Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Marshalltown during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia was intentionally sprayed with cold water by a CNA at the end of a shower, despite objections from other staff and the resident's distress. Witnesses reported the CNA laughed during the incident and ignored requests to stop, violating the facility's abuse prevention policy and the resident's right to be free from abuse.
A resident with severe cognitive impairment was intentionally sprayed with cold water by a staff member during a shower, an act witnessed by two CNAs who did not immediately report the incident. The facility did not notify the State Agency of the abuse allegation within the required 2-hour window, as mandated by policy.
A resident with severe cognitive impairment was intentionally sprayed with cold water by a CNA during a shower, while other staff present protested the action. The incident was not immediately reported, and the CNA continued to work several shifts before the facility took action to investigate or separate the alleged abuser, contrary to facility policy.
A resident with intact cognition and multiple psychiatric diagnoses did not have their controlled medication, lorazepam, properly stored or documented after pharmacy delivery. Staff provided inconsistent accounts regarding the handoff and storage of the medication, and the required documentation and secure storage procedures were not followed, resulting in the medication being unaccounted for.
The facility did not correct repeated deficiencies in dignity, infection control, and food service processes, despite having a QAPI plan that required systematic identification and correction of such issues. The lack of follow-through on required audits by the previous DON and ongoing concerns in infection control and kitchen processes contributed to the continued deficiencies.
Surveyors identified deficiencies in food storage and handling, including undated and expired food items, improper use of gloves, and lack of beard nets for staff with facial hair. Staff failed to follow facility policies for labeling, discarding food, and maintaining sanitary conditions, as confirmed by the CDM.
Multiple residents with intact cognition reported being treated disrespectfully by the previous DON, who argued with them, used a demanding tone, made inappropriate comments about personal habits, and talked down to both residents and their families. Facility investigation and staff interviews confirmed a pattern of unprofessional conduct that did not meet expectations for respectful care.
Multiple residents reported significant delays in call light responses and unmet care needs due to insufficient staffing, with documented instances of waiting up to an hour or more for assistance. Staffing records showed that actual staff levels, particularly for CNAs and licensed nurses, were below the facility's own assessed requirements on several shifts, especially on weekends. The administrator acknowledged awareness of these staffing issues.
A resident with an indwelling urinary catheter and a history of neurogenic bladder and diabetes was repeatedly observed over several days with catheter tubing resting on or dragging across the floor while in a wheelchair. Staff interviews confirmed the expectation that tubing should be kept off the floor, but the facility's catheter care policy lacked specific guidance on this practice. The resident's care plan aimed to prevent UTIs, and the resident had recently been treated for a UTI.
Staff did not follow enhanced barrier precautions during wound care for a resident with a diabetic foot ulcer and risk for MDRO colonization. Despite clear care plan instructions and posted signage requiring gowns and gloves for high-contact care, an LPN and a CMA performed a dressing change without wearing gowns, contrary to facility policy.
A resident with moderately impaired cognition and multiple diagnoses did not receive appropriate eligibility screening, education, or documentation regarding follow-up pneumococcal vaccination. The facility only offered pneumonia vaccines at admission and did not ensure ongoing assessment or documentation of consent or refusal for recommended vaccines, contrary to CDC guidelines and facility policy.
A resident with Alzheimer's and a history of wandering left the facility unsupervised after staff failed to properly investigate a door alarm and confirm the resident's location. Staff did not follow policy requiring a thorough visual check of the exit area, resulting in the resident being found several blocks away before being safely returned.
A resident with multiple chronic conditions suffered a fall resulting in rib fractures and was ordered to receive PT and OT for pain management. The facility failed to initiate OT as ordered and delayed the start of PT for several weeks, despite staff being notified of the physician's orders. Leadership confirmed that therapy services were not provided in accordance with protocol.
The facility failed to maintain a safe and comfortable environment by not keeping resident equipment in good repair. Observations showed that several residents had wheelchairs with damaged armrests, inadequately repaired with tape. A resident's power wheelchair had electrical tape holding a cup holder in place. The Maintenance Supervisor acknowledged challenges in keeping up with repairs and lacked documentation for necessary repairs.
The facility failed to provide scheduled showers for four residents, leading to unmet personal hygiene needs. Residents reported receiving fewer showers than scheduled, with documentation showing inconsistencies and missed dates. The facility's policy required showers as requested or per schedule, but this was not adhered to, resulting in a deficiency in care.
The facility failed to provide adequate restorative nursing programs for residents with limited mobility, as documented in their care plans. A resident with heart failure and weakness did not receive prescribed ROM exercises, while another with hemiparesis lacked consistent exercise provision. Two other residents also did not receive their prescribed exercises. Staff confirmed the absence of a dedicated Restorative Assistant, contributing to the deficiency.
