Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Spirit Lake during CMS and state inspections, most recent first.
Surveyors found that multiple residents were living in unclean and uncomfortable conditions, including sticky bedside tables, discolored toilet seats, and bathrooms with used washcloths, clothing, incontinent pads, paper towels, and gloves on the floor, as well as unflushed toilets with strong odors. Staff interviews confirmed that CNAs were expected to remove soiled linens and incontinent products and keep items off the floor, but these practices were not consistently followed, resulting in failure to maintain a safe, clean, and homelike environment.
Three residents with indwelling or suprapubic catheters did not receive proper catheter care and infection prevention. One resident with neurogenic bladder had orders for regular catheter and leg bag changes and two-hour monitoring, but the leg bag had not been changed for nearly a month and there was no documentation of the ordered monitoring. Another resident with a catheter for urinary retention was repeatedly observed with the drainage bag hanging from a trash can that contained garbage. A third resident with neurogenic bladder had their catheter bag emptied by a CNA who, after touching oxygen tubing on the floor, continued the catheter manipulation without changing gloves or performing additional hand hygiene.
Improper Hot Food Temperature at Meal Service: Staff D checked mashed potatoes in the steam table and found them at 131.9°F, below the facility’s 135°F minimum. Despite this, the potatoes were served to residents without being reheated. The DM confirmed hot foods in the steam table should be kept at least 135°F and reheated if they fall below that temperature.
Unsanitary food storage and prep conditions were observed in the kitchen serving a census of 66 residents. Surveyors found food debris in prep sinks, water with debris in one sink, straw wrappers on the floor, dried food debris on the wall behind a blender, a cracked egg shell in a carton of eggs, and improperly arranged thawing meat in the refrigerator with raw chicken, ham, and raw ground beef stored in the wrong order. The Dietary Manager acknowledged the egg shell should not have been left in the carton and the meat should have been thawed in the correct order.
A resident with anemia, DM, CKD, and severe cognitive impairment was transferred to the hospital twice for UTI-related concerns and a colon tear, but the facility did not notify the LTCO as required. Review of the transfer forms did not include the resident’s name, and the SW confirmed the resident should have been reported when sent out to the hospital.
Incomplete incontinence care and hand hygiene lapses were observed for two residents. CNAs removed soiled briefs, reused gloves and cleansing wipes during perineal care, failed to cleanse the full buttock area, touched other body areas with soiled gloves, and did not consistently perform hand hygiene after glove removal. One resident had dementia and Diabetes Mellitus with severe cognitive impairment noted on the MDS, and the DON stated the facility did not have a policy on incontinence care.
Improper Texture Consistency for Puree Diets: Staff served a puree meal with visible chunks of beef to one resident and gave another resident on a puree diet regular consistency cottage cheese without a verified order. The DM and Dietician confirmed the food did not match the residents’ ordered diet textures, and facility policy required food and fluid consistencies to be prepared as ordered.
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 Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents, particularly in resident rooms and bathrooms. Surveyors observed that one resident’s bedside table was sticky on two separate days, and the resident reported being upset about it and was unsure how long it had been that way. The same resident’s toilet seat had large brown discolorations; one CNA believed the staining was due to loose stools, while another CNA did not know the cause. The Administrator acknowledged the toilet seat discoloration had been present for a while. These conditions occurred despite the facility’s policy that soiled linen should be treated as potentially contaminated and should not touch the floor. Additional environmental observations showed multiple resident bathrooms with soiled items and trash left on the floor or in open view. One resident’s bathroom had used washcloths on the floor; another had clothes on the floor and an unflushed toilet with a strong odor. Other bathrooms were found with an open bag of incontinent pads spilling onto the floor, used paper towels on the floor, a soiled pad with visible incontinence in the trash can, garbage on the floor near the trash can, a partially pulled-up grip strip in front of the toilet, used gloves on the floor, and towels and clothing on the floor. In interviews, the ADON and Environmental Services Supervisor stated that CNAs were expected to clean up after providing care, including removing clothing and incontinent products and ensuring linens did not touch the floor, indicating that these expectations were not met at the time of the observations.
Failure to Provide Proper Catheter Care and Infection Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter care and infection prevention measures for three residents with indwelling or suprapubic catheters. One resident with a suprapubic catheter and neurogenic bladder had care plan instructions and TAR orders for monthly catheter changes, twice-monthly leg bag changes, and monitoring of the catheter every two hours during the day. Surveyors observed that this resident’s leg bag, dated from the prior month, had not been changed as ordered, and the clinical record lacked documentation that the catheter bag was monitored every two hours or by whom. The ADON confirmed that the family had requested two-hour checks of the leg bag and acknowledged that the leg bag had not been changed since the prior month. Another resident with an indwelling catheter for urinary retention was observed on two occasions with the catheter drainage bag hanging from a trash can that contained garbage. The ADON stated the catheter bag could hang from a trash can only if it was used solely for that purpose and did not collect trash, which conflicted with the observed presence of garbage in the can. A third resident with an indwelling catheter and neurogenic bladder, who sometimes emptied his own catheter bag, was observed during catheter bag emptying by a CNA who performed hand hygiene and donned gown and gloves, but then moved oxygen tubing lying on the floor with the same gloved hand before handling and opening the catheter bag drain. The CNA completed the procedure without changing gloves or performing additional hand hygiene after touching the tubing on the floor, and the ADON later stated she would have changed gloves after that contact. These observations demonstrated failures to follow proper catheter maintenance and standard precautions during catheter manipulation.
