Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Lake City, Llc during CMS and state inspections, most recent first.
Unsanitary food service practices were observed during meal service. A Dietary Manager served lunch without a beard net despite visible facial hair, and a staff member used the same gloves to handle buns, a hamburger, utensils, pan lids, menu slips, and the steam table while also adjusting glasses and fanning herself. Facility policy stated beard nets were required when facial hair was visible and that disposable gloves were single-use items.
Failure to include high-risk medications in the care plan: A resident with intact cognition and diagnoses of chronic pain, anxiety disorder, and HTN received anticoagulant, opioid, antidepressant, and diuretic medications daily, but the care plan lacked personalized documentation for these medications and the side effects to monitor. The DON acknowledged that care plans were behind and said high-risk medications should be addressed on the care plan.
Surveyors found that a resident with COPD and severe cognitive impairment received oxygen at a higher flow rate than ordered, with documentation and observations showing use of 2 L/min instead of the prescribed 1.5 L/min via nasal cannula. During med pass, a CMA administered pain and diuretic medications to two cognitively intact residents but left before confirming the medications were swallowed. For another cognitively intact resident with atrial fibrillation, the CMA removed Tylenol tablets from a non-original container stored in a med cart drawer and handled the pills with bare fingers, contrary to infection control and medication storage standards.
The facility failed to provide adequate staffing to complete restorative programs and scheduled baths as care planned. Three residents with conditions including heart failure, MS, hemiplegia, dementia, COPD, diabetes, and mobility limitations had restorative nursing plans calling for daily or near-daily AROM and PROM exercises 3–6 days per week, but documentation showed these services were provided only a few times over a month or once weekly over several weeks. A CNA assigned as the restorative aide reported being pulled from restorative duties to work the floor when the facility was short-staffed. Additionally, three residents who required varying levels of assistance with bathing and were scheduled for two baths per week received only one bath during certain weeks. A CNA stated they had been working short and could not confirm that all scheduled baths were completed, and the DON acknowledged a staffing crisis.
Staff reported that during a recent noon meal featuring apricot chicken, several residents were served poultry that appeared pink, red, or “bleeding,” and one CNA discovered raw chicken thighs while preparing a plate, with some residents stating they received bloody chicken and did not eat it. During observation of a separate noon meal service, staff delivering trays to rooms found that hot food items on heated plate warmers were below the facility’s required 135°F, with meat temperatures recorded around 130°F and as low as 126°F, and side dishes also below standard, indicating failure to ensure food was fully cooked and maintained at safe serving temperatures.
Surveyors found unsanitary conditions in the kitchen, including food debris, residue on equipment, and undated food items in both the refrigerator and pantry. Despite established cleaning schedules and policies requiring food to be dated when opened, staff did not consistently follow these procedures, resulting in improper food storage and preparation practices.
The facility did not notify the responsible parties for two residents when there were significant changes in their conditions, including a hospital admission for pneumonia and a positive Influenza A diagnosis. In both cases, families were not informed in a timely manner, and documentation of notification was lacking, despite facility policy and staff expectations.
Two residents experienced deficiencies in care when staff failed to follow physician orders and professional standards. One resident with a history of falls and on anticoagulant therapy was not consistently offered or documented as refusing ER evaluation after falls with possible head injury, and staff did not update or follow dietary and swallowing precautions as recommended by speech therapy. Another resident with a UTI did not receive timely initiation of prescribed antibiotics after lab results, and there was a lack of documentation regarding physician notification and follow-up.
Two residents requiring staff assistance for bathing did not receive scheduled baths as documented in their care plans, with records showing missed and insufficient bathing over a 30-day period. Both residents reported receiving fewer baths than scheduled, and facility staff were unable to provide documentation of refusals or additional efforts to encourage bathing. The facility lacked a formal bathing policy and had inconsistencies in documentation and understanding of bathing schedules.
A resident at risk for pressure ulcers, with multiple comorbidities and requiring significant assistance with mobility, developed a stage 2 pressure ulcer on the right heel. The care plan did not include individualized interventions for pressure ulcer prevention, and there was no documentation of risk management or root cause analysis, despite facility policy requiring such measures.
