Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Cresco during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least eight consecutive hours on multiple days over a multi‑month period, despite having a census of 26 residents. Review of nursing schedules and staff interviews confirmed repeated dates with no RN coverage, and the Administrator acknowledged that RN staffing was an ongoing problem. The facility assessment noted that the facility was working toward meeting minimum staffing requirements.
Failure to designate a qualified Infection Preventionist: The facility did not have an Infection Preventionist to implement, track, and oversee the infection control program after the prior IP left, and the ADON assumed the role without proof of completing the required training. The DON, ADON, and Administrator all confirmed the staffing gap and the inability to verify the ADON's certificate, and the training transcript showed she did not pass the course.
Kitchen Equipment Not Kept Clean and Sanitary: The oven, stove, and griddle had visible brown, black, and white discoloration and sticky buildup during repeated kitchen observations. A Cook signed off cleaning tasks before completing them, and later stated he had been in a hurry and had to cook pancakes. The ADM and DM were aware of the discoloration, and the cleaning checklist showed tasks marked complete despite the equipment remaining dirty.
Repeated Kitchen Sanitation Deficiencies and Ineffective QAPI Oversight: The facility was cited again for kitchen sanitation after prior recertification and complaint surveys had already identified similar issues, including an unsanitary kitchen and a stove top with excessive black burnt-on buildup. The Administrator acknowledged the kitchen had not been great in the cleaning process and that the facility had been trying to work on it over the past few weeks. The facility’s QAPI/QAA policy stated the QAPI Committee monitors whether interventions are implemented and effective in sustaining improvements.
A resident with paraplegia and a stage 4 sacral pressure ulcer had specific wound clinic orders for acetic acid application, Calmoseptine to the buttock wound, Melgisorb Ag to the wound base, air time, and then ABD dressing with tape. An RN did not leave the acetic acid–soaked gauze in place for the ordered duration, did not provide ordered air time, placed the resident on the bed without a barrier and with the wound uncovered, and repeatedly touched the computer and wound care supplies without performing hand hygiene. The RN also used the same gloved hand to apply Calmoseptine to multiple wounds and then handle and cut Melgisorb Ag before dressing the wound and documenting the treatment as completed per orders.
Failure to notify resident representatives of significant weight loss for two residents. One resident had severe cognitive impairment, bipolar disorder, Alzheimer's disease, and Down syndrome, with an 11.1% weight loss; the other had a BIMS of 4, severe cognitive impairment, diabetes, thyroid disorder, and Alzheimer's disease, with a 6.6% weight loss. Progress notes lacked documentation that the family representatives were informed, and the resident representative for one resident stated he was shocked the facility had not notified him.
Inaccurate PASRR coding on MDS. A resident with a PASRR Level II outcome and diagnoses of anxiety, depression, and PTSD had an MDS that documented a BIMS of 15/15 and incorrectly stated the resident was not a PASRR Level II. The Administrator stated the MDS should have been coded to reflect the resident's Level II status.
A facility failed to resubmit a PASRR for a resident after a new psychosis diagnosis was added. The resident’s MDS showed a BIMS of 15/15 with diagnoses of depression and psychotic disorder, and the EHR documented a new diagnosis of unspecified psychosis requiring medical management. The most recent PASRR had not been updated to include psychosis, and the Administrator acknowledged it should have been submitted for review.
A resident with moderately impaired cognition and diagnoses of depression and anxiety had psych documentation noting homicidal and suicidal comments, but the current care plan did not include related instructions or interventions. The DON acknowledged that homicidal comments should have been addressed on the care plan with interventions in place.
Failure to complete root cause analysis and add interventions for a resident with severe cognitive impairment and multiple diagnoses after repeated falls and injury events. The resident fell out of his wheelchair near the nurses station, had his hand run over by another resident's electric wheelchair in the hallway, and later slid out of his wheelchair in the dining room. The incident reports lacked in-depth root cause analysis and interventions, and the care plan did not include interventions tied to the causes of the events.
QAA Committee Lacked Required Members: The facility failed to have the minimum required members present at the QAA meeting. Sign-in sheets showed the Administrator, Medical Director, DON, and at least two other staff attended, but the Infection Preventionist was not present at the quarterly meeting. The DON stated the facility did not have an Infection Preventionist at that time, despite the QAPI plan requiring quarterly QAA meetings with the DON, Medical Director, Infection Preventionist Nurse, and additional staff.
A facility failed to follow standard infection control practices and EBP during wound care for two residents with pressure ulcers and other complex conditions. Staff did not consistently use PPE correctly, did not perform hand hygiene at required points, left urine-contaminated areas unclean during care, used improper peri-care technique, and mishandled wound treatment steps. The DON and Administrator also reported the infection prevention surveillance plan had not been reviewed annually.
Two residents were transferred to other facilities without completed discharge summaries or necessary documentation. Both residents arrived at their new locations without paperwork, causing delays in obtaining admission orders and necessary treatments. Receiving providers had to contact the original facility multiple times to obtain essential information for ongoing care.
Two residents with PICC lines did not have care plans that documented the presence of the device, associated risk factors, or required monitoring, despite receiving IV medications and having relevant medical conditions. This was confirmed through record review, staff interview, and policy review.
The facility did not follow professional standards for assessing and documenting the status of PICC lines for two residents receiving IV medications. For both residents, there was no documentation of PICC site, location, or length assessments in the medical record, and required monitoring per facility policy was not performed or recorded.
A resident's trust account was not closed within the required timeframe after discharge, and the facility continued to deposit and withdraw funds from the account without the resident's knowledge or authorization. The resident was cognitively intact and managed his own finances, yet the facility failed to follow policy and regulatory requirements for account closure and proper authorization of transactions.
After the departure of the Restorative Aide, the facility discontinued all restorative programs for several residents with no documentation or rationale, and failed to conduct required monthly reviews. Staff interviews revealed a lack of training and oversight, with the DON confirming that programs were ended for staff convenience rather than resident need.
A resident with multiple chronic conditions and at risk for pressure ulcers was found by a CNA to have an open, red, and bleeding scrotum during a shower. The issue was documented on a skin monitoring form, but there was no evidence that a nurse assessed the area or that a physician was notified as required by facility policy. The DON was not informed at the time, and the area was not properly tracked or monitored.
A resident with cognitive impairment and multiple diagnoses did not receive prescribed artificial tears for 14 days due to supply issues, with no documentation of physician notification or timely pharmacy ordering. Staff interviews confirmed awareness of the shortage, and facility policy lacked clear instructions for handling unavailable medications.