The facility failed to maintain the dignity and respect of two residents. One resident was left uncleaned by staff after a bowel movement, leading to feelings of degradation. Another resident experienced a verbal altercation with the DON, who had previously received counseling for communication issues. The incidents were not promptly addressed, highlighting deficiencies in resident care.
A resident with severe dementia and a stage 2 pressure ulcer did not receive Prostat as ordered in their wound treatment plan. The ADON documented the new treatment plan, but the MAR lacked the Prostat order, which was confirmed by an LPN. The DON expected staff to follow physician orders, but the facility could not provide a policy for this.
A facility failed to ensure safe operation of a mechanical lift by allowing underage CNAs to use it without adult supervision. A resident requiring substantial assistance was transferred by staff under 18, contrary to federal guidelines. The DON acknowledged the expectation for adult supervision, highlighting a lapse in compliance with safety regulations.
A facility failed to ensure CPR was performed by certified staff for a resident who had requested resuscitation. Despite the presence of a CPR-certified RN, non-certified CNAs performed CPR on the unresponsive resident until EMTs arrived. The facility's policy required CPR to be initiated by certified staff, which was not followed.
The facility's dietary staff failed to properly label and store food items, leading to outdated and unlabeled items in the kitchen, and did not ensure that dish machine temperatures were documented, compromising food safety and sanitation. The Dietary Manager confirmed these issues, which violated the facility's food storage policy.
The facility failed to screen, educate, and document COVID-19 vaccinations for three residents, despite CDC guidelines and facility policy. A resident with intact cognition and another with severely impaired cognition did not receive education or consent documentation for additional vaccinations after August 2022. Staff confirmed no vaccination clinics were held since then, and the facility's policy to offer vaccinations was not followed.
The facility failed to provide necessary safety smoking equipment for two residents, despite assessments indicating the need for supervision and smoking aprons. Observations showed that neither resident wore a smoking apron during supervised smoking times. Staff interviews revealed a lack of awareness about the residents' needs, highlighting a communication breakdown in the facility.
A facility failed to develop a comprehensive care plan for a resident with severely impaired cognition and a history of exit-seeking behavior. Despite multiple attempts by the resident to leave the facility, the care plan did not include the use of a wander guard, which was observed on the resident. Staff acknowledged the oversight, and the facility lacked a specific policy for wander guard use.
The facility failed to provide and document restorative care for three residents, leading to deficiencies in maintaining their ability to perform ADLs. One resident, with diagnoses including CHF and obesity, participated in restorative services only once in a 30-day period. Another resident, with impaired ROM due to a CVA, did not participate in any restorative activities despite recommendations. A third resident, with a history of stroke and hip fracture, also did not receive the recommended restorative care. Staff interviews highlighted inconsistencies in the implementation and documentation of restorative programs.
A resident with severe cognitive impairment and multiple health conditions experienced significant weight loss due to inconsistent supplement serving amounts. The facility's physician orders lacked specific instructions on supplement quantities, leading to varied administration by staff. Despite the resident's care plan and facility policy emphasizing the need for consistent nutrition interventions, the facility failed to ensure proper supplement administration, contributing to the resident's continued weight loss.
A CNA failed to follow infection control practices by not wearing a gown while performing urinary bag care for a resident with severe cognitive impairment and multiple infections. Additionally, the CNA did not properly rinse the graduate used for measuring urine, leaving it with residual urine, contrary to CDC guidelines. The facility's Enhanced Barrier Precaution policy required the use of gowns and gloves, which was not adhered to during the observation.
The facility did not post the daily nurse staffing information for its 53 residents, as observed on a specific day. The Administrator confirmed the absence of the posting and noted that the information was kept in a binder at the nurses' station, not accessible to residents and visitors. Additionally, the facility lacked a policy for daily nurse staffing postings, failing to adhere to the standard of care.
