Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Holy Spirit Retirement Home during CMS and state inspections, most recent first.
Food was served below the required hot-holding temperature when mashed potatoes were observed at 125 degrees on a steam table and 121 degrees on a room tray, with salisbury steak at 130 degrees. Two cognitively intact residents reported that meals were sometimes served cool or not hot, especially with room trays. The CDM stated hot foods should be above 135 degrees, and facility policy required hot foods to be held and served at least 135 degrees.
Improper food storage, hand hygiene, and hair restraint practices were observed during kitchen and meal service activities. Staff found multiple open food items and condiments without proper dates or with expired best-by dates, a dietary aide licked her fingers and continued serving food without hand hygiene, a CNA assisted two residents with meals without hand hygiene, and staff entered the kitchenette without hair nets. A dietary staff member also checked tray temperatures through foil covering resident food items.
Staff failed to follow infection control practices during wound and catheter care for multiple residents. A CNA performed catheter care without hand hygiene and without proper EBP, while another CNA also failed to use hand hygiene during catheter care. In addition, an LPN changed a wound dressing without wearing a gown for EBP, and another resident with surgical wounds had no EBP equipment or signage present. The DON and IP acknowledged the lapses, and facility policy required gown and glove use for EBP and hand hygiene before and after catheter handling, dressing changes, and resident contact.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
The facility failed to refer a resident for a Level II PASRR evaluation after a negative Level I when the resident later had diagnoses of psychotic disorder, depression, and schizophrenia. The resident’s MDS showed a BIMS score of 15, and current orders included Venlafaxine ER for major depressive disorder and Quetiapine for schizoaffective disorder and bipolar disorder. The PASRR approval on file had not been resubmitted since 2014, the admission criteria policy lacked instructions for when a new Level I was needed, and the DON and IP acknowledged medication changes had occurred.
A resident with moderate cognitive impairment had a physician order for knee-high TED hose to be applied each morning and removed each evening, but repeated observations found the resident wearing ankle socks and no TED hose. CNAs reported the TED hose were often sent to laundry and not returned, and if the hose were not available they placed regular socks on the resident instead. An LPN and the DON stated staff were expected to verify TED hose placement before charting, but the resident was still observed without the ordered TED hose.
The facility did not properly document vaccine refusals in the medical records for several residents with various chronic conditions. Although the electronic health record immunization section showed that vaccines were refused, there were no corresponding entries in the progress notes, and declination forms were not obtained as required by facility policy. Interviews with the DON and Administrator confirmed that refusals were not consistently documented.
Four residents with documented needs for restorative care did not consistently receive or have restorative services documented, despite care plans indicating such interventions were necessary to maintain ADLs. Residents and family members reported infrequent or absent restorative care, and staff interviews revealed that the restorative aide was often reassigned to other duties due to staffing shortages, resulting in restorative care not being performed as required by facility policy.
Staff did not follow the planned menu for a lunch meal, omitting bread and margarine that were listed and selected by residents, including those on pureed diets. Observations and staff interviews confirmed that these items were not prepared or served as required by facility policy.
The facility did not ensure the Medical Director attended required quarterly QAA meetings, as evidenced by missing signatures on meeting minutes and confirmation from the DON. Facility policy specifies the Medical Director must participate in these meetings.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice, but staff failed to update the care plan to include hospice services. Despite documentation confirming hospice admission and ongoing services, the care plan did not reflect this change, contrary to facility policy and expectations.
Two residents who were dependent on staff for ADL support did not receive adequate care, including timely toileting, proper positioning in wheelchairs, and correct management of an indwelling Foley catheter. One resident was left in a urine-saturated brief and without required leg support, while another had a catheter bag improperly placed above the bladder, contrary to care plans and facility policy. Staff interviews and observations confirmed lapses in following required care procedures.
A resident with severe cognitive deficits and total dependence on staff for care was found with an unexplained bruise under her eye. Staff could not determine how the injury occurred, despite the resident's care plan indicating a need for close supervision and specific interventions. The incident was discovered by an LPN, and neither the overnight nurse nor CNA were aware of any event leading to the injury.
