Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Newton East, Llc during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility failed to ensure daily RN coverage on 2 separate days during a schedule review. Nursing schedules showed no RN assigned on those days, and two LPNs covered the licensed nurse shifts instead. The Administrator confirmed the missed RN coverage and stated it was due to recent staffing changes that reduced floor RN availability. The facility also did not have a staffing policy outlining the need for RN coverage at least 8 consecutive hours 7 days a week.
Food safety logs were not consistently completed for refrigerators, freezers, the dishwasher, the red bucket sanitizer station, and steamtable food temps. During kitchen observations, multiple logs had blank entries, and a red bucket sanitizer log lacked required checks. Staff also observed raw beef thawing on top of ready-to-eat ham and cheese sandwiches in a refrigerator, and the DM confirmed the sandwiches were discarded after the cross-contamination issue was identified.
The facility failed to implement EBP for residents with wounds and indwelling devices, including a resident with a wound, a resident with an indwelling catheter, and a resident with a feeding tube, as staff performed high-contact care without the required gown and glove use. The facility also failed to handle isolation linens properly for two residents on contact precautions, with staff not separating or washing the linens as required, and failed to replace a heavily soiled urinal that remained in use at a resident’s bedside.
Missing Dependent Adult Abuse Training Documentation: The facility failed to ensure a CNA completed required dependent adult abuse training within the required timeframe. File review showed the CNA was hired but there was no documentation of the initial abuse training within 6 months of hire, and the DON/administrator confirmed the omission during interview. The facility policy required the training for all employees and annual abuse prevention training for nurse aides.
A resident with a documented tobacco-use history and intact cognition was observed vaping in the designated smoking area, yet smoking assessments were not completed throughout most of the year. Staff and the resident confirmed the resident had stopped smoking, later resumed vaping, and occasionally smoked cigarettes, while the ADON acknowledged the missing quarterly assessments despite the facility policy requiring tobacco-use screening and safe smoking assessments for e-cigarette users.
A resident’s care plan was not updated after he resumed vaping and continued occasional cigarette use, despite prior tobacco history and staff acknowledgment that the plan should have reflected the change. Another resident with cancer, reduced mobility, and a decline in BIMS score was observed driving his vehicle off campus, but his care plan lacked documentation of driving status, sign-out needs, or supervision requirements, and staff were unaware he was driving.
Wound care was not performed as ordered for a resident with a left knee abscess requiring packing. An RN applied lidocaine gel to the wound during the dressing change even though the current order did not include it and the med had already been discontinued. The ADON stated the lidocaine was not part of the new order and should not have been used; the care plan also lacked the wound location while directing staff to give meds as ordered.
A resident with liver cancer, reduced mobility, gait abnormalities, and a declining BIMS score was not assessed for safe driving, and the EHR and care plan lacked documentation about his vehicle use. Staff were unaware he was driving, the facility had no driving policy, and the resident was observed leaving the building, getting into a car, and driving away without being documented in the sign-out book.
A resident with severe cognitive impairment and a history of malnutrition had significant weight loss while meal intake was inconsistently documented and staff often provided little or no cueing, encouragement, or substitute foods during meals. Dietary notes repeatedly identified that the resident needed tray set-up, cueing, and the assisted table, but observations showed the resident frequently sat at meals without eating or left the table after minimal intake.
Multiple residents received their meals significantly later than the facility's posted dining schedule, with lunch and breakfast trays delivered well past the designated times. Staff, including an LPN and the Dining Services Manager, attributed these delays to high staff turnover and performance issues in the kitchen, resulting in grievances from residents about late meal service.
A resident with intact cognition and mental health diagnoses reported missing money and suspected a CNA of taking it. The Administrator received the allegation but did not report it to the State Agency, citing inconsistencies in the resident's story and lack of witnesses, despite facility policy requiring prompt reporting of all abuse allegations, including misappropriation.
A resident with moderate cognitive impairment and physical limitations did not consistently receive weekly showers or baths as required, sometimes going up to three weeks without bathing. Despite requiring staff assistance for bathing, facility records and the resident's account indicated missed showers and inadequate documentation, with staff often postponing care and failing to follow up as expected by the DON.
A facility failed to ensure resident safety in a smoking area and during transport. A resident with COPD and on oxygen was observed smoking with an oxygen tank attached, despite policies prohibiting this. Housekeeping staff supervising smoking times did not remove the tank, posing a safety risk. Another resident with dementia was transported in a wheelchair without foot pedals, contrary to safety expectations. These lapses resulted in Immediate Jeopardy to resident safety.