Resident Subjected to Physical Abuse During Shower
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) intentionally sprayed a resident with cold water at the end of a shower, despite the resident's cognitive impairment and care plan interventions. The resident, who had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder, was assessed as having severely impaired cognition and required substantial assistance with showering. During the incident, the CNA told other staff to "watch this," turned the water to cold, and sprayed the resident for several seconds, causing the resident to become angry and strike the shower head against the wall. Two other CNAs were present during the incident. One CNA reported witnessing the event and described the resident as noncombative at the time, while the other CNA heard the resident yelling and saw the CNA continue to spray him with cold water despite being told to stop. Both witnesses stated that the CNA laughed during the incident, and the resident verbally expressed his discomfort and distress. The facility's policy clearly stated that all residents have the right to be free from abuse, including any act intended to cause pain, injury, or offensive physical contact. The incident was not reported immediately by the witnesses, as they did not initially recognize it as abuse. The Director of Nursing and Administrator both stated that staff are expected to treat residents with dignity and respect and to report suspected abuse immediately. The CNA involved denied intentionally spraying the resident, claiming it may have been accidental while turning off the water, but witness accounts contradicted this statement. The failure to protect the resident from physical abuse constituted a violation of the facility's abuse prevention policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for a resident with severely impaired cognition and multiple diagnoses, including Alzheimer's disease and anxiety disorder. According to the facility's policy, allegations of abuse must be reported to the State Agency within 2 hours. On the date of the incident, a staff member intentionally sprayed the resident with cold water during a shower, an act witnessed by two other CNAs. The resident reacted by grabbing the shower head and banging it against the wall, and verbally expressed discomfort due to the cold water. Both witnesses acknowledged the incident but did not report it immediately, with one stating she was new and the other admitting she did not initially recognize the act as abuse. Interviews with staff revealed that both witnesses were present during the incident and discussed it afterward, but delayed reporting it to facility leadership. The Director of Nursing and Administrator confirmed that the expectation was for immediate reporting of suspected abuse, which did not occur in this case. The facility lacked documentation showing that the allegation was reported to the State Agency within the required 2-hour timeframe following the incident.
Failure to Timely Investigate and Separate Alleged Abuser Following Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and did not separate the alleged perpetrator from residents in a timely manner. A resident with severely impaired cognition, requiring substantial assistance with showering and diagnosed with Alzheimer's, non-Alzheimer's dementia, and anxiety disorder, was involved in the incident. According to staff interviews and documentation, a CNA intentionally sprayed the resident with cold water during a shower, despite protests from other staff present. The resident reacted by yelling, screaming, and attempting to stop the action, while the CNA laughed and continued for 10-15 seconds. Two CNAs witnessed the event and told the perpetrator to stop, but the incident was not immediately reported. The facility's policy required immediate measures to prevent further potential abuse, such as suspending the employee, and prompt investigation and reporting to the State Agency. However, records show that the CNA continued to work several shifts after the incident before any action was taken. There was no documentation that the alleged abuser was separated from residents or that an investigation was initiated prior to several days after the event. The deficiency centers on the facility's failure to respond appropriately and promptly to an alleged violation of abuse policy.
Failure to Secure and Document Controlled Substance Storage
Penalty
Summary
The facility failed to store and handle controlled medications in accordance with professional standards for one resident. Specifically, a resident with diagnoses including anxiety disorder, schizophrenia, and hallucinations had an active order for lorazepam, a controlled substance. Documentation showed that a quantity of lorazepam was delivered by the pharmacy and signed for by an LPN. However, staff interviews revealed confusion and lack of clear documentation regarding the receipt and storage of the medication. The medication was not properly accounted for, with staff unable to locate it after delivery, and there was no documentation confirming the transfer of the medication between staff members. Staff involved in the medication handoff provided conflicting accounts of the events, with one nurse stating she gave medications to the ADON, who then returned them, and another nurse stating she did not receive any narcotics or related documentation. The DON confirmed uncertainty about the whereabouts of the missing medication and acknowledged that the process for checking in and storing narcotics was not followed as required. The facility's policy required that controlled substances be signed in and stored in a locked compartment, but this was not consistently done, resulting in the medication being unaccounted for.
Failure to Correct Repeated Deficiencies in QAPI Areas
Penalty
Summary
The facility failed to correct previously identified deficiencies in three areas: dignity, infection control, and food procurement/store/prepare/serve/sanitation. Despite having a QAPI plan in place that outlined systematic approaches for identifying and correcting quality deficiencies, the facility did not ensure that these processes were effectively implemented. The QAPI plan emphasized staff participation, accountability, and data-driven decision-making, but repeated deficiencies were still observed in the cited areas. The Administrator acknowledged that while a correction plan was developed for dignity concerns, the previous DON did not follow through with required audits as directed, and this lack of follow-through contributed to the ongoing issues. The repeated deficiencies in infection control and kitchen processes were also recognized during the survey, indicating that the facility's QAPI activities were not successful in addressing and resolving these concerns.
Deficient Food Storage, Labeling, and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and handling practices within the facility's kitchen. Several food and drink items, including tomato juice, soy milk, grape juice, white milk, chocolate milk, and orange juice, were found open and not dated. Additionally, containers of apricots, ham salad, and mixed berries were stored past their recommended discard dates. Staff interviews confirmed a lack of understanding regarding proper labeling and discard timelines, with one staff member incorrectly stating that food items remained good for three days after opening. The Certified Dietary Manager (CDM) verified that these items should have been discarded and that all opened food should be labeled and dated according to facility policy. Further observations revealed lapses in personal hygiene and food handling procedures. A male dietary aide with a beard was not wearing a beard net, contrary to facility policy, and reported he was unaware of the requirement. Staff preparing and serving food were seen wearing gloves for multiple tasks without changing them or performing hand hygiene between tasks, including handling utensils, food containers, and food items. On several occasions, staff donned new gloves without washing their hands, and used gloved fingers to handle food directly. The CDM confirmed that gloves should be used for a single task and changed to prevent cross-contamination, and that hand hygiene is required after glove removal.
