Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Gracewell, An Eventide Community

Denison, IA · 84 certified beds · Last Life Safety survey October 31, 2024

CMS Certification Number 165532 · first certified April 2004

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

10
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within IA

10 citations — more than 34% of the 387 certified nursing homes in IA. Compared within IA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (September 2025 to November 2025), and past the point by which nine in ten IA facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in IA are typically surveyed 11–13 months after the last one (median 12), measured over 700 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

1 of the 10 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IA, and nationally. Surveyors differ markedly between states, so the IA figure is the meaningful one.

This facility10IA median12National median11
Citations on file over three years, compared
MeasureCitations
This facility10
Median facility in IA12
Median facility nationally11

Survey history

Citations at each Life Safety survey
52022-0722023-0932024-10
Citations at each Life Safety survey
Survey dateCitations
July 21, 20225
September 21, 20232
October 31, 20243

Most-cited tags

Most-cited tags at this facility
K-03742K-09231K-09201K-01611K-09221K-07121K-09181E-00391
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.22024-10-31
K-0923Have proper medical gas storage and administration areas.12022-07-21
K-0920Ensure proper usage of power strips and extension cords.12022-07-21
K-0161Use approved construction type or materials.12022-07-21
K-0922Meet requirements for the use and maintenance of medical gas equipment.12023-09-21
K-0712Have simulated fire drills held at unexpected times.12024-10-31
K-0918Have generator or other power source capable of supplying service within 10 seconds.12023-09-21
E-0039Conduct testing and exercise requirements.12024-10-31

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Smoke Deficiencies 3
  • Construction Deficiencies 1
  • Miscellaneous Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies4
Smoke Deficiencies3
Construction Deficiencies1
Miscellaneous Deficiencies1
Emergency Preparedness Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 31, 2024 — 3 citations

Citations issued on October 31, 2024
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (November 20, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (November 22, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (November 22, 2024)

September 21, 2023 — 2 citations

Citations issued on September 21, 2023
TagWhat the surveyor checksStatus
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 27, 2023)
K-0922Meet requirements for the use and maintenance of medical gas equipment.Deficient, Provider has date of correction (September 21, 2023)

July 21, 2022 — 5 citations

Citations issued on July 21, 2022
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (July 22, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 25, 2022)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (August 15, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (July 22, 2022)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (July 22, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.