Accura Healthcare Of Cresco

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to provide treatment as ordered to promote the healing and prevent infection of existing pressure ulcers for 1 of 3 residents reviewed (Resident #13).The facility reported a census of 26 residents.

Findings include:Resident #13's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.

The MDS included diagnoses of paraplegia and stage 4 pressure ulcer (full thickness skin and tissue loss) of the sacral region. Resident #13's orders from the wound clinic dated 12/18/25 documents the sacral pressure ulcer orders to Apply Acetic Acid dampened gauze to the wound base and the skin around and allow to stay in place for 10-15 minutes then remove, apply Calmoseptine around the left buttock wound, apply Melgisorb Ag (Calcium Alginate) to the wound base and pat dry and allow for air time for 30 minutes, then return and place ABD and secure with Medipore tape. On 1/28/26 at 2:25 PM Staff G, Registered Nurse (RN) went to complete the wound treatment to the sacral area.

Staff G looked at the order on the computer and then did hand hygiene.

She applied gloves and opened a gauze package.

Placing half the gauze on the supplies without a barrier under, she went to the computer to read the order again touching the computer with her gloved hand then took the acetic acid and dampened some gauze with it.

Staff G cleansed the wound with the dampened gauze.

Staff G did not leave it on the wound for 10-15 minutes as the order states.

Staff G then rolled Resident #13 onto her back with no barrier under her, placing the resident down on the bed after cleansing the area and not covering it, to apply pain cream to the shoulder on the right side. At 2:35 PM Staff G did hand hygiene and assisted the resident to her right side.

Staff G looked at the computer to read the order for the sacral area and applied gloves not doing hand hygiene after touching the computer.

Staff G took the tube of calmoseptine and used her gloved finger to get some cream from the tube.

She applied it with the gloved finger to the first wound in the sacral area.

Then with the same gloved finger, took more out of the tube and applied it to the second wound.

Staff G with the same gloved hand she used for the calmoseptine, took melgisorb ag (calcium alginate), cut it to size and placed it on the wound base.

She then removed her gloves and applied new gloves. No hand hygiene done between.

Staff G took an ABD and placed over the wounds and secured it with tape.

She rolled the resident onto her back.

She then removed her gloves and went to the computer and signed off on the treatments completed. On 1/29/26 at 10:05 AM, the Director of Nursing (DON) explained they expected the nurses to follow the order correctly for wound cares.

The DON acknowledged the treatment was not completed per orders.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Accura Healthcare of Cresco

701 Vernon Road SW Cresco, IA 52136

SUMMARY STATEMENT OF DEFICIENCIES