PLEASANTVILLE, IA - Federal inspectors documented multiple infection control breaches and staffing deficiencies at Accura Healthcare of Pleasantville during a May 2025 inspection, raising concerns about resident safety protocols and workforce stability at the 45-bed facility.
Critical Staffing Shortages Impact Care Quality
Accura Healthcare of Pleasantville received a one-star staffing rating from the Centers for Medicare & Medicaid Services for the final quarter of 2024, the lowest possible ranking on the federal five-star rating system. This rating, derived from Payroll Based Journal data covering October through December 2024, indicates the facility operated with significantly fewer nursing staff hours per resident day than recommended by federal guidelines.
The one-star staffing designation reflects more than just numbers on a spreadsheet. Adequate nurse staffing levels directly correlate with resident outcomes, including lower rates of pressure ulcers, falls, infections, and emergency department transfers. When facilities operate with insufficient staff, nursing assistants and licensed nurses must care for more residents than recommended, reducing the time available for each person's care needs.
According to the facility administrator, interviewed on May 7, 2025, the staffing crisis stemmed from significant turnover in nursing leadership positions. The facility experienced complete turnover of key positions including the Director of Nursing, Assistant Director of Nursing, and MDS (Minimum Data Set) nurse. The administrator noted that the entire nursing department turned over in January 2025, creating continuity challenges that affected both resident care and regulatory compliance.
The leadership instability created a cascade effect throughout the organization. When experienced nursing leaders depart, institutional knowledge disappears with them. New leaders require time to learn facility systems, resident needs, and staff capabilities. This transition period often results in gaps in oversight, inconsistent implementation of care protocols, and delayed identification of emerging problems.
The administrator, who had only been with the facility since April 22, 2024, acknowledged that the facility had been working on staff hiring and retention strategies, along with enhanced staff education programs to address resident concerns. However, these initiatives take time to yield measurable improvements in staffing levels and care quality.
Infection Prevention Protocols Breached During Routine Care
Federal inspectors observed significant infection control failures that exposed residents to preventable health risks. On May 1, 2025, surveyors documented nursing staff failing to follow proper glove-changing protocols while providing personal care to Resident #18, a patient with significant medical complexity including stroke-related paralysis, neurogenic bladder, and an indwelling urinary catheter.
During the observed care episode at 10:25 AM, two staff members—a Certified Nursing Assistant and a Certified Medication Aide—began the procedure correctly by donning appropriate personal protective equipment including gown, mask with face shield, and gloves. However, critical errors occurred during the incontinence care process.
After the CNA changed the resident's brief tabs and cleaned the perineal area, she changed her gloves appropriately. But as care continued, the same staff member touched multiple surfaces—the resident's shirt, blanket, call light, and a grabber device—without changing gloves between these contacts. The CMA then picked up the resident's beverage mug and offered water while still wearing contaminated gloves, creating a direct pathway for pathogen transmission.
These actions violate fundamental infection prevention principles. Gloves become contaminated when staff perform personal care tasks, particularly those involving bodily fluids. Once contaminated, gloves transfer bacteria, viruses, and other pathogens to every surface they touch. When staff touch environmental surfaces like call lights, blankets, or drinking containers with contaminated gloves, they create reservoirs for microorganisms that can spread to other residents, staff, and visitors.
For Resident #18, who had an indwelling urinary catheter, proper infection control was particularly critical. Catheter-associated urinary tract infections (CAUTIs) represent one of the most common healthcare-associated infections, affecting an estimated 13,000 deaths annually in the United States according to the Centers for Disease Control and Prevention. Patients with catheters face constant infection risk, making meticulous hygiene practices essential.
The facility's own policy, updated November 13, 2024, specified that gloves "must be replaced as soon as practical when contaminated." The observed practice directly contradicted this written standard. Both the Director of Nursing and a Licensed Practical Nurse confirmed during interviews that staff should change gloves "before and after cares, and anytime staff went from a dirty to a clean task or area."
Particularly concerning, the Assistant Director of Nursing stood in the room observing the care delivery alongside the surveyor. This suggests either inadequate understanding of infection control requirements among nursing leadership or inconsistent enforcement of established protocols.
Equipment Disinfection Failures Create Cross-Contamination Risk
Inspectors documented a second infection control violation involving failure to disinfect shared patient care equipment. On April 30, 2025, surveyors observed a CNA wearing gloves while pushing a mechanical lift from one resident's room into the hallway. The staff member parked the lift along the hallway railing, removed her gloves, and walked away. At 2:03 PM, a hospice CNA took the same mechanical lift and pushed it into another resident's room without any disinfection occurring.