The facility failed to maintain a clean kitchen environment due to inadequate and untrained dietary staff. The Kitchen Manager, promoted from a non-dietary role, lacked the necessary qualifications and had not completed required training. Unsanitary conditions, including dirty floors and uncovered food, were observed, and the facility's cleaning policy was not effectively implemented. The Registered Dietician and Administrator acknowledged the need for improvement.
The facility failed to provide palatable and appetizing meals to residents, with reports and observations indicating that meals were often cold or served late. Residents consistently reported dissatisfaction with the temperature and timing of their meals. The facility's administrator noted that the kitchen staff were new and undergoing training.
The facility failed to provide appropriate portion sizes for residents requiring a mechanical soft diet. Inconsistencies in serving sizes were observed, with new kitchen staff lacking proper training. The Dietary Manager was unaware of the discrepancies, and the Registered Dietitian confirmed the required serving size. The Administrator noted that all kitchen staff were new and training was limited.
The facility failed to maintain a clean and sanitary kitchen environment, with observations of missing floor tiles, grime, food crumbs, and uncovered food. Staff interviews revealed that the kitchen was not cleaned as required, with the Kitchen Manager and Registered Dietician acknowledging the unsanitary conditions. The Administrator noted that most kitchen staff were new, indicating a need for improvement.
The facility failed to maintain essential laundry equipment safely, with one washer out of order and a dryer not shutting off or cooling down. Staff confirmed operational issues, and the Administrator was unaware of the dryer problem, highlighting a lack of communication and maintenance oversight.
The facility failed to maintain an effective pest control program, leading to pest issues in the kitchen and laundry areas. Observations showed multiple pest traps and food debris, while staff interviews revealed a lack of communication and coordination regarding pest control measures. The Dietary Manager was not informed about necessary improvements, and the Administrator was unaware of pest control findings.
The facility failed to meet professional standards during medication administration for two residents. A resident with dementia was left unsupervised with medications, contrary to the care plan. Another resident's medication was left unsecured on a cart while the RN administered other medications. The DON confirmed the expectation for staff to supervise medication intake and secure medications properly.
A facility failed to provide necessary restorative care for a resident with a leg fracture, as outlined in their care plan. Despite a program requiring exercises 3-5 times weekly, documentation showed a lack of care for 29 days. The resident reported not receiving care, and staff confirmed the restorative aide was often reassigned to other duties, leaving the resident's needs unmet.
The facility failed to ensure timely provider notification and response to pharmacy recommendations for two residents regarding unnecessary medications. One resident on Mirtazapine for appetite stimulation and another on multiple psychotropic medications did not have documented provider responses to recommended gradual dose reductions. The facility's policy requires action and documentation of pharmacy recommendations, which was not adhered to, leading to the deficiency.
The facility has failed to maintain an effective QAPI program, resulting in repeat deficiencies in infection control, professional standards, and cleanliness over the past two years. The Administrator acknowledged these issues, attributing them to high turnover and new staff in the kitchen. The Regional Director of Operations identified the root cause as staff turnover, impacting efficiency and standards.
The facility failed to maintain clean and safe bathroom facilities for several residents, with issues such as leaking toilets, dirty floors, and cluttered bathrooms. Observations revealed that bathrooms remained unchanged despite housekeeping duties, and staff interviews highlighted challenges with clutter and a lack of deep cleaning. Residents reported ongoing issues with cleanliness and maintenance.
The facility failed to maintain a clean and orderly environment, with issues such as dirty floors, detached baseboards, missing tiles, and collapsed ceiling tiles observed in several resident rooms. The sudden departure of the maintenance man left the facility with limited maintenance support, contributing to unresolved issues.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to ensure daily RN coverage for 2 separate days within a 30-day schedule review for a census of 52. Review of nursing schedules from 1/16/26 to 2/14/26 showed no RN scheduled for 2/8/26 and 2/14/26. On both days, two LPNs provided the licensed nurse coverage, with one LPN working the 12-hour day shift and another LPN working the 12-hour night shift. During an interview on 2/18/26 at 1:00 PM, the Administrator acknowledged and confirmed the lack of RN coverage on both dates and stated it was an oversight related to recent staffing changes that reduced the number of floor RNs available. The facility also did not have a staffing policy outlining the need for RN coverage at least 8 consecutive hours 7 days a week.
