Accura Healthcare Of Spirit Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Spirit Lake, Iowa.
- Location
- 1912 Zenith Avenue, Spirit Lake, Iowa 51360
- CMS Provider Number
- 165528
- Inspections on file
- 18
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Accura Healthcare Of Spirit Lake during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported being treated roughly by a CNA, who allegedly threw her into a wheelchair. Despite the incident being reported to multiple staff members, including an LPN and the ADON, the facility delayed the investigation until later in the day, leaving residents exposed to potential abuse. The facility's progress notes lacked documentation of the incident, and the delay in action resulted in Immediate Jeopardy to the resident's safety.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as well as in dishwashing practices. Observations revealed unlabeled and outdated food items, improper hand hygiene by a cook, and incomplete temperature logs for meals and dishwashing equipment. Staff interviews indicated a lack of understanding of proper procedures, contributing to the deficiencies.
The facility failed to provide nourishing and palatable food, as observed during meal service. Scrambled eggs were served below the required temperature, and French toast was tough and dried out. The meatloaf served at lunch had burnt edges, making it difficult to cut and inedible for several residents. The Certified Dietary Manager acknowledged the meatloaf issue but was unaware of the other food quality problems.
The facility failed to implement proper infection control practices during wound care and meal assistance. Two LPNs did not use Enhanced Barrier Precautions (EBP) for a resident's wound care, despite CDC guidelines suggesting EBP for any wound care. Additionally, a Restorative Aide and a CNA assisted multiple residents with meals without performing hand hygiene between tasks, contrary to the facility's hand hygiene policy. The DON confirmed the absence of a specific policy for hand hygiene during meal assistance.
A facility failed to refer a resident for a Level II PASRR evaluation after new diagnoses of anxiety disorder, psychotic disorder, and delusional disorders were identified. The resident had a BIMS score indicating severe cognitive impairment, and the care plan noted dementia with behaviors. The clinical record lacked an updated PASRR, and the Social Services Director acknowledged the oversight.
The facility was found deficient in food preparation methods, as a cook used hot water to puree meatloaf and carrots, which does not conserve nutritive value and flavor. The Certified Dietary Manager acknowledged that water is not the most appropriate liquid for pureeing, as industry standards recommend using liquids that add flavor, calories, or protein.
A facility failed to properly assess and care plan the use of Paid Nutritional Aides (PNAs) for a resident with swallowing difficulties. The resident, diagnosed with dysphagia and other conditions, was fed by a PNA despite the care plan not addressing PNA use. The Director of Nursing admitted to the lack of formal assessments for PNA use, and the Speech and Language Pathologist was not involved in the decision-making process. Facility policy prohibits PNAs from assisting residents with complicated eating problems, yet this was not adhered to.
A resident with moderate cognitive impairment and a history of heart issues was sent to the ER due to a low pulse rate and drowsiness, but the family was not informed until the next day. Later, the resident became unresponsive, and the family was again not notified until a friend intervened. The resident was then sent to the ER, where a severe infection and high heart rate were discovered. The facility failed to follow its policy on notifying family members of significant health changes.
A resident with moderate cognitive impairment reported being roughly handled by a CNA during a transfer, leading to visible distress and crying. Despite multiple staff members being aware of the incident, the facility failed to document the event in the resident's progress notes. The facility's policy on abuse prevention was not adequately implemented to protect the resident from the alleged abuse.
A resident with moderate cognitive impairment reported being handled roughly by an aide, which was corroborated by the resident's husband. The incident was reported internally to an LPN and then to the RN ADON, but the ADON was not informed until later in the day. The facility failed to report the allegation to the Iowa Department of Inspections & Appeals within the required 2-hour timeframe, submitting the report several hours after the incident was first reported.
A resident with moderate cognitive impairment and heart-related diagnoses experienced a decline in condition, including low pulse and drowsiness, leading to an ER visit. Despite returning with no new medications, the resident's condition worsened with symptoms like nausea and low oxygen saturation. The facility failed to reassess the resident's condition timely and did not effectively communicate with the family, resulting in the resident becoming unresponsive and being diagnosed with multiple severe conditions upon a subsequent ER visit.