A resident with severe cognitive impairment and a history of wandering accessed a key code locked basement door, fell down the stairs, and sustained injuries including a hematoma and abrasions. The care plan identified elopement and fall risks, but the resident was able to bypass the locked door, and staff were unaware of the door's vulnerability. The incident revealed a failure to ensure a hazard-free environment and adequate supervision.
A Dietary Manager's personnel file lacked documentation of required dependent adult abuse training within the mandated timeframe. Facility policy requires this training for all employees, but the employee could not provide proof of completion, and the Administrator confirmed the absence of documentation.
A resident with severe cognitive impairment and behavioral issues kicked another resident, who also had severe cognitive impairment and was on hospice care. Despite facility policy requiring notification, neither the family nor the physician of either resident was informed of the incident, and this was confirmed by staff interviews and clinical record review.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly physically and verbally targeted another resident with significant cognitive and physical disabilities. Despite multiple documented incidents and staff awareness of the ongoing abuse, the care plan lacked interventions to address or prevent these behaviors until after a major incident occurred. Staff interviews confirmed the pattern of aggression and the absence of timely reporting or protective measures.
A resident was kicked in the face by another resident in the dining room, an incident witnessed by dietary staff. The facility did not report this abuse allegation to the Iowa Department of Inspections, Appeals, and Licensing as required by policy, and there was no documentation of the event being reported.
A resident with severe cognitive impairment and a documented history of physical and verbal aggression repeatedly exhibited abusive behaviors toward another resident and staff, including kicking and hitting, over an extended period. Despite these incidents being recorded in progress notes, no care plan interventions or investigations were initiated until much later, contrary to facility policy requiring prompt investigation of abuse.
A facility failed to complete a background check for a CNA before employment, violating its abuse prevention policy. The CNA worked several shifts over months without the required checks, despite the facility's policy mandating screening for abuse history prior to hiring. The Business Office Manager could not locate the background check and was unsure why it was not completed.
The facility was found deficient in maintaining cleanliness and proper maintenance in its kitchen and dining areas. Observations revealed multiple stains on the dining room carpet and a large black discoloration on the kitchen stove cooktop. Additionally, the kitchen floor had missing tile sections with black discoloration. The DON confirmed that the carpet's condition had been discussed in QA meetings due to infection control concerns, but no plan was in place to address it.
A facility failed to implement comprehensive care plans for two residents. One resident with a Stage 4 pressure ulcer lacked specific interventions in her care plan. Another resident on psychotropic medications and with HSV did not have documented adverse reaction monitoring or interventions in her care plan. The DON acknowledged these deficiencies.
A facility failed to conduct daily nursing assessments for a resident who tested positive for SARS-CoV-2. The resident, who was very weak and required assistance with all cares, did not have any documented assessments or vital signs on a specific day, indicating a lapse in care. The DON expected routine assessments every 12 hours, but this was not adhered to, leading to a deficiency in the care provided.
A facility failed to complete required pre and post-dialysis assessments for a resident with renal insufficiency, as documented in their care plan. The resident, who is cognitively intact, receives dialysis three times a week. A review of the EHR showed missing assessments over a 90-day period. Staff interviews confirmed the assessments were not completed, and the facility lacked a dialysis policy.
A facility failed to ensure proper monitoring and documentation for a resident on anti-viral medication. The resident's EHR lacked the HSV diagnosis, and the valacyclovir prescription did not specify a diagnosis. The care plan did not document the HSV diagnosis or necessary interventions, and the pharmacy did not review the medication usage. The DON expected pharmacy oversight, as outlined in the Medical Director's responsibilities.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers. Record reviews showed that two residents were hospitalized without documentation of notification. The DON confirmed the absence of such documentation, despite the facility's policy requiring nurses to complete a packet including the bed-hold notice during transfers.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours on several days, as required by federal regulations. A review of RN timesheets showed the absence of an RN on specific dates, which was confirmed by the Administrator. The facility had 27 residents at the time.
A resident with cognitive impairment repeatedly eloped from a facility due to unsecured doors and inadequate lighting. The resident accessed an unlocked medication cart, taking cigarettes and going outside unsupervised. Staff interviews and observations confirmed that medication carts were often left unattended, and the facility failed to address maintenance issues, contributing to the resident's elopement.
A resident reported waiting 45 minutes for assistance, highlighting the facility's failure to answer call lights within the professional standard of 15 minutes due to staffing issues. Additionally, the facility did not provide restorative exercises as per the resident's care plan, as confirmed by staff interviews. The lack of an active restorative program was attributed to low staffing levels, with a restorative aide often reassigned to other duties.
The facility failed to properly manage and secure narcotic medications, with issues in documentation and accountability. A resident received Baclofen without a nurse's signature, and staff often failed to sign Controlled Drug Count Records. Interviews revealed that the ADON accessed medication carts and administered drugs without proper documentation. The facility's policy for handling narcotics was not consistently followed, leading to significant deficiencies in medication management.
The facility failed to provide necessary treatment supplies for two residents, resulting in incomplete wound care due to the unavailability of Silversorb gel and other items. Additionally, staff lacked access to a policy and procedure book, as the Administrator provided an employee handbook instead. The Administrator acknowledged the issue of restricted access to the P drive where policies were stored, and efforts were underway to organize a policy book.
A resident with cognitive impairments and a history of elopement was able to leave a secure courtyard area due to a malfunctioning garage door latch and nonfunctional floodlights. The facility allowed residents to enter the courtyard unattended, contributing to the incident. The administrator failed to report these issues to the corporate office, and the maintenance director only temporarily secured the door, leading to multiple elopement incidents.
A facility failed to report alleged financial exploitation and drug diversion to management and state authorities. Staff reported missing narcotics and muscle relaxers, but the Administrator allegedly ignored these reports. Staff feared retaliation for contacting corporate. The Administrator received a report of drug diversion late, and the Regional Clinical Quality Specialist was only informed of Flexeril discrepancies. The facility's policy required immediate reporting of such issues.
A facility failed to maintain an accurate care plan for a resident with COPD and incontinence. The resident's care plan, requiring assistance with a walker and gait belt, was not updated to reflect a change in mobility status to modified independence with a front-wheeled walker indoors. This discrepancy was confirmed by a CNA, highlighting a failure to adhere to the facility's policy for timely care plan updates.
