Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Exira Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident left the facility unsupervised after a door alarm was not properly investigated by staff. The resident, who had a history of wandering and mild cognitive impairment, was found in a car in the parking lot. The facility's policies for door alarm response and missing resident procedures were not followed, contributing to the incident.
A facility failed to accurately complete MDS assessments for a resident with a history of wandering and high elopement risk. Despite the resident wearing a wanderguard, the MDS assessments did not document its use. Staff were aware of the wanderguard but unsure of its duration. The DON acknowledged the oversight, which was identified through observations, record reviews, and staff interviews.
The facility failed to include necessary interventions in the care plans of two residents with cognitive impairments who exhibited wandering and elopement behaviors. One resident eloped and was found in a staff member's car, while the other frequently wandered and became agitated. Despite these behaviors, their care plans lacked specific strategies for staff to manage these risks, highlighting a deficiency in the facility's care planning process.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to the resident leaving the building without staff knowledge. The resident, who had a history of mild cognitive impairment, hallucinations, and delusions, was last seen by staff at approximately 12:45 PM. The door alarm sounded at 1:01 PM, but the responding staff member only took a few steps outside, did not see anyone, and returned inside without conducting a thorough search or notifying other staff members. At 1:30 PM, another staff member found the resident in the driver's seat of a car in the parking lot, with the car running and the doors locked. The resident had a Brief Interview of Mental Status (BIMS) score of 8, indicating mild cognitive impairment, and had been experiencing hallucinations and delusions. The resident's care plan noted poor safety awareness and dementia that could lead to wandering, but lacked specific interventions for wandering or exit-seeking behavior. The resident had a history of wandering and was known to be more confused than usual on the day of the incident, possibly due to a Fentanyl patch for back pain. Staff interviews revealed that the door alarm response was inadequate, as the staff member who responded did not conduct a thorough search or initiate a head count. The facility's policies for door alarm response and missing resident procedures were not followed, contributing to the resident's unsupervised exit from the building. The incident highlighted gaps in staff response and communication, as well as deficiencies in the resident's care plan regarding wandering and elopement prevention.
Removal Plan
- Immediate education and coaching with staff on the facility's door alarm response procedure.
- All door alarms and wander guard alarms were checked for proper functioning.
- Elopement drills were completed successfully.
- Staff completed door response education. The facility updated the wandering assessment in their Electronic Health Record (EHR) to be completed on admission, 72 hours after admission and quarterly.
- Elopement drills will continue every quarter, alternating shifts for three quarters and reviewed at Quality Assurance (QA) meetings. If the drill is not successfully completed, they will increase the frequency to weekly.
Inaccurate MDS Assessment for Resident with Wanderguard
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who was admitted on May 2, 2024, was observed with a wanderguard on her left ankle during a dining room observation. However, the MDS assessments, including the admission, quarterly, and significant change assessments, did not document the use of a wander/elopement alarm, despite the resident's history of wandering and high elopement risk. The care plan and elopement risk assessment checklist indicated the use of a wanderguard due to the resident's dementia and poor safety awareness. Staff interviews revealed that multiple Certified Nursing Assistants (CNAs) were aware of the resident wearing a wanderguard but were unsure of the duration. The Director of Nursing (DON) acknowledged the oversight in the MDS assessments, which should have documented the use of the wanderguard. The deficiency was identified through observations, clinical record reviews, and staff interviews, highlighting the discrepancy between the resident's documented care plan and the MDS assessments.
Deficient Care Plans for Wandering and Elopement Risks
Penalty
Summary
The facility failed to ensure that the care plans for two residents included necessary interventions for staff to follow in the event of wandering or elopement behaviors. Resident #1, who had a history of mild cognitive impairment and various medical conditions, including moderate dementia with psychotic disturbance, was not provided with a care plan that addressed her wandering and exit-seeking behaviors. Despite having a wanderguard, her care plan lacked specific interventions for staff to implement when she exhibited these behaviors. This oversight became evident when Resident #1 eloped from the building and was found in a staff member's car, an incident that was not documented in her care plan. Resident #3, with severe cognitive impairment and a history of daily wandering, also had a care plan that failed to include interventions for wandering or exit-seeking behaviors. Although Resident #3 utilized a wander/elopement alarm, the care plan did not provide guidance for staff on how to manage her wandering tendencies. The resident's progress notes indicated frequent wandering and agitation, with staff needing to redirect her multiple times. Despite these behaviors, the care plan did not reflect specific strategies to address her wandering. The Director of Nursing acknowledged that the care plans were not updated to include interventions for wandering or elopement risks. The care plans were supposed to be revised quarterly and as needed, but this did not occur for the two residents in question. The lack of appropriate interventions in the care plans for residents at risk of wandering or elopement represents a significant deficiency in the facility's care planning process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 57 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Exira
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Home Association | 9.3 mi | — | 0 | 0 |
| Salem Lutheran Home | 9.4 mi | — | 2 | 0 |
| Caring Acres Nursing And Rehab Center | 11.9 mi | — | 20 | 0 |
| Heritage House | 14.4 mi | — | 8 | 0 |
| Atlantic Specialty Care | 14.8 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Exira Care Center.
100% money-back within 48 hours.
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.