Improper Hot Food Temperature at Meal Service
Penalty
Summary
The facility failed to ensure proper temperatures for foods served to residents. During observation on 10/1/2025 at 11:19 a.m., Staff D checked the temperature of mashed potatoes in the steam table and found them at 131.9 degrees Fahrenheit, which was below the facility’s stated minimum holding temperature of 135 degrees Fahrenheit. Staff D then proceeded with meal service and served the mashed potatoes to residents without reheating them to an appropriate safe temperature. The facility’s policy titled Food Temperatures, dated 2013, stated that all hot food items must be cooked to appropriate internal temperatures and held and served at a temperature of at least 135 degrees Fahrenheit, with temperatures checked periodically to ensure hot foods stay above that level. During interview on 10/1/2025 at 1:16 p.m., the Dietary Manager stated that food in the steam table should be kept at least 135 degrees Fahrenheit and, if it falls below that temperature, should be reheated before meal service; the Dietary Manager also stated the mashed potatoes should have been reheated prior to serving.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
Food was not stored and prepared under sanitary conditions in the kitchen serving a census of 66 residents. During an initial walkthrough on 09/29/2025, surveyors observed food debris in the bottoms of the prep sinks, including one sink with approximately 1/4 inch of water and food debris sitting in it. Straw wrappers were observed on the floor in the walking path by the storage area, and dried food debris was noted on the wall behind the food blender in the puree food preparation area. In the refrigerator, a flat of eggs ready for use had a cracked and empty egg shell on the flat of unused eggs. A cart with meat thawing was also observed with raw chicken on the bottom dated 9/23, ham above it dated 9/25, and raw ground beef above the ham dated 9/27. The Dietary Manager stated the egg shell should not have been in the carton and should have been thrown away after the egg was used, and the meat should not have been thawing in that order in the refrigerator and should have been in the correct order.
Failure to Notify LTCO of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman (LTCO) for 1 of 1 residents reviewed who transferred to the hospital, Resident #10. Resident #10 had diagnoses of anemia, diabetes mellitus, and chronic kidney disease, and the MDS documented a BIMS score of 3 indicating severe cognitive impairment. The resident’s census tab showed hospital leave-unpaid status on 10/31/2024 and 2/4/2025, with returns to active status on 11/1/2024 and 2/6/2025. Progress notes documented that the resident was transferred to a larger hospital on 10/31/2024 for UTI and a tear in the colon, returned to the facility on 11/5/2024, and was sent to the emergency department from a doctor appointment on 2/4/2025 for lethargy and UTI symptoms, returning on 2/6/2025. Review of the facility’s Notice of Transfer Form to LTCO for October, November, and February did not include Resident #10’s name, and the facility had no policy regarding reporting to the LTCO office, stating it followed federal guidelines. Staff H, Social Worker, stated that if a resident goes to the hospital she would report it to the LTCO office and verified that Resident #10 should have been reported when she went to the hospital in October and February.
Incomplete Incontinence Care and Hand Hygiene Lapses
Penalty
Summary
The facility failed to provide complete and appropriate incontinence care for two residents, including care intended to help prevent urinary tract infections. Resident #10 had diagnoses of dementia and Diabetes Mellitus, and the MDS documented a BIMS score of 10 indicating severe cognitive impairment. During observation, two CNAs completed perineal care, but one CNA removed soiled briefs, removed gloves, and put on new gloves without performing hand hygiene. Perineal care was performed using different areas of the same cleansing wipe, and the resident’s buttock area was not fully cleansed. After care was completed, both staff removed gloves and failed to perform hand hygiene before dressing the resident and arranging the bed and blankets. Resident #51 was also observed receiving incontinence care from two CNAs. One CNA lowered the brief and performed perineal care with the same soiled gloves, then used those gloves while turning the resident and touched the resident’s shoulder and hands before continuing care. The CNA used a wipe with three wiping strokes over the hip area before turning the wipe and completing care. After removing gloves and performing hand hygiene, the CNA put on another pair of gloves to apply a clean brief, then removed the gloves again and did not perform hand hygiene before covering the resident and adjusting the bed controls. The DON stated the facility did not have a policy on incontinence care and that staff should have performed hand hygiene right away after removing gloves.
Improper Texture Consistency for Puree Diets
Penalty
Summary
The facility failed to ensure residents received food prepared in the proper texture to meet their individual needs. During meal service, a cook plated a puree meal for Resident #17 but served mashed potatoes topped with puree beef tips that still contained visible chunks of beef. When the Dietary Manager was asked if the plate could be served, she stated it could not be served with the chunks of beef present and removed the plate from service, along with the remaining portion of puree beef tips from the steam table. The facility reported a census of 66 residents. The facility also served Resident #24 regular consistency cottage cheese even though the resident was on a puree diet. The cook stated the resident had an order for regular cottage cheese, but the Dietary Manager could not find an order supporting regular consistency cottage cheese and stated it should not have been served. Facility policy titled Dysphagia Diets stated the food service department is responsible for prepping and serving diet and fluid consistency as ordered, and the Dietician stated that if a resident is on a puree diet, the food must be pureed properly unless there is an order for regular consistency.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 126 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spirit Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Milford | 6.8 mi | ★★★★★ | 0 | 0 |
| Aspire Of Lake Park | 10.2 mi | — | 0 | 0 |
| Good Samaritan - Estherville | 15 mi | ★★★★★ | 11 | 0 |
| Good Samaritan Society - Jackson | 15.1 mi | ★★★★★ | 0 | 0 |
| Estherville Community Care Center | 15.4 mi | ★★★★★ | 18 | 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.