Two residents with sleep apnea and respiratory conditions did not have current CPAP settings available to staff, and their CPAP masks and tubing were not monitored or replaced according to policy or supplier schedules. Both residents used visibly worn equipment for extended periods, and neither clinical orders nor care plans included the required settings. Staff interviews confirmed a lack of awareness and procedures for CPAP supply maintenance.
A resident with COPD and other conditions did not receive proper staff support for CPAP use, as no trained personnel were available to monitor or adjust the device. The receptionist, rather than clinical staff, assisted with the CPAP on two occasions due to lack of staff knowledge, and the DON confirmed the absence of trained staff or a respiratory therapist to oversee CPAP settings.
Staff did not follow hand hygiene protocols during incontinence care for a dependent resident with multiple medical conditions. CNAs changed gloves without using hand sanitizer and left the room without washing their hands, despite facility policies requiring proper hand hygiene to prevent infection.
The facility failed to implement proper infection prevention practices, including hand hygiene and enhanced barrier precautions, during care for residents with medical devices. Staff were observed not following hand hygiene protocols, and no enhanced barrier precautions were in place for residents with feeding tubes and catheters. Additionally, the facility lacked documented COVID-19 vaccination policies, despite claiming to follow CDC guidelines.
The facility did not conduct the required Iowa Criminal Background check and dependent adult/child abuse registry check for a CNA before employment. The facility's policy exempted staff under a certain age from these checks, contrary to federal regulations. The Administrator was aware of the federal requirements but not the facility's non-compliant policy.
The facility failed to provide food in the correct consistency for residents on mechanically altered diets. During a lunch service, four residents with dietary needs were served coleslaw instead of the steamed cabbage listed on the menu. Staff F, a Dietary Aide, admitted to the oversight. The facility's policy requires meals to be checked against the therapeutic diet spreadsheet, but this was not followed, as confirmed by the Certified Dietary Manager and Registered Dietitian.
The facility failed to maintain proper food handling and sanitation practices, affecting 61 residents. During a lunch service, a dietary aide did not perform hand hygiene between tasks and handled hamburger buns directly with their hands instead of using tongs. This was contrary to the facility's hand washing policy, which requires hand hygiene to prevent cross-contamination. The Certified Dietary Manager confirmed the improper handling of food.
A resident with severe cognitive impairment was left with food debris on their clothing protector and face after a meal, which was not cleaned up by staff in a timely manner. The resident's family member later addressed the issue, highlighting a failure to adhere to the facility's dignity policy.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident was diagnosed with major depressive disorder and psychotic disorder. Despite these new diagnoses, the facility did not resubmit the PASRR for further evaluation, as required by their policy. The oversight was confirmed by the DON, who expected the social worker to handle the resubmission.
A facility failed to follow a care plan requiring supervision for a resident with moderate cognitive impairment and a high risk of falls. Despite the care plan's directive, the resident was observed unattended in a wheelchair multiple times. Staff interviews revealed a lack of awareness of the supervision needs, and the DON acknowledged the care plan did not reflect the requirement.
A facility failed to follow its policies for feeding tube management for a resident with no cognitive impairment. The staff did not accurately measure the prescribed 330 mL of supplemental formula, instead 'eyeing' the amount to just above 300 mL. Additionally, medications were pushed with a piston syringe rather than administered by gravity flow, contrary to facility expectations. The DON confirmed these actions were not in line with the facility's procedures.
A facility failed to store medications properly, as a bottle of Tums was found in a resident's room on two occasions. The resident's records lacked an assessment for self-administration of medications, and the DON confirmed the resident was not able to self-administer. The facility's policy requires adherence to professional standards, which was not followed.
