Cedar Manor Nursing Home
1200 Mulberry Street, Tipton, IA 52772 · Cedar County · 54 certified beds · avg 46 residents/day · certified since Jul 1, 2010
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 1, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 1, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 7, 2023 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 8, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 29, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 1, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Dec 7, 2023 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jun 29, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 29, 2023 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Jun 29, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 29, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 29, 2023 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 2 | G ▲ |
| 2024 | 6 | 2 | G ▲ |
| 2025 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $32,289.
| Date | Type | Amount / length |
|---|---|---|
| May 1, 2024 | Fine | $24,099 |
| Dec 7, 2023 | Fine | $8,190 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.42 | 4.37 | 3.95 | top 43% in Iowa; top 25% in the U.S. |
| Registered Nurse hours | 0.74 | 0.85 | 0.69 | bottom 42% in Iowa; top 32% in the U.S. |
| Weekend total nurse staffing | 3.78 | 3.86 | 3.50 | top 49% in Iowa; top 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.51 | 0.48 | top 45% in Iowa; top 35% in the U.S. |
| Total nursing staff turnover (%) | 43.6 | 44.0 | 45.8 | bottom 46% in Iowa; top 46% in the U.S. |
| RN turnover (%) | 50.0 | 42.1 | 42.9 | bottom 41% in Iowa; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.16, RN 0.70, weekend 3.56. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| BCG Holdings INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Brighton Consulting Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Cattail BCG LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Cattail INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Clarence Nursing Home INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/10/2025 |
| Clarence Nursing Home INC | Organization | ADP of the SNF | NOT APPLICABLE | 02/10/2025 |
| Ecsi INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Ford, Cathy | Individual | Corporate Director | NOT APPLICABLE | 09/01/2020 |
| Gama, Julie | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/30/2022 |
| Iowa Health Care Association | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Jedlicka, Dale | Individual | Corporate Director | NOT APPLICABLE | 03/05/2025 |
| Jorgensen, James | Individual | Corporate Officer | NOT APPLICABLE | 03/09/2025 |
| Knipe, Teresa | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/13/2024 |
| McKay, Deborah | Individual | ADP of the SNF | NOT APPLICABLE | 11/28/2005 |
| Miller, Bart | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/12/2017 |
| Onr National Speech Pathology INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
| Paul, Rhonda | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/26/1984 |
| Pelzer, Michael | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2025 |
| PM Acquisition LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2019 |
| Potter and Brant PLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Clarence Nursing Home | 8.2 mi | Clarence, IA | ★★★★★ | 4/5 | |
| Mechanicsville Specialty Care | 11.2 mi | Mechanicsville, IA | ★★★★★ | 4/5 | |
| Crestview Specialty Care | 13.6 mi | West Branch, IA | ★☆☆☆☆ | 1/5 | |
| Wilton Retirement Community | 13.9 mi | Wilton, IA | ★★★★★ | 5/5 | |
| Wheatland Manor | 15.4 mi | Wheatland, IA | ★★★★☆ | 4/5 | |
| Simpson Memorial Home | 15.4 mi | West Liberty, IA | ★★★☆☆ | 4/5 | |
| Rehabilitation Center of Lisbon | 17.0 mi | Lisbon, IA | ★★★★☆ | 4/5 | |
| Hallmark Care Center | 18.1 mi | Mount Vernon, IA | ★★☆☆☆ | 2/5 | |
| Solon Nursing Care Center | 19.0 mi | Solon, IA | ★★★★★ | 5/5 | |
| Iowa City Rehab & Health Care | 19.9 mi | Iowa City, IA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165599.