Food Safety Logs Incomplete and Raw Beef Stored Above Ready-to-Eat Food
Penalty
Summary
The facility failed to ensure required food safety checks were completed and documented for refrigerators, freezers, the dishwasher, the red bucket sanitizer station, and steamtable food temperatures. During two kitchen observations, all 4 refrigerators and 2 freezers had temperature logs posted, but the logs contained multiple blank entries. Facility records showed that refrigerator temperatures were to be checked twice daily and freezer temperatures twice daily, yet several logs lacked documentation across the review period, including missing morning and evening checks for multiple units. The dishwasher temperature log also lacked entries for nearly the entire review period, with only one entry documented on the morning shift of 2/16/26. The facility also failed to regularly test the chemical solution used for surface sanitation. During both kitchen observations, one red bucket sanitizer station was in use, and the posted log had multiple blank entries. The facility record for the red bucket sanitizer log required checks six times per day and specified sanitizer concentration levels between 150 and 400 ppm, but the log lacked documentation for 11 of 16 days reviewed. In addition, the steamtable temperature log used to document food temperatures for items served at meals had many blank entries, including missing documentation for breakfast, lunch, and dinner meals across the review period. The facility further failed to prevent cross contamination during food storage. During the initial kitchen observation, a plastic container of ready-to-eat ham and cheese sandwiches dated 2/14/26 was stored on the bottom shelf of a refrigerator, and a tray containing thawing raw beef was placed on top of the sandwich container. The Dietary Manager confirmed that temperature logs had not been completed during the observation and later stated that the ham and cheese sandwiches were discarded because raw product had been stored above ready-to-eat products. The Dietary Manager also reported being in the role for approximately 2 months, and the facility denied having policies or procedures for food storage, food temperatures, or sanitation upon request.
Infection Control Failures With EBP, Isolation Linen Handling, and Urinal Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for residents with wounds and indwelling devices. Resident #40 had a left knee abscess that was drained and required packing and dressing changes, and the care plan indicated she was placed in EBP for wounds. During wound care, Staff A, RN performed the dressing change without wearing a gown, even though an EBP sign was posted on the resident’s door. Resident #47 had neurogenic bladder and an indwelling catheter, and her care plan indicated she was placed in EBP. During observation, Staff J, CNA took her to the shower room and then returned to her room to make the bed and place an adult brief without wearing a gown or gloves, despite an EBP sign on the outside of the room. Resident #7 had cognitive impairment, stroke-related deficits, aphasia, malnutrition, and a feeding tube. The care plan addressed artificial nutrition but did not identify infection risk or EBP interventions related to the indwelling device. During observation, the room lacked signage for EBP, and Staff J entered and exited the room multiple times without additional PPE while transporting the resident, retrieving linens, and handling soiled clothing and trash. Later, Staff A, RN flushed the feeding tube without wearing additional EBP PPE. The facility policy stated that EBP applies to residents with wounds or indwelling medical devices and requires gown and glove use during high-contact care activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs, device care, and wound care. The facility also failed to properly handle linens for residents in Transmission Based Precautions. Resident #4 returned from the hospital on an antibiotic for a UTI, and Resident #56 had bacteremia and was receiving antibiotic transfusions. Both rooms had contact precaution signs and PPE containers outside the doors, but the care plans lacked documentation that they were in Transmission Based Precautions. Observation and staff interviews showed isolation linens were not being placed in a separate colored bag or washed separately, and the Environmental Services Director stated she was not aware isolation linen needed to be washed separately or last. Staff later placed a special container with yellow isolation bags near the rooms, and the DON stated isolation linens should be sent to laundry separately in yellow biohazard bags. The facility also failed to change out a resident’s urinal in a timely manner. Resident #10 required partial assistance with toileting hygiene, and a heavily soiled urinal with yellow residue and black grime was observed on the bedside table with a date of 1/16 on it. The resident confirmed the urinal was still in use and the date was correct. The same urinal remained in place two days later, and the room sink was unusable because it was full of empty pop bottles. Staff stated they believed urinals were changed monthly, while the ADON stated they should be changed weekly or when needed due to infection control issues, and the Administrator confirmed there was no policy related to changing urinals.
Missing Dependent Adult Abuse Training Documentation
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to ensure completion of dependent adult abuse training for 1 of 5 employees reviewed, Staff K, a CNA. Employee file review showed Staff K had a hire date of 8/6/25, but the file did not contain documentation that the required dependent adult abuse training was completed within six months of hire. During an interview on 2/18/26 at 1:00 PM, the Facility Administrator acknowledged and confirmed the missing training documentation. The facility’s policy, Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting, updated 10/22/22, required each employee to complete an initial 2-hour Iowa Department of Human Services training on identification and reporting of dependent adult abuse within six months of hire, and required all nurse aides to receive initial and annual resident adult abuse prevention training.
