Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
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Polk City, IA · 40 certified beds · Last Life Safety survey December 31, 2025
CMS Certification Number 165281 · first certified July 1996
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.
Position within IA
5 citations — more than 12% 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
The latest survey found 2 citations; the earlier surveys in the window averaged 1.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was December 2025. 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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Physical environment (health survey)
1 physical-environment citation 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 5 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IA, and nationally. Surveyors differ markedly between states, so the IA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 5 |
| Median facility in IA | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 28, 2023 | 2 |
| December 12, 2024 | 1 |
| December 31, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-09-28 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-12-31 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-09-28 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2024-12-12 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2025-12-31 |
What the citations cover
- Smoke Deficiencies 3
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 31, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 6, 2026) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (January 7, 2026) |
December 12, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 20, 2024) |
September 28, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 5, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.