A resident with COPD was observed using oxygen, but the facility failed to maintain accurate EHR documentation. The resident's care plan included oxygen therapy, yet the most recent order was discontinued months prior, and no current order was found in the MAR or TAR. The DON acknowledged the oversight, noting the order might have been missed after a hospital stay.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature when mashed potatoes were found at 125 degrees Fahrenheit on the steam table before lunch service and at 121 degrees Fahrenheit on a room tray. The deficiency involved 2 of 8 residents reviewed, Resident #24 and Resident #40, both of whom had BIMS scores of 15 on their MDS assessments, indicating intact cognitive functioning. Resident #40 stated on 4/27/26 that food is served cool when it should be warm a couple of times a week and that she would like warm food to be served warm. Resident #24 stated on 4/27/26 that food is sometimes not hot, especially on days when she orders room trays. During observation on 4/29/26, mashed potatoes on the 2nd floor kitchenette steam table were measured at 125 degrees Fahrenheit during lunch service. Later that day, a Dietary Aide used a temperature probe through the foil covering a room tray and measured mashed potatoes at 121 degrees Fahrenheit and salisbury steak at 130 degrees Fahrenheit. The Certified Dietary Manager stated that food temperatures were to be above 135 degrees Fahrenheit. The facility policy titled Food Temps P&P, dated 3/29/21, stated that all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit.
Improper Food Storage, Hand Hygiene, and Hair Restraint Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards. During a kitchen observation, several food items were found improperly dated or without required date markings, including open juices, dressing, salsa, an open bag of lettuce, items in the south pod refrigerator, and dry storage noodles without open or in dates. On the drink cart, expired items were also observed, including chocolate milk, grape juice, and prune juice with open dates and best-by dates that were past due or inconsistent with required labeling. During meal service observations, Staff B, a Dietary Aide, did not perform hand hygiene before lunch service and licked her fingers three times while reviewing meal tickets, then continued handling plates and serving food without hand hygiene. Staff D, a CNA, assisted two residents with oral intake of lunch without performing hand hygiene beforehand or during the meal, including while moving between the two residents. Staff C, a Dietary Aide, was also observed using a temperature probe through foil covering resident tray items to check temperatures, with mashed potatoes at 121 degrees Fahrenheit and steak at 130 degrees Fahrenheit. Additional observations showed multiple staff members entered the kitchenette during meal service without wearing hair nets. Staff C stated the kitchenette did not have hair nets and staff had to go to the main kitchen to obtain one before coming up. Staff E, the CDM, stated staff should perform proper hand hygiene after finger licking and that hair nets should be worn at all times during food service and in the kitchen or kitchenette. Facility policies reviewed required opened condiments and food items to be labeled and dated, food to be rotated and discarded by safe use dates, hair restraints for staff involved in food preparation or direct service of exposed food, and hand hygiene before and after handling food and assisting residents with meals.
Failure to Follow EBP and Hand Hygiene During Wound and Catheter Care
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions during wound care for two residents and failed to use universal infection control measures, including hand hygiene, during catheter care for two residents. The report documents observations, interviews, EHR review, and policy review showing that staff did not consistently follow the facility’s infection prevention procedures during direct resident care. For one resident with a Foley catheter and a history of urinary tract infection, a CNA performed peri-care and emptied the catheter leg bag without performing hand hygiene at the start, during the procedure, or after changing gloves. The CNA wore the same gloves throughout peri-care, handled soiled washcloths and trash while continuing to wear those gloves, emptied the catheter bag, and assisted the resident with dressing and transfer before removing gloves and gown. The resident stated staff often failed to clean his penis correctly and reported that staff did not wear gowns when providing peri-care or emptying the catheter bag. An RN confirmed the resident was taking antibiotics for a UTI, and the DON stated the catheter care was not performed correctly and that hand hygiene was not performed as expected. For another resident with a catheter, a CNA gathered supplies, failed to perform hand hygiene, and applied gloves without full EBP before emptying the leg bag. After removing soiled gloves, the CNA again failed to perform hand hygiene before applying new gloves, discarding urine, changing the garbage bag, and leaving the room. The DON stated staff must use EBP for catheter care and perform hand hygiene immediately before and after changing gloves. The Infection Preventionist stated she had provided staff EBP and hand hygiene education but felt overwhelmed by her duties and could not complete necessary follow-up. The report also documents two residents with surgical wounds who were not managed with EBP as expected. One resident had surgical wounds to the right ankle and reported that staff did not wear gowns when changing the dressing; observation showed no EBP equipment in the room and no EBP sign outside the room. Another resident had a dressing change to the right foot/right big toe and was on EBP per the care plan, but the LPN removed the old dressing and completed the dressing change without wearing a gown. The DON stated the resident should have EBP in place and that staff should wear gowns for EBP during dressing changes. Facility policies reviewed in the report required gown and glove use for EBP, and hand hygiene before and after resident contact, catheter handling, dressing changes, glove use, and contact with body fluids or wounds.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Resubmit PASRR After New Mental Health Diagnoses and Medication Changes