Failure to Complete Required Smoking Assessments
Penalty
Summary
The facility failed to consistently complete smoking assessments for Resident #22, who had a documented history of tobacco use and intact cognitive skills with a BIMS score of 15 out of 15. The Annual MDS completed on 11/13/25 noted tobacco use and a readmission from a short-term hospital stay on 8/22/25. During an observation on 2/16/26, the resident was seen vaping in the designated smoking area. Review of the smoking assessment record showed no smoking assessments completed during all of 2025, with the two most recent assessments dated 10/23/24 and 2/11/26. Staff interviews confirmed the resident had been vaping since at least September 2025 and may also smoke an occasional cigarette when the vape pen was not charged. The resident stated they had stopped smoking in January 2025, then started vaping sometime between July 2025 and September 2025, and confirmed occasional cigarette use. The ADON stated smoking assessments are completed quarterly by nursing staff or the MDS Coordinator and acknowledged the lack of smoking assessments for late 2025, noting they should have resumed once the resident was identified as vaping. The facility policy required residents to be asked about tobacco use during admission and each quarterly or comprehensive MDS assessment, and required a safe smoking assessment for residents using e-cigarettes.
Care plans not updated for smoking and resident driving status
Penalty
Summary
The facility failed to keep the care plan updated for a resident who had a history of tobacco use and later resumed vaping and occasional cigarette use. The Minimum Data Set assessment completed on 11/13/25 noted tobacco use for Resident #22, and on 2/16/26 the resident was observed vaping in the designated smoking area. The care plan, with an end target date of 5/13/26, did not include a focus area or interventions for active smoking. Smoking had been addressed on earlier care plan updates but was removed on 7/28/25. During interview, the resident stated he had stopped smoking in January 2025 but began vaping sometime between July 2025 and September 2025, and he confirmed occasional cigarette use. The ADON stated care plans should be updated as needed and acknowledged the care plan should have been updated when the resident started vaping. The facility also failed to address a resident’s driving status and change in cognition in the care plan and clinical record. Resident #36 had diagnoses including malignant neoplasm of the liver, reduced mobility, and gait abnormalities, and was receiving chemotherapy through 2/6/26. His current MDS on 2/5/26 showed a BIMS score of 10, down from prior scores of 15 on admission and on multiple other assessments, but the record lacked documentation addressing the decline or evaluating his ability to drive safely. The care plan initiated on 9/9/24 did not document that he had a vehicle at the facility, was driving, needed to sign out, or could leave campus without supervision. On observation, he was seen leaving the building, entering his vehicle, driving away, and later returning and parking next to his walker. The resident stated he could drive if he wore his glasses and said he had to sign in and out. Staff and leadership were unaware he was driving, and the Administrator stated the facility did not have a policy for residents driving.
Wound Care Performed With Medication Not Ordered
Penalty
Summary
The facility failed to perform wound care as ordered for one resident with a left knee abscess that had been drained and required a dressing change with packing. The Electronic Health Record showed the dressing order was changed, but the new order did not include lidocaine external gel 2%, which had been discontinued earlier. During an observation, an RN removed the old dressing, cleaned the wound, and then applied lidocaine gel directly over the wound site and waited one minute before continuing the dressing change, even though the current order did not include lidocaine. During interview, the RN stated the wound nurse had given the dressing change orders to the ADON and that she assumed lidocaine was still part of the order because it had been used previously when packing was done. The ADON stated the new wound order did not include lidocaine gel and that it should not have been used; she said it had been used in the past because the resident had pain during dressing changes, but the resident was not experiencing pain during the new dressing change. The care plan also indicated the resident was on Enhanced Barrier Precautions for wounds, but it lacked documentation of the wound location and directed staff to administer medications as ordered.
Failure to assess resident driving safety and prevent unsafe vehicle use
Penalty
Summary
The facility failed to identify, evaluate, and analyze hazards and risks to prevent avoidable accidents for one resident, and also failed to assess whether that resident was safe to drive a vehicle on his own. The resident had diagnoses including malignant neoplasm of the liver, reduced mobility, and unspecified abnormalities of gait and mobility, was receiving chemotherapy through 2/6/26, and had a BIMS score of 10 on the quarterly MDS, down from 15 on the prior assessment. The EHR lacked documentation of any evaluation of his ability to drive safely, and the care plan did not document that he was driving or had a vehicle at the facility. The DON documented asking the resident whether he wanted to drive himself to a medical appointment or have transportation arranged, and he requested transportation. However, during observation the resident went outside, entered a vehicle, left his walker on the sidewalk, and drove away; later he returned, parked next to his walker, and re-entered the facility. The resident sign-out book did not document that he had left the facility on that date. Staff interviews showed the Life Enrichment Coordinator, Corporate Nurse, DON, Administrator, and DMP were unaware he was driving, and the facility had no policy for resident driving. The only document provided was the resident’s current driver’s license.
