Below 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 Muscatine during CMS and state inspections, most recent first.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient protective measures and oversight.
A resident was mistakenly transferred to a non-VA contracted facility due to miscommunication and lack of coordination among staff. The resident, a veteran requiring VA-approved long-term care, was initially sent to Facility A instead of Facility B, which had the necessary VA contract. The error was discovered after the transfer, leading to a delay in the resident's care and necessitating a subsequent transfer to the correct facility.
The facility failed to maintain sanitary practices in food storage and preparation. Observations revealed improperly stored food, such as undated seasoning containers and pot roasts thawing outside the refrigerator. Staff members were seen handling food without changing gloves or performing hand hygiene, and a sanitizer solution test showed no sanitizing solution present. These actions violated the facility's policies on food safety and sanitation.
The facility failed to provide a call light system within reach for two residents with severe cognitive impairment, leading to a deficiency. One resident was repeatedly observed without a call device or bell, despite care plan instructions and family concerns. Staff initially could not locate the call device and had to provide a new one.
A CNA at the facility worked multiple shifts without a current Dependent Adult Abuse (DAA) certification. The employee's file lacked documentation of the required Iowa Department of Public Health (IDPH) approved DAA training. The facility's Administrator admitted a gap in training, with the corporate office responsible for verification checks. Facility policy mandates DAA training within six months of employment and every three years thereafter.
A resident experienced a significant decline in condition after a fall, including increased pain and decreased mobility, but the facility failed to complete a Significant Change MDS Assessment within the required timeframe. The resident's care plan and medication regimen were updated to address the changes, but the oversight was acknowledged by the MDS Coordinator.
A resident with intact cognition and multiple diagnoses, including diabetes, underwent LASIK surgery. The facility failed to follow post-operative physician orders, which included administering specific eye drops and ensuring eye protection. The Assistant Director of Nursing confirmed the orders were not initiated, leading to a deficiency.
Two residents with moderate cognitive impairments and respiratory conditions were found with empty oxygen tanks, despite physician orders for continuous oxygen therapy. Observations and records showed a lack of adherence to prescribed oxygen levels and monitoring, with one resident's family member reporting multiple instances of empty tanks. The DON confirmed staff should ensure tanks are full and monitor them according to facility policy.
A facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for a resident who no longer exhibited the behaviors for which the medications were prescribed. Despite stable behavior and no documented negative behaviors, the facility did not follow its policy to monitor and document behaviors or attempt a GDR. The DON acknowledged the oversight and the potential for a GDR.
A facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter. The resident's catheter tubing was observed on the floor, and a CNA did not follow hand hygiene protocols after handling the catheter drainage bag. The facility's policy required hand hygiene after glove removal, which was not followed.
A resident with moderate cognitive impairment and dysphagia experienced two choking incidents due to the facility's failure to follow the care plan. The resident was on a mechanically altered diet and required supervision during meals. However, staff were not consistently present at the resident's table, leading to unsupervised eating. Despite re-education efforts, the care plan was not followed, resulting in the resident choking on two occasions.
The facility failed to provide prescribed therapeutic diets for two residents. One resident, with conditions requiring a double protein diet for wound healing, did not receive the necessary portions. Another resident, with severe cognitive impairment and conditions necessitating a low sodium diet, was served a regular diet instead. These deficiencies were confirmed by staff and dietary personnel.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular residents or incidents described.
Resident Transferred to Incorrect Facility Due to Miscommunication
Penalty
Summary
The facility failed to ensure the discharge needs of a resident were met, resulting in the resident being transferred to the wrong facility. The resident, who was a veteran with long-term care benefits available through the Veteran's Administration (VA), required authorization and approval by the VA for continued care at a facility under VA contract. However, the resident was mistakenly transferred to Facility A, which did not have a VA contract, instead of Facility B, which was the correct facility with a VA contract. The error occurred due to miscommunication and lack of coordination among the facility staff. The Social Service Designee (SSD) was responsible for coordinating the discharge and had been in contact with the VA and the Regional Clinical Admission Specialist. Despite being informed that Facility A did not have a VA contract, the SSD mistakenly believed the resident was to be transferred there. This misunderstanding was compounded by the SSD's failure to recall the correct information and the lack of proper verification of the transfer details. The resident was transported to Facility A without prior notification or acceptance from the facility, leading to confusion and a delay in the resident's care. The resident's family was present at Facility A and had to assist in resolving the situation. The resident was eventually transferred to Facility B by ambulance the following day, but the process was complicated and stressful for all parties involved. The facility's failure to adhere to its own transfer/discharge policy and ensure proper communication and coordination resulted in this deficiency.