The facility failed to assess pressure areas for two residents and did not follow medication orders for a resident, leading to delayed treatment and dissatisfaction. A resident's pressure area was not assessed for several days, and another resident's medications were administered late, contrary to the facility's policy.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide required Registered Nurse (RN) coverage for eight consecutive hours per day on 26 days between November 1, 2025, and January 25, 2026, while reporting a census of 26 residents. Review of nursing schedules showed that in November 2025 there was no RN coverage on the 8th, 9th, 15th, 16th, 22nd, 23rd, 27th, 29th, and 30th; in December 2025 there was no RN coverage on the 6th, 7th, 13th, 14th, 20th, 21st, 25th, 27th, and 28th; and in January 2026 there was no RN coverage on the 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th. Staff interviews and schedule review confirmed that the facility did not have an RN in the building for the required eight hours on these dates. The Administrator acknowledged that RN coverage was an ongoing issue and verified the lack of RN coverage on the identified dates. The facility assessment documented that the facility would continue working toward a staffing level that meets the minimum staffing final rule. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist to implement, track, and oversee the infection control program from September 2025 through 1/29/26. The facility reported a census of 26 residents. During an interview on 1/28/26, the DON stated the prior Infection Preventionist left in September 2025 and the ADON took over in January 2026. On 1/29/26, the ADON stated she had been trying to obtain her Infection Preventionist certificate, but the course record showed she did not complete the course and the facility was having her retake it because she could not print the certificate. The Administrator stated the ADON assumed the Infection Preventionist role in January 2026 and that the facility was unable to obtain proof of completion. Review of an undated transcript provided as the ADON's Infection Preventionist training record showed that on 8/30/24 she took the Nursing Home Infection Preventionist Training course and did not pass.
Kitchen Equipment Not Kept Clean and Sanitary
Penalty
Summary
Kitchen equipment, including the oven, stove, and griddle, was not maintained in a clean and sanitary manner. During an initial kitchen observation on 1/26/26 at 10:34 AM, dark brown sticky discoloration was seen on the oven door handles, white discoloration splatters were observed on the oven doors and handles, and black and brown discoloration was noted on the backsplash in the middle, left, and right sides. Black and brown sticky discoloration was also observed surrounding the edges of the griddle on all four sides, and the left side of the wall and heat register by the sink and dishwasher had scattered brown discoloration. Follow-up observations on 1/27/26 at 8:25 AM and 1/28/26 at 8:12 AM showed the oven, stove, and griddle continued to have brown sticky discoloration. On 1/29/26 at 8:57 AM, the kitchen cleaning checklist binder showed cleaning tasks were signed off for both the AM and PM shifts by Staff A, Cook, even though the equipment remained discolored. At 9:03 AM, Staff A stated he had not completed the cleaning when he signed off because he was in a hurry, nervous, and had to cook pancakes that morning, and agreed he should not have signed off before completing the tasks. At 9:00 AM and 9:06 AM, the Administrator and Dietary Manager acknowledged the stove and oven discoloration and stated they were aware of it.
Repeated Kitchen Sanitation Deficiencies and Ineffective QAPI Oversight
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies related to kitchen sanitation. Review of the facility’s CMS-2567 from a recertification and complaint survey conducted 2/12/24 to 2/20/24 documented that the facility failed to maintain a sanitary kitchen. The facility’s plan of correction for that survey stated that staff were educated on kitchen sanitation requirements and that the ED and/or designee would audit kitchen staff and complete kitchen sanitation audits over a set period of time. Review of the facility’s CMS-2567 from a 2025 recertification and complaint survey documented another kitchen sanitation deficiency, including that the kitchen stove top was not free from excessive black burnt-on buildup. The facility’s plan of correction again stated that staff were educated on kitchen sanitation requirements and that the Administrator and/or designee would conduct kitchen sanitation audits on a scheduled basis. During the current recertification and complaint survey initiated on 1/26/26, the facility was again found deficient for kitchen sanitation. On 1/29/26 at 11:24 AM, the Administrator acknowledged that the kitchen had not been great in the cleaning process and that the facility had been trying to work on it over the past few weeks. The facility policy titled Quality Assurance and Performance Improvement Plan (QAPI)/Quality Assessment and Assurance (QAA), dated 5/23/23, stated that the QAPI Committee monitors progress to ensure interventions or actions are implemented and effective in making and sustaining improvements.
Failure to Follow Ordered Pressure Ulcer Treatment and Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered for a resident with a stage 4 sacral pressure ulcer and paraplegia. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented diagnoses including paraplegia and a stage 4 sacral pressure ulcer. Wound clinic orders dated 12/18/25 directed staff to apply acetic acid–dampened gauze to the wound base and surrounding skin and leave it in place for 10–15 minutes, then remove it, apply Calmoseptine around the left buttock wound, apply Melgisorb Ag (calcium alginate) to the wound base, pat dry, allow 30 minutes of air time, and then return to place an ABD pad secured with Medipore tape. During an observed wound treatment, the RN reviewed the order on the computer, performed hand hygiene, donned gloves, and opened gauze, placing half of it on supplies without a barrier. The RN touched the computer with gloved hands, dampened gauze with acetic acid, and cleansed the wound but did not leave the acetic acid–dampened gauze in place for the ordered 10–15 minutes. The resident was rolled onto her back without a barrier and the area was left uncovered while the RN applied pain cream to the resident’s shoulder. Later, the RN again touched the computer and then donned gloves without hand hygiene, used a gloved finger to obtain and apply Calmoseptine to two sacral wounds, and with the same gloved hand handled and cut Melgisorb Ag and placed it on the wound base. The RN then changed gloves without performing hand hygiene, applied an ABD pad, secured it with tape, and documented completion of the treatment. The DON acknowledged that the treatment was not completed per the physician’s orders.
Failure to Notify Resident Representatives of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident, the resident representative, or the family member of significant weight loss for 2 of 2 residents reviewed. Resident #16 had an MDS assessment documenting severely impaired cognitive skills for daily decision making, partial to moderate assistance with eating, and diagnoses of bipolar disorder, Alzheimer's disease, and Down syndrome. His recorded weights showed a loss from 110.4 lb. on 12/1/25 to 98.2 lb. on 1/8/26, a decrease of 12.2 lb. or 11.1%, and the progress notes from 1/8/26 through 1/29/26 lacked documentation that the family representative was informed of the weight loss. Resident #24 had an MDS assessment documenting a BIMS score of 4 out of 15, indicating severe cognitive impairment, and she was independent with eating. Her diagnoses included diabetes, thyroid disorder, and Alzheimer's disease. Her recorded weights showed a loss from 140 lb. on 12/8/25 to 130.8 lb. on 1/5/26, a decrease of 9.2 lb. or 6.6%, and the progress notes from 1/5/26 through 1/29/26 lacked documentation that the family representative was notified. The resident representative stated he was shocked to learn of the weight loss and said the facility had not notified him. The DON stated there was no documentation that the resident representatives for Resident #24 and Resident #16 were informed, and the Administrator stated the facility did not have a family notifications policy and follow the regulations/standard of care.