Penalty
Summary
The facility failed to refer 1 resident with a negative Level I PASRR result for a Level II PASRR evaluation and determination after the resident later had newly evident or possible serious mental disorder, intellectual disability, or other related condition. Resident #3’s MDS documented diagnoses of psychotic disorder, depression, and schizophrenia, and the BIMS score was 15, indicating no cognitive impairment. The PASRR Notice of Nursing Facility Approval dated 1/29/14 stated the facility failed to resubmit the PASRR with changes that occurred since 2014, and it also did not identify the medications prescribed at the time of approval. The resident’s current physician orders showed Venlafaxine ER 77.5 mg started for major depressive disorder and Quetiapine 300 mg started for schizoaffective disorder and bipolar disorder. The facility’s admission criteria policy revised in March 2019 did not include instructions for when a new Level I screening must be initiated. In interview, the DON stated staff should resubmit a Level I when there are medication changes, and the IP stated she felt overwhelmed by her duties, which prevented her from catching changes that would require resubmission of a Level I. The IP acknowledged medication changes had occurred since 2014 and stated she started the resubmission yesterday morning.
Failure to Apply Ordered TED Hose
Penalty
Summary
The facility failed to maintain a professional standard of quality when Resident #7 did not consistently receive the ordered knee-high TED hose. The resident had a BIMS score of 10, indicating moderate cognitive impairment. The EHR order summary documented a physician order for TED hose to be applied in the morning and removed in the evening, and the TAR showed daily nurse signatures for application and removal throughout April. However, observations on 4/27/26, 4/28/26, and 4/29/26 found the resident without TED hose in place and wearing white ankle socks instead. During interviews, the resident’s daughter stated she believed the TED hose should be worn daily and said she had never seen her mother wearing them during visits. CNAs reported that the TED hose were often sent to laundry and did not always return, and that if the hose were not found in the resident’s room they would place regular socks on the resident instead. One CNA admitted she did not apply the TED hose because none were available in the room and did not report the omission. An LPN stated staff were supposed to verify TED hose placement before charting, and the DON stated nurses must ask CNAs about application or removal and personally verify placement before documenting. The facility policy stated care and treatment were to be provided according to the most recent medical orders and standards of practice.
Failure to Document Vaccine Refusals in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for four out of five residents reviewed. Specifically, for multiple residents with various diagnoses including heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, and respiratory failure, the electronic health record immunization section indicated that these residents refused vaccines such as the Covid-19, influenza, and pneumococcal vaccines. However, there were no corresponding entries in the progress notes documenting these refusals, as required by facility policy. Interviews with the DON revealed that declination forms were not obtained when residents refused vaccines, and documentation was only made if a vaccine was accepted. The DON stated that for residents with lower cognitive scores or a medical POA, the POA would be contacted, and refusals by POA would be documented in the progress notes. The Administrator confirmed that refusals should be charted in the medical record with a signed declination form. Facility policy also required that vaccine refusals be documented in the resident's medical record, which was not done in these cases.
Failure to Provide and Document Restorative Care for Residents
Penalty
Summary
The facility failed to provide and document restorative care for four residents who were identified as needing such services to maintain their activities of daily living (ADLs). Each resident had documented diagnoses such as muscle wasting, weakness, unsteadiness, repeated falls, or stroke, and their care plans included restorative programs to maintain or improve their functional abilities. Despite these documented needs and care plans, restorative care was either not provided as scheduled or was provided infrequently, as evidenced by restorative care flow records and weekly reviews showing little to no restorative care delivered over a 15-day period. Resident interviews confirmed the lack of restorative care, with residents reporting that they only received therapy or restorative interventions once or twice a week, or not at all. Some residents expressed concern about the potential for loss of function due to the lack of regular restorative therapy. Family members also voiced dissatisfaction, noting that the restorative program was not being implemented as expected and expressing concern about the residents' declining abilities. Staff interviews revealed that the restorative aide was frequently reassigned to direct resident care due to staffing shortages, preventing her from performing restorative duties. The DON acknowledged that restorative care was not consistently provided, attributing this to staff turnover and the need to reallocate the restorative aide to cover other care needs. The facility's own policy required that residents receive restorative nursing care as needed to promote optimal safety and independence, but this was not followed for the residents reviewed.