Mechanical lifts contact residents' skin, clothing, and sometimes bodily fluids during transfers. The equipment's slings, bars, and control panels become contaminated with each use. When staff move this equipment between residents without proper disinfection, they create direct pathways for pathogen transmission between vulnerable individuals.
This practice poses particular risk in nursing home settings where residents often have compromised immune systems, open wounds, and multiple chronic conditions. Bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridioides difficile can survive on surfaces for hours to months, depending on environmental conditions.
Industry standards require disinfection of patient care equipment between each use. The facility's own policy, updated November 13, 2024, stated that "equipment cleaned and sanitized prior to using in other areas." Both the Director of Nursing and a Licensed Practical Nurse confirmed during interviews that equipment such as mechanical lifts required disinfection before and after use.
The observed practice represented a systemic failure rather than an isolated incident. When multiple staff members handle equipment without disinfecting it, and when nursing leadership doesn't intervene, it suggests inadequate training, insufficient supplies, or lack of accountability mechanisms.
Staff Education Requirements Not Met
Federal regulations require nursing assistants to complete at least 12 hours of in-service education annually to maintain their skills and knowledge. Inspectors found that three of four sampled CNAs who had worked at the facility for more than one year failed to meet this minimum requirement.
Staff G, employed since May 20, 2021, completed only 8.95 hours of education during the review period from May 2024 through April 2025—falling short by more than three hours. Staff M, hired October 9, 2023, completed only one hour of required education. Most concerning, Staff N, employed since July 6, 2022, completed zero hours of mandatory training during the entire 12-month period.
Continuing education serves critical functions in nursing home care. Annual training refreshes staff knowledge of proper techniques for infection control, safe patient handling, recognizing signs of resident deterioration, and preventing abuse. As medical practices evolve and new evidence emerges about best practices, education ensures staff remain current with standards of care.
The education gaps documented at Accura Healthcare likely contributed to the infection control failures observed during the inspection. Staff who don't receive regular training on glove-changing protocols and equipment disinfection are more likely to develop unsafe habits or fail to recognize when their practices deviate from standards.
During an interview on May 6, 2025, the Director of Nursing stated that mandatory staff in-services occurred monthly and education courses were available through the Relias online platform. However, availability of training doesn't ensure completion. The administrator acknowledged on May 7, 2025, that staff working night shifts didn't attend staff meetings or in-service training sessions, noting "when they worked nights, it was hard."
While scheduling challenges exist for facilities operating 24-hour care, federal regulations don't exempt night shift workers from education requirements. Facilities must develop strategies to ensure all staff members, regardless of shift, receive mandatory training. Solutions might include recorded training sessions accessible at any time, dedicated education periods during night shifts, or requiring staff to complete certain training hours on their own time.
Quality Assurance Processes Under Scrutiny
The facility's Quality Assurance and Performance Improvement (QAPI) plan, updated May 23, 2023, outlined a systematic approach to improving care quality and services. The plan described using root cause analysis to identify improvement opportunities and monitor progress to ensure sustained improvements.
However, the violations documented during this inspection—combined with the administrator's acknowledgment of "repeat deficiencies"—suggest the QAPI process wasn't effectively identifying and correcting systemic problems. The administrator noted the Quality Assurance Committee met quarterly and had identified areas needing improvement, but the persistence of basic infection control failures and education deficiencies indicates implementation gaps.
The facility received its one-star staffing rating for Quarter 1 of 2025 (October-December 2024), yet the May 2025 inspection still found fundamental care practice failures. This timeline suggests either the QAPI committee didn't recognize these issues as priorities, or interventions implemented proved ineffective.
Additional Issues Identified
Beyond the major violations detailed above, the inspection revealed systemic challenges affecting multiple aspects of facility operations. The complete nursing department turnover in January 2025 created leadership instability that impacted regulatory compliance and care consistency. The facility's difficulty filling the Assistant Director of Nursing position for an extended period further strained management capacity.
The administrator reported working on staff hiring and retention strategies, recognizing that workforce stability directly affects resident outcomes. However, these efforts hadn't yet translated into improved staffing levels or prevented the practice failures documented during the survey.
The inspection occurred approximately seven months after a previous survey that identified deficiencies requiring correction plans. The recurrence of violations in similar areas suggests persistent challenges with implementing and sustaining improvements, particularly during periods of leadership transition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Pleasantville, LLC from 2025-05-08 including all violations, facility responses, and corrective action plans.
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