Inaccurate PASRR coding on MDS
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on record review and staff interview, the facility failed to accurately code 1 of 2 Minimum Data Set (MDS) assessments reviewed for Preadmission Screening and Resident Review (PASRR) level outcome for Resident #6. Resident #6 had a PASRR dated 4/23/25 that documented a Level II outcome with short-term approval ending 9/20/25. However, the MDS dated 5/26/25 documented a BIMS score of 15 out of 15, indicating no cognitive impairment, and also documented that the resident was not considered to be a PASRR Level II. The same MDS documented diagnoses of anxiety, depression, and PTSD. A later PASRR dated 10/8/25 again documented a Level II outcome with short-term approval. During interview, the Administrator stated she had recently started at the facility and was working on getting all residents' PASRRs reviewed and updated, and she would have expected the MDS Coordinator who completed the 5/26/25 assessment to code the MDS accurately to reflect the resident's Level II outcome.
Failure to Resubmit PASRR After New Psychosis Diagnosis
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a resident received a new diagnosis of psychosis. The resident’s MDS assessment documented a BIMS score of 15 out of 15, indicating no cognitive impairment, and also listed diagnoses of depression and psychotic disorder. The resident’s EHR documented that on 1/10/25 he received a new diagnosis of unspecified psychosis not due to a substance or known physiological condition and required medical management for that diagnosis. However, the resident’s most recent PASRR, reviewed on 1/29/26, had not been submitted for review since 12/23/24 and did not include the psychosis diagnosis. During interview, the Administrator stated she was working on getting all residents’ PASRRs reviewed and acknowledged that this resident’s psychosis diagnosis should have been submitted for review. The Administrator also stated the facility did not have a PASRR policy and followed the regulations.
Care Plan Not Updated for Homicidal Comments
Penalty
Summary
The facility failed to revise Resident #4’s care plan after homicidal comments were documented in the resident’s medical record. Resident #4’s MDS assessment showed a BIMS score of 8 out of 15, indicating moderately impaired cognition, and listed diagnoses of depression and anxiety. An Encounter Psych Progress Note documented that the resident was to continue to be monitored due to homicidal and suicidal comments and to follow up in 4 weeks or as needed. Despite this documentation, the current care plan did not include instructions or interventions related to the homicidal comments. The DON stated that nurses on the floor are expected to read psych notes and ensure psych issues are care planned properly, and acknowledged that homicidal comments should have been addressed on the care plan with interventions in place.
Failure to Analyze Repeated Falls and Injury Events
Penalty
Summary
The facility failed to complete root cause analysis and implement new interventions for a resident with severe cognitive impairment and multiple diagnoses, including bipolar disorder, Alzheimer's disease, and Down syndrome. The resident's MDS documented that he needed partial to moderate assistance with eating, and the Care Area Worksheet attached to the MDS stated he would not be care planned for falls. Despite this, the resident experienced multiple incidents involving falls and injury events. A witnessed fall report documented that the resident fell out of his wheelchair by the nurses station and the wheelchair landed on top of him, but the report lacked an in-depth root cause analysis and interventions. An unusual event report documented that the resident's hand was run over by another resident in an electric wheelchair while he was in the hallway, and this report also lacked an in-depth root cause analysis and interventions to prevent recurrence. A later witnessed fall report documented that he slid out of his wheelchair in the dining room onto the floor; the facility lacked an in-depth root cause analysis for why the fall occurred, although staff education was implemented about not leaving him unattended in the dining room when he was in his wheelchair. The resident's current care plan lacked interventions related to the root causes of the incidents, and it only stated that he should not be left unattended in the dining room and that he was independent with ambulation and preferred to sit on the floor and scoot.
QAA Committee Lacked Required Membership
Penalty
Summary
The facility failed to have the minimum required members present at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility had a census of 26 residents. Review of QAA sign-in sheets showed that the Administrator, Medical Director, DON, and at least two other staff attended the meetings, but the Infection Preventionist was not present at the November 2025 quarterly meeting. During an interview on 1/28/26 at 3:48 PM, the DON stated there was no Infection Preventionist present at that quarterly meeting because the facility did not have an Infection Preventionist at that time. Review of the facility's Quality Assurance and Performance Improvement Plan updated on 5/23/2023 showed the QAA Committee was required to meet at least quarterly and include the DON, Medical Director, Infection Preventionist Nurse, and 3 other staff members, with one member required to be the Executive Director or another leadership team member.
Infection Control and EBP Not Properly Implemented During Wound Care
Penalty
Summary
The facility failed to implement standard infection control practices and Enhanced Barrier Precautions during routine wound care for two residents with pressure ulcers and other complex medical conditions. Resident #5 had a BIMS score of 12, a diagnosis of urinary tract infection, and a stage 4 sacral pressure ulcer. The care plan identified the resident as needing EBP related to the chronic wound, with instructions for staff to wear a gown and gloves during care. During observed wound care, staff donned PPE, but the resident was incontinent of urine and the saturated brief was removed without complete peri care before wound treatment. The wound was cleaned only around the wound edges, the resident’s back side that had urine was left unclean, and the wound dressing was applied over areas that had not been cleaned. Later, staff transferred the resident to a wheelchair without wearing PPE and without hand hygiene before the transfer. The resident’s door also lacked an EBP sign during observation. Resident #13 had intact cognition, an indwelling catheter, neurogenic bladder, paraplegia, and a stage 4 sacral pressure ulcer. During observed treatment, staff entered the room with supplies, applied gloves and a gown without hand hygiene, and performed multiple wound and skin treatments while the gown repeatedly hung down and was not worn properly. Staff touched the computer with gloved hands, changed gloves without hand hygiene, and used the same gloved finger and same gloves across multiple wound areas and products. The sacral wound was cleansed with acetic acid but was not left on the wound for the ordered 10 to 15 minutes. Peri care was performed by wiping from back to front and using the same wipe multiple times, and the catheter area was also wiped in a manner that did not follow the documented competency. During catheter flushing, the gown remained hanging down at the arms. Staff later realized a treatment had been applied to the wrong foot area and corrected the dressing after the resident pointed out the error. The facility also failed to review its General Infection Prevention and Control Surveillance annually. The surveillance document was last updated on 10/5/23, and the DON stated she had never seen the overall infection control surveillance plan and had not reviewed it since becoming DON in May 2025. The Administrator stated the document in place was the 10/5/23 version and that documentation of annual review could not be located.
