Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Lone Tree Health Care Center Inc during CMS and state inspections, most recent first.
A resident with malnutrition, anemia, and heart failure experienced complications with tube feeding due to staff not following the physician's order. Staff added water to the feeding to make it run faster, leading to the resident's tube feeding site leaking fluid and requiring hospital evaluation. The facility policy directed staff to administer the feeding slowly by gravity and to flush the tube with water before and after feeding.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to provide tube feeding according to the physician's order for a resident with malnutrition, anemia, and heart failure. The resident, who had moderate cognitive impairment, required tube feeding due to swallowing problems. The care plan directed the staff to follow the physician's order for tube feeding and water flushes. However, staff members were found to be adding water to the feeding to make it run faster, contrary to the physician's order and facility policy. This led to the resident's tube feeding site leaking fluid, resulting in the resident being sent to the hospital for evaluation. The hospital records indicated that the feeding tube was functioning appropriately but emphasized the need for the feeding to be administered slowly over several minutes rather than quickly as a bolus. Staff interviews revealed that both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) admitted to adding water to the feeding to thin it out, which was against the physician's order. The Assistant Director of Nursing (ADON) confirmed that the facility policy directed staff to follow the physician's orders and that adding water to the feeding was not in compliance with these orders. The facility's policy on enteral feeding specified that the feeding should be administered slowly by gravity and that the tube should be flushed with water before and after feeding to prevent clogging. The failure to adhere to these guidelines resulted in the resident experiencing complications with their tube feeding.
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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 Lone Tree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Simpson Memorial Home | 10.7 mi | — | 6 | 0 |
| Iowa City Rehab & Health Care | 13.3 mi | — | 7 | 0 |
| Briarwood Healthcare Center | 13.5 mi | — | 1 | 0 |
| Oaknoll Retirement Residence | 13.6 mi | — | 5 | 0 |
| Crestview Specialty Care | 13.8 mi | — | 15 | 1 |
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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.