Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Aspire Of Sutherland during CMS and state inspections, most recent first.
The facility failed to manage bed hold agreements for residents transferred to hospitals, resulting in missing documentation and communication issues. A resident's bed hold agreement lacked a daily rate, another resident's family did not sign a declination, and two residents had no bed hold documents. The facility's policy on providing bed hold information during emergency transfers was not followed.
A LTC facility failed to administer prescribed medications to several residents due to unavailability, impacting their care. Residents with conditions such as schizophrenia, dementia, and hyponatremia did not receive medications like clozapine, sodium chloride, Allegra, and others as ordered. The facility did not notify physicians of these omissions, despite being aware of the medication shortages.
The facility staff did not follow the planned menu for a lunch meal, serving items that differed from the menu without prior approval. The Dietary Manager admitted to not seeking approval for menu substitutions, contrary to facility policy, which requires dietitian approval for any changes. The Administrator confirmed that the Dietary Manager should have obtained such approval.
The facility failed to maintain sanitary conditions in food service. The Dietary Manager (DM) did not perform hand hygiene upon entering the kitchen or when changing gloves. The DM handled a water pitcher and ice with soiled gloves, contrary to the facility's policy requiring handwashing before serving food and after handling soiled items. This was confirmed by the Administrator.
The facility did not provide a homelike environment during meal service as staff served meals on plastic trays and left them in front of residents, contrary to the facility's policy. The Administrator expected staff to place plates directly on the table, but this was not done.
The facility did not maintain licensed nursing coverage 24/7 during a fiscal quarter, affecting 19 residents. On multiple occasions, there was no licensed nurse on duty, contrary to the facility's assessment that required an RN or LPN for each shift. The Administrator was unable to locate the schedules for the months in question, despite the expectation for continuous nursing coverage.
The facility failed to update care plans for two residents, neglecting to address high-risk medications and dementia care. A resident with Bipolar Disorder was prescribed an opioid without care plan documentation on its usage or side effects. Another resident with moderate cognitive impairment and dementia experienced falls, but their care plan lacked dementia care strategies and post-fall interventions. The facility's policy requires comprehensive, individualized care plans, which were not adequately developed.
A facility failed to address dementia care for a resident with Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder. The resident's MDS assessment showed moderate cognitive impairment, but their care plan lacked dementia care information. The deficiency was confirmed by the DON, who acknowledged the oversight.
The facility failed to implement gradual dose reductions (GDR) and review psychotropic medications for three residents. A resident with intact cognition was on multiple psychotropic medications without GDR attempts, and another resident with dementia had a PRN order for Lorazepam without an end date. A third resident with moderate cognitive impairment was on Nefazodone without evaluation for the lowest dose. The Director of Nursing acknowledged the lapse in GDRs due to other priorities.
The facility did not ensure food was served at safe temperatures. The Dietary Manager pureed broccoli with cold milk, microwaved it briefly, and attempted to serve it at 123.6 F, below the required 135 F. The DM reheated it after a surveyor's prompt. The Administrator expected all foods to be served at safe temperatures.
The facility did not provide required dependent adult abuse training within six months of hire for a CNA. The personnel file for the CNA lacked evidence of the training, and the facility's policy did not specify the requirement for completing a two-hour training course. The Administrator acknowledged the absence of documentation and mentioned ongoing policy refinements.
A facility failed to protect residents from potential abuse after a CNA allegedly slapped a resident. Despite the allegation, the CNA was allowed to complete their shift, exposing residents to potential risk. The resident, with no cognitive impairment, reported the incident to staff, but the facility did not follow its abuse prevention policy, which requires immediate suspension of the accused staff member and prompt reporting to the DON and Administrator.
A resident with bipolar disorder, hypertension, and diabetes, who was cognitively intact, reported being slapped on the hands by a CNA when requesting a pop. The incident was confirmed through interviews with the resident and staff, revealing a failure to protect the resident from abuse. The facility's policy on abuse prevention was not followed, as the CNA continued to assist the resident after the incident, and there was a delay in reporting the incident to the DON.