Failure to Provide Discharge Summaries and Documentation During Resident Transfers
Penalty
Summary
The facility failed to complete and provide discharge summaries and necessary documentation to the receiving facilities for two residents who were transferred. For one resident with intact cognition and diagnoses including cellulitis, lymphedema, and hypertension, the electronic health record did not contain a completed discharge summary or evidence of communication with the receiving provider. The receiving facility reported delays in obtaining admission orders, which resulted in delayed medication and treatments, as the resident arrived without any paperwork or discharge summary. The facility's own discharge planning policy requires all relevant information to be provided in a discharge summary to facilitate a smooth transition and avoid unnecessary delays. Another resident, also with intact cognition and diagnoses of depression, anemia, and hypertension, was discharged to another facility without a completed discharge summary or documented communication with the receiving provider. The resident reported that the discharge process was rushed, and no discharge paperwork or orders were sent with her. The receiving facility confirmed that no discharge records accompanied the resident and that they had to repeatedly contact the prior facility to obtain the necessary information for care.
Failure to Address PICC Line Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that addressed the presence of Peripherally Inserted Central Catheters (PICC) and associated risk factors for two residents. For one resident with severely impaired cognition and diagnoses including heart failure, anemia, and hypertension, the care plan did not document the existence of a PICC line or include interventions and monitoring related to the device, despite the resident receiving IV medications through the PICC. The Director of Nursing acknowledged that the care plan lacked this essential information. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension was discharged from the hospital with a PICC line and received IV medications in the facility. However, the care plan for this resident also failed to document the presence of the PICC line, associated risk factors, or necessary monitoring. These omissions were identified through clinical record review, staff interview, and policy review, and were inconsistent with the facility's policy requiring comprehensive, person-centered care plans that address all identified needs and services.
Failure to Assess and Document PICC Line Status for Residents Receiving IV Therapy
Penalty
Summary
The facility failed to follow professional standards for the assessment and documentation of Peripherally Inserted Central Catheter (PICC) lines for two residents who required IV medications. For one resident with severe cognitive impairment and diagnoses including heart failure, anemia, and hypertension, there was no documentation in the electronic health record of any assessment of the PICC site, its location, or length during the resident's stay. The admission assessment also did not note the presence of a PICC line, and the discharge summary indicated the central line was removed due to occlusion. The Director of Nursing confirmed that nurses were expected to assess the site when administering medication but acknowledged that there was no documentation to support that these assessments occurred, nor were measurements of the catheter performed to ensure it had not moved out of place. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension had a PICC line on admission, but the electronic health record lacked documentation of any assessment of the PICC site, location, or length. The admission assessment also failed to document the presence of a PICC line. Facility policy required nurses to monitor the dressing, line, and resident every shift for signs of infection, malposition, or occlusion, and to document these assessments, but this was not done for either resident.
Failure to Timely Close Resident Trust Account and Unauthorized Transactions Post-Discharge
Penalty
Summary
The facility failed to close a resident's trust account within 30 days of discharge, as required by both facility policy and federal regulations. After discharge, the resident, who was cognitively intact and managed his own financial affairs, continued to have income deposited into and funds withdrawn from his trust account by the facility without his knowledge or authorization. The facility was not the representative payee for the resident, and there was no documentation authorizing these post-discharge transactions. Bank statements and trust transaction histories confirmed that deposits and withdrawals occurred for several months after the resident's discharge. Additionally, the facility did not provide documentation that the trust account had been closed or that a refund of the remaining balance had been processed in a timely manner. The administrator acknowledged the ongoing balance in the account and the lack of proper authorization for the transactions. Facility policy required that trust accounts be closed within 24 hours of discharge and refunded within 30 days, with all disbursements properly authorized, but these procedures were not followed in this case.
Failure to Document and Maintain Restorative Programs After Staff Departure
Penalty
Summary
The facility failed to provide documentation and rationale for discontinuing restorative programs for three residents after the designated Restorative Aide left the restorative nursing department. Record reviews showed that for each resident, restorative programs such as active range of motion exercises and other therapeutic activities were discontinued on the same date, with no evidence of monthly restorative program reviews or documented reasons for stopping the interventions. The residents involved had varying degrees of cognitive impairment and physical limitations, including needs for assistance with ambulation, dressing, and other activities of daily living, as well as diagnoses such as diabetes, obesity, muscle weakness, heart failure, anxiety, and depression. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for overseeing the Restorative Program, had minimal training and had not completed any charting or reviews of restorative plans since assuming the role. The discontinuation of all restorative programs was attributed to the absence of a trained Restorative Aide, and no alternative arrangements or documentation were made to continue or review the programs. The Director of Nursing confirmed that all restorative programs were resolved or discontinued for staff convenience, and there had been no RN monthly restorative reviews for any residents in the past six months.
Failure to Document Nursing Assessment After Skin Issue Identified
Penalty
Summary
A deficiency occurred when the facility failed to document a nursing assessment after a bath aide identified an open, red, and bleeding scrotum on a resident. The resident, who had diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, was dependent on staff for toileting hygiene and required substantial assistance with transfers. The resident was also at risk for pressure ulcers. The Certified Nursing Assistant (CNA) documented the skin issue on a shower review form, but there was no evidence in the progress notes from the date of discovery through several days later that a nurse assessed the area or that a physician was notified. Interviews revealed that the CNA reported new skin issues using a designated form, which was then placed in the MDS Coordinator's mailbox. The MDS Coordinator charted a note several days after the initial finding but did not verify that the area was tracked or monitored. The Director of Nursing (DON) was not made aware of the issue at the time and did not assess the area until days later, by which time only chronic redness was observed. Facility policy required notification of the DON and wound nurse for new skin alterations, completion of incident reports, and physician notification if deterioration or infection was observed, but these steps were not documented as completed in this case.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, diabetes, dementia, and hemiplegia did not receive their ordered artificial tears for 14 days, missing 55 doses. The September Medication Administration Record showed the medication was not administered from 9/10/25 through 9/24/25. There was no documentation in the resident's progress notes indicating that the physician was notified about the unavailability of the artificial tears or that the resident was not receiving the medication as ordered. Staff interviews revealed that the facility was aware the artificial tears were on back order with the stock supply distributor, but the medication was not ordered through the pharmacy until 9/24/25, when a nurse called the pharmacy and the medication was delivered later that day. The facility's policy instructed nurses to report supply deficiencies to the DON but did not provide guidance on notifying the prescriber or pharmacist when medications were unavailable. The DON confirmed that the physician should have been notified when medications were not received.