Failure to Ensure Resident Dignity Due to Unprofessional Staff Conduct
Penalty
Summary
The facility failed to ensure residents' dignity and respect for five residents with intact cognition, as evidenced by multiple reports of unprofessional and disrespectful conduct by a staff member, specifically the previous Director of Nursing (DON), referred to as Staff A. Residents reported that Staff A argued with them, persisted in trying to convince them to perform activities such as showering against their wishes, and used a demanding and superior attitude, particularly during night shifts. Several residents described being talked down to, yelled at, or directed to go to their rooms in a manner they found disrespectful. One resident recounted Staff A making a blunt and upsetting comment about their eating habits in front of a family member, while another described Staff A as treating them like a child and being rude to their family member over the phone. Facility documentation and interviews with both residents and staff confirmed a pattern of inappropriate and unprofessional behavior by Staff A, including repeated complaints about her conduct. The facility's own investigation revealed that Staff A's actions did not align with the expectations of leadership and the facility's policy on employee standards and code of conduct, which requires staff to maintain a positive and respectful environment. The incidents involved residents who were cognitively intact, as indicated by their BIMS scores, and who were able to clearly articulate their experiences of being treated without dignity and respect.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed call light responses and unmet care needs. Several residents reported waiting from 30 minutes to over an hour for staff to respond to call lights, particularly during the day and night shifts. One resident noted that staff were too busy with other tasks, such as showers, resulting in delays in assistance with getting out of bed and eating meals. Another resident described being left unattended over the weekend due to short staffing, with staff indicating they would return but failing to do so. A grievance from a family member also documented long call light response times and uncompleted linen changes. Payroll Based Journal (PBJ) data and daily staff postings revealed that staffing levels, especially on weekends and certain shifts, were below the facility's own assessment of required staff-to-resident ratios. The facility assessment specified higher numbers of RNs, LPNs, CNAs, and medication aides per shift than were actually present according to the daily postings. The administrator acknowledged awareness of ongoing staffing concerns and indicated the facility assessment needed to be updated to reflect current needs.
Failure to Maintain Catheter Tubing Off the Floor for Resident with Indwelling Catheter
Penalty
Summary
Surveyors identified a deficiency in the care of a resident with an indwelling urinary catheter, who had diagnoses including neurogenic bladder and diabetes mellitus. Over a four-day review period, multiple observations were made of the resident sitting in a wheelchair with 6 to 7 inches of catheter tubing resting on or dragging across the floor in various locations throughout the facility, including the dining room, hallways, and at the nurses' station. These observations were consistent across several days and times, indicating a persistent issue. Staff interviews revealed that facility staff expected catheter tubing to be kept off the floor, with one CNA stating that the tubing should be placed in a dignity bag and clipped to the resident's leg to prevent it from touching the floor. However, the facility's catheter care policy did not provide specific direction regarding the placement of catheter tubing off the floor. The resident's care plan included a goal to prevent urinary tract infections, and the resident had a recent history of a UTI, as evidenced by a positive urine culture and antibiotic treatment.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) during wound care for a resident with a diabetic foot ulcer and increased risk for colonization of multidrug resistant organisms (MDRO). The resident required substantial assistance with mobility and had multiple diagnoses, including diabetes, renal disease, and dementia. The care plan specifically directed staff to use EBP, and signage on the resident's door instructed staff to wear gloves and gowns during high-contact care activities such as wound care. During an observed dressing change, an LPN and a Certified Medication Aide assisted with the procedure but did not wear gowns as required by facility policy and posted instructions. The LPN acknowledged forgetting to don a gown despite having received education on the policy. The facility's policy, updated prior to the incident, clearly defined EBP and required the use of gowns and gloves during wound care for residents with wounds requiring dressings.
Failure to Screen, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to conduct proper eligibility screening, offer, and provide education regarding the pneumococcal (pneumonia) immunization for a resident. Clinical record review showed that the resident, who had moderately impaired cognition and diagnoses including Alzheimer's disease, anxiety, and hypertension, had received the pneumococcal polysaccharide vaccine (PPV23) in the past. However, there was no documentation that the resident was offered or educated about the recommended follow-up pneumococcal vaccines (PCV20 or PCV21), nor was there documentation of consent or refusal for these vaccines. Staff interviews revealed that pneumonia vaccinations were only offered at admission, and subsequent eligibility for additional vaccinations was not routinely assessed or offered. The facility's policy required that all residents be given the opportunity and encouragement to receive pneumococcal vaccinations, but the process for ongoing review and offering of vaccines was not followed. The physician was expected to review vaccination history and order immunizations, but this did not consistently occur, resulting in a lack of compliance with CDC recommendations and facility policy.