Failure to Support Adequate Intake and Monitor Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for a resident with severe cognitive impairment, a BIMS score of 5, and a history of mild protein-calorie malnutrition, irritable bowel syndrome, and rheumatoid arthritis. The care plan identified that the resident ate in the dining room with set-up, needed cueing, tray set-up, socialization at meals, and assistance with filling out the menu. It also documented unplanned weight loss related to poor food intake and directed staff to monitor intake, offer substitutes, and notify nursing or dietary if the resident was not consuming meals routinely. The resident experienced progressive weight loss over several months, with documented weights decreasing from 186 lbs to 174.9 lbs, then 155.8 lbs, 147.8 lbs, and 142.6 lbs. Dietary notes stated the resident was often seen getting up and leaving without eating or eating very little, and that she would benefit from sitting with other tablemates and receiving staff cueing and tray set-up. The notes also stated she liked to snack throughout the day and could be offered higher nutrition snacks such as a half sandwich and milk, banana and peanut butter, or yogurt. Meal documentation was incomplete for multiple lunches in January and February, with many meals lacking documentation of the amount eaten. During observations, the resident was repeatedly seen sitting at meals without eating or with minimal intake while staff provided little or no encouragement, cueing, or substitute food. On one occasion staff cut up pancakes and opened syrup but provided no further assistance for an extended period, and no substitute was offered. Staff interviews confirmed the resident needed reminders to eat, that dietary had repeatedly recommended the assisted table, and that the resident was not consistently placed there until later.
Failure to Serve Meals According to Scheduled Times Due to Staffing Issues
Penalty
Summary
The facility failed to serve meals in a timely manner according to its established dining schedule, as evidenced by observations, staff and resident interviews, and review of the facility's meal schedule. The posted dining times were breakfast at 8:00 AM, lunch at 12:00 PM, and dinner at 5:00 PM. However, multiple residents reported and were observed receiving their meals significantly later than scheduled. For example, one resident stated she often received her lunch as late as 2:30 PM, and another reported not receiving lunch until 1:30 PM. Observations confirmed that lunch trays were delivered to several residents between 1:25 PM and 1:29 PM, and a breakfast tray was delivered at 8:53 AM, all later than the scheduled times. Staff interviews revealed that the kitchen experienced high turnover and staffing issues, which contributed to delays in meal service. The Dining Services Manager acknowledged that the goal was to serve breakfast and lunch trays at 7:30 AM and 12:30 PM, respectively, but staffing challenges hindered timely delivery. The manager also reported receiving several grievances from residents regarding late meal service. The Administrator confirmed that the kitchen faced barriers such as performance issues, which affected the ability to serve meals on time.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of missing money, which is considered misappropriation of resident property and a form of abuse, for one resident. The resident, who had intact cognition and diagnoses including anxiety disorder, depression, and schizophrenia, reported to the Administrator that $10 given by a friend was missing and suspected a CNA had taken it. The Administrator acknowledged receiving the report but did not notify the State Agency, citing inconsistencies in the resident's account and lack of witness to the friend's visit as reasons for not reporting. There was no documentation that the allegation was reported as required by the facility's policy, which mandates reporting all abuse allegations, including misappropriation, within two hours.
Failure to Provide Regular Showers or Baths to Resident Requiring Assistance
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, hemiplegia, heart failure, and depression did not consistently receive showers or baths at least once a week as required. Clinical record review and interviews revealed that the resident, who required assistance from one staff member for bathing due to an ADL deficit related to a stroke, reported going up to three weeks at times without a shower. The resident stated that staff frequently postponed her showers, promising to provide them the next day but often failing to follow through. She also indicated that she did not refuse showers, but sometimes tried to accommodate staff when they were busy, which resulted in further delays. Review of facility documentation showed inconsistent and insufficient records of showers provided to the resident over several months, with some months showing as few as one or two showers. The electronic health record for the previous 30 days only documented a single refusal and lacked further documentation of showers or baths. The DON confirmed that the expectation was for residents to receive showers twice a week unless otherwise requested, and that refusals should be documented and re-offered the next day. However, the documentation and resident reports indicated this standard was not met for the resident in question.