A resident with moderate cognitive impairment was reportedly handled roughly by a morning aide, as observed by her husband and reported by a CNA. The incident was communicated to an LPN and the ADON, but the facility's records lacked documentation of the event, contrary to its Risk Management policy.
Failure to Protect Resident from Potential Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse after an allegation was made against a Certified Nursing Assistant (CNA) for treating a resident roughly and throwing her into her wheelchair. The incident was reported by the resident to a staff member, who then informed the charge nurse and the Assistant Director of Nursing (ADON). However, the ADON denied being aware of the situation. The incident occurred before breakfast, but the facility did not begin investigating until after 3:00 PM, leaving residents exposed to potential abuse. The resident involved in the incident had a history of bipolar disorder, hypertension, and diabetes mellitus, with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident expressed fear of the staff member and reported the rough treatment to multiple staff members, including a CNA and a Licensed Practical Nurse (LPN). The resident's husband also witnessed the incident and reported that the aide threw the gait belt across the room. Despite these reports, the facility's progress notes lacked documentation of the incident. Interviews with various staff members revealed that the resident was visibly upset and crying, and she described the aide's actions as rough and inappropriate. The resident expressed that she did not want anyone to get into trouble but felt the treatment was unjust. The facility's policy required immediate reporting and action to prevent further abuse, but the delay in investigation and lack of immediate protective measures resulted in an Immediate Jeopardy to the health, safety, and security of the resident.
Removal Plan
- Staff member remains suspended and hasn't worked since 5/3/24
- Staff education was initiated to ensure all staff understand the facility abuse policy and reporting procedures.
- All staff through the evening shift have been educated. Anyone not educated or not on the schedule will be educated on the vulnerable adult policy and reporting procedures prior to coming on shift.
- All nursing leadership were educated by the Registered Nurse (RN) Nurse Specialist on their corporation's investigation and allegation of abuse process and procedure.
- Any concerns will be reported to the Administrator immediately and addressed in facility Quality Assurance (QA).
Sanitation and Temperature Log Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner, as well as ensuring dishes and utensils were cleaned properly to prevent foodborne illness. During an initial kitchen tour, surveyors found a container of oil on the floor, unlabeled and undated containers of food, and outdated food items in the walk-in cooler. A follow-up tour revealed additional issues, including an open bag of frozen chicken and an unlabeled bag of food in the freezer, as well as outdated pea salad in the cooler. During a lunch service observation, a cook failed to perform hand hygiene, used bare hands to handle food and equipment, and did not change gloves appropriately, leading to potential cross-contamination. The facility also failed to maintain accurate temperature logs for both food and dishwashing equipment. Numerous meal temperatures were not recorded over several months, and dish machine temperature logs showed significant gaps in documentation. Staff interviews revealed a lack of understanding regarding which temperature gauge to monitor for proper sanitization. The facility's policies on food storage, hand washing, food temperatures, and dish machine temperature logging were not adhered to, contributing to the deficiencies observed.
Deficiency in Providing Nourishing and Palatable Food
Penalty
Summary
The facility failed to provide food that is nourishing and palatable, as evidenced by multiple observations and staff interviews. During a breakfast test tray observation, scrambled eggs were recorded at a temperature of 123 degrees, below the facility's standard of 135 degrees, and the French toast was noted to have tough and dried-out edges. During a kitchen lunch observation, the meatloaf on the steam table was found with burned edges, making it difficult for staff to cut into individual pieces. During a resident meal round in the East Dining Room, several residents complained that the meatloaf was burnt and inedible, with hard, burnt crusts observed on their plates. A lunch test tray also confirmed the meatloaf was burnt along the edges and crunchy. Staff J, the Certified Dietary Manager, acknowledged the meatloaf was dried out but was unaware of the issues with the French toast and scrambled eggs temperature.