Failure to Supervise Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia and a history of wandering was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident, who had a BIMS score indicating intact cognition but was known to wander and required supervision for safety, was last seen walking toward the dining room. Staff assumed the resident had entered the dining room, but when a door alarm sounded, staff failed to immediately and thoroughly investigate the cause of the alarm or confirm the resident's whereabouts. Instead of conducting a prompt and comprehensive search, staff turned off the door alarm after a brief visual check and did not go outside to verify if anyone had exited the building. It was only after the resident could not be located inside that a head count and neighborhood search were initiated. The resident was eventually found several blocks away and returned to the facility without injury. Interviews revealed that staff did not follow the facility's policy, which required a visual check of the area around the exit, including outside the building, when a door alarm sounded. Documentation showed that the resident was considered at moderate risk for elopement due to his diagnosis and history, and the care plan directed staff to monitor and redirect him as needed. Despite these interventions, staff actions were insufficient to prevent the resident from leaving the facility, and the required protocols for responding to door alarms and missing residents were not followed as outlined in facility policy.
Failure to Initiate Ordered Therapy Services After Resident Fall
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident following a fall that resulted in acute right posterior rib fractures. The resident, who had a history of hypertension, COPD, diabetes mellitus, and muscle weakness, experienced a fall in her room and subsequently complained of pain in her left shoulder, ankle, and ribs. Despite a physician's order for both physical therapy (PT) and occupational therapy (OT) evaluations and treatment due to increased pain, the clinical record showed that OT services were never initiated and PT services were not started until several weeks after the order was given. Documentation confirmed that the staff notified therapy of the new order, but there was no evidence that OT was ever provided, and PT was delayed significantly. Interviews with facility leadership verified that the staff did not follow the physician's orders according to facility protocol, and there was no policy in place regarding the timely processing of such orders. The failure to initiate therapy services as ordered constituted a deficiency in providing required specialized rehabilitative services.
Failure to Maintain Resident Equipment in Good Repair
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not keeping their equipment in good repair. Observations revealed that four residents had wheelchairs with damaged armrests, including torn vinyl and exposed foam, which were inadequately repaired with tape. Specifically, Resident #13's wheelchair had a torn right armrest, Resident #15's wheelchair had a right armrest wrapped with clear plastic tape, and Resident #5's wheelchair had both armrests with torn vinyl and exposed foam. Additionally, Resident #2's power wheelchair had black electrical tape on the left armrest to hold a cup holder in place. The Maintenance Supervisor admitted difficulty in keeping up with necessary repairs and lacked documentation for the repairs needed on resident wheelchairs.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers per the residents' requests for four residents, leading to a deficiency in care. Resident #6, with intact cognition and requiring substantial assistance due to left-sided hemiparesis, reported receiving only one shower a week and expressed a preference for a bed bath as a second option. Documentation for November 2024 through January 2025 showed inconsistencies and lack of records indicating that Resident #6 received the scheduled showers, with several instances of refusal noted without alternative care provided. Resident #1, also with intact cognition and requiring partial to maximum assistance, reported receiving fewer showers than scheduled, sometimes not even one per week. Documentation from November 2024 to January 2025 revealed multiple missed scheduled showers, with no records indicating that Resident #1 received the necessary personal hygiene care. Similarly, Resident #14, who required substantial assistance, confirmed not receiving the scheduled twice-weekly showers, with documentation showing several missed dates in November and December 2024, and no records for January 2025. Resident #7, who was independent in showering, reported receiving only one shower a week at times, despite a schedule of two showers per week. Documentation indicated refusals on several dates, with limited records of showers being provided. Interviews with staff revealed issues with equipment suitability for Resident #8, who was not directly part of the deficiency but highlighted potential systemic issues. The facility's policy required showers as requested or per schedule, but the documentation and resident reports indicated a failure to adhere to this policy, resulting in unmet personal hygiene needs.
