Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Onawa during CMS and state inspections, most recent first.
The facility did not have an RN on duty for 8 consecutive hours on two days, as confirmed by the DON and a review of the nursing schedule. The staffing plan was based on census, acuity, and hiring availability, but there was no formal policy on RN coverage.
The facility did not post the correct lunch menu and failed to ensure residents were offered meal alternatives. Staff served a different meal than what was posted, did not consistently ask residents about their meal preferences, and several residents reported not being informed of or offered alternatives, including those with dietary restrictions or food intolerances. The Dietary Manager was unaware of a policy regarding food choices, and the process for offering alternatives was not reliably completed.
Surveyors found that staff did not consistently discard expired food items, including shredded carrots and graham cracker crumbs, until prompted during inspection. The Dietary Manager was unaware of a policy for routine checks of outdated food, despite the facility having a policy for discarding expired items brought in by families or visitors.
A resident with moderate cognitive impairment reported missing personal clothing items, which were not replaced despite notifying staff. Staff interviews revealed inconsistent use and awareness of inventory sheets, and the resident's inventory record could not be found, resulting in a failure to safeguard the resident's belongings.
A resident with multiple medical conditions and significant pain management needs received both scheduled and PRN oxycodone, but the facility failed to accurately document and monitor the administration of this controlled substance. Discrepancies were found between the number of tablets delivered, administered, and recorded, and required signatures were missing from drug count records. Staff also used a single sheet for multiple orders, contrary to facility policy.
A resident with multiple health conditions, including ESRD and diabetes, received Midodrine despite physician orders to withhold it when systolic BP exceeded 130. The medication was administered multiple times in June when BP readings were above this threshold, indicating non-compliance with the prescribed parameters.
A facility failed to conduct timely assessments for a readmitted resident with diabetes and end-stage renal disease. Upon readmission, staff did not document current vital signs or obtain a blood glucose level, despite care plan requirements and hospital discharge instructions. The DON noted that vital signs were recorded on paper but not entered electronically, and there was no policy on admission assessments.
The facility failed to conduct pre-dialysis assessments for two residents requiring hemodialysis. One resident, with moderate cognitive deficits and multiple diagnoses, was sent to the ED with a high pulse and low blood pressure without prior vital sign documentation. Another resident, with severe cognitive deficits, also lacked pre-dialysis assessments. The DON stated that dialysis staff completed these assessments, contrary to facility policy.
The facility's kitchen was found in unsanitary conditions during an inspection, with grease, food splatter, and debris on the stove top, shelving, carts, and floor. The Dietary Manager acknowledged the issue, attributing it to an employee's weekend work, despite routine cleaning logs being completed.
A facility failed to send a bed hold notice to a resident or their responsible person after a verbal consent was given during a transfer to the emergency room. The resident, with heart failure, hyperlipidemia, and asthma, was transferred and returned within a few days. The clinical record lacked documentation of the required notice, contrary to the facility's policy.
A facility failed to resubmit the PASRR for a resident with new mental health diagnoses and ongoing services. The resident had diagnoses of depression, anxiety disorder, and PTSD, but the PASRR did not reflect these or the mental health services received. The BOM acknowledged the oversight, and the facility's policy lacked guidance on PASRR resubmission requirements.
A facility failed to complete necessary skilled assessments for a resident with paraplegia, COPD, and neurogenic bladder, who was readmitted after hospitalization for Acute Kidney Injury. Despite the requirement for twice-daily assessments, several were missed, and the facility's policy lacked clear instructions on assessment frequency. The DON confirmed the oversight, with no additional documentation found.
A facility failed to follow mechanical lift requirements, leading to a deficiency in accident prevention. A resident with paraplegia and other conditions was transferred using a mechanical lift by two CNAs, who did not lock the wheelchair brakes as required by the lift's guide and facility policy. The DON confirmed the brakes should have been applied.
The facility did not follow the prescribed menu for mechanical soft diets, serving peas instead of buttered waxed beans to four residents. The Dietary Manager acknowledged the error, and the Dietician confirmed the importance of adhering to the menu to accommodate residents with chewing difficulties. The Director of Nursing expected staff to follow the planned therapeutic menus.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident. An RN did not wear a gown as required by EBP guidelines while changing a dressing on a resident's heel. The RN admitted to not being trained on EBP, and the DON confirmed that gowns should be worn during such procedures.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for 8 consecutive hours each day, as required. A review of the April 2025 nursing schedule revealed that there was no RN coverage on two specific days, the 13th and the 17th. The Director of Nursing (DON) confirmed the absence of RN coverage on these dates. Additionally, a nurse consultant was unsure if there was a formal policy regarding RN coverage but stated that the facility follows the standard of care to provide 8 consecutive hours of RN coverage daily. The facility assessment indicated that staffing plans are based on census, acuity, and hiring availability, with a reported census of 32 residents at the time.
