Accura Healthcare Of Newton East, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Iowa.
- Location
- 1743 South Eighth Avenue East, Newton, Iowa 50208
- CMS Provider Number
- 165421
- Inspections on file
- 21
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Accura Healthcare Of Newton East, Llc during CMS and state inspections, most recent first.
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.
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.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