Safety Lapses in Smoking Area and Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents in a designated smoking area, particularly concerning Resident #32, who was observed smoking with a portable oxygen tank attached to his wheelchair. Despite the facility's policy prohibiting oxygen use in smoking areas, Resident #32, who had been on oxygen since November 2024, was seen smoking with the oxygen tank present, posing a significant safety risk. The resident, diagnosed with paraplegia, COPD, and asthma, was non-compliant with continuous oxygen orders and required supervision while smoking. However, the supervision provided by housekeeping staff was inadequate, as they did not remove the oxygen tank before the resident smoked. Additionally, the facility failed to ensure the safe transport of Resident #25, who was moved from the dining room to his room in a wheelchair without foot pedals. Resident #25, diagnosed with dementia and severe cognitive impairment, required extensive assistance for mobility. The lack of foot pedals during transport posed a risk to the resident's safety, as confirmed by the Director of Nursing, who stated that the expectation was for staff to use wheelchair pedals when transporting residents. These deficiencies highlight the facility's failure to adhere to safety protocols and provide adequate supervision, resulting in Immediate Jeopardy to the health and safety of the residents. The facility's policies and procedures were not effectively implemented, leading to unsafe conditions for residents who required special care and supervision.
Removal Plan
- Staff education provided to ensure all staff and all departments are aware oxygen equipment cannot be on residents or in the designated smoking area while residents smoked. All staff educated prior to the start of their next shift.
- Facility educated Resident #32, and the other residents who smoke, that oxygen equipment cannot be with them while smoking.
- Facility posted a sign near the exit to the designated smoking area stating that oxygen use is not allowed in the designated area.
- Facility posted a sign near the front entrance for visitors stating that oxygen use is not allowed while smoking.
- Facility planned to audit for compliance to ensure oxygen equipment not present in the designated smoking area while residents are smoking and any concerns to be reported to the Administrator immediately and addressed in facility Quality Assurance meeting.
Inadequate Dietary Staff and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure adequate and trained dietary staff to maintain a clean kitchen environment, as evidenced by the lack of appropriate sanitary conditions in the kitchen. The Kitchen Manager, Staff B, who was promoted from a laundry/housekeeper position, did not meet the regulated educational qualifications for the role and had not completed the Certification for Dietary Manager (CDM) coursework. During an interview, Staff B acknowledged the unsanitary conditions, including dirty floors, equipment, and uncovered food, which had not been cleaned over the weekend. The Registered Dietician, Staff C, also noted the poor cleanliness and stated that the kitchen should have been mopped before food preparation began. The facility's policy on cleaning and sanitation, dated 2021, requires the dietary services department to maintain cleanliness through a comprehensive cleaning schedule, with tasks designated to specific positions and staff held accountable for their completion. However, the policy was not effectively implemented, as evidenced by the unsanitary conditions observed. The Administrator confirmed that most kitchen staff were new and that the Kitchen Manager had not completed the necessary training or passed the credentialing exam. The job description for the Director of Dining Services, signed by Staff B, outlined responsibilities for maintaining a clean, safe, and sanitary environment, which were not met in this instance.
Failure to Serve Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature for five residents, as observed and reported during interviews. Residents consistently reported receiving meals that were cold or delivered late. For instance, Resident #13 mentioned that lunch was served late, and breakfast was always cold. Resident #17 had a meal tray that was untouched because it was cold, and Resident #35 also reported late lunch and cold breakfast. Resident #43 stated that room tray food was always cold, including eggs, sausage, toast, and lukewarm milk. Observations on 2/11/25 revealed that breakfast trays for the affected residents sat in the kitchen/dining window for 15 minutes before being delivered, contributing to the cold meals. Interviews with the residents confirmed that the breakfast served was cold, and some residents could not eat it. The facility's administrator acknowledged that the kitchen staff were new and had been receiving training, indicating a possible lack of experience or training among the staff as a contributing factor to the deficiency.