A resident with multiple diagnoses and a history of falls was not consistently provided with care plan interventions intended to reduce fall risk, such as keeping the room door ajar for monitoring and maintaining the bed in a low position. Observations showed these interventions were not followed, and the resident experienced several falls. Staff interviews indicated some CNAs were unaware of the care plan details, contributing to the deficiency.
A resident with a history of frequent falls and diagnoses including dementia and hallucinations experienced multiple unwitnessed falls, one resulting in a hand fracture, due to the facility's failure to implement timely and effective interventions and provide adequate nursing supervision. Incident reports and root cause analyses were often not completed as required, and interventions were inconsistently applied or delayed, despite the facility's policy mandating prompt reporting and investigation of such events.
A resident with moderate cognitive impairment and swallowing difficulties choked on a sandwich in the dining area, with only a noncertified nurse aide present. The aide was unable to perform the Heimlich maneuver effectively and could not summon help due to a malfunctioning walkie talkie. The delay in assistance led to the resident experiencing severe respiratory distress and ultimately passing away from cardiac arrest related to the choking incident.
The facility failed to maintain an effective pest control program, leading to a mouse infestation affecting multiple residents. A resident was startled by a mouse in her room, causing her to fall. Staff confirmed ongoing issues, with mice seen in several rooms and potential entry points identified. The facility's administrator was aware of the problem and had changed pest control companies.
A facility failed to provide sufficient nursing staff with appropriate training, leading to a choking incident during a meal. A Training CNA, lacking state-approved training, was unable to perform the Heimlich maneuver effectively on a resident. The walkie-talkie failed, delaying assistance by approximately three minutes. The facility's job description required supervision for aides in training, which was not provided during this incident.
The facility failed to ensure a nurse aide, Staff A, was properly trained and competent according to state requirements. Staff A's file lacked evidence of training by a state-approved program or enrollment in a CNA class, despite having worked as a Training CNA at another facility. The facility's administrator noted that nurse aides could work for up to four months if they demonstrated skills and competencies with an RN, which Staff A had done at her previous facility. However, her file did not show enrollment in a state-certified CNA course, leading to the deficiency.
A facility failed to maintain a proper drug reconciliation system, resulting in a missing Methadone pill for a resident. The discrepancy was discovered during a shift change narcotic count, where a CMA noticed the count was off. The overnight nurse, who had access to the medication cart, was unaware of the pill's whereabouts. An internal investigation revealed lapses in the documentation process, with missing signatures on the controlled drug count record.
A resident with moderately impaired cognition and multiple health conditions experienced an unwitnessed fall, but the facility failed to document follow-up fall assessments and neurological checks. The DON acknowledged a late entry in the progress notes and the absence of a specific neurological policy, leading to the omission of necessary assessments.
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision. A broken laundry room door allowed 11 mobile residents access to hazardous chemicals. A resident with moderate cognitive impairment was found near the laundry room door on multiple occasions. Hazardous chemicals were stored openly, posing a significant safety risk.
A facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) after a resident reported that a CNA was rough with them during a brief change. The facility conducted an internal investigation but did not report the incident, concluding there was no harm and the resident did not feel the CNA's actions were intentional abuse.
The facility failed to ensure timely response to resident call lights, with two residents reporting waits longer than 15 minutes. Staff interviews indicated insufficient staffing, particularly on the 2pm-10pm shift, contributing to the delays.
Unsanitary Food Service Practices
Penalty
Summary
Food was not served under sanitary conditions during one observed meal service. On 4/20/26 at 11:45 AM, the Dietary Manager served the lunch meal without a beard net covering his beard. The facility’s Food Safety and Sanitation Policy, dated 2021, stated that beard nets are required when facial hair is visible. On 4/21/26 from 11:35 AM to 12:00 PM, Staff A applied gloves and then touched ladle handles, steam table pan lids, and, with the same gloves, placed a hamburger bun on a plate, placed a hamburger on the bun, and touched the bun again to cut the sandwich in half. Staff A continued using the same gloves to touch multiple hamburger and hotdog buns, scoop and ladle handles, paper menu slips, pan lids, and the steam table. Staff A also pushed her glasses up several times and used a plate to fan herself before continuing to touch more buns. The facility’s Employee Sanitary Practices Policy, dated 2021, stated that utensils are to be used to handle food and disposable gloves are a single-use item that should be discarded after each use. The Administrator stated that gloves were expected to be single use, utensils were to be used to touch food items, and staff with facial hair were expected to wear a beard net when preparing or serving food.
