Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Algona Manor Care Center during CMS and state inspections, most recent first.
A CNA was hired without a documented background check, as required by facility policy and state regulations. The Administrator confirmed the omission, noting it was missed due to a new office manager at the time of hire.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses received a new diagnosis of delusions, but the facility did not complete a new PASRR Level I screening as required. The Social Worker, responsible for PASRRs, confirmed the oversight during interview.
A resident with Non-Alzheimer's Dementia, dependent on staff for toileting, did not receive appropriate perineal care. During an observation, two CNAs assisted the resident, but one failed to cleanse the resident anteriorly, contrary to the Nurse Aide Skills Checklist directives. This deficiency was confirmed by the CNA involved.
The facility failed to store and label food items according to professional standards, as observed during a kitchen tour. Various opened food items in the refrigerator, freezer, and dry storage were not labeled with dates, contrary to facility policy. The Dietary Manager confirmed the expectation for staff to label and date items when opened, with leftover food considered good for seven days.
A resident with COPD and other health conditions was prescribed azithromycin for prophylactic antibiotic therapy. Despite physician orders and pharmacy consultation, the resident's care plan was not updated to include this medication, its potential side effects, or monitoring requirements. The DON acknowledged the omission, which was contrary to the facility's policy on care plan development.
A facility failed to provide necessary assessments and interventions for a resident with a UTI, compromising their well-being. The resident, with severely impaired cognition, had frequent UTIs and was treated with antibiotics multiple times. The care plan did not address UTI risks or monitoring. During the latest UTI treatment, the facility did not document urinary assessments, vital signs, or adverse drug effects. The DON expected documentation of vital signs and symptoms during antibiotic treatment, but no such documentation was found, and the facility lacked relevant policies.
A resident at high risk for pressure ulcers developed a stage 1 ulcer on the left heel due to the facility's failure to update the care plan with new interventions. Despite existing measures like pressure-reducing devices, the Treatment Administration Record lacked documentation of treatment orders for the ulcer. Observations showed inconsistent use of pressure-relieving devices, and the DON confirmed the treatment was not properly documented.
A resident with multiple health conditions, including amputations, did not receive proper infection control during a dressing change. The RN failed to change gloves and perform hand hygiene between handling supplies and cleansing the wound, contrary to the facility's policy. The DON confirmed the expectation for staff to follow proper procedures.
A facility failed to follow its antibiotic stewardship program for a resident prescribed Methenamine for urinary tract infections without an end date. The clinical records lacked documentation of monitoring the long-term use of this antibiotic. The IP stated that the facility reviews long-term antibiotic use annually, and the Pharmacy Consultant noted the issue was addressed earlier but lacked follow-up. The facility's policy aims to ensure antibiotics are used only when necessary, which was not adhered to in this case.
The facility failed to answer call lights within the required 15 minutes for a resident, who reported waiting 30 minutes or longer, causing her to feel neglected and experience pain. Staff interviews and Resident Council Minutes confirmed the issue, citing operational inconsistencies during the second shift.
Failure to Complete Required Background Check for CNA
Penalty
Summary
The facility failed to complete a required background check for one of six current employees reviewed, specifically a Certified Nurse Aide (CNA) who was hired on 9/20/24. Review of the CNA's employee file showed no documentation of a background check. During an interview, the Administrator confirmed that the background check was not completed, attributing the oversight to the office manager, who had just started around the time of the CNA's hire. The facility's policy, dated October 2022, requires a criminal record check prior to hire in accordance with 481 Iowa Administrative Code 58.11(3).
Failure to Complete New PASRR Following New Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASRR) Level I for a resident who received a new diagnosis of delusions on 2/27/25. Clinical record review showed that the resident had a history of moderate cognitive impairment, as indicated by a BIMS score of 12, and diagnoses including anxiety, psychotic disorder (other than schizophrenia), and malnutrition. The existing PASRR Level I screening, dated 8/12/24, was completed at the hospital prior to admission and indicated that no Level II was required. Despite the new diagnosis, the facility did not submit a new PASRR as required. During staff interview, the Social Worker confirmed responsibility for completing PASRRs when new diagnoses or medications are identified but was unsure why the new PASRR was not completed in this instance.
Inadequate Perineal Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident diagnosed with Non-Alzheimer's Dementia, who was cognitively impaired with a BIMS score of 8 out of 15. The resident was dependent on staff for toilet transfers and toileting and was frequently incontinent of bowels and bladder. The care plan for the resident required assistance with activities of daily living, including toileting upon rising, before or after activities, and at bedtime, as well as assistance with incontinent care as needed. During an observation, two CNAs were assisting the resident with toileting. Staff A confirmed the resident was incontinent and removed the soiled brief. However, Staff A failed to cleanse the resident anteriorly after cleaning the mid gluteal region and bilateral buttocks. This was confirmed by Staff A during an interview. The Nurse Aide Skills Checklist from 2012 directed staff to wash and rinse the abdomen and anterior thighs, and for women, to gently separate the labia and wash from front to back, which was not followed in this instance.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen tour. Various food items in the kitchen's refrigerator were found to be opened and not labeled with dates, including American cheese slices, ham salad, smoked ham, Swiss cheese, tomato juice, butter blend spread, cookies, salsa, Worcestershire sauce, ketchup, tartar sauce, mayonnaise, Hershey syrup, Dijon mustard, honey mustard, chocolate milk, 2% milk, half & half cream, almond milk, heavy whipping cream, cucumber salad, and hot dogs. Additionally, items in the kitchen's freezer, such as fish sticks, omelets, and chicken strips, were also not labeled with dates after opening, with the fish sticks showing signs of freezer burn. In the dry storage area, several items were found open and not dated, including instant banana pudding mix, dry gelatin mix, chocolate pudding mixture, and Raisin Bran cereal. The Dietary Manager confirmed that the expectation was for dietary staff to label and date items when opened, and that leftover food was considered good for seven days after opening. The facility's policy required that once a product was opened, it should be dated with the date of opening, and food should be stored, prepared, distributed, and served according to professional standards for food service safety.