A resident with bipolar disorder, hypertension, and diabetes reported being slapped by a CNA when asking for a pop. Despite the incident being known to several staff members, including the Administrator and DON, the facility failed to report the allegation to the state agency within the required 2-hour timeframe. The delay was partly due to the DON's unawareness of the reporting timeframe.
A facility failed to provide appropriate incontinence care for a resident with cerebral palsy, leading to a deficiency in preventing urinary tract infections. A CNA was observed using the same part of a disposable wipe multiple times during perineal care and did not perform hand hygiene after removing soiled gloves. The DON expected staff to use a clean part of the wipe for each wipe.
Deficiency in Bed Hold Documentation and Communication
Penalty
Summary
The facility failed to properly manage bed hold agreements for residents who were transferred to hospitals, resulting in deficiencies in documentation and communication. For Resident #2, the facility did not include a daily rate for the bed hold in the agreement, despite having a verbal order to sign for the Power of Attorney. Resident #5's family did not want to hold the bed during the resident's hospital stay, but there was no signed declination of the bed hold. Resident #7 also lacked a bed hold document for their hospitalization, indicating a pattern of missing documentation. Resident #10, who had moderate cognitive impairment, was sent to the hospital for pneumonia, but the facility did not have a bed hold for this hospitalization. The facility's policy required providing bed hold information during emergency transfers, but this was not adhered to. Interviews with the Administrator revealed an expectation for all residents to have a signed and complete bed hold agreement when transferred to the hospital, which was not met in these cases.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide prescribed medications as necessary care and services, impacting the residents' highest practical physical well-being. For Resident #21, who has diagnoses of paranoid schizophrenia and dementia, the nursing staff did not administer clozapine as ordered on multiple occasions. The medication was unavailable on specific dates, and there was no documentation indicating that the physician was notified of these omissions. The facility's administrator acknowledged that staff should manage medications to avoid missed doses and ensure physician notification for omitted doses. Resident #4, diagnosed with hyponatremia, did not receive sodium chloride tablets as prescribed from late November to early December due to the medication being out of stock. Despite multiple progress notes indicating the unavailability of the medication and the Director of Nursing's awareness, there was no documentation of physician notification regarding the missed doses. Interviews with the Director of Nursing and the Administrator confirmed that medications should be ordered and available at the facility as per the doctor's orders. For Resident #10, with diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder, Allegra Allergy tablets were not administered for several days due to unavailability. Similarly, Resident #13, with similar diagnoses, experienced multiple instances where prescribed medications, including Divalproex Sodium, Sertraline, Scopolamine transdermal patch, and Quetiapine fumarate, were not available. In both cases, there was no evidence of physician notification for the omitted medications. The facility's policy requires medications to be ordered in advance, but this was not adhered to, leading to the deficiencies noted.
Failure to Follow Planned Menu
Penalty
Summary
The facility staff failed to adhere to the planned menu for residents, as evidenced by a discrepancy observed during a lunch meal service. The planned menu for Week 1 Day 4 included lasagna, seasoned broccoli, a wheat roll with margarine, and strawberries and bananas. However, during the observation, the meal served consisted of lasagna, broccoli, and applesauce, deviating from the planned menu. An interview with the Dietary Manager revealed that she does not seek prior approval for making substitutions to the menu. The facility's policy requires that menus meet the nutritional needs of residents, be prepared in advance, and be followed, with any deviations noted and approved by a dietitian. An interview with the Administrator confirmed that the Dietary Manager should obtain approval from the dietitian before making any menu changes.
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as observed during a survey. The Dietary Manager (DM) entered the kitchen without performing hand hygiene and proceeded to apply gloves. With these gloves on, the DM opened and closed the refrigerator door, handled a water pitcher, and exited the kitchen. The DM returned with the same soiled gloves and an uncovered water pitcher full of ice, which was used to fill glasses. The DM continued to handle ice with the soiled gloves and did not perform hand hygiene when changing gloves during meal service. The facility's policy on food preparation and service, effective from October 2024, requires food service staff to wash their hands before serving food and after handling soiled items. However, the DM did not adhere to these guidelines, as confirmed by the Administrator during an interview. The DM's actions, including not washing hands upon entering the kitchen and during glove changes, directly contributed to the unsanitary conditions observed during the meal service.
