0 | 0 |
| Spencer Post Acute Rehabilitation Center | 16.8 mi | — | 1 | 0 |
| Sanford Senior Care Sheldon | 18.1 mi | — | 8 | 0 |
| St Luke Lutheran Nursing Home | 18.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.