Infection Control Deficiencies in Wound Care and Meal Assistance
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care treatment for a resident and while assisting residents with meals. During an observation, two LPNs performed wound care on a resident's left lower calf without implementing Enhanced Barrier Precautions (EBP), as there was no signage indicating the need for EBP. The staff justified the absence of EBP by stating that it was not required since the wound was not classified as chronic, which they defined as lasting more than 30 days. However, the facility's policy and CDC guidelines suggest that EBP should be used for any wound care, regardless of the wound's chronicity. Additionally, during a breakfast observation, a Restorative Aide and a CNA were seen assisting multiple residents to eat without performing hand hygiene between tasks. The Restorative Aide was observed touching one resident and then assisting another without sanitizing hands, while the CNA wiped a resident's mouth and nose and then proceeded to assist another resident without hand hygiene. The facility's Director of Nursing confirmed that there was no specific policy for hand hygiene during meal assistance, although the facility's hand hygiene policy requires sanitizing hands after touching a resident or their environment and after contact with bodily fluids.
Failure to Update PASRR for Resident with New Diagnoses
Penalty
Summary
The facility failed to refer a resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR) to the appropriate state-designated authority for a Level II PASRR evaluation and determination. This deficiency was identified for one resident who was later diagnosed with newly evident or possible serious mental disorder, intellectual disability, or other related condition. The resident, identified as Resident #57, had a Minimum Data Set (MDS) assessment documenting diagnoses of anxiety disorder, psychotic disorder, and delusional disorders, with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The active diagnosis list in the clinical record showed delusional disorders and anxiety disorder with active dates in 2024. The care plan also noted dementia with behaviors, delusional disorder, and anxiety. However, the clinical record lacked an updated PASRR to reflect these diagnoses. An interview with the Social Services Director confirmed that the PASRR should have been updated with the new diagnoses.
Inappropriate Pureeing Methods Used in Food Preparation
Penalty
Summary
The facility failed to provide food prepared by methods that conserve nutritive value and flavor, as observed during a survey. On August 21, 2024, at 11:00 AM, a cook, identified as Staff I, was seen preparing four servings of pureed meatloaf and carrots. The cook used hot water to thin the items to achieve the correct puree consistency. When questioned, Staff I admitted that water is primarily used when pureeing foods. Later, during an interview at 12:30 PM, the Certified Dietary Manager, Staff J, acknowledged that using water is not the most appropriate liquid for pureeing. Industry standards recommend using liquids that add additional flavor, calories, or protein to conserve the nutritive value and flavor of pureed foods.
Inappropriate Use of Paid Nutritional Aides for Resident with Swallowing Difficulties
Penalty
Summary
The facility failed to accurately care plan the use of Paid Nutritional Aides (PNAs) and assess the appropriateness of their use for a resident with swallowing difficulties. Resident #27, who has an intact cognitive status, was diagnosed with conditions including aphasia, dyskinesia of the esophagus, and dysphagia. The resident was observed being fed by a PNA despite having a puree diet and regular consistency liquids, which was not addressed in the care plan. The care plan did not specify the use of PNAs for meal assistance, and there were no formal assessments conducted to determine the appropriateness of PNA use for this resident. The Director of Nursing (DON) acknowledged the lack of regularly scheduled formal assessments for the continued use of PNAs and stated that PNAs are not allowed to assist residents with thickened liquids. However, no further restrictions were in place. The facility's Speech and Language Pathologist (SLP) was not involved in the decision to utilize a PNA for Resident #27, who was identified as having a higher than normal aspiration risk. The facility's policy stated that PNAs should not assist residents with complicated eating problems, such as difficulty swallowing, and that resident selection for PNA use should be based on the charge nurse's assessment and the resident's latest comprehensive assessment and plan of care.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family of a change in condition for one resident, who had moderate cognitive impairment and was independent with eating. The resident had a history of heart failure, atrial fibrillation, and long-term use of anticoagulants. On a particular day, the resident exhibited a significantly low pulse rate and increased drowsiness, prompting the nurse to contact the doctor and receive orders to send the resident to the emergency room (ER) for evaluation. Although a message was left for the family, they were not successfully informed until the following day, after the resident had already returned from the ER. Further communication issues were noted when the resident's condition deteriorated again, with the resident becoming unresponsive and not eating or drinking much. The family was not informed of these changes until a friend of the resident contacted them. The family member then called the facility and requested the resident be sent to the ER, where it was discovered that the resident had a severe infection and a dangerously high heart rate. The facility's policy required notifying the resident's physician and representative of significant