Failure to Provide Adequate Restorative Nursing Programs
Penalty
Summary
The facility failed to provide adequate restorative nursing programs to maintain or improve the mobility of four residents with limited range of motion and mobility issues. Resident #13, with intact cognition and multiple diagnoses including heart failure and weakness, did not receive the prescribed active range of motion (ROM) exercises with weights and a green band for the upper body, as documented in their care plan. Despite having a care plan that included these interventions, there was no documentation of restorative therapy being provided for the entire month, and the resident confirmed the lack of exercises during an interview. Resident #6, also with intact cognition and functional limitations in range of motion due to left-sided hemiparesis, was supposed to receive active ROM exercises using a MOTOmed and a green TheraBand. However, the documentation did not reflect that these exercises were consistently provided, with only one instance of exercise recorded. The resident confirmed the absence of restorative therapy, expressing a desire to participate in the recommended exercises. Similarly, Resident #5 and Resident #1, both with intact cognition and various medical conditions, did not receive the prescribed ROM exercises as outlined in their care plans. Resident #5's documentation lacked evidence of consistent exercise provision, while Resident #1's records showed sporadic exercise offerings. Interviews with staff confirmed that the facility did not have a dedicated Restorative Assistant to ensure the completion of these programs, contributing to the deficiency in providing necessary mobility services to the residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, impacting their quality of life. One resident, with intact cognition and a history of trauma, was left uncleaned by staff after a bowel movement, which made her feel degraded. This incident was reported during a resident council meeting, but the facility's administration was unaware of it until the meeting minutes were reviewed. The Director of Nursing was not informed of the incident, and no immediate investigation was conducted. Another resident, also with intact cognition and diagnosed with multiple sclerosis and depression, experienced an altercation with the Director of Nursing shortly after admission. The resident and the DON had a verbal argument, during which the DON raised her voice. The incident was self-reported, and the resident expressed that they had moved past the issue. The DON had previously received educational counseling to improve interactions with residents and staff. The facility's failure to address these incidents promptly and effectively highlights a deficiency in maintaining residents' dignity and respect. The lack of immediate action and communication among staff and administration contributed to the residents' negative experiences, as documented in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with severe dementia, cerebral atherosclerosis, and incontinence, and was at risk for developing pressure ulcers. The resident had a stage 2 pressure ulcer on the sacrum upon admission. A Wound Treatment Plan dated December 13, 2024, included orders to discontinue the current treatment and start a new regimen, which involved cleansing the wound, applying a collagen pad, and covering it with a silicone super absorbent dressing. Additionally, the plan included administering Prostat, a nutritional supplement, to promote wound healing. However, the Medication Administration Record (MAR) for December 2024 and January 2025, as well as the Clinical Physician Orders printed on January 9, 2025, lacked the order for Prostat. The Assistant Director of Nurses (ADON) documented the new wound treatment plan in the Nurses Notes, MAR, and Treatment Administration Record (TAR) on December 16, 2024, and notified the resident's family. Despite this, the order for Prostat was not included in the MAR, which was confirmed by a Licensed Practical Nurse (LPN) on January 13, 2025. The ADON acknowledged not seeing the order for Prostat on the Wound Treatment Plan received on December 13, 2024. The Director of Nursing (DON) confirmed that staff are expected to follow physician orders. The facility was unable to provide a policy for following physician orders, indicating a lapse in ensuring adherence to prescribed treatments.
Underage Staff Operate Mechanical Lift Without Supervision
Penalty
Summary
The facility failed to ensure the safe operation of a full-body mechanical lift by allowing workers under the age of 18 to operate the lift without adult supervision. This deficiency was identified through resident and staff interviews, revealing that the facility did not adhere to the guidelines set forth by the Fair Labor Standards Act (FLSA) regarding the operation of power-driven hoisting apparatus by minors. Specifically, the facility allowed Certified Nursing Assistants (CNAs) and nursing assistants under the age of 18 to use the lift without the presence of an adult over the age of 18, which is a violation of the child labor provisions. Resident #6, who had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition, required substantial to total assistance with activities of daily living due to conditions such as stroke, hemiplegia, and renal insufficiency. The care plan for Resident #6 specified that assistance from two staff members was needed for all transfers using the lift. However, on a specific date, Resident #6 was transferred using the lift by Staff A, Staff B, and Staff C, all of whom were under the age of 18, without adult supervision. Additionally, Staff C had not received training on how to use the facility's lift. The Director of Nursing (DON) acknowledged that staff under the age of 18 were expected to have someone over the age of 18 present when operating a lift. The facility's failure to comply with these expectations and federal regulations resulted in the improper use of the mechanical lift, as the CNAs involved did not have the necessary supervision or training to safely operate the equipment. This oversight posed a risk to both the residents and the underage staff involved in the transfer process.