Sanitary Practices Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary practices in food storage and preparation, as observed during a survey. An initial kitchen observation revealed improperly stored food items, including an opened box of various items in an opened plastic bag in the freezer, and opened, undated seasoning containers. Additionally, pot roasts were found thawing on a baking sheet outside the refrigerator, contrary to the manufacturer's instructions. Staff C, a cook, was observed preparing a peanut butter sandwich without changing gloves or performing hand hygiene after handling the peanut butter container, and the sandwich was subsequently served to a resident. Further observations highlighted additional sanitary lapses. Staff E was seen touching kitchen utensils and equipment with gloved hands before handling sandwich bags, causing direct contact with the food. She also handled a bag of potato chips with the same gloves used for food preparation. Staff C was observed placing a lunch ticket on a plate, rearranging tickets, and then serving food on the same plate without changing gloves. Additionally, Staff C touched a resident's bread with ungloved fingers before covering the plate, which was then delivered to the resident. A sanitizer solution test conducted by Staff C showed no sanitizing solution present, indicating improper cleaning practices. The facility's policies required proper labeling, storage, and sanitizing procedures, which were not followed.
Failure to Provide Call Light System for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to provide a call light system within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #29, with severe cognitive impairment as indicated by a BIMS score of 00, was observed multiple times without a call device or bell within reach, despite the care plan instructing staff to encourage the use of a bell for assistance. Staff B, a CNA, was unable to locate the call device initially and had to obtain a new one to clip to the resident's shirt. A family member confirmed the absence of a call device, noting that the resident had one upon arrival at the facility. Observations on subsequent days continued to show the resident without a call device or bell. Similarly, Resident #49, also with severe cognitive impairment, was identified in the report, although specific observations regarding the call device were not detailed for this resident.
Failure to Maintain Current DAA Certification for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), referred to as Staff G, had a current Dependent Adult Abuse (DAA) certification. An employee file review revealed that Staff G was hired on a specific date, but the file lacked documentation of the Iowa Department of Public Health (IDPH) approved DAA Mandatory Reporter training. The facility provided a DAA certificate that had expired. Despite this, Staff G was scheduled to work multiple first shifts over a period of time. The facility's Administrator acknowledged a gap in Staff G's training, noting that the corporate office is responsible for verification checks for new employees. The facility's policy requires each employee to complete two hours of DAA training within six months of employment and additional training every three years.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days for a resident who experienced a fall resulting in a fracture. This oversight was identified during a clinical record review, staff interview, and policy review. The resident, who was initially assessed as independent in various activities of daily living, experienced a significant decline in their condition following the fall, including increased pain and a need for substantial assistance with mobility. The resident's condition changed significantly after the fall, as documented in subsequent MDS assessments. The resident, who initially denied experiencing pain and required no pain medication, later reported severe pain and required frequent administration of pain medications, including acetaminophen, tramadol, and oxycodone-acetaminophen. The resident's care plan was updated to reflect the need for assistance with transfers and ambulation, utilizing a front-wheeled walker and gait belt, and the resident began using a wheelchair for mobility. The MDS Coordinator acknowledged the oversight in not completing a Significant Change MDS, which should have been done due to the resident's decline in multiple areas of health status. The facility's policy and the Resident Assessment Instrument (RAI) Manual require a comprehensive assessment when a significant change in a resident's condition occurs, impacting more than one area of health status and necessitating an interdisciplinary review and revision of the care plan.
Failure to Follow Post-Operative Physician Orders
Penalty
Summary
The facility failed to follow physician orders for a resident who had undergone LASIK eye surgery. The resident, who had intact cognition and was diagnosed with hypotension, diabetes mellitus, depression, and seizure disorder, was prescribed insulin and an antidepressant. The care plan included arranging consultations with an eye care provider as required. However, during an observation, it was noted that the resident was wearing an eye patch, and staff interviews revealed that the resident had LASIK surgery. The post-operative instructions required the application of specific eye drops and wearing eye protection, but these orders were not initiated as per the Medication Administration Record and Treatment Administration Record. The Assistant Director of Nursing confirmed that the eye drop orders were not initiated, and a medication error report was completed. The facility's failure to administer the prescribed medications and ensure eye protection as per the post-operative instructions led to the deficiency. The administrator stated that the facility follows industry standards for initiating and following physician orders, but in this case, the orders were not followed, resulting in a deficiency being identified by the surveyors.