Failure to Post Correct Menu and Offer Meal Alternatives
Penalty
Summary
The facility failed to post the correct lunch menu and did not ensure that residents were offered meal options as required. On the day of observation, the posted menu listed spaghetti with meat sauce, seasonal vegetable, garlic toast, and pumpkin dessert for lunch, but the meal actually served was goulash, garlic toast, mixed vegetables, and poppy seed cake. Staff reported that menu changes were due to transitioning to a new management company and using up existing food supplies. The dietary staff did not complete the task of asking residents about meal alternatives that morning, and residents were not informed of the menu changes. Multiple residents reported that they were not asked about their meal preferences or offered alternatives, despite facility documents stating that dietary staff should be informed of alternatives by a specific time. One resident with intact cognitive ability noted that staff did not always come around to ask about meal choices. Another resident with a moderate cognitive deficit could not tolerate peas in the mixed vegetables and was not offered a substitute. A third resident on a low salt, diabetic diet stated she would have preferred a smaller portion if asked. The Dietary Manager was unaware of any facility policy on food choices, and the process for offering alternatives was inconsistently followed.
Failure to Discard Outdated Food Items in a Timely Manner
Penalty
Summary
Surveyors observed that the facility failed to discard outdated food items in a timely manner. During an inspection of the kitchen and storage areas, a bag of shredded carrots was found in the walk-in refrigerator with an expiration date that had already passed, and staff disposed of it only after it was pointed out. In the dry storage area, two bags of graham cracker crumbs were found with an open date several months prior, and the Dietary Manager was unable to confirm their expiration date but agreed they should be discarded. The Dietary Manager stated that checks for outdated food were typically done on delivery days, and there was no awareness of a specific policy for regularly checking for outdated food, despite the facility having a policy for discarding expired food brought in by families or visitors. The facility reported a census of 32 residents at the time of the survey.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft, as evidenced by the missing blouse and two pairs of jeans reported by a resident with moderate cognitive impairment. The resident stated she informed staff about the missing items, but they were never replaced. Staff interviews revealed a lack of awareness and inconsistent completion of inventory sheets, with one staff member admitting she did not know she was responsible for maintaining these records until a recent change in laundry service. The resident's inventory sheet could not be located. The facility's policy requires appropriate action when residents' rights are violated, but the deficiency occurred due to the failure to properly document and safeguard the resident's belongings.
Failure to Accurately Document and Monitor Controlled Substance Administration
Penalty
Summary
The facility failed to accurately document and monitor the use of controlled substances for a resident who was prescribed both scheduled and PRN oxycodone for pain management. The Controlled Drug Count Record (CDCR) did not match the Medication Administration Record (MAR), with discrepancies in the number of tablets administered and recorded. Specifically, the pharmacy delivered a total of 106 oxycodone tablets, but the MAR showed 85 administrations while the CDAR indicated 105 tablets had been administered. Additionally, the CDCR was missing required signatures on several dates, and staff reported that both scheduled and PRN doses were being tracked on the same sheet, contrary to facility policy, which required separate sheets for each prescription. The resident involved had multiple diagnoses, including anemia, renal insufficiency, pneumonia, cellulitis, and pressure ulcers, and was dependent on staff for toileting and transfers. The care plan indicated ongoing pain related to wounds, and the resident reported experiencing pain and delays in receiving medication. Staff interviews confirmed inconsistencies in the documentation and counting process for controlled substances, and policy review revealed that the facility was not following its own procedures for controlled substance documentation.
Failure to Follow Medication Orders for Blood Pressure Management
Penalty
Summary
The facility failed to adhere to medication orders for a resident with a prescription for Midodrine, intended to treat low blood pressure. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure exceeded 130. However, during June 2024, the medication was administered multiple times when the resident's systolic blood pressure was above the specified threshold. Specific instances included blood pressure readings of 135/95, 148/75, 138/74, and others, indicating a clear deviation from the prescribed parameters. The resident involved had a moderate cognitive deficit and was dependent on staff for daily activities, including transfers and dressing. The resident's medical history included conditions such as anemia, hypertension, gastroesophageal reflux disease, end-stage renal disease, and diabetes mellitus. The care plan required staff to monitor vital signs and communicate with the dialysis unit, given the resident's need for hemodialysis. Despite these directives, the facility's staff failed to follow the physician's order regarding the administration of Midodrine, as evidenced by the medication administration records.