Failure to Ensure CPR Certified Staff Performed Resuscitation
Penalty
Summary
The facility failed to ensure that staff certified in cardiopulmonary resuscitation (CPR) performed the procedure for a resident who had requested CPR in their care plan and had signed an Iowa Physician Orders for Scope of Treatment (IPOST) indicating their desire for resuscitation. The incident involved a resident with intact cognition and medical conditions including coronary artery disease, hypertension, and atrial fibrillation. On the day of the incident, the resident was found unresponsive, and although a registered nurse (RN) with CPR certification was present, the CPR was performed by certified nurse aides (CNAs) who were not certified in CPR. The RN, identified as Staff A, initially assessed the resident and left to call 911, during which time the resident stopped breathing. Despite being CPR certified, Staff A directed the CNAs to perform CPR, and they took turns doing so until emergency medical technicians arrived. Interviews revealed that the CNAs involved were not CPR certified, and another RN, Staff D, who was CPR certified, did not assist with the CPR efforts. The facility's policy required that CPR be initiated by any staff member currently certified to perform it, which was not adhered to in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The dietary staff at the facility failed to properly label and store food items, which compromised food quality and increased the risk of contamination and foodborne illness. During an initial tour of the main kitchen, several issues were identified, including outdated food items in the cooler, such as a squirt bottle of ranch dated 7/8/24, a squirt bottle of French dressing dated 6/30/24, and a bag of bacon bits dated 7/13/24. Additionally, four out of five plastic containers of cereal were either unlabeled or had outdated labels, and plastic containers under the prep table were either incompletely labeled or not labeled at all. There were also undated and unlabeled bags of cereal in dry storage, unsecured plastic bags of pasta, and a box labeled cocoa powder with another bag placed on top of a partially opened bag of cocoa powder. The facility also failed to ensure that resident dishes and kitchen equipment reached the appropriate sanitizing temperature when using the dish machine, as evidenced by missing entries in the dish machine temperature log for several days in July 2024. The Dietary Manager confirmed the lack of documented temperatures and acknowledged the presence of outdated and improperly labeled food items. The facility's policy on food storage requires that food be dated when placed on shelves, stored in containers with tight-fitting covers or sealable bags, and labeled and dated accurately. Leftover food should be used or discarded within seven days, but these procedures were not consistently followed, leading to the identified deficiencies.
Failure to Provide COVID-19 Vaccination and Documentation
Penalty
Summary
The facility failed to comply with CDC guidelines and its own policy regarding COVID-19 vaccinations for residents. Specifically, the facility did not screen for eligibility, offer, provide education, or document vaccine consent or refusal for three residents. Resident #23, with intact cognition, had received a COVID-19 vaccination in August 2022, but there was no documentation of education or consent for an additional vaccination. Similarly, Resident #43, with severely impaired cognition, also lacked documentation of education or consent for an additional vaccination after receiving one in August 2022. Resident #22, with intact cognition, had a similar deficiency in documentation for an additional vaccination. The facility's failure to offer updated COVID-19 vaccinations was further highlighted by staff interviews. The Administrator and ADON confirmed that no vaccination clinics had been held since August 2022, and the QA Nurse reported the last attempt to set up a clinic was in March 2023. The facility's policy, updated in May 2024, stated that residents should be provided the opportunity to receive COVID-19 vaccinations, and if a resident wished to be up to date, the facility would contact the primary physician for an order. However, this policy was not followed for the residents in question.
Failure to Provide Safety Smoking Equipment for Residents
Penalty
Summary
The facility failed to accurately assess the need for safety smoking equipment for two residents, leading to a deficiency in ensuring resident safety during smoking activities. Resident #56, who had severely impaired cognition and used a wheelchair, was assessed as having no cognitive losses and was noted to require supervision and a smoking apron. However, observations on two separate occasions revealed that Resident #56 was not wearing a smoking apron during supervised smoking times. This discrepancy between the assessment and actual practice indicates a failure in implementing the necessary safety measures as outlined in the resident's care plan. Similarly, Resident #22, who had intact cognition and used a manual wheelchair, was assessed to need supervision and a smoking apron. Despite this, observations showed that Resident #22 was not wearing a smoking apron during supervised smoking times. Interviews with staff, including a CNA and the ADON, revealed a lack of awareness regarding the need for smoking safety equipment for these residents. The staff expressed surprise and concern upon learning about the inaccurate assessments, indicating a breakdown in communication and documentation processes within the facility.
Failure to Implement Comprehensive Care Plan for Resident with Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of exit-seeking behavior. The resident, who had severely impaired cognition and utilized a wheelchair, had attempted to leave the facility on multiple occasions. Despite these incidents, the care plan did not include information regarding the resident's wandering behavior or the need for a wander guard. The clinical record review also did not show an active order for the use of a wander guard or instructions for staff to check its placement. Observations and staff interviews confirmed that the resident was wearing a wander guard, yet the care plan did not reflect this intervention. A registered nurse acknowledged the oversight and noted that the care plan should address the resident's fluctuating exit-seeking behaviors and the current use of a wander guard. Additionally, the facility lacked a policy or procedure specifically related to wander guard use or care plan development, as confirmed by the facility administrator.