changes in health status, but this protocol was not followed effectively in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a certified nursing assistant (CNA) who was reported to have been rough during a transfer. The resident, who has a history of bipolar disorder, hypertension, and diabetes mellitus, and a moderate cognitive impairment, expressed distress and reported the rough handling to multiple staff members. The incident was initially reported by the resident's husband and observed by other staff members who noted the resident was visibly upset and crying. The resident described the aide as having thrown her gait belt across the room, ripped her pajamas off, and performed a rough transfer that resulted in her leg being hit on the wheelchair. Despite the resident's visible distress and multiple reports from staff, the facility's progress notes lacked documentation of the incident. Interviews with staff revealed that the incident was reported to the administrator, who then initiated an investigation. However, there was a failure to document the assessment conducted by the Assistant Director of Nursing (ADON) in the resident's chart. The facility's policy on abuse prevention mandates that residents must not be subjected to abuse by anyone, yet the facility did not appropriately implement interventions to protect the resident from the alleged abuse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with a history of bipolar disorder, hypertension, and diabetes mellitus, who was assessed to have moderate cognitive impairment. On the morning of the incident, the resident was observed crying and reported to a CNA that an aide had been rough during a transfer and had thrown a gait belt across the room. The resident's husband corroborated the account of the aide's rough behavior. The CNA reported the incident to an LPN, who then informed the RN Assistant Director of Nursing (ADON) between 8:00 a.m. and 9:00 a.m. However, the ADON was not aware of the situation until the Administrator informed her around 3:00 p.m. The facility's self-report indicated that they became aware of the incident at 3:00 p.m. and submitted a report to the authorities at 5:04 p.m., which was beyond the 2-hour reporting requirement. The facility's policy mandates that all allegations of resident abuse be reported to the appropriate authorities within two hours of the allegation being made.
Failure to Provide Timely Intervention and Communication for Resident
Penalty
Summary
The facility failed to provide adequate assessment and timely intervention for a resident with a change of condition, leading to a deficiency. The resident, who had moderate cognitive impairment and was independent with eating, had diagnoses including heart failure, atrial fibrillation, and long-term use of anticoagulants. The care plan indicated a potential for dehydration and required the nurse to observe for signs and symptoms of dehydration and notify the doctor of any changes. However, the facility did not adequately monitor the resident's condition or communicate effectively with the family. On July 1st, the resident exhibited a low pulse and increased drowsiness, prompting a nurse to contact the doctor and send the resident to the emergency room. The resident returned from the ER with no new medications, but continued to show signs of decline, including nausea, decreased energy, and crackles in the lungs. Despite these symptoms, the resident's condition was not reassessed until July 5th, when a nurse noted low oxygen saturation and diminished lung sounds. The resident was given a new order for Albuterol nebulizer treatments and oxygen, but there was a lack of follow-up assessment of lung sounds. The facility also failed to communicate effectively with the resident's family. The family was not informed of the resident's initial hospitalization on July 1st until the following day, and there were further communication lapses over the weekend. The resident's condition continued to deteriorate, with no food or fluids consumed since July 5th, and the resident became unresponsive by July 7th. The family was not notified of the resident's unresponsive state until a friend of the resident intervened. The resident was eventually sent to the ER, where they were diagnosed with pneumonia, atrial fibrillation with rapid ventricular response, sepsis, congestive heart failure, acute kidney injury, and acute hypoxic respiratory failure.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain accurate resident records for one of its residents, identified as Resident #71. The Minimum Data Set (MDS) assessment for this resident documented diagnoses of bipolar disorder, hypertension, and diabetes mellitus, with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. An incident occurred where Resident #71 was reportedly handled roughly by a morning aide during a transfer, as observed by the resident's husband and reported by a Certified Nursing Assistant (CNA), Staff D. The incident was communicated to a Licensed Practical Nurse (LPN), Staff E, who then informed the Assistant Director of Nursing (ADON), Staff F. However, the facility's records, specifically the Progress Notes for Resident #71, lacked documentation of this incident. The facility's policy on Risk Management, updated in October 2021, mandates that all accidents and incidents involving residents be reported, investigated, and reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) process. Despite this policy, the Director of Nursing (DON) expressed uncertainty about whether the incident should have been documented in the resident's chart. This oversight in documentation represents a failure to adhere to the facility's own policies and accepted professional standards for maintaining accurate and complete medical records.
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.
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