Failure to Provide a Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents during meal service. Observations on December 4th revealed that staff served meals to residents in the dining room by placing plated meals, drinks, and silverware on plastic trays. These trays were then placed in front of the residents, and staff left the table without removing the trays. Once the residents finished eating, staff returned to remove the trays with the dishes still on them. This practice was contrary to the facility's policy, which emphasized minimizing characteristics that reflect a depersonalized, institutional setting. An interview with the Administrator confirmed that the expectation was for staff to remove the plate from the tray and set it directly on the table for the residents to eat their meals.
Failure to Provide 24/7 Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide licensed nursing coverage 24 hours a day, as required, during the fiscal year 3rd quarter from April 1st through June 30th, 2024. Specifically, there was no licensed nursing coverage on several dates in April, May, and June. The facility reported a census of 19 residents during this period. An interview with the Administrator revealed that she could not locate the schedules for these months, although her expectation was for nursing staff to be scheduled 24/7. The facility's assessment document indicated that there should be one Director of Nursing (DON) Registered Nurse (RN) full-time on the day shift and either one RN or one Licensed Practical Nurse (LPN) for each shift, with the facility operating on 12-hour shifts, requiring two nurses per day not counting the DON.
Deficiencies in Care Plan Updates for High-Risk Medications and Dementia Care
Penalty
Summary
The facility failed to revise and update care plans for two residents, leading to deficiencies in addressing high-risk medications, dementia care, and post-fall interventions. Resident #9, who has diagnoses of amputation and Bipolar Disorder, was prescribed oxycodone-acetaminophen, an opioid medication, but the care plan did not include information on the usage of this medication or the side effects to monitor. This oversight indicates a lack of comprehensive care planning for managing high-risk medications. Resident #10, with a BIMS score indicating moderate cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, experienced falls on two separate occasions. However, the care plan did not include dementia care strategies or interventions to prevent further falls. The facility's policy requires individualized, person-centered care plans with measurable objectives and time frames, but these were not adequately developed for the residents in question. The Director of Nursing acknowledged that the care plans should have included these critical elements.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address dementia care for a resident diagnosed with Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder. The Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 9, suggesting moderate cognitive impairment. Despite these diagnoses, the resident's care plan lacked information regarding dementia care. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility should have included dementia care in the care plan.
Failure to Implement Gradual Dose Reductions and Review Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and ensure proper review of psychotropic medications for three residents. Resident #4, with intact cognition, was on multiple psychotropic medications, including Paxil, Oxcarbazepine, Olanzapine, and Buspirone, without evidence of GDR attempts. Additionally, Resident #4 received Lorazepam as needed multiple times over several months without a review to ensure the necessity of continued use. Resident #14, who has renal insufficiency, Alzheimer's disease, and non-Alzheimer's dementia, had a PRN order for Lorazepam without an end date, and the medication was administered multiple times without a physician review. Resident #10, with moderate cognitive impairment and diagnoses of non-Alzheimer's dementia, anxiety disorder, and bipolar disorder, was on Nefazodone without documentation of an evaluation for the lowest possible dose. The facility's policy requires periodic reviews of medications and attempts at GDR for antipsychotic drugs unless clinically contraindicated. However, the Director of Nursing acknowledged that GDRs had not been completed due to other priorities, indicating a lapse in adherence to the facility's policy and federal guidelines.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appropriate temperature. During an observation, the Dietary Manager (DM) was seen pureeing broccoli and adding cold milk to it. After pureeing, the DM microwaved the broccoli for 15 seconds, stirred it, and placed it on a tray to be served. When prompted by the surveyor, the DM checked the temperature of the pureed broccoli, which was 123.6 degrees Fahrenheit, below the required safe temperature. The facility's policy mandates that mechanically altered hot foods must remain above 135 F during preparation or be reheated to 165 F instantaneously. The DM acknowledged that the broccoli was not hot enough to serve and reheated it to a safe temperature before serving it to the resident. The Administrator confirmed the expectation that all foods should be served at safe and appropriate temperatures.