Deficiency in Restorative Care Documentation and Implementation
Penalty
Summary
The facility failed to provide and document restorative care for three residents, leading to deficiencies in maintaining their ability to perform activities of daily living (ADLs). Resident #7, with intact cognition and diagnoses including congestive heart failure and obesity, was recommended for a restorative nursing program (RNP) after being discharged from occupational therapy. Despite the recommendations, documentation showed that Resident #7 only participated in restorative services once in a 30-day period, and staff interviews confirmed the lack of consistent participation and documentation. Resident #24, who had impaired range of motion due to a cerebrovascular accident, was also not provided with adequate restorative care. Although physical therapy recommended an RNP to prevent ADL decline, documentation revealed that Resident #24 did not participate in any restorative activities during the look-back periods. Interviews with staff indicated a lack of awareness and documentation of the resident's participation in restorative programs, despite the resident's need for extensive assistance with ADLs. Similarly, Resident #43, who required assistance due to a history of stroke and hip fracture, did not receive the recommended restorative care. The care plan included group exercises and the use of an exercise bike, but documentation showed a lack of participation in these activities. Staff interviews highlighted inconsistencies in the implementation and documentation of the resident's restorative program, contributing to the deficiency in maintaining the resident's functional abilities.
Inconsistent Supplement Administration Leads to Resident Weight Loss
Penalty
Summary
The facility failed to implement consistent supplement serving amounts for a resident with severe cognitive impairment and multiple health conditions, including anemia, hypertension, heart failure, renal disease, diabetes, cerebrovascular accident, non-Alzheimer's disease, malnutrition, dysphagia, and anoxic brain damage. The resident required supervision and assistance with eating and had a history of weight loss. Despite the resident's care plan directing staff to serve supplements as ordered, the physician's orders lacked specific instructions on the amount of supplement to administer. The resident's weight decreased significantly over several months, with a notable weight loss of 10.3% in 180 days and 12.6% in 180 days. The facility's records showed that the resident's supplement intake was documented, but the amount consumed was not specified. Staff interviews revealed inconsistencies in the amount of supplement given, with some staff administering varying amounts based on the resident's mood and willingness to consume the supplement. The Director of Nursing acknowledged the lack of specific directions in the physician's orders and the inconsistency in serving amounts. The facility's policy on nutrition interventions for unintended weight loss emphasized the importance of determining appropriate calorie, protein, and nutrient needs for residents. However, the facility did not adhere to these guidelines, as evidenced by the lack of specific supplement serving instructions and the resident's continued weight loss. The Director of Nursing and other staff members recognized the issue but did not take corrective action to ensure consistent supplement administration.
Infection Control Deficiency: Improper PPE Use and Equipment Cleaning
Penalty
Summary
The facility staff failed to adhere to infection control practices, specifically in the use of personal protective equipment (PPE) and proper cleaning of resident equipment. During an observation, a certified nursing assistant (CNA), identified as Staff G, was seen performing urinary bag care for a resident with severe cognitive impairment and multiple medical conditions, including septicemia and a urinary tract infection. The resident required total assistance for personal hygiene and had a urinary catheter. Despite the facility's Enhanced Barrier Precaution (EBP) policy requiring the use of gowns and gloves for residents with indwelling medical devices, Staff G only wore gloves and did not don a gown while emptying the urinary bag. Additionally, after emptying the urinary bag, Staff G did not rinse the graduate used for measuring urine, leaving it with a small amount of urine present. This action was contrary to the CDC guidelines, which recommend using a separate, clean collection container for each patient. The Assistant Director of Nursing (ADON) confirmed that Staff G self-reported not wearing a gown and acknowledged the CNA's preference for using a cup to rinse the graduate, although it was unclear if this was done. The failure to follow these infection control practices was observed despite the presence of EBP signage on the resident's door, which outlined the required PPE.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information, as required, for a reported census of 53 residents. On July 23, 2024, at 11:50 AM, it was observed that the facility did not have the daily nurse staffing information posted. At 12:00 PM, the Administrator acknowledged and confirmed the absence of the posting and stated that the information was not readily accessible to residents and visitors. Instead, the daily nurse schedules were kept in a binder at the nurses' station. The Administrator also reported that the facility did not have a policy regarding the daily nurse staffing postings and admitted that the facility did not follow the standard of care in this instance.
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 121 citations issued within 25 miles in the last 12 months — 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 Marshalltown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southridge Specialty Care | 0.3 mi | — | 0 | 0 |
| Harmony Marshalltown | 1.2 mi | — | 17 | 0 |
| Iowa Veterans Home | 2.6 mi | — | 6 | 0 |
| State Center Specialty Care | 13.1 mi | — | 11 | 0 |
| Oakview Nursing Home | 14.5 mi | — | 1 | 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 August 2026) and official state health department websites.