Failure to Meet Dietary Needs for Mechanical Soft Diets
Penalty
Summary
The facility failed to prepare food to meet the dietary needs of eight residents who required a mechanical soft diet. During an observation, the Dietary Manager prepared mechanical soft meat by processing chicken pieces and placing them on the steam table. However, inconsistencies were noted in the portion sizes served to residents, with some plates receiving less than the required amount. Staff N, who was new to the facility and previously worked in a fast-food restaurant, was observed serving the meals without knowing the correct scoop size, leading to incorrect portion sizes being served. The Dietary Manager, Staff B, was unaware of the discrepancies in portion sizes and believed the scoop used was appropriate for the 3-ounce serving size specified in the menu. The Registered Dietitian confirmed that the menu required 3 ounces of baked Swiss chicken for mechanical soft diets. The facility's Administrator acknowledged that the kitchen staff were new and that training attempts had been made, with the dietitian available for consultation only one day a week. This lack of adequate training and oversight contributed to the failure to meet the dietary needs of the residents.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen, as observed during an initial tour. The observations included missing floor tiles with gray/black residue, grime and water stains under the sinks, and food crumbs on the refrigerator handle and interior tray. Additionally, the front of the stove had dripping residue and traces of food, stainless appliances were not clean, and there was sand-like debris on top of the dishwasher. Various items such as silverware, cups, papers, food crumbs, and spills were found on the floor. Furthermore, bowls of cereal were uncovered, and a tub of peanut butter was half empty and covered loosely with a piece of plastic. Sticky pest traps were also noted in most corners of the kitchen. Interviews with staff revealed that the kitchen was not cleaned as required. The Kitchen Manager acknowledged the unsanitary conditions and stated that the kitchen should be cleaned at the end of each shift, which had not occurred over the weekend. The Registered Dietician admitted that cleanliness had not been addressed with the staff and noted that the kitchen was in its worst state. The Administrator confirmed that the kitchen should be cleaned every night and mentioned that most of the kitchen staff were new, indicating a need for improvement. The facility's policy on cleaning and sanitation required staff to maintain cleanliness through a comprehensive cleaning schedule, which was not adhered to, leading to the observed deficiencies.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential laundry equipment in safe operating conditions, as observed during a survey. One of the two large industrial washers was marked out of order, and there were water stains and grayish debris behind the washer, indicating issues with the piping. Additionally, one of the industrial dryers did not automatically shut off or cool down, posing a risk of overheating. Staff A, a Laundry/Housekeeper, confirmed that only one washer was operational and explained that the pipes could back up, causing debris to shoot out. Staff A also noted that the dryer had a faulty sensor, leading to very hot metal parts on clothing. The Administrator later clarified that both washers could not run simultaneously due to circuit panel overload and was unaware of the dryer issue, indicating a lack of communication and equipment maintenance oversight.
Ineffective Pest Control and Poor Communication in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as roaches in the kitchen and laundry areas. Observations revealed multiple pest traps throughout these areas, and staff interviews confirmed ongoing pest issues, including roaches in laundry bins and clothing. The facility did not follow through with recommendations from the commercial pest control service, which included sealing holes and gaps that could allow pest entry and ensuring proper disposal of food waste. The kitchen was observed to have food debris and water leaks, contributing to the pest problem. Interviews with staff indicated a lack of communication and coordination regarding pest control measures. The Dietary Manager was not directly informed about necessary improvements, and the Administrator was unaware of the pest control findings, having only signed the report without discussing its contents. The Registered Dietician noted that the kitchen's cleanliness was subpar, and the facility's cleaning efforts were insufficient. Despite the presence of a cleaning list, staff admitted that it was not fully adhered to, exacerbating the pest issue.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for two residents. For Resident #5, who has a diagnosis of dementia, the care plan required staff to administer medications as ordered and supervise the resident. However, on February 11, 2025, Resident #5 was left unsupervised with medications in a cup, while the LPN responsible was across the hall. The LPN acknowledged the facility policy that required nursing staff to stay with residents until they had taken their medications. For Resident #47, there was a failure to secure medications properly. The RN removed insulin pens and an Ozempic pen from a zipper bag on the medication cart but left the Ozempic pen unsecured while administering other medications in the resident's room. The RN admitted that the Ozempic was not administered as it was not the scheduled day, and the medication was left unsecured. The DON confirmed that the expectation was for nursing staff to stay with residents until all medications were taken and to secure medications in the cart before leaving to administer them.
Failure to Provide Restorative Care for Resident
Penalty
Summary
The facility failed to provide appropriate restorative care for a resident who required rehabilitation services following a left lower leg fracture. The resident's care plan indicated a need for participation in a restorative plan three times weekly, but the Minimum Data Set (MDS) showed zero days of restorative care provided. The Restorative Therapy Program outlined specific exercises to be performed 3-5 times a week, yet documentation revealed a lack of recorded restorative care for 29 days. Interviews with the resident and staff confirmed that the restorative aide was often reassigned to other duties, such as driving residents to appointments or performing CNA and CMA tasks, resulting in the neglect of the resident's restorative care needs. The resident expressed concerns about not receiving the necessary restorative care, which was crucial for her physical preparation to return home. Staff interviews revealed that when the restorative aide was unavailable, the responsibility for providing restorative care was supposed to fall on the CNAs, but this did not occur. The administrator and restorative nurse acknowledged the issue, confirming that the restorative exercises were not completed when the aide was reassigned. This failure to adhere to the rehabilitation directives and provide consistent restorative care contributed to the deficiency identified in the facility's care practices.