Failure to Provide Supplemental Oxygen as Ordered
Penalty
Summary
The facility failed to provide supplemental oxygen as ordered for two residents, both of whom had moderate cognitive impairments and required oxygen therapy due to their medical conditions. Resident #22, diagnosed with heart failure, respiratory failure with hypoxia, and diabetes mellitus, was observed with an empty oxygen tank despite having a physician's order for continuous oxygen therapy at 1 to 4 liters per minute via nasal cannula. The resident's care plan included the provision of oxygen therapy as ordered, yet observations and records indicated that oxygen saturation levels were measured without supplemental oxygen on two occasions. Similarly, Resident #163, with diagnoses including heart failure, atrial fibrillation, and COPD, was also found connected to an empty oxygen tank. The resident had a physician's order for oxygen at 2 liters per minute at bedtime and as needed for dyspnea, with instructions to maintain oxygen saturation between 89-91%. However, the Treatment Administration Record lacked documentation of oxygen saturation levels, and a family member reported finding empty oxygen tanks multiple times. The Director of Nursing acknowledged that staff should ensure tanks are full and monitor them, as per the facility's policy on oxygen administration.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for a resident who no longer exhibited the behaviors for which the medications were initially prescribed. The resident, identified with a severe cognitive impairment, was on medications such as Paxil and Klonopin for anxiety and depression, as well as for managing hypersexual behaviors. Despite the resident's Minimum Data Set (MDS) indicating no physical or verbal behaviors directed towards others and no significant changes in cognitive status or depression, the facility did not document any negative behaviors in the Treatment Administration Record (TAR) for several months. Psychiatry progress notes indicated that the resident's behaviors were stable on the current medication regimen, and no changes were recommended. However, the facility's policy required monitoring and documentation of behaviors and response to interventions, as well as attempting a GDR unless clinically contraindicated. The Director of Nursing acknowledged that behaviors should have been charted in behavior monitoring and admitted that the facility could attempt a GDR, highlighting a lapse in following the facility's behavior management procedures.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices to prevent cross-contamination of invasive medical devices, specifically concerning the handling of an indwelling urinary catheter for a resident with severely impaired cognition. The resident, who had a history of cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, and seizure disorder, was observed with the catheter tubing lying on the floor and the drainage bag partially on the floor. This observation was made despite the care plan directing staff to position the catheter bag and tubing below the level of the bladder and away from the entrance door. During a subsequent observation, a Certified Nurse Aide (CNA) was seen emptying the resident's catheter drainage bag without following proper infection control protocols. The CNA performed hand hygiene and donned gloves but did not wear a gown. After emptying the urine into a container, the CNA failed to perform hand hygiene after removing gloves and proceeded to touch various items and enter another resident's room. The facility's policy required staff to remove gloves and wash hands immediately after emptying the urine, which was not adhered to in this instance. The Director of Nursing confirmed that staff should perform hand hygiene before leaving the resident's room.
Failure to Follow Care Plan Leads to Choking Incidents
Penalty
Summary
The facility failed to follow the care plan for a resident with moderate cognitive impairment and a history of dysphagia, leading to two choking incidents. The resident, diagnosed with non-Alzheimer's dementia, Parkinson's Disease, and a prior stroke, was on a mechanically altered diet due to coughing or choking during meals. The care plan required the resident to eat in the assisted dining room with staff present to assist with feeding and provide cues to take small bites and chew thoroughly. However, during observations, staff were not consistently present at the resident's table, and the resident was left eating without supervision. On two separate occasions, the resident experienced choking incidents while eating in the dining room. During the first incident, a nurse was paged to the dining room where the resident was choking on eggs, and the Heimlich maneuver was performed successfully. In the second incident, the resident choked on chili, and again, the Heimlich maneuver was performed. In both cases, the root cause analysis identified the resident's tendency to eat too fast and not take breaks between bites as contributing factors. Interviews with staff revealed inconsistencies in the implementation of the care plan. Staff members were not always present at the resident's table, and there was a lack of communication regarding the need for a staff member to be specifically present with the resident before serving meals. The Director of Nursing acknowledged that staff should be sitting with the resident during meals, and the dietary staff should not serve the resident's meal until a nurse is present. Despite re-education efforts, the care plan was not consistently followed, leading to the resident being unsupervised during meals.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide appropriate therapeutic diets for two residents, as observed during a survey. Resident #5, who had a diagnosis of atrial fibrillation, anemia, heart failure, and osteomyelitis, was ordered a double protein diet to aid in wound healing due to low blood albumin levels. However, during a lunch service observation, the resident did not receive the prescribed double portion of protein, as confirmed by both the resident and the Registered Dietitian. The Assistant Director of Nursing acknowledged that the double protein diet was necessary for the resident's condition. Resident #12, who had severely impaired cognition and multiple diagnoses including hypertension and renal failure, was prescribed a low sodium diet. Despite this, during a lunch service observation, the resident was served a regular diet instead of the required low sodium meal. The Registered Dietitian noted that the resident did not adhere to the diet, and the Director of Nursing stated that staff should ensure the correct diet is served. These observations indicate a failure in adhering to prescribed dietary orders for residents with specific medical needs.
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What surveyors actually found near you
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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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Nursing homes near Muscatine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Of Muscatine | 1.2 mi | — | 2 | 0 |
| Lutheran Living Senior Campus | 2.2 mi | ★★★★★ | 8 | 0 |
| Wilton Retirement Community | 11 mi | ★★★★★ | 2 | 0 |
| Simpson Memorial Home | 12.8 mi | ★★★★★ | 6 | 0 |
| Lone Tree Health Care Center Inc | 17.6 mi | ★★★★★ | 5 | 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.