01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-31 | 1 | 2025-12-31 | 2 |
| Cycle 2 | 2024-12-12 | 2 | 2024-12-12 | 1 |
| Cycle 3 | 2023-09-28 | 4 | 2023-09-28 | 2 |
CMS CCN 1652812026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
On With Life Long Term Care
1002 W Washington Ave. · Polk City, IA 50225 · Polk County
Certified beds40CMS provider file
Recent citation rows12current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
12 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 0 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-31 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-01-062025-12-31 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2026-01-072025-08-05 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-08-27 · complaint2024-12-12 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-12-312024-12-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-12-312024-12-12 · FIREK0374Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2024-12-202023-09-28 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2023-10-202023-09-28 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-10-282023-09-28 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-09-292023-09-28 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2023-10-202023-09-28 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2023-10-052023-09-28 · FIREK0914Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2023-10-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FORS, RUDYIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2024
- HOOGESTRAAT, DIANAIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2024
- BENSON LARSON, KATEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- FORS, RUDYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- HOOGESTRAAT, DIANAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- SNYDER, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2024
- FOREMAN, JIMIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2015
- SHELTON, JEANETTEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/01/2017
- ON WITH LIFE EXTENDED SERVICES LTDOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2011
- ON WITH LIFE INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2001
- LEWIS, JENNIFERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2019
- SHELTON, JEANETTEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours—per resident day
RN hours—per resident day
Weekend nurse hours—per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Iowa ledger →Other published facilities nearby
No second facility in the same city met the directory rule.