Failure to Respond to Pharmacy Recommendations for Medication Review
Penalty
Summary
The facility failed to ensure timely provider notification and response to pharmacy recommendations for two residents regarding unnecessary medications. Resident #29, with intact cognition and diagnoses including Bipolar Disorder and PTSD, was on Mirtazapine for appetite stimulation. Despite pharmacy recommendations for a gradual dose reduction (GDR) of Mirtazapine, there was no documented response from the provider. The Director of Nursing (DON) confirmed that the pharmacy recommendations were sent to the provider, but there was no response, and the resident expressed a desire to switch providers due to lack of attention. Resident #36, also with intact cognition and diagnoses including Bipolar Disorder and dementia, was on multiple psychotropic medications. The pharmacy recommended GDRs for several medications, but there was no documented response from the provider. The nursing progress notes indicated that the resident's mental health provider had not seen the resident since June 2024 and therefore had not responded to the recommendations. The resident and family decided to switch mental health providers due to the lack of attention. The facility's Medication Regimen Review Policy requires that all pharmacy recommendations be acted upon and documented by the staff or provider. If a physician chooses not to act on a recommendation, they must document the rationale in the resident's record. The lack of provider response and documentation for both residents indicates a failure to adhere to this policy, leading to the deficiency.
Ineffective QAPI Program and Repeat Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring quality care for its residents. The facility, with a census of 48 residents, has had repeat deficiencies over the past two years in areas such as infection control, professional standards, and maintaining a clean environment. The deficiencies were identified through a review of the Department of Inspections and Appeals website and confirmed by the facility's Administrator. The Administrator acknowledged the repeat deficiencies and attributed them to issues in the kitchen, where all staff members are new. The Regional Director of Operations identified the root cause of the deficiencies as high turnover in the kitchen staff, which led to concerns about efficiency and standards in that area.
Facility Fails to Maintain Clean and Safe Bathroom Facilities
Penalty
Summary
The facility failed to maintain safe, clean, sanitary, and orderly bathroom facilities for five out of eight resident bathrooms reviewed. Observations revealed that Resident #2's bathroom had a leaking toilet with a damp and odorous towel on the floor, which had been there for weeks. The resident confirmed the ongoing issue with the toilet leak. Additionally, the bedroom floors appeared dirty and gritty, and wall tiles above the toilet were missing. Resident #3's bathroom was observed with briefs and a toilet plunger on the floor, which remained unchanged over two days. Similarly, Resident #4's bathroom had multiple unused briefs and plastic wrap scattered on the floor, with no change in condition after housekeeping duties were completed. Resident #6's bathroom had a full trash can with used briefs and clothing on the floor, emitting an odor. Resident #7's bathroom had a soiled brief in the trash, a toilet plunger, and packages of briefs on the floor, with the resident stating that housekeeping had not cleaned the room for three days. Interviews with staff revealed that the facility had three housekeepers on weekdays and two on weekends, with a routine cleaning schedule that included removing trash, tidying up, and sanitizing surfaces. However, challenges with clutter and a lack of deep cleaning were noted. Staff members mentioned the absence of a maintenance person and the use of a fix-it ticket system for repairs, but there was no recall of recent deep cleaning activities.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and orderly environment for residents, as evidenced by observations in five out of eight resident rooms. Resident #1's room had dirty and gritty floors, and a piece of baseboard was detached and improperly reattached. Resident #2's room also had dirty floors, a blanket on the bathroom floor, and missing wall tiles. Resident #3's bathroom had a hole with a missing tile and supplies scattered on the floor. Resident #5's bathroom had a similar hole and staining along the toilet bowl seal. Resident #7's room had baseboards pulling off the wall, and there were collapsed ceiling tiles in the hallway due to water damage. The facility's maintenance issues were exacerbated by the sudden departure of the maintenance man on 11/25/24, leaving the facility with only part-time maintenance support from a staff member at a sister facility. This staff member, Staff C, was involved in catching up on fire and disaster drills and had not yet addressed the reported maintenance problems. The facility's system for reporting maintenance issues involved department heads notifying the maintenance department through an app or a work order system, but these issues remained unresolved at the time of the survey.
What surveyors are citing around you — mapped
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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 128 citations issued within 25 miles in the last 12 months — 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 Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Vista For Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 18 | 0 |
| Wesley Park Centre | 1.4 mi | ★★★★★ | 4 | 0 |
| Newton Village Health Care Center | 1.4 mi | ★★★★★ | 3 | 0 |
| Traditions Memory Care Of Newton | 2.5 mi | ★★★★★ | 2 | 0 |
| Mayflower Home | 16.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.