The Payroll Based Journal (PBJ) Staffing Data Report for 10/1/24 to 12/31/24 (Quarter 1) revealed the facility had a 1 Star Staffing Rating.
In an interview 5/7/25 at 2:40 PM, the Administrator reported she believed the PBJ 1-star rating was due to staff turnover. The facility had a high turnover in nursing leadership, including the Director of Nursing, the Assistant Director of Nursing, and the MDS nurse.
08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/08/2025 Accura Healthcare of Pleasantville, LLC 909 North State Street Pleasantville, IA 50225 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
On 5/7/25 at 3:15 PM, the Administrator reported the Quality Assurance Committee met quarterly and had identified areas they needed to work on. The Administrator acknowledged awareness of repeat deficiencies and stated the facility had a turