Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Le Mars during CMS and state inspections, most recent first.
A resident with a history of hemiplegia and other conditions, identified as a moderate fall risk, fell and fractured their femur due to inadequate supervision. The resident was assisted by only one CNA instead of the required two, and no gait belt was used. The CNA did not seek additional help due to fear of the nurse's reaction. The resident was hospitalized for surgery following the fall.
A resident with diabetes and hypertension fell from her bed due to a broken bed rail, resulting in a shoulder fracture. Staff interviews revealed the rail had been loose for some time, and maintenance checks were missed due to staffing changes. The Maintenance Director confirmed the rail's locking mechanism was compromised, and the facility's records showed no maintenance actions were recorded for the months leading up to the incident.
The facility failed to develop comprehensive care plans for residents taking high-risk medications and undergoing dialysis. A resident with diabetes, neurogenic bladder, and hypertension was on insulin, diuretics, and opioids, but their care plan lacked details on medication usage and monitoring. Another resident on insulin and opioids also had an incomplete care plan. A third resident receiving anticoagulation medication did not have this addressed in their care plan. Additionally, a resident with a dialysis fistula lacked care instructions in their plan. The DON acknowledged these omissions, which contravened the facility's policy on comprehensive care plans.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, with observations of food debris and dried liquid in various locations, and a thick layer of ice in the milk freezer. Cleaning schedules showed incomplete tasks, despite being signed off as completed. The Dietary Manager acknowledged the oversight, attributing it to her recent absence.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident was identified with new serious mental disorders, including anxiety, depression, and hallucinations. Despite receiving mental health services and having additional diagnoses of delusional disorder and dementia, the PASRR was not resubmitted. Interviews revealed a lack of understanding and policies regarding PASRR resubmission requirements.
A facility failed to update a resident's care plan to reflect a mechanical soft diet order, resulting in the resident being served peas, which could pose a choking hazard. The care plan had not been updated despite the facility's policy requiring timely updates. The DON acknowledged the care plan should reflect the current diet order.
A facility failed to include dementia care in the care plan of a resident diagnosed with Vascular Dementia. Despite the resident's MDS assessment showing no cognitive impairment, the active diagnosis of dementia was not reflected in the care plan. The DON admitted the oversight, noting the diagnosis was new.
A dietary staff member failed to follow the planned menu for a resident on a pureed diet. The meal served lacked pureed bread and margarine, contrary to the facility's policy and the dietitian's expectations.
A resident on a mechanical soft diet was served peas instead of the ordered waxed beans, which could pose a choking hazard. The care plan was not updated to reflect the diet order, and the dietitian confirmed the need to follow the mechanical soft diet menu. The DON acknowledged the requirement for dietary staff to serve the therapeutic diet as per the menu.
A resident with diabetes, neurogenic bladder, and hypertension fell from bed due to a malfunctioning bed rail, which staff knew was loose but did not repair. The incident was not documented in the resident's electronic health record, violating professional standards for maintaining accurate medical records.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent a fall that resulted in a distal femur fracture for a resident. The resident, who had a history of hemiplegia, seizure disorder, and traumatic brain injury, was identified as a moderate fall risk and required assistance from two staff members for transfers and toileting hygiene. Despite these requirements, the resident was assisted by only one Certified Nursing Assistant (CNA) while using the urinal, which led to the resident losing balance and falling. The incident occurred when the CNA assisted the resident to stand and use the urinal without the required second staff member and without using a gait belt, as the resident usually refused it. During the process, the resident attempted to pull up his pants, leaned forward, and fell, hitting his head on the bedside commode and complaining of left leg pain. The CNA admitted to not asking for additional help because her partner was on break and she feared the nurse's reaction. The Director of Nursing (DON) acknowledged that the CNA did not follow the resident's care plan by failing to wait for another staff member and not using a gait belt. The facility lacked specific policies related to gait belt usage and falls, which contributed to the incident. The resident was subsequently hospitalized for a left distal femur fracture, requiring surgical intervention and a non-weight-bearing status for several weeks.
Failure to Inspect Bed Rails Leads to Resident Injury
Penalty
Summary
The facility failed to appropriately inspect bed rails, leading to an incident involving a resident with a history of diabetes mellitus, neurogenic bladder, and hypertension, who had no cognitive impairment. The resident experienced a fall from her bed when a loose bed rail broke off during assistance, resulting in a visit to the emergency room for left shoulder pain. Subsequent medical evaluations revealed an acute intra-articular fracture of the anterior aspect of the glenoid. Interviews with staff revealed that the bed rail had been loose for some time, and maintenance checks were not conducted in November or December due to the retirement of the previous maintenance person. The Maintenance Director noted that the bed rail's locking mechanism was compromised due to wear and tear. The facility's work history report showed no recorded action for preventative maintenance tasks due in November and December, indicating a lapse in regular inspections and maintenance of bed rails.
Deficiencies in Comprehensive Care Plans for High-Risk Medications and Dialysis
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing high-risk medication usage and dialysis care. Resident #8, who had diagnoses of diabetes mellitus, neurogenic bladder, and hypertension, was taking insulin, diuretics, and opioids. However, the care plan lacked information on the usage of these medications and the signs and symptoms to monitor. Similarly, Resident #15, with diagnoses of diabetes mellitus, anemia, and hypertension, was on insulin and opioid medications, but the care plan did not include details on these medications or their potential side effects. Resident #32, diagnosed with atrial fibrillation, heart failure, and hypertension, was receiving anticoagulation medication. The care plan for this resident did not address the anticoagulant medication, its potential side effects, or monitoring requirements. The Director of Nursing (DON) acknowledged that the care plan should have included this information. Additionally, Resident #2, who had renal failure and a fistula for dialysis, did not have the fistula or its care instructions included in the care plan. The DON confirmed that the fistula should have been documented in the care plan. The facility's policy on comprehensive care plans, dated January 30, 2024, mandates the development of person-centered care plans with measurable objectives and timeframes to meet residents' medical, nursing, and psychosocial needs. However, the facility did not adhere to this policy, resulting in incomplete care plans for the residents mentioned. The DON expressed expectations for high-risk medications and dialysis care to be included in the care plans, indicating a gap between policy and practice.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, as observed during an initial kitchen tour. The inspection revealed an accumulation of food debris and dried liquid at the bottom of refrigerators and freezers, on the kitchen and dishwashing area floors, and on open shelving beneath preparation tables. Additionally, the snack cart and vegetable storage bin were found with scattered food debris, and the handles on the snack cart were grimy. A milk freezer was noted to have a thick layer of ice buildup. The facility's cleaning schedules for May 2024 indicated that staff did not complete cleaning tasks on most days, except for one. Despite this, the cleaning schedule showed that the milk cooler cleaning task was signed off as completed. The facility's policy from 2021 required regular cleaning and sanitizing of refrigerators and thorough cleaning of the kitchen daily. The Dietary Manager acknowledged the oversight, noting that the staff signed off on cleaning tasks that were not completed, and attributed the lapse to her recent absence from work.
Failure to Resubmit PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident with a negative Level I PASRR result for a Level II PASRR evaluation after the resident was identified with newly evident or possible serious mental disorders. The resident, identified as Resident #19, had diagnoses of anxiety disorder, depression, psychotic disorder, and hallucinations documented in the Minimum Data Set (MDS) assessment. Despite these diagnoses, the facility did not resubmit the PASRR for further evaluation, even though the resident was receiving mental health services and had additional diagnoses of delusional disorder, hallucination disorder, and dementia. The clinical record review revealed that the facility did not follow up or resubmit the PASRR with the updated diagnoses. Interviews with the Director of Nursing (DON) and the Social Worker (SW) indicated a lack of understanding and policies regarding the need for resubmission of PASRR when there are changes in mental health diagnoses or services. The SW admitted to not resubmitting the PASRR due to a misunderstanding that a dementia diagnosis did not require resubmission, regardless of changes in mental health conditions.
Failure to Update Care Plan for Mechanical Soft Diet
Penalty
Summary
The facility failed to update the care plan for a resident to reflect the current diet order of a mechanical soft texture, as prescribed by the physician on 4/22/24. During a meal service observation on 5/29/24, the resident, who was on a mechanical soft diet, was served peas instead of the prescribed waxed beans, which could pose a choking hazard according to the dietitian. The resident's care plan had not been updated to reflect the mechanical soft diet order, despite the facility's policy requiring timely updates to ensure the resident's highest practicable well-being. The Director of Nursing acknowledged that the care plan should reflect the current diet order.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address dementia care for a resident diagnosed with Non-Alzheimer's Dementia. The Minimum Data Set (MDS) assessment indicated that the resident had a BIMS score of 13, suggesting no cognitive impairment, yet the resident had an active diagnosis of Vascular Dementia with mood disturbance. Despite this diagnosis being recorded, the care plan for the resident, revised on a later date, lacked any information regarding dementia care. During an interview, the Director of Nursing acknowledged that the dementia diagnosis was relatively new for the resident and should have been addressed in the care plan.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility staff failed to adhere to the planned menu for a resident requiring a pureed diet. On the specified date, the Week 1 menu for a pureed lunch meal included pureed swiss steak, mashed potatoes, pureed peas, pureed bread with margarine, a pureed candy bar, and milk. However, during observation, Staff G, a dietary staff member, did not puree the bread and margarine as required. The meal was plated and served to the resident without the pureed bread and margarine. The facility's policy from 2021 mandates that food should be served at the appropriate temperature and with the correct serving size according to the planned menu. The dietitian confirmed that pureed diets should be served as per the menu.
Failure to Serve Correct Diet Texture
Penalty
Summary
The facility failed to ensure that the food served to a resident met their dietary needs according to their assessment and diet orders. During a meal service observation, a resident who was on a mechanical soft diet was served peas instead of the ordered waxed beans. The resident's physician's order and diet type report both indicated a mechanical soft diet, but the care plan had not been updated to reflect this order. The dietitian confirmed that peas could pose a choking hazard for the resident and emphasized the requirement for staff to follow the mechanical soft diet menu. The Director of Nursing acknowledged that dietary staff should adhere to the therapeutic diet as per the menu.
Failure to Maintain Accurate Resident Records and Address Equipment Malfunction
Penalty
Summary
The facility failed to maintain accurate resident records for one of its residents, identified as Resident #8. The incident involved a malfunctioning bed rail that led to the resident falling out of bed. The Minimum Data Set (MDS) assessment for Resident #8 documented diagnoses of diabetes mellitus, neurogenic bladder, and hypertension, with a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment. On December 25, 2023, while being repositioned in bed, the side rail became disengaged, causing the resident to fall and sustain a shoulder injury. The incident was not documented in the resident's electronic health record, which is a failure to maintain accurate medical records as per professional standards. Interviews with staff members revealed that the bed rail had been loose for some time, but no action was taken to repair it. Staff B, a Certified Nursing Assistant (CNA), admitted to noticing the looseness but did not believe it would break. The Director of Nursing confirmed that the incident should have been charted in the Progress Notes, indicating a lapse in proper documentation procedures. The lack of documentation and the failure to address the known issue with the bed rail contributed to the deficiency in safeguarding resident-identifiable information and maintaining accurate medical records.
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What surveyors actually found near you
We read the 99 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.
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A prioritized, do-first checklist
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Nursing homes near Le Mars
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Lemars | 1.3 mi | ★★★★★ | 3 | 0 |
| Happy Siesta Health Care Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Kingsley Specialty Care | 16.2 mi | ★★★★★ | 7 | 1 |
| Prairie Ridge Care Center | 16.9 mi | ★★★★★ | 0 | 0 |
| Heartland Care Center | 18 mi | ★★★★★ | 8 | 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.