Resident with Cognitive Impairment Accesses Locked Door, Falls Down Stairs
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk was not adequately protected from accident hazards within the facility. The resident's care plan identified risks for elopement and falls, directing staff to provide supervision, diversions, and structured activities to prevent wandering. Despite these interventions, the resident was last seen in the dining room with staff before going missing. Staff initiated a search, including looking outside, and eventually found the resident at the bottom of a basement staircase, having accessed a key code locked door with his wheelchair and fallen down the stairs. The incident report documented that the resident sustained a hematoma to the face and right forearm, as well as an abrasion and bruise to the left hand, requiring evaluation at the emergency room. Staff interviews revealed that the resident may have figured out the code to the basement door, which was supposed to be locked. Observations showed that the door had a key code lock with a deadbolt latch that, if turned, would allow the door to open without entering the code, although the keys would still light up as if the code was being entered. Staff were generally unaware that the door could be accessed in this manner, and some were not even aware of the basement's existence. The maintenance staff confirmed that the door and lock were functioning as intended upon inspection, and that the door was supposed to lock automatically. However, the incident demonstrated that the resident was able to access the basement, leading to a fall and injury. The facility census at the time was 29 residents, and the event highlighted a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for this resident.
Lack of Documentation for Dependent Adult Abuse Training
Penalty
Summary
The facility failed to provide required dependent adult abuse training within six months of hire for one of five employees reviewed. Personnel file review for the Dietary Manager showed a hire date of 1/20/23, but there was no documentation of the mandatory Dependent Adult Abuse training in the employee's file. Facility policy requires each employee to complete a two-hour initial training, followed by a one-hour recertification every three years. During an interview, the Administrator confirmed that the training documentation was missing from the employee's file, and the employee was unable to provide proof of completion, despite claiming to have taken the training in 2023.
Failure to Notify Family and Physician of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify both the family and physician of an incident involving resident-to-resident abuse. Specifically, a resident with severe cognitive impairment and a history of physical and verbal behaviors was documented as having kicked another resident in the face. Progress notes indicated that the nurse observed the incident and addressed the behavior with the resident, but there was no documentation that the physician or the family of either resident involved were informed of the event. The facility's risk management policy requires that such incidents be reported to the appropriate parties, including the physician and family, and that a progress note be entered in the resident's chart. Both residents involved had severe cognitive impairment, with one resident also diagnosed with Alzheimer's disease, Down Syndrome, and moderate intellectual disabilities, and was on hospice care. Despite these vulnerabilities, the clinical records for both residents lacked evidence that their families or physicians were notified about the incident. Staff interviews confirmed that the family should have been informed, but this did not occur, constituting a failure to follow facility policy and ensure appropriate communication after a significant event.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, despite multiple documented incidents of aggressive behavior. One resident with severe cognitive impairment and a history of both physical and verbal aggression, including wandering, was involved in several altercations targeting another resident. These incidents included attempts to kick, ramming with a wheelchair, verbal insults, and physical attacks such as kicking in the face and legs. Staff progress notes documented a pattern of escalating behaviors over several months, with specific references to the aggressor seeking out and targeting the same resident multiple times. Despite these ongoing incidents, the resident's care plan did not include interventions to address or prevent abusive behaviors toward others until after a significant incident occurred. Staff interviews confirmed awareness of the aggressor's pattern of seeking out and attempting to harm the other resident, yet no specific measures were implemented to prevent further abuse prior to the addition of interventions on the care plan. The facility's own abuse prevention policy defines resident-to-resident physical contact resulting in harm, pain, or mental anguish as abuse, and presumes such outcomes in residents with cognitive or physical impairments, even if no immediate injury is observed. The resident who was targeted had severe cognitive impairment, Alzheimer's disease, Down Syndrome, moderate intellectual disabilities, and was on hospice care. There were no behaviors noted for this resident during the assessment period. Staff and administrative interviews revealed a lack of timely reporting and investigation of the incidents, as well as a failure to notify family and the physician. The deficiency centers on the facility's inaction in updating the care plan and implementing protective interventions despite clear evidence of ongoing abuse.
Failure to Report Resident-to-Resident Abuse to Authorities
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) as required by policy. Specifically, a resident was kicked in the face by another resident in the dining room, an event witnessed by dietary staff. Review of facility records showed no documentation that this incident was reported to DIAL. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported to the appropriate authorities within specified timeframes, but this protocol was not followed in this case. The administrator confirmed during an interview that such incidents should be reported to DIAL, yet the required reporting did not occur.
Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and implement interventions in response to multiple incidents of resident-to-resident abuse involving a resident with severe cognitive impairment and a history of physical and verbal aggression. Clinical record review showed that this resident exhibited repeated aggressive behaviors, including kicking, hitting, and verbal abuse directed at another resident and staff over several months. Despite documentation of these behaviors in progress notes, there were no care plan interventions addressing the resident's abusive behaviors toward others until a focused area and interventions were added months after the initial incidents. Interviews with facility leadership confirmed that no actions were taken to address or investigate the incidents prior to the addition of care plan interventions. The administrator stated that she would have investigated the abuse if she had been made aware of it, and the DON acknowledged that staff did not report the incidents as required. Facility policy directs that any observed or suspected abuse should be investigated by management, but this protocol was not followed in these cases.
Failure to Complete Background Check for CNA
Penalty
Summary
The facility failed to complete a background check for one of its current employees, a Certified Nurse Aide (CNA) referred to as Staff B, prior to employment. This deficiency was identified during a review of records, staff interviews, and policy review. The facility's policy mandates that all potential employees be screened for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents before hiring. However, the background check for Staff B was only completed on January 8, 2025, despite her having worked several hours at the facility since August 2024. During an interview, the Business Office Manager was unable to locate the background check for Staff B when requested. She stated that she typically runs a background check before hiring an employee and was unsure why it was not completed or if it was misplaced. The facility's policy requires conducting an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees prior to hire, as per the Iowa Administrative Code. Despite this requirement, Staff B worked multiple shifts over several months without the necessary background check being completed, which is a violation of the facility's abuse prevention policy.
Facility Maintenance and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in its kitchen and dining areas, as observed during a survey. In the dining room, there were multiple stains on the carpet, with the largest stain measuring approximately 10 feet by 3 feet, located next to lower cabinets in the common areas. In the kitchen, the stove cooktop had a large area of black discoloration on the stainless steel part, and the floor had multiple tiles missing sections with black discoloration between them. The Director of Nursing (DON) acknowledged that the carpet's condition had been discussed in Quality Assurance meetings due to infection control concerns and stains, but no plan was in place to address the issue.