Failure to Provide Required Abuse Training for CNA
Penalty
Summary
The facility failed to provide dependent adult abuse training within six months of hire for one of the five employees reviewed, specifically a Certified Nursing Assistant (CNA) identified as Staff A. The personnel file for Staff A documented a hire date of March 25, 2024, but lacked evidence of the required training. The facility's policy on Freedom of Abuse, Neglect, and Exploitation, dated September 20, 2024, did not specify the requirement for each employee to complete an initial two-hour training course provided by the Iowa Department of Human Services within six months of hire. During an interview, the Administrator acknowledged the absence of documentation in Staff A's file and mentioned ongoing policy refinements due to recent organizational changes.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse after an allegation was made against a Certified Nurse Aide (CNA). On July 11, 2024, a nurse learned that a CNA allegedly slapped a resident on the hands. Despite this allegation, the facility allowed the CNA to complete their shift and continue working with other residents behind closed doors, which exposed residents to the potential risk of abuse. This situation resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The incident involved a resident with a diagnosis of bipolar disorder, hypertension, and diabetes mellitus, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The resident reported to multiple staff members that the CNA slapped her hands when she asked for a pop. Staff interviews revealed that the CNA continued to assist the resident after the incident, and the staff did not immediately report the allegation to the Director of Nursing (DON) or the Administrator. The facility's policy on abuse prevention requires that any staff member accused of abuse be suspended pending investigation. However, this protocol was not followed, as the CNA was allowed to finish their shift. The policy also mandates immediate reporting of abuse allegations to the charge nurse and subsequent notification of the Administrator and DON, which did not occur promptly in this case. The failure to adhere to these procedures contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a resident with diagnoses of bipolar disorder, hypertension, and diabetes mellitus, who had a BIMS score indicating no cognitive impairment. The resident reported that a CNA slapped her hands when she requested a pop. This incident was documented in the facility's incident report and progress notes. Interviews with the resident and various staff members, including an LPN, the Administrator, the DON, and other CNAs, confirmed the resident's account of the incident. The staff failed to implement appropriate interventions to protect the resident from abuse, as evidenced by the CNA continuing to assist the resident after the incident was reported. The facility's policy on abuse prevention outlines a zero-tolerance approach to abuse and emphasizes person-centered care. However, the staff did not adhere to these policies, as the CNA's actions were in direct conflict with the facility's standards. The DON acknowledged that the resident should have been allowed to have the pop, and the staff should have respected the resident's rights. The failure to immediately remove the CNA from the resident's care and the delay in reporting the incident to the DON further highlight the facility's inadequate response to the situation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with diagnoses of bipolar disorder, hypertension, and diabetes mellitus, who reported that a Certified Nursing Assistant (CNA) slapped her hand when she asked for a pop. The resident, who had no cognitive impairment, made the allegation to multiple staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), but the report to the state agency was delayed. Interviews with staff revealed that the incident was known to several staff members, including the Administrator and the DON, on the morning following the alleged abuse. Despite this, the facility did not submit a self-report to the state agency until later that morning, beyond the 2-hour requirement. The facility's policy mandates immediate reporting of abuse allegations, but the DON was unaware of the specific timeframe for reporting, contributing to the delay.
Inappropriate Incontinence Care Leading to Deficiency
Penalty
Summary
The facility failed to provide complete and appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, who had diagnoses of cerebral palsy, abnormal posture, and muscle wasting and atrophy, was observed to be incontinent of bowel and bladder. During an observation, a Certified Nursing Assistant (CNA) performed perineal care on the resident but used the same part of a disposable wipe multiple times to clean feces from the anus to the buttocks area before switching to a clean part of the wipe. Additionally, the CNA did not perform hand hygiene after removing soiled gloves and before assisting with applying a clean incontinent brief. The Director of Nursing indicated that staff are expected to use a clean part of the wipe for each wipe during perineal care.
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 115 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sutherland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Memorial Health Center | 14.6 mi | ★★★★★ | 16 | 0 |
| Cherokee Specialty Care | 14.7 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Cherokee, Llc | 14.9 mi | ★★★★★ | 6 | 0 |
| Careage Hills Rehabilitation And Healthcare | 15.1 mi | ★★★★★ | 9 | 0 |
| Prairie View Home | 16.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aspire Of Sutherland.
100% money-back within 48 hours.
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.