Failure to Include High-Risk Medications in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #6 to address the resident’s use of anticoagulant, opioid, antidepressant, and diuretic medications, including the side effects to watch for with each medication. Resident #6’s MDS assessment identified a BIMS score of 14, indicating intact cognition, and listed diagnoses of chronic pain, anxiety disorder, and hypertension. The MDS also showed that the resident received anticoagulant medication, opioid medication, antidepressant medication, and diuretic medication 7 out of the last 7 days during the review period. Review of the care plan dated 12/1/25 showed that it lacked personalized documentation related to the resident’s use of these medications and the side effects to monitor. The facility policy titled Comprehensive Care Plans stated that each resident should have a comprehensive person-centered care plan with measurable objectives and timeframes, and that the plan should be reviewed and revised after each comprehensive and quarterly MDS assessment. On 4/23/26 at 4:15 pm, the DON acknowledged that the care plans were behind and stated there had been staffing challenges, and that high-risk medications should be addressed on the care plan.
Failure to Follow Oxygen Orders and Medication Administration Standards
Penalty
Summary
Surveyors identified multiple failures to follow professional standards of quality related to oxygen administration, medication administration, infection control, and medication storage. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a physician order and care plan for oxygen at 1.5 L/min via nasal cannula. However, clinical records, including weights and vitals and progress notes, repeatedly documented the resident receiving oxygen at 2 L/min on several occasions. During observation, the resident was seen in bed on 1.5 L/min via concentrator, but later in the dining room on 2 L/min via a portable tank, inconsistent with the ordered 1.5 L/min. Facility leadership could not explain why oxygen was documented or set at 2 L/min and acknowledged that an agency CNA had turned the oxygen up to 2 L/min. Surveyors also observed failures in medication administration and infection control practices. A cognitively intact resident with pain was given ibuprofen 200 mg by a CMA, who walked away before confirming the resident swallowed the medication. Another cognitively intact resident on diuretic therapy was given Coenzyme Q10 and Lasix 40 mg by the same CMA, who again left the room before observing ingestion. For a third cognitively intact resident with atrial fibrillation, the CMA prepared PRN Tylenol by taking two round white tablets from a clear plastic cup stored in the top drawer of the med cart, handling the tablets with bare fingers and not from the original container. The DON, ADON, and Administrator confirmed that staff should observe residents swallowing medications, should not touch medications with bare hands, and should store medications in their original containers until administration, as required by the facility’s medication administration policy.