Failure to Revise Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to revise the care plan for a resident receiving prophylactic antibiotic therapy. The resident, who had intact cognition, was diagnosed with coronary artery disease, hypertension, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. The care plan, last revised on 7/24/24, included the need for assistance with activities of daily living due to COPD and the use of supplemental oxygen. However, it did not address the antibiotic medication, azithromycin, prescribed for COPD exacerbation, pneumonia, and rehospitalization, nor did it include potential side effects or monitoring requirements for this high-risk medication. A physician order dated 5/15/24 directed the administration of azithromycin 250 mg on specific days, and a pharmacy consulting form dated 6/19/24 confirmed the continuation of this order for 365 days. Despite these directives, the care plan was not updated to reflect the antibiotic therapy. The Director of Nursing acknowledged the omission and stated that the antibiotic should have been included in the care plan. The facility's policy on care plan development requires comprehensive plans to include approaches, goals, and interventions reflecting the resident's preferences and choices, and to be reviewed periodically for necessary updates.
Failure to Monitor and Document UTI Treatment
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident diagnosed with a urinary tract infection (UTI), compromising the resident's highest practical physical well-being. The resident, who had severely impaired cognition and was dependent on staff for toileting, had a history of frequent UTIs and was treated with antibiotics multiple times from January to July 2024. Despite this, the resident's care plan did not address the risk of UTIs, nor did it include monitoring for signs and symptoms or interventions to reduce the risk. During the resident's most recent UTI treatment in July 2024, the facility did not document urinary assessments, routine vital signs, or any adverse drug effects while the resident was on antibiotic therapy. The Director of Nursing expected staff to document full sets of vital signs and monitor urinary symptoms and signs of infection during the first three days of antibiotic treatment and on the last day to assess improvement. However, there was no documentation of these assessments, and the facility lacked policies on what to document or monitor when a resident was on antibiotics.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to prevent a stage 1 pressure ulcer in a resident, identified as being at high risk for pressure ulcers due to conditions such as malnutrition, diabetes, dementia, and Parkinson's disease. The resident's care plan included interventions like pressure-reducing cushions and mattresses, weekly skin assessments, and the use of heel protectors, which the resident sometimes refused. Despite these measures, the care plan did not include any new interventions after the discovery of a stage 1 pressure ulcer on the resident's left heel. The facility's documentation revealed inconsistencies in the treatment of the pressure ulcer. The Treatment Administration Record (TAR) for July and August 2024 did not show any orders for treatment of the left heel, despite the presence of a pressure ulcer. Observations noted that the resident was not always using pressure-relieving devices, and there was no documentation of the resident's refusal to wear heel boots, which was reported verbally by staff. Interviews with the Director of Nursing (DON) confirmed that the treatment for the pressure ulcer was not entered into the treatment sheet as required. The DON acknowledged that the treatment should have been documented and that there was no alternative intervention in place before the pressure ulcer was discovered. The facility's policy emphasized the importance of timely intervention and care plan revision, which was not adhered to in this case.
Inadequate Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, specifically in hand hygiene and glove use, during a dressing change for a resident. The resident, who had intact cognition and required assistance for mobility and toileting, had a history of multiple health conditions including diabetes mellitus, multidrug-resistant organism, and amputations. The resident's care plan included specific instructions for wound care on the left great toe amputation site, which was not followed correctly by the staff. During the dressing change, the RN did not change gloves or perform hand hygiene between handling supplies and cleansing the wound, which is against the facility's standard precautions policy. The RN acknowledged the failure to adhere to proper hand hygiene and glove-changing protocols. The Director of Nursing confirmed the expectation for staff to change gloves and perform hand hygiene between dirty and clean procedures, as outlined in the facility's policy.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which is designed to monitor and regulate the use of antibiotics. This deficiency was identified in the case of a resident who was prescribed Methenamine 1 Gram, to be taken twice daily as a prophylactic measure for urinary tract infections, with no specified end date. The clinical records did not show any documentation of monitoring the long-term use of this antibiotic. During an interview, the Infection Preventionist (IP) mentioned that the facility has a system to monitor long-term antibiotic use, but it is generally reviewed only once a year. Additionally, the Pharmacy Consultant confirmed that the prophylactic antibiotic use was addressed in January 2023 but expressed a desire for the IP to have followed up on it. The facility's policy on Antibiotic Stewardship, effective since December 2017, aims to ensure antibiotics are administered only when necessary and in collaboration with the consulting pharmacy and provider, but this was not followed in this instance.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to answer resident call lights within the professional standard of 15 minutes for one of the three residents reviewed. Resident #3 reported waiting for 30 minutes or longer for her call light to be answered, causing her to feel neglected and experience pain when left in the bathroom for extended periods. Staff interviews confirmed that call lights were often not answered within the required time frame, particularly during the second shift due to various operational inconsistencies such as meal times, staff breaks, and shift changes. Resident Council Minutes from January, February, and March also documented residents' concerns about call light wait times. The facility's policy mandates that all call lights should be answered within 15 minutes, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Algona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Algona | 1.6 mi | ★★★★★ | 4 | 0 |
| West Bend Health And Rehabilitation | 14.3 mi | ★★★★★ | 0 | 0 |
| Titonka Care Center | 14.3 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Bancroft | 15.6 mi | ★★★★★ | 0 | 0 |
| Westview Care Center | 20.1 mi | ★★★★★ | 0 | 0 |
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