Failure to Serve Menu Items as Planned
Penalty
Summary
Facility staff failed to follow the planned menu for residents, as evidenced by observations and menu reviews. On the specified lunch meal, the planned menu included turkey tetrazzini, buttered peas, bread and margarine, fruited gelatin, and milk. However, during the puree process and meal service, bread and margarine were not pureed or served, despite being listed on the menu and selected by residents as a meal choice. Observations confirmed that no bread and margarine were provided to residents, including those on pureed diets. Staff interviews with the Dietary Manager and Dietician confirmed that bread and margarine should have been served according to the menu and resident selections. Facility policy requires that meals be served as listed on the menu and checked against therapeutic diet spreadsheets, which was not followed in this instance.
Medical Director Absent from Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the quarterly Quality Assessment and Assurance (QAA) meetings as required. Review of the Quality Assurance Performance and Improvement Meeting Minutes for a meeting dated 11/13/24 showed that the Medical Director's signature was missing, indicating their absence. The facility's own policy, dated March 2020, specifies that the Medical Director is a required member of the QAA committee, which must meet at least quarterly. During an interview, the Director of Nursing confirmed that the Medical Director should be present at these quarterly meetings. The facility reported a census of 61 residents at the time of the review.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to update the care plan for one resident after the initiation of hospice services. Specifically, a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple diagnoses including diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia, and oral dysphagia, was admitted to hospice on 4/16/25. Despite this significant change in care needs, the resident's care plan, last updated on 4/8/25, did not include a focus area for hospice services, even though documentation confirmed hospice admission and services had begun. Observations and interviews confirmed the resident was receiving hospice care, and the DON stated that hospice should be added to the care plan as soon as a resident is admitted to hospice. Facility policy requires that comprehensive, person-centered care plans include all services necessary to meet the resident's needs, but this was not followed in this case, resulting in the omission of hospice from the care plan.
Failure to Provide Adequate ADL Assistance and Catheter Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were dependent on staff for care. One resident, who had severe cognitive deficits, post-polio syndrome, and was non-ambulatory, was observed multiple times in a wheelchair with her feet dangling unsupported and without a padded footrest as directed in her care plan. She was also found sitting in a urine-saturated brief, and during a transfer with a mechanical lift, urine spilled from her clothing and pooled in the wheelchair and on the floor. Staff interviews revealed that this resident was routinely awakened and transferred to her wheelchair before 6:00 AM, often left to sleep in the chair, and not always provided with timely toileting or repositioning as required by her care plan and facility policy. Another resident, who had moderate cognitive deficits and an indwelling Foley catheter, was found in bed with the catheter drainage bag hanging on the bedrail above the level of his bladder, contrary to infection control guidelines and facility policy. Nursing notes indicated that this resident had experienced issues with catheter blockage, cloudy urine, and was treated for a urinary tract infection. Staff acknowledged that the catheter bag should be kept below the bladder to prevent backflow and potential infection, but this was not done during the observation. Facility policies required incontinent residents to be checked and changed every two hours and for catheter care to be provided every shift. Despite these policies, direct observations and staff interviews confirmed that care was not consistently provided as required, resulting in residents being left in soiled briefs, improperly positioned, and with improper catheter management.
Failure to Adequately Supervise Resident to Prevent Injury
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a vulnerable resident to prevent injury. The resident, who had severe cognitive deficits, was totally dependent on staff for dressing, toileting, and transfers, and required two staff members and a mechanical lift for transfers. She was observed with a large bruise under her right eye, which staff could not fully explain. The resident was unable to communicate how the injury occurred due to her cognitive condition. Staff hypothesized about possible causes, including accidental contact with the mechanical lift or her glasses, but no definitive cause was identified. The incident was first noticed by an LPN while the resident was in her wheelchair in the dining room, and neither the overnight nurse nor CNA on duty at the time were aware of any accident or incident that could have caused the bruise. The resident's care plan indicated she was at risk for falls and required staff to anticipate and meet her needs, including the use of a padded foot rest and regular toileting assistance. Despite these interventions, the facility was unable to determine how the injury occurred, and there was no documentation or witness to an event that could explain the bruise. The facility's policy required evaluation of injuries of unknown source and changes to the care plan to prevent recurrence, but the lack of supervision or failure to identify the cause of the injury led to the deficiency.