Insufficient Staffing Leading to Missed Restorative Services and Scheduled Baths
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to complete restorative nursing programs as planned for three residents. One resident with heart failure, atrial fibrillation, asthma, arthritis, and advanced age had a care plan revised in September that called for daily upper extremity exercises with Thera bands or light weights, 3–6 days per week, but documentation showed restorative exercises were completed only five times in the previous 30 days. A second resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for transfers had a care plan for active range of motion to the neck and shoulders with specified repetitions and sets, but the restorative program was documented as completed only four times in the previous 30 days. A third resident with hemiplegia, moderate cognitive impairment, and functional limitations in range of motion of one side of the body had a care plan for daily active and passive range of motion to upper and lower extremities, 3–6 days per week, yet the point-of-care records showed restorative services were provided only once per week over multiple weeks. The report further documents that the certified nursing assistant assigned as the restorative aide stated she tried to complete all required tasks but, when the facility was short-staffed, she was pulled from restorative duties to work on the floor. The facility’s Restorative Program Process, updated in October, stated that its purpose was to ensure residents achieved and maintained their highest level of function and that licensed nurses would monitor daily restorative documentation and follow up with staff as needed. Despite this written process, the recorded frequency of restorative interventions for the three residents did not match the planned frequency outlined in their care plans and task lists. The deficiency also includes the facility’s failure to ensure three residents received at least two baths per week as planned. One resident with severe cognitive impairment, COPD, osteomyelitis, and diabetes with neuropathy was care planned to receive assistance of one to two staff for bathing and was documented as dependent for baths, with records showing two baths per week except for one week when only one bath was provided. A second resident with no cognitive impairment, diabetes, muscle weakness, and gait abnormalities required supervision or touching assistance with bathing and was care planned for bathing assistance of one, but documentation showed only one bath during a particular week instead of the usual two. A third resident with severe cognitive impairment, non-Alzheimer’s dementia, and limited mobility required partial to moderate assistance and was care planned for assistance of one with bathing, yet records showed only one bath during a specified week. A CNA reported that staffing had been short, that most residents were scheduled for two baths per week, and that with increased use of agency staff she could not confirm whether all baths were being completed. The DON later stated they were experiencing a staffing crisis and had recently admitted a new resident.
Undercooked Poultry and Improper Hot Food Holding Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures. Menu review showed apricot chicken was served on a Wednesday noon meal. Multiple staff members, including an LPN and several CNAs, reported that about one to two weeks prior, residents had been served chicken that was not fully cooked, with meat described as still pink or red and, in one case, “bleeding.” One CNA reported discovering raw chicken thighs while removing meat from the bone for a resident and stated that other plates contained similarly undercooked chicken. Staff reported that some residents received bloody chicken and did not eat it. The Administrator and Dietary Manager later identified the meal as the apricot chicken menu item and stated that when they checked the remaining chicken at kitchen tear-down time, it appeared cooked but contained veins that might have been misinterpreted as blood. In addition to concerns about undercooked chicken, observations during a noon meal service showed that hot foods were not consistently maintained at or above the facility’s required hot-holding and serving temperature of 135°F. Trays for residents in their rooms were assembled using heated plate warmers and transported on two carts. When one staff member checked a tray upon reaching a resident’s room, the meat temperature was 130.7°F and the potatoes were 133°F. Shortly afterward, another cart’s meat temperature was measured at 126°F. These temperatures were below the facility’s policy requirement that all hot food items be cooked to appropriate internal temperatures and held and served at a minimum of 135°F.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
Surveyors observed multiple instances of unsanitary conditions and improper food storage practices in the facility's kitchen. During an initial kitchen tour, they noted a milk cooler with dried liquid residue, smudge prints on the freezer and refrigerator doors, and crumbs or food debris at the bottom of both refrigerators and freezers. Additional findings included a steam table with a brown, crusty dried substance and a warmer with crumbs and food debris on its bottom. Several food items, such as an open container of ranch salad dressing in the refrigerator and packages of country gravy, dried pudding, and ranch dressing seasoning in the pantry, were found without open dates. Review of facility policies revealed that staff are required to maintain cleanliness and sanitation in food service areas through adherence to a comprehensive cleaning schedule, and all food items must be properly dated and stored to prevent contamination. Interviews with the Certified Dietary Manager confirmed the existence of daily, weekly, and monthly cleaning schedules and checklists, as well as the expectation for staff to date food packages when opened. Despite these policies, the observed conditions and undated food items indicated that staff did not consistently follow established procedures for cleaning and food storage.
Failure to Notify Family of Resident Condition Changes and Hospitalization
Penalty
Summary
The facility failed to notify the family or responsible party of significant changes in condition for two residents. One resident, who was cognitively intact and independent in mobility, developed a productive cough, abnormal lung sounds, a high fever, and low oxygen saturation. The resident was subsequently diagnosed with pneumonia and admitted to the hospital. There was no documentation that the resident's niece and power of attorney (POA) was notified of the change in condition or the hospital transfer. The niece/POA later contacted the facility, upset about not being informed, and the resident confirmed she wanted her POA notified of such events. Another resident, with diagnoses including non-traumatic brain dysfunction and dementia but no cognitive impairment, tested positive for Influenza A. The family was not notified of the positive result and only learned of it upon visiting, when they found precaution signs and personal protective equipment outside the resident's room. Facility records did not show any documentation of family notification regarding the positive influenza result. Staff interviews confirmed that the expectation was for families to be notified promptly, but this did not occur.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a history of falls, Parkinson's disease, atrial fibrillation, and use of anticoagulant medication, there were multiple incidents where the facility did not follow physician orders and care plan directives after falls, particularly those involving potential or actual head injuries. Documentation was lacking regarding whether the resident or his wife was offered or refused emergency room evaluation after unwitnessed falls with possible head injury, despite clear physician recommendations and care plan instructions to do so. Additionally, there was a failure to document and follow up on the status of the resident's anticoagulant medication after it was held due to a subdural hematoma, with no further action or physician guidance documented for an extended period. The same resident also experienced deficiencies in the implementation of speech therapy recommendations. Despite clear orders and therapy recommendations for a modified diet and no use of straws due to coughing and swallowing difficulties, staff continued to provide straws and did not update the care plan or CNA Kardex to reflect these restrictions. Observations confirmed that the resident was given straws with liquids and whole pills without the recommended modifications, resulting in episodes of coughing during medication administration and meals. Staff were observed to be unaware or inconsistent in following the therapy recommendations, and the care plan was not updated to reflect the current dietary and swallowing precautions. For another resident with a history of urinary tract infections, the facility failed to promptly act on laboratory results and physician orders. After a urine culture indicated a significant infection, there was no documentation that the results were received or communicated to the physician in a timely manner. The prescribed antibiotic was not started until the evening of the day after the order was received, despite the medication being available in the facility's emergency kit. The facility's policy required prompt notification and follow-up with the physician for abnormal lab results, but this was not documented or carried out as required.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to two residents who required staff support for activities of daily living. One resident, with diagnoses including peripheral vascular disease, diabetes mellitus, non-Alzheimer's dementia, and an unstageable pressure ulcer, was scheduled for two baths per week but only received a bath once a week according to both facility documentation and the resident's own report. The clinical record lacked documentation of refusals or attempts to encourage or offer additional bathing, and there was no evidence of other efforts to meet the resident's scheduled bathing needs. Another resident, with a history of diabetes mellitus, cerebrovascular accident, psychotic disorder, anxiety, and depression, required substantial assistance for bathing and was dependent on staff for transfers. This resident was also scheduled for two baths per week but received only four baths in a 30-day period, with documentation showing missed and refused baths but lacking evidence of re-approach or encouragement as directed in the care plan. Both residents reported receiving fewer baths than scheduled, and staff interviews confirmed a lack of documentation and understanding regarding bathing schedules and refusals. The facility did not have a formal bathing policy and relied on regulations and standard practice.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the development of a stage 2 pressure ulcer on the right heel of a resident who was identified as being at risk for pressure ulcers. The resident had diagnoses including hip fracture, peripheral vascular disease, and renal insufficiency, and required substantial to maximal assistance with mobility and transfers. The resident's baseline care plan did not include any interventions specifically aimed at preventing pressure ulcers, despite the resident's risk status and the presence of a pressure reducing device on the bed. A skin assessment later identified a stage 2 pressure ulcer on the resident's right heel. Facility policy required evidence-based, individualized interventions for residents at risk for pressure injuries, with documentation in the care plan and communication to staff. However, the care plan lacked such interventions, and there was no documentation of risk management, incident review, or root cause analysis related to the pressure ulcer. The DON confirmed that interventions were not put in place and that the area was thought to have resulted from the resident's shoe, but no further investigation or preventive measures were documented.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions designed to reduce the risk of falls for a resident with multiple medical conditions, including hypertension, CVA, non-Alzheimer's dementia, Parkinson's disease, seizure disorder, and paroxysmal atrial fibrillation. The resident's care plan identified them as being at risk for injury related to falls and included specific interventions such as keeping the room door ajar for closer monitoring and ensuring the bed was in the lowest position when occupied. However, clinical record review showed that these interventions were not consistently followed, as evidenced by repeated observations of the resident's door being closed and the bed not in the low position, contrary to the care plan directives. Additionally, the resident experienced seven falls over a four-month period, further indicating that the care plan interventions were not effectively implemented. Staff interviews revealed a lack of awareness among some CNAs regarding the care plan and kardex, which contributed to the failure to carry out the prescribed interventions. The facility's policy required that qualified staff be notified of their responsibilities for implementing care plan interventions, but this was not consistently done, leading to the deficiency.