Deficiencies in Care Plan Implementation for Pressure Ulcers and Medication Monitoring
Penalty
Summary
The facility failed to comprehensively assess and implement necessary interventions for pressure ulcers and other medical conditions for two residents. Resident #6, who had a Stage 4 pressure ulcer in the sacral region, did not have specific interventions documented in her care plan to address her condition. This oversight was identified during a record review of her care plan dated 1/7/2024, which lacked resident-specific interventions for her pressure ulcer, despite an After Visit Summary dated 12/5/2024 indicating the severity of her condition. Additionally, Resident #24, who was on multiple psychotropic medications, did not have a care plan that documented adverse reactions to monitor for or interventions and goals related to her medication use. Furthermore, her care plan lacked documentation of her diagnosis of Herpes Simplex Virus (HSV) and the necessary interventions and monitoring for her condition, despite her admission orders indicating she was on prophylactic Valtrex. The Director of Nursing acknowledged these deficiencies, stating that she would have expected comprehensive care plans for both residents, including interventions for pressure ulcers, psychotropic medication monitoring, and HSV management.
Failure to Conduct Daily Assessments for SARS-CoV-2 Positive Resident
Penalty
Summary
The facility failed to ensure that a resident who tested positive for SARS-CoV-2 received daily nursing assessments as required. The resident, identified as Resident #80, was placed in isolation due to the positive test result. Despite the resident's condition of being very weak and requiring assistance with all cares, the facility did not document any assessments or vital signs for the resident on January 8, 2025. This lack of documentation indicates that no assessments were completed on that day. The Director of Nursing (DON) stated that she would expect a SARS-CoV-2 positive resident to receive routine assessments at least every 12 hours, including a full head-to-toe assessment documented in the resident's Electronic Health Record (EHR). The facility's Agreement for Medical Director Services outlines the responsibilities of the Medical Director, which include the surveillance of the health status of residents and acting as a consultant to the Administrator and/or DON. However, the facility did not adhere to these expectations, resulting in a deficiency in the care provided to Resident #80.
Incomplete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to provide complete dialysis assessments for a resident requiring such services. Resident #16, who is cognitively intact with a BIMS score of 15, has diagnoses including heart failure, hypertension, and renal insufficiency, and receives dialysis three times a week. The care plan for Resident #16 included specific instructions for monitoring vital signs and conducting pre and post-dialysis assessments on dialysis days, as well as monitoring for signs of infection and renal insufficiency. However, a review of Resident #16's Electronic Health Record (EHR) revealed missing pre and post-dialysis assessments on multiple occasions over a 90-day period. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that these assessments were not completed as required. Additionally, the facility lacked a dialysis policy, which may have contributed to the oversight in completing the necessary assessments.
Failure to Ensure Proper Monitoring and Documentation for Anti-Viral Medication
Penalty
Summary
The facility failed to ensure proper routine monitoring and documentation for a resident receiving anti-viral medication. The resident, who was admitted with a diagnosis of Herpes Simplex Virus (HSV), was prescribed prophylactic valacyclovir. However, the resident's current diagnoses in the Electronic Health Record (EHR) did not include HSV, and the Order Summary Report did not specify the diagnosis for the valacyclovir prescription. Additionally, the resident's progress notes lacked a review by the facility's pharmacist and did not include a request for the rationale behind the valacyclovir usage. Furthermore, the resident's current care plan did not document the HSV diagnosis or the interventions needed for managing the condition. It also failed to mention the anti-viral medication and the potential adverse reactions to monitor. During an interview, the Director of Nursing expressed an expectation for the pharmacy to ensure proper diagnoses are in place for all medications. The facility's agreement with the Medical Director outlined responsibilities for coordinating medical care, including policy development and health status surveillance, but these were not adequately fulfilled in this case.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified through a review of records, staff interviews, and policy documents. Specifically, the records for three hospitalizations involving two residents lacked documentation that the residents or their Power of Attorneys (POAs) were informed of the facility's bed-hold policy. Resident #15 was discharged to the hospital and returned without any record of notification, and Resident #16 experienced two hospitalizations with no documentation of notification. The Director of Nursing confirmed the absence of such documentation and explained that the nurse on duty is responsible for completing a packet that includes the bed-hold notice during acute transfers, which was not done in these cases. The facility's Acute Care Transfer Checklist requires the completion of an emergency notice of transfer/discharge and a notice of bed-hold policy and return, which was not adhered to in these instances.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with federal regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours each day. A review of RN timesheets from May 26, 2024, through June 6, 2024, revealed that the facility did not have an RN on duty on May 27, 2024, and from June 4 to June 6, 2024. The facility had a census of 27 residents during this period. The deficiency was confirmed during an interview with the Administrator on June 7, 2024, at 3:15 p.m., who acknowledged the failure to provide the required RN coverage.
Facility Fails to Secure Environment and Medication Carts
Penalty
Summary
The facility failed to maintain a safe and secure environment for a resident with multiple diagnoses, including schizophrenia, bipolar disorder, and moderate cognitive impairment. The resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on multiple occasions. On one occasion, the resident was found in a garage after leaving the courtyard through an unsecured door. The garage door had been previously reported as faulty, and temporary measures to secure it were inadequate. Additionally, the courtyard was inadequately lit, further compromising safety. Staff interviews revealed that residents were allowed to enter the courtyard unattended, even at night, which contributed to the resident's ability to leave the area unnoticed. The facility's maintenance director confirmed that the floodlight outside the garage was nonfunctional, and the administrator failed to notify the corporate office about the malfunctioning door and lights. This lack of communication and oversight contributed to the resident's repeated elopement incidents. Furthermore, the facility failed to secure medication carts, allowing the resident to access them unsupervised. On one occasion, the resident took cigarettes from an unlocked medication cart and went outside to smoke, later becoming upset when denied another smoke break. Observations confirmed that medication carts were left unlocked and unattended in areas accessible to residents, posing a risk to cognitively impaired individuals.
Staffing Issues Lead to Delayed Call Light Responses and Incomplete Restorative Care
Penalty
Summary
The facility failed to meet the professional standard of answering resident call lights within 15 minutes, as evidenced by interviews with Resident #3 and staff members. Resident #3 reported waiting 45 minutes for assistance, which made her feel neglected. Staff interviews confirmed that call lights were not consistently answered within the required timeframe due to staffing issues. The Resident Council minutes also documented concerns about delayed responses to call lights on multiple occasions. Additionally, the facility did not provide restorative exercises according to the individual plan of care for Resident #3. Interviews with staff, including the Administrator and the Regional Clinical Quality Specialist, revealed that the facility lacked an active restorative program due to low staffing levels. A restorative aide was frequently reassigned to other duties, preventing the implementation of restorative programs. The Director of Rehabilitation Services confirmed that restorative programs were not followed as intended.