Failure to Maintain and Monitor CPAP Equipment and Settings
Penalty
Summary
The facility failed to provide staff with current CPAP machine settings and did not monitor or maintain CPAP mask and tubing needs for two residents. For one resident with diagnoses including COPD, CAD, and renal insufficiency, observations revealed that the CPAP machine was present at the bedside, but the resident had been using the same mask and tubing since admission, which were visibly worn and misshaped. The resident was unaware of the CPAP settings, and neither the clinical physician orders nor the care plan included the required CPAP settings. Chart review confirmed the absence of documentation regarding CPAP settings or supply changes, and the equipment supplier reported no supplies had been ordered since 2019. For another resident with COPD, insomnia, and renal insufficiency, similar deficiencies were observed. The resident and a family member reported that the same CPAP mask and tubing had been used for over a year, and the family member had to take the machine to the supplier to verify settings due to uncertainty about possible changes. The clinical orders and care plan also lacked CPAP settings, and there was no documentation of supply changes. The equipment supplier confirmed that no supplies had been ordered since the previous year, despite an established replacement schedule. Interviews with facility staff, including the DON, revealed a lack of awareness and procedures regarding the maintenance and replacement of CPAP supplies. The DON acknowledged that the facility is responsible for maintaining CPAP machines and that settings should be available to staff, but admitted to not having considered the supply replacement process. The facility's own policy requires physician orders to specify CPAP settings and mandates regular cleaning and replacement of equipment, which was not followed in these cases.
Failure to Train Staff on CPAP Use and Maintenance
Penalty
Summary
Staff failed to maintain and monitor CPAP settings for a resident diagnosed with COPD, insomnia, and renal insufficiency, who used a non-invasive mechanical ventilator. The resident's CPAP machine was observed on the bedside table, and a family member reported concerns that staff were not knowledgeable about the device, leading her to take the machine to the home supplier to verify its settings. The family member also stated that no staff assisted with the CPAP, and that the receptionist, rather than clinical staff, had to help with the device on two occasions because no one else knew how to operate it. Interviews confirmed that the receptionist assisted the resident with the CPAP due to a lack of trained staff, and the DON acknowledged that the facility did not have staff trained in CPAP use or a respiratory therapist available for consultation. The DON stated that only a respiratory therapist should monitor CPAP settings, but the facility did not have one accessible, resulting in unqualified personnel providing assistance with the resident's CPAP machine.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate hand hygiene protocols during incontinence care for a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple complex medical conditions including post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On two separate occasions, certified nurse aides (CNAs) provided care to the resident after an episode of incontinence, including transferring her using a mechanical lift and changing soiled clothing and linens. During these cares, staff removed soiled gloves and either failed to wash their hands or did not use hand sanitizer between glove changes. In both instances, staff left the resident's room without performing required hand hygiene. Facility policies required staff to wear gloves when in contact with blood, body fluids, or excretions, and to discard gloves after a single use. The hand hygiene policy mandated that all personnel follow handwashing procedures to prevent the spread of infection. Despite these policies, direct observation and interviews confirmed that staff did not consistently adhere to hand hygiene protocols during resident care, resulting in a failure to implement the facility's infection prevention and control program.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention practices, as evidenced by multiple observations and interviews. Staff E, an LPN, was observed not performing hand hygiene before entering a resident's room and during the administration of enteral feeding. The staff member did not follow the facility's hand hygiene policy, which requires hand hygiene before and after direct resident contact and glove use. Additionally, no enhanced barrier precautions were in place during the care of Resident #24, who had a feeding tube, and no gown was donned during the procedure. In another instance, Staff J, Staff K, and Staff L were observed performing catheter and peri care on Resident #44 without using enhanced barrier precautions or gowns, despite the resident having a suprapubic catheter. Although hand hygiene was performed, the lack of enhanced barrier precautions was noted. The facility's failure to implement these precautions was confirmed through interviews with staff, who indicated that no residents were currently on enhanced barrier precautions, despite the presence of indwelling medical devices. Furthermore, the facility lacked written policies related to COVID-19 vaccinations, as revealed during an interview with the Director of Nursing. The facility claimed to follow CDC guidelines but did not have these guidelines documented. This lack of documentation and adherence to infection prevention protocols, including enhanced barrier precautions for residents with indwelling medical devices, contributed to the deficiencies identified during the survey.