Failure to Prevent Repeated Falls and Inadequate Supervision
Penalty
Summary
The facility failed to implement effective interventions and provide adequate nursing supervision to prevent accidents and injuries from falls for a resident with a known history of repeated falls. Over a three-month period, the resident experienced thirteen falls, including an unwitnessed fall that resulted in a fracture to the left hand. Despite the resident's identified risk for falls, the care plan interventions were often delayed or insufficient, with some interventions not implemented until after further assessment or review by other disciplines, such as medication reviews or physical therapy evaluations. In several instances, the facility did not complete required incident reports or root cause analyses following falls or other significant incidents. The resident's clinical records indicated no cognitive impairment, but diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, and hallucinations. The resident was independent in most mobility tasks but required supervision for toileting and was frequently incontinent of urine. The incident reports and progress notes documented multiple unwitnessed falls in various locations, including the resident's room, hallway, and bathroom. Interventions such as encouraging the use of gripper socks, reviewing medications, and replacing furniture were inconsistently applied, and in some cases, no immediate interventions were put in place following incidents. Staff interviews revealed inconsistencies in the implementation and documentation of frequent checks and supervision, particularly regarding the resident's wandering behavior and entry into other residents' rooms. The facility's policy required all accidents and incidents to be reported, investigated, and reviewed through the QAPI process, with specific procedures for completing incident reports and root cause analyses. However, the facility failed to adhere to these policies in several instances, as evidenced by missing incident reports and delayed or inadequate interventions following repeated falls and other incidents involving the resident.
Inadequate Supervision During Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision during a choking incident involving a resident with moderate cognitive impairment and a history of swallowing difficulties. The resident, who was on a mechanical soft diet with honey thick liquids, choked while eating a sandwich in the assisted dining area. At the time of the incident, the only staff present was a noncertified nurse aide who was unable to perform the Heimlich maneuver effectively and could not summon help due to a malfunctioning walkie talkie. The noncertified nurse aide attempted to assist the choking resident by providing back thrusts, but these efforts were unsuccessful. The aide's inability to perform the Heimlich maneuver and the failure of the walkie talkie to function properly delayed the arrival of additional help. A dietary aide eventually responded to the aide's calls for help and sought further assistance from the nursing staff. By the time the licensed practical nurse arrived and performed abdominal thrusts, the resident had already experienced significant respiratory distress. The resident's condition deteriorated rapidly, with symptoms including cyanosis, low oxygen saturation, and acute respiratory failure. Despite the efforts of the nursing staff and emergency medical technicians, the resident was unable to recover and ultimately passed away due to cardiac arrest related to the choking incident. The facility's failure to ensure appropriately trained staff were present and equipped to handle such emergencies contributed to the severity of the incident.
Removal Plan
- The Administrator initiated staff education to ensure all nursing staff are carrying a functioning walkie talkie.
- All nursing staff will be educated on the requirement to ensure licensed nurses or certified nurse aides are the only staff assisting residents during meals.
- There are no uncertified nurse aides on the nursing schedule.
- Staff A is no longer employed at the facility.
- The DON/Administrator and/or designee will audit staff for compliance with walkie talkie usage.
- The DON/Administrator and/or designee will audit the nursing daily schedule sheets to ensure licensed/certified staff are scheduled.
- Any concerns will be reported to the Administrator and addressed in facility QA.
Mouse Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mouse infestation that affected multiple residents. A resident reported seeing a mouse in her room in November, which startled her and caused her to fall. She later encountered another mouse caught in a sticky trap. Staff confirmed the presence of mice, with a CNA stating that the infestation had been ongoing and residents and family members had raised concerns. The LPN also acknowledged the issue, noting that a mouse was seen the previous day. The pest control report dated January 7, 2025, documented active rodent activity in nine rooms, with four rooms having potential entry points that needed sealing. The maintenance staff confirmed that the pest control company had identified areas where mice could enter and had begun sealing these points. The facility's administrator was aware of the infestation and had recently changed pest control companies, indicating ongoing efforts to address the issue.
Inadequate Training and Supervision During Meal Leads to Choking Incident
Penalty
Summary
The facility failed to ensure sufficient nursing staff with appropriate training to provide supervision during a meal, as evidenced by the incident involving Staff A. Staff A, who was working as a Training Certified Nursing Assistant (CNA), lacked training by a state-approved program or enrollment in a CNA class. Her personnel file indicated previous experience in a restaurant and a short tenure at another facility as a Training CNA. During a meal, Staff A was feeding a resident when another resident began choking. Despite her attempts to perform the Heimlich maneuver, she was unable to do so effectively due to her inability to fit her arms around the resident. She called for help, but the walkie-talkie did not work, leading to a delay in assistance. The incident occurred in the dining room, where Staff A was the only staff member present at the time. The resident who was choking did not lose consciousness, but the situation was not resolved until other staff arrived approximately three minutes later. The facility's job description for an Aide in Training indicated that such staff should perform duties under direct supervision, yet Staff A was left unsupervised during this critical incident. The facility's failure to provide adequate training and supervision contributed to the deficiency noted in the report.
Failure to Ensure Proper Training and Competency of Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide, referred to as Staff A, was properly trained and competent according to state requirements. Staff A's personnel file indicated that she had worked as a Training CNA at another facility from August 2024 to September 2024 and had previously worked in a restaurant from July 2021 to July 2024. Although Staff A signed a job description for a Certified Nursing Assistant (CNA) and had a CNA/Nurse Aide-Skills and Competency checklist from her previous employment, her personnel file lacked evidence of training by a state-approved program or enrollment in a CNA class. The facility's administrator stated that nurse aides could work for up to four months if they had demonstrated skills and competencies with a Registered Nurse (RN), which Staff A had done with the Director of Nursing (DON) at her previous facility. However, the previous facility had closed, and Staff A, along with others, transferred to the current facility. The facility's job description for an Aide in Training (CNA Scholarship) indicated that candidates would be enrolled in a state-certified CNA course either before joining the team or after a predetermined period of non-certified work. Despite this, Staff A's file did not show enrollment in such a course, leading to the deficiency finding.
Failure in Drug Reconciliation Leads to Missing Methadone Pill
Penalty
Summary
The facility failed to maintain a system of drug reconciliation, resulting in a missing Methadone pill for one resident. The incident was discovered during a narcotic count when a Certified Medication Assistant (CMA) noticed a discrepancy in the Methadone count for a resident, with one 2.5 mg tablet missing. The discrepancy was identified during the shift change narcotic count, which was conducted by the oncoming CMA and a Licensed Practical Nurse (LPN). The overnight nurse, who was the only one with access to the medication cart during the time the pill went missing, stated she did not know where the medication went. The internal investigation revealed that the missing medication could not be found, and the facility's controlled drug count record showed missing signatures on several dates, indicating lapses in the documentation process. The facility's procedure for controlled substance count requires that two authorized persons count and validate the accuracy of narcotics supply at each shift change. However, the investigation found that a CMA did not follow this policy, as she counted by herself and found the medication missing. The Director of Nursing (DON) and the Administrator in Training (AIT) conducted a narcotic count and confirmed that all other controlled substances were accounted for. The report highlights that the facility's controlled substance policy was not adhered to, leading to the discrepancy in the narcotic count and the missing Methadone pill.
Failure to Document and Assess After Unwitnessed Fall
Penalty
Summary
The facility failed to assess and document necessary interventions following an unwitnessed fall involving a resident with moderately impaired cognition and multiple health conditions, including coronary artery disease, heart failure, hypertension, and renal disease. The incident report noted that the resident was found sitting on the floor in front of a recliner, claiming not to have fallen or sustained any injuries. Despite this, the facility's clinical records lacked documentation of follow-up fall assessments and neurological checks, which are critical in such situations. The Director of Nursing (DON) acknowledged that a late entry was made in the progress notes nearly three weeks after the incident, and confirmed that the fall was not added to the hot charting, leading to the omission of necessary assessments. The DON also reported that the facility does not have a specific neurological policy but follows standards of care, expecting staff to complete neurological assessments as per the assessment form. This oversight resulted in the failure to conduct timely and appropriate neurological assessments following the unwitnessed fall.
Failure to Secure Laundry Room and Supervise Residents
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, the door to the laundry room was broken, allowing 11 mobile residents access to hazardous chemicals stored within. The Director of Nursing (DON) confirmed that the door had a key-coded pad but could be pushed open without entering a code. The door had been broken for a couple of months, and the facility was awaiting a new maintenance person to fix it. Staff interviews revealed that Resident #7, who has moderate cognitive impairment and is independent with ambulation and transfers, was found near the laundry room door looking for clothing. Staff also confirmed that hazardous chemicals were stored openly in the laundry room, posing a risk to residents who might access the area. Resident #7, who has diagnoses of hypertension and dissociative and conversion disorder, was observed seeking access to the laundry room. Staff H and Staff I confirmed that Resident #7 had been found near the laundry room door on separate occasions. The chemicals observed in the laundry room included Laundry Chlorine Destainer, Laundry Soft Sour, and Laundry Emulsion Detergent, all of which have hazardous warnings indicating they are harmful if swallowed, cause severe skin burns and eye damage, and are harmful upon contact with skin. The facility's failure to secure the laundry room and supervise residents adequately led to a significant safety hazard.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for a resident who reported that a Certified Nursing Assistant (CNA) was being rough with them. The resident, who had no cognitive impairment and required assistance with various activities of daily living, reported that the CNA pushed hard on their right leg thigh area, causing them to yelp in pain. The CNA then left the room without completing the brief change, leaving the resident exposed. The facility conducted an internal investigation but did not report the incident to DIAL, as they concluded there was no harm and the resident did not feel the CNA's actions were intentional abuse. The facility's policy mandates that all allegations of abuse be reported to DIAL within two hours. Despite this, the facility did not report the incident, believing it was non-reportable due to the lack of harm and the resident's perception of the event. The Director of Nursing confirmed that no pending investigations had been sent to DIAL. The facility's failure to report the incident as required by their policy and state regulations constitutes a deficiency in their abuse reporting procedures.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for two residents. Resident #4, who has intact cognition and requires extensive assistance for transfers, bed mobility, dressing, and toileting, reported waiting longer than 15 minutes for her call light to be answered on at least two occasions. The facility's call light report confirmed that on one occasion, it took staff 26 minutes to respond to Resident #4's call light. Resident #6, who also has intact cognition and requires extensive assistance for bed mobility and transfers, reported similar delays. The call light report showed that it took staff 18 minutes to respond to Resident #6's call light on one occasion. Interviews with staff members revealed that there is a perceived lack of sufficient staffing, particularly on the 2pm-10pm shift, which contributes to the delays in answering call lights. Staff members expressed concerns about the adequacy of staffing levels to meet resident needs in a timely manner. The facility does not have a specific call light policy and relies on state guidelines for response times.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Knoll Care Centre | 11.4 mi | — | 0 | 0 |
| Accura Healthcare Of Carroll | 13.9 mi | ★★★★★ | 18 | 0 |
| St Anthony Senior Services | 15.4 mi | ★★★★★ | 6 | 0 |
| Park View Rehabilitation Center | 15.6 mi | ★★★★★ | 12 | 0 |
| Regency Park Nursing & Rehab Center Of Carroll | 15.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Accura Healthcare Of Lake City, Llc.
100% money-back within 48 hours.
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.