Failure to Conduct Timely Assessments for Readmitted Resident
Penalty
Summary
The facility failed to provide complete and timely assessments and interventions for a resident who was readmitted after a long hospitalization. Upon readmission, the staff did not document current vital signs and failed to obtain a blood glucose level, which was necessary due to the resident's diabetes mellitus. The resident's care plan required monitoring for signs of renal insufficiency and blood sugar levels, but these were not adequately followed. The Director of Nursing (DON) acknowledged that the admitting nurse documented vital signs on paper but did not enter them into the electronic chart, and there was no documentation of a blood glucose check upon admission. The resident had a history of anemia, hypertension, gastroesophageal reflux disease, end-stage renal disease, and diabetes mellitus, requiring hemodialysis and insulin management. The hospital discharge instructions specified that blood glucose should be checked before meals and at bedtime, with specific thresholds for notifying the physician. However, the facility did not have a policy on admission assessments, and the insulin was not delivered from the pharmacy on the day of readmission. The DON stated that the resident was not showing symptoms of hypo or hyperglycemia, and there was no order for blood glucose checks, which contributed to the oversight.
Failure to Conduct Pre-Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre-dialysis assessments for two residents who required hemodialysis services. Resident #1, with moderate cognitive deficits and multiple diagnoses including end-stage renal disease, was dependent on staff for daily activities and required regular hemodialysis. The care plan directed staff to monitor vital signs and communicate with the dialysis unit. However, records showed that on several occasions in June, staff did not document pre-dialysis assessments, including vital signs or weights. On one occasion, the resident was sent to the emergency department with a high pulse and low blood pressure, and there was no documentation of vital signs before the resident was sent to dialysis. Similarly, Resident #3, with severe cognitive deficits and dependent on staff for daily activities, required hemodialysis due to renal failure. The care plan also required staff to monitor vital signs and report significant changes. However, in July, staff failed to document pre-dialysis assessments on multiple occasions. The Director of Nursing stated that the facility staff did not perform pre-dialysis assessments because the dialysis department completed them, leaving the form blank for dialysis nurses. This practice was contrary to the facility's policy, which required nurses to record vital signs and other relevant information before and after dialysis appointments.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen where food was prepared and stored, as observed during a walkthrough. The inspection revealed a thick layer of grease with food splatter and debris on the stove top, food debris and dried liquid on open shelving, scattered food debris on two carts, and an accumulation of food debris and dried liquid on the floor. The Dietary Manager acknowledged these unsanitary conditions and noted that routine cleaning logs were completed, but attributed the issue to an employee who worked over the weekend. The facility's Cleaning and Sanitizing policy, last revised in June 2015, emphasizes maintaining a clean and sanitary environment, but these standards were not met during the inspection.
Failure to Provide Bed Hold Notice After Resident Transfer
Penalty
Summary
The facility failed to ensure that a bed hold notice was sent to a resident or the resident's responsible person after a verbal consent was given when the resident was transferred out of the facility. This deficiency was identified for one of the three residents reviewed, specifically Resident #19, who had diagnoses of heart failure, hyperlipidemia, and asthma, with a BIMS score of 13 indicating no cognitive impairment. The resident was transferred to the emergency room on 8/26/23 and returned to the facility on 8/29/23. The clinical record review revealed that the bed hold dated 8/26/23 lacked documentation of a bed hold notice being sent, despite the facility's policy requiring written notification within a specified timeframe in cases of emergency transfer.