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to ensure that all employees had completed the required Iowa Criminal Background check and dependent adult/child abuse registry check before beginning work. This deficiency was identified for one out of five employees reviewed, specifically a Certified Nurses Assistant (CNA) referred to as Staff N. Staff N was hired on 2/4/24, but their personnel file lacked documentation of the Iowa Criminal Background Check. The facility's policy, as reviewed, indicated that background checks were not required for staff under a certain age, which contradicts federal regulations mandating background checks for all employees regardless of age. During interviews, the Human Resource Generalist confirmed that the facility policy did not require background checks for staff under a certain age. The Administrator, who was new to the facility, acknowledged awareness of the federal regulations requiring background checks for all employees but was unaware of the facility's policy that did not align with these regulations.
Failure to Provide Correct Diet Consistency for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents, specifically those on mechanically altered diets. During a lunch service observation, it was noted that four residents who required mechanical soft diets were served coleslaw instead of the steamed cabbage that was listed on the menu for their dietary needs. This error was attributed to Staff F, a Dietary Aide, who admitted to forgetting to serve the appropriate food to the residents on mechanical soft diets. The residents involved had varying levels of cognitive impairment and dietary requirements, including diagnoses of dysphagia. The facility's policy, titled 'Accuracy and Quality of Tray Line Services,' mandates that meals be checked against the therapeutic diet spreadsheet to ensure accuracy. However, this policy was not followed, as confirmed by Staff G, the Certified Dietary Manager, and Staff H, the Registered Dietitian, who both acknowledged that the menu and modified diets should have been adhered to.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, affecting 61 out of 63 residents. During a lunch service observation, a dietary aide, identified as Staff F, initially performed hand hygiene but subsequently failed to maintain it while serving food. Staff F used their left hand to handle hamburger buns directly, instead of using tongs, and continued to serve food without performing hand hygiene between tasks. This practice was repeated for all plates served during the observation period. The facility's hand washing policy, dated 2021, requires hand hygiene to be performed as often as necessary to prevent cross-contamination when changing tasks. Staff G, the Certified Dietary Manager, confirmed that Staff F should not have touched the buns with their hands and should have used tongs to open them.
Failure to Maintain Resident Dignity by Not Cleaning Food Debris
Penalty
Summary
The facility failed to uphold the dignity of a resident by not promptly addressing food debris left on the resident's clothing protector and face after a meal. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2, was dependent on staff for personal hygiene and required substantial assistance with eating. An observation noted that the resident had 2-3 tablespoons of orange food on their clothing protector and dry orange food on their chin, which was not cleaned up in a timely manner. The incident was confirmed by the resident's family member, who reported finding and cleaning the food debris from the resident's clothing protector and face several hours after lunch. The facility's policy on dignity, which emphasizes treating residents with respect and ensuring their well-being, was not adhered to in this instance. The Director of Nursing (DON) acknowledged that the clothing protector should have been changed and the resident's face cleaned before returning to their room.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PreAdmission Screening and Resident Review (PASRR) evaluation after the resident was identified with newly evident or possible serious mental disorders. The resident, identified as Resident #48, had a negative Level I PASRR result but was later diagnosed with major depressive disorder and psychotic disorder with hallucinations. Despite these diagnoses, the facility did not follow up with a resubmission for a Level II PASRR evaluation, as required by their Behavioral Assessment, Intervention, and Monitoring policy. The resident's clinical records showed diagnoses of anxiety disorder, depression, and psychotic disorder, and the resident was on medications such as buspirone, donepezil, and sertraline. The facility's failure to act was confirmed during an interview with the Director of Nursing, who stated that the social worker should have resubmitted the PASRR for a Level II screening upon the new diagnoses. This oversight was identified during a review of the resident's chart, which lacked documentation of a follow-up PASRR submission.