Deficiencies in Narcotic Medication Management
Penalty
Summary
The facility failed to properly manage and secure narcotic medications, as evidenced by several deficiencies in the handling and documentation of controlled substances. A review of the Controlled Drug Administration Record for a resident revealed that a Baclofen pill was administered without a nurse's signature to validate who administered the medication. Additionally, there were multiple instances where staff failed to sign the Controlled Drug Count Record forms, indicating that narcotics were not properly counted or accounted for during shift changes. This lack of documentation and accountability was observed on several dates and shifts, leading to discrepancies in the narcotic counts. Interviews with staff members further highlighted issues with the facility's medication management practices. One LPN admitted to not counting narcotics when handing over keys during meal breaks, and it was revealed that the Assistant Director of Nursing (ADON) had access to medication carts and narcotic drawers, administering medications without proper documentation. Staff members reported that the ADON sometimes worked alone and signed off on narcotic sheets without documenting the administration of drugs on the Medication Administration Records (MARS), leading to inaccuracies. The ADON confirmed carrying spare keys to medication carts and narcotic boxes, and the facility's administrator acknowledged that multiple nurses had access to these keys, contributing to medication errors. The facility's Controlled Substances policy outlined procedures for handling, storing, and documenting narcotics, but these were not consistently followed. The policy required a physical inventory of narcotics at each shift change by two nurses, with discrepancies reported immediately to the Director of Nursing. However, the report indicated that these procedures were not adhered to, as evidenced by the lack of proper record-keeping and accountability for controlled drugs. The failure to follow established protocols and secure narcotic medications resulted in a significant deficiency in the facility's medication management practices.
Supply Shortages and Policy Access Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient supplies to meet the treatment needs of two residents. Resident #2 had a treatment order for a stage IV pressure area on the right hip and gluteal region, which required cleansing with wound cleanser, application of Silversorb gel, collagen powder, and an ABD pad daily. However, the facility staff were unable to perform the complete treatment on two occasions due to the unavailability of Silversorb gel. Similarly, Resident #3 had a treatment order for a wound on the right medial third toe, which required cleansing with normal saline and Betadine, but the treatment was not performed on two occasions due to a lack of supplies. Additionally, the facility failed to provide a policy and procedure book readily accessible to staff. Staff members reported that they were unable to access the necessary policies and procedures, as the Administrator directed them to an employee handbook instead. The Administrator acknowledged that the facility staff did not have direct access to the P drive where the policies were stored, and efforts were being made to organize a policy and procedure book. The Regional Clinical Quality Specialist also confirmed the lack of access to the P drive for nurses, and the Director of Nursing had to print and provide copies of the policies for the staff.
Facility Fails to Secure Environment, Leading to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe and secure environment for its residents, as evidenced by multiple incidents involving a resident with a history of schizophrenia, bipolar disorder, and other health issues. This resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on several occasions. On one occasion, the resident was found in a garage after leaving the courtyard area, which was supposed to be secure. The garage door had been left in disrepair, and the resident was able to access it due to a malfunctioning latch. Staff interviews revealed that residents were allowed to enter the courtyard area unattended, even at night, which contributed to the resident's ability to leave the secure area. The staff's response to the door alarm was delayed, and the resident was unaccounted for several minutes. The facility's maintenance director had been aware of the garage door's disrepair but had only temporarily secured it with a board, which proved insufficient. Additionally, the facility's administrator failed to notify the corporate office about the malfunctioning garage access door and nonfunctional floodlights, which could have prevented the resident's elopement. The facility also identified six other residents who were cognitively impaired and prone to wandering, indicating a broader issue with maintaining a secure environment for vulnerable residents.
Failure to Report Drug Diversion and Financial Exploitation
Penalty
Summary
The facility failed to report alleged violations involving financial exploitation and drug diversion to management and the Iowa Department of Inspections, Appeals, and Licensing as required by policy. This deficiency was identified for one of six residents reviewed. Staff interviews revealed that narcotics and muscle relaxers were reported missing, but the Administrator allegedly ignored these reports. Staff members expressed fear of retaliation if they reported concerns to corporate, as they were instructed not to contact corporate directly. The Administrator admitted that the facility staff did not report the alleged drug diversion directly to her, but rather left a note under her office door, which she did not receive until three days later. The Regional Clinical Quality Specialist was only informed of discrepancies with Flexeril and expected the Administrator to report missing narcotics to the appropriate authorities. The facility's Controlled Substances policy required immediate reporting of discrepancies to the Director of Nursing, who would then initiate an investigation and report missing narcotics to the Clinical Quality Team.
Inaccurate Care Plan for Resident with COPD
Penalty
Summary
The facility failed to maintain a complete and accurate care plan for one of the residents reviewed. The care plan for this resident, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and incontinence, indicated a deficit in activities of daily living (ADLs) due to shortness of breath. The care plan, initiated on August 16, 2022, required the resident to have assistance with a walker and gait belt. However, a Rehab Communication form dated May 28, 2024, indicated a change in the resident's mobility status to modified independence with a front-wheeled walker when indoors, but not outdoors. This change was not reflected in the care plan, as confirmed by a Certified Nursing Assistant during an interview on June 18, 2024. The facility's policy, revised on January 30, 2024, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which should include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The policy also requires timely updates to the care plan to ensure that the services provided represent the resident's highest practicable physical, mental, and psychosocial well-being. The failure to update the care plan in accordance with the resident's current needs and the facility's policy led to the identified deficiency.
Failure to Assess Pressure Areas and Follow Medication Orders
Penalty
Summary
The facility failed to provide adequate assessment and intervention for pressure areas in two residents. Resident #2 experienced an increase in drainage from a pressure area on the right hip and buttocks, which was not assessed by the facility on multiple occasions, including 5.21.24, 5.23.24, 5.24.24, 5.26.24, and 5.27.24. Similarly, Resident #3 had a pressure area on the left heel that went unassessed from 4.24.24 to 5.7.24. A corporate representative confirmed the lack of assessment for Resident #3 during an interview. Additionally, the facility failed to follow physician's orders for Resident #3 regarding medication administration. On 6.11.24, medications prescribed to be administered at 7 p.m. were given at 9:43 p.m. The resident expressed dissatisfaction with the delay, as it affected her ability to sleep due to neuropathy. The facility's Medication Administration Policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to in this instance. Interviews with staff confirmed the delay and the resident's concerns.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cresco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evans Senior Living Community | 1.3 mi | ★★★★★ | 2 | 0 |
| Gundersen Harmony Care Center | 13.7 mi | ★★★★★ | 5 | 0 |
| Green Lea Senior Living | 16.1 mi | ★★★★★ | 12 | 2 |
| The Highlands | 17.1 mi | ★★★★★ | 2 | 0 |
| Colonial Manor Of Elma | 18.3 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.