Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Spurgeon Manor during CMS and state inspections, most recent first.
A resident with vascular dementia, anxiety, depression, and moderately impaired cognition was admitted from the ER for suicidal ideation after prior documented suicidal gestures, but the interim and comprehensive care plans did not address suicidal ideation, suicide precautions, or specific interventions for self-harm. Over time, progress notes recorded multiple self-harm behaviors and suicidal statements, including attempts to cut the wrist with objects, break glasses, and ingest jewelry, as well as reaching for a telephone cord, while staff provided one-on-one supervision. The resident was eventually sent to the hospital and later returned, yet the comprehensive care plan was not updated upon readmission and was only revised at a later date to include self-harm interventions, contrary to facility policy requiring comprehensive, measurable care plans based on the resident’s assessed mental and psychosocial needs.
The facility failed to develop comprehensive care plans for a resident with repeated pneumonia hospitalizations and two residents on high-risk medications. Despite policies requiring care plan updates upon status changes, these were not implemented, leaving significant gaps in addressing the residents' medical needs.
A resident at risk for pressure ulcers developed unstageable pressure ulcers on both heels due to inadequate preventative measures in their care plan. Despite being provided with pressure-reducing devices, the resident's care plan lacked specific interventions for the heels, and the facility's skin and wound care policy was not effectively followed. The resident's limited mobility and use of a recliner contributed to the development of the ulcers.
The facility did not properly post past survey results and ombudsman information in accessible areas for residents and their families. A family member noted the absence of these documents, and observations confirmed that the ombudsman information was outdated and obscured, while survey results were in a poorly labeled binder. The facility lacked a policy to ensure accessibility, as confirmed by the Administrator.
Failure to Timely Care Plan for Suicidal Ideation and Self-Harm Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing suicidal ideation and self-harm behaviors for a resident with known psychiatric concerns. The resident’s MDS showed moderately impaired cognition (BIMS score of 11) and diagnoses of vascular dementia with anxiety disorder and depression, with partial/moderate assistance needed for bed mobility and transfers. A hospital psychiatry consult documented that the resident had presented from an assisted living facility for suicidal gestures after being informed of a transition to a higher level of care, including using a pen and the lens of her glasses to cut her wrist, and a prior suicidal gesture using a plastic cup. The admission progress note to the facility documented admission from the ER for suicidal ideation. Despite this history and documentation, the interim plan of care and the comprehensive care plan initiated shortly after admission did not address suicidal ideation, suicidal gestures, suicide precautions, or provide direction or interventions for staff if the resident expressed suicidal ideation or attempted self-harm. Subsequently, multiple progress notes documented repeated self-harm behaviors and suicidal statements by the resident without a corresponding, timely update to the care plan. On one day, the resident was observed rubbing a drink coaster across her wrist and stated she was trying to kill herself; staff removed the coaster and provided one-on-one supervision. Later the same day, the resident broke her glasses, made statements about wanting to die, and was assisted to bed with continued one-on-one. Additional notes described the resident attempting to swallow rings and earrings and reaching for a telephone cord while repeatedly stating she wanted to kill herself and die, with documentation that one-on-one supervision with the nurse was not effective. The resident was ultimately sent to the hospital by ambulance. After the resident’s hospital stay and return to the facility, the comprehensive care plan was not updated upon readmission and was only revised later to include interventions related to self-harm, despite facility policy requiring comprehensive care plans with measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs identified in the assessment.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical needs. Resident #36, who had a history of repeated hospitalizations for pneumonia and respiratory failure, did not have these conditions adequately addressed in their care plan. Despite having a BIMS score indicating no cognitive impairment, the care plan initiated in November 2023 lacked necessary interventions for monitoring and managing these serious health issues. Additionally, Resident #35, with severe cognitive impairment and diagnoses including diabetes and anxiety disorder, was receiving insulin and an antidepressant without appropriate care plan documentation for monitoring blood sugar levels and potential medication side effects. Similarly, Resident #7, with moderately impaired cognition and multiple diagnoses, was prescribed high-risk medications such as a diuretic, anticoagulant, and antidepressant, yet their care plan failed to include information on these medications and necessary monitoring. The facility's policy required care plan revisions upon status changes, but these were not implemented, as acknowledged by the MDS Coordinator and ADON.
Failure to Prevent Pressure Ulcers on Resident's Heels
Penalty
Summary
The facility failed to prevent the development of an unstageable pressure ulcer on the bilateral heels of a resident, identified as Resident #28, who was at risk for pressure ulcers due to limited mobility and other health conditions. The resident's care plan, revised earlier in the year, did not include specific preventative interventions for the heels, despite the resident being identified as at risk for pressure ulcers. The facility's policy on skin and wound care was not adequately followed, as the care plan lacked necessary interventions to prevent pressure ulcers on the heels. The resident's medical history included non-Alzheimer's dementia, arthritis, anxiety, and depression, with a moderate cognitive impairment score. The resident was dependent on staff for transfers, bed mobility, toileting, and dressing, and had been provided with pressure-reducing devices for the bed and chair. Despite these measures, the resident developed pressure ulcers on both heels, which were later identified as unstageable by a nurse practitioner. The facility's records showed that the resident had complained of heel pain, and new interventions were initiated, including the use of bunny boots and floating the heels. Interviews with facility staff revealed that the resident had been wearing shoes and placing her heels on a recliner, which may have contributed to the pressure ulcers. The facility's policy required regular skin assessments and interventions for residents at risk of skin breakdown, but these measures were not effectively implemented for the resident's heels. The facility's failure to include specific preventative measures in the care plan and to adequately monitor and address the resident's skin condition led to the development of the unstageable pressure ulcers.
Deficiency in Posting Survey Results and Ombudsman Information
Penalty
Summary
The facility failed to properly post past survey results and ombudsman information in a readily accessible area for residents, family members, and legal representatives. A family member of a resident reported that the facility did not have the survey results or ombudsman notification information available, and the only ombudsman information sheet found was outdated and located by a locked unit. An observation revealed that only one copy of ombudsman information was present at the southeast entrance, but it was covered by another document and unreadable. Additionally, past survey results were found in a binder with a faded label in a hallway across from the kitchen, making it difficult to locate. The facility lacked a policy to ensure these documents were accessible, as confirmed by the Administrator's interview.
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 289 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 Dallas Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adel Acres | 6 mi | — | 7 | 0 |
| The Village Of Legacy Pointe Nursing Facility | 7.7 mi | — | 0 | 0 |
| Kennybrook Village | 7.9 mi | — | 5 | 0 |
| Granger Nursing & Rehabilitation Center | 8.7 mi | — | 4 | 0 |
| Deerfield Health Care Center | 9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spurgeon Manor.
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.