Failure to Follow Care Plan for Resident Supervision
Penalty
Summary
The facility failed to adhere to a care plan for a resident with moderate cognitive impairment, depression, muscle weakness, and a history of a left fracture. The care plan, last revised on May 20, 2024, included an intervention initiated on April 2, 2024, requiring staff not to leave the resident unattended in a wheelchair while in his room due to a high risk of falls. However, during the survey, it was observed that the resident was left unattended multiple times while in a wheelchair, both in the hallway and in his room, despite the care plan's instructions. Interviews with staff members, including LPNs and CNAs, revealed a lack of awareness regarding the resident's supervision needs as outlined in the care plan. Staff members incorrectly believed the resident did not require supervision while in his room or in a wheelchair. The Director of Nursing also reported being unaware of the supervision requirement and acknowledged that the current care plan did not reflect the need for supervision. This oversight led to the resident being left unattended, contrary to the care plan's directives.
Failure to Accurately Measure and Administer Feeding Tube Formula
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the technical aspects of feeding tube management for a resident, identified as Resident #24. The resident, who had no cognitive impairment, was documented to have a feeding tube and required 330 mL of supplemental formula to be administered via PEG tube three times daily. However, observations revealed that the staff did not accurately measure the formula as per the physician's order. Instead, the staff member, identified as Staff E, was observed to 'eye' the formula, filling the bag just above the 300 mL line, rather than the prescribed 330 mL. This discrepancy was further evidenced when a significant amount of formula remained in the carton after administration, indicating that the correct volume was not being delivered. Additionally, the facility's procedures for medication administration through the feeding tube were not followed. Staff E was observed pushing medications with a piston syringe, rather than allowing them to flow by gravity as expected by the facility's standards. The Director of Nursing confirmed that the facility's expectation was for nurses to measure the supplemental formula using a graduated cylinder and to administer medications with gravity flow, highlighting a deviation from established protocols in the care of Resident #24.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in a locked storage area for one resident, as observed during a survey. On two separate occasions, a bottle of Tums was found sitting by the sink in the resident's room. The resident's clinical record did not include documentation of an assessment for self-administration of medications. An interview with the Director of Nursing revealed that the resident was not able to self-administer medications and no self-administration assessments had been completed. The facility's policy, revised in April 2007, requires that policies, procedures, and operational practices conform to current professional standards, which was not adhered to in this instance.
Incomplete Documentation of Oxygen Therapy in EHR
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for a resident, identified as Resident #5, who was observed wearing oxygen in his bedroom. Despite the resident's statement that he had been using oxygen almost daily for a couple of years and his care plan documenting oxygen therapy related to shortness of breath and a diagnosis of COPD, the most recent physician's order for oxygen had been discontinued in January 2023. A Licensed Practical Nurse (LPN) believed there was a PRN order for oxygen to maintain saturation above 90%, but upon review, no current order for oxygen was found in the resident's Medication Administration Records (MAR) or Treatment Administration Records (TAR) for May. The Director of Nursing (DON) confirmed that the facility's expectation was for the current oxygen order to be present in the resident's MAR, but it was missing. The DON suggested that the order might have been discontinued when the resident was hospitalized and not re-entered into the Electronic Health Records (EHR) upon their return. The facility's procedure for noting a physician's order required confirmation in the PointClickCare (PCC) system once processed by the pharmacy, but this step was evidently not completed for Resident #5's oxygen order.
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.
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What surveyors actually found near you
We read the 84 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 Sioux City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa De Paz Health Care Center | 0.5 mi | ★★★★★ | 11 | 0 |
| Westwood Specialty Care | 1.8 mi | ★★★★★ | 16 | 0 |
| St Luke's Regional Medical Center Snf | 2 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Sioux City, Llc | 3.1 mi | ★★★★★ | 10 | 0 |
| Adept Nursing & Rehab Of South Sioux City | 4.1 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.