Failure to Resubmit PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit the Preadmission Screening and Resident Review (PASRR) for a resident who had new mental health diagnoses and had begun receiving mental health services. The resident, identified as Resident #2, had documented diagnoses of depression, anxiety disorder, and post-traumatic stress disorder (PTSD) on their Minimum Data Set (MDS) assessment. Despite these diagnoses and the initiation of mental health services, the PASRR Level I Determination dated 4/9/24 did not reflect the active diagnosis of major depressive disorder and PTSD, nor did it document the ongoing behavioral health services the resident was receiving. The deficiency was identified through a review of clinical records, staff interviews, and policy review. The Business Office Manager (BOM) acknowledged that the PASRR should have been resubmitted, indicating a lapse in the facility's process for updating PASRRs when there are significant changes in a resident's mental health status. Additionally, the facility's Pre-Admission Screening policy failed to instruct staff on the requirements for resubmitting a PASRR, contributing to the oversight. Interviews with facility staff revealed that the responsibility for PASRR resubmissions was in transition, with plans to assign this task to a new social worker once training was completed.
Failure to Complete Skilled Assessments for Resident
Penalty
Summary
The facility failed to complete necessary skilled assessments for a resident, leading to a deficiency in maintaining the resident's highest practical physical well-being. The resident, who had diagnoses of paraplegia, Chronic Obstructive Pulmonary Disease (COPD), and neurogenic bladder, was hospitalized for an Acute Kidney Injury and returned to the facility. Despite the requirement for skilled assessments to be conducted twice daily from the resident's readmission, the facility did not complete these assessments on several specified dates. The Director of Nursing (DON) confirmed that the skilled assessments were not completed as required, and no additional documentation was found in the Progress Notes. The facility's policy from August 2015 instructed staff to enter a narrative note once a day but did not specify the frequency of skilled assessments, contributing to the oversight. This lack of adherence to assessment protocols resulted in a failure to provide appropriate treatment and care according to the resident's needs and goals.
Failure to Lock Wheelchair Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to adhere to mechanical lift requirements, resulting in a deficiency related to accident hazards and inadequate supervision. Resident #2, who has diagnoses of paraplegia, chronic obstructive pulmonary disease (COPD), and neurogenic bladder, was observed being transferred from bed to wheelchair using a mechanical lift by two Certified Nurse's Aides (CNAs). The resident, who is totally dependent on assistance for transfers, was not properly secured as the CNAs did not lock the wheelchair brakes before lowering the resident into the wheelchair. This action was contrary to the instructions in the mechanical lift's Owner's Guide and the facility's Lift Devices policy, which both mandate locking the wheelchair brakes during such transfers. The Director of Nursing (DON) confirmed that the wheelchair brakes should have been applied in accordance with the lift operator's guide.
Failure to Follow Mechanical Soft Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for mechanical soft diets for four residents during meal service. On the specified date, the Dietary Manager served peas instead of the buttered waxed beans that were listed on the therapeutic mechanical lunch menu. This deviation from the menu affected four residents who were supposed to receive mechanical soft diets. The Dietary Manager acknowledged the error upon review of the menu and expressed uncertainty about the reason for the specific menu item, suggesting a lack of understanding of the dietary requirements. The Dietician confirmed that the menu should have been followed and explained that the mechanical soft diet is intended for individuals with chewing difficulties, which may include those with dental issues or other conditions affecting chewing. The facility's Menu Planning Guide specifies that certain foods, including peas, should be omitted from mechanical soft diets due to potential chewing or swallowing difficulties. The Director of Nursing also acknowledged awareness of the potential issues certain foods could cause and expressed an expectation for staff to adhere to the planned therapeutic menus.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during wound care for one resident. During an observation, a Registered Nurse (RN) performed hand hygiene and donned gloves before removing the old dressing from a resident's left heel. After removing the dressing, the RN doffed the gloves, performed hand hygiene again, and donned new gloves to complete the dressing change as ordered by the physician. However, the RN did not wear a gown during the procedure, which is required by EBP guidelines. In an interview, the RN admitted to not being trained on EBP and acknowledged that a gown should have been worn during the wound care. The Director of Nursing (DON) confirmed that the expectation was for gowns to be worn during such procedures. The facility's infection control policy and CDC guidelines both emphasize the importance of wearing gowns to protect skin and prevent clothing contamination during procedures likely to generate splashes or sprays of bodily fluids, especially when dealing with chronic wounds.
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What surveyors actually found near you
We read the 38 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.
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Nursing homes near Onawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Care Center | 6.7 mi | ★★★★★ | 0 | 0 |
| Carl T Curtis Health Education Center Nursing Home | 14.3 mi | ★★★★★ | 7 | 0 |
| Maple Heights | 17.5 mi | ★★★★★ | 17 | 0 |
| Accura Healthcare Of Tekamah | 18.7 mi | ★★★★★ | 14 | 0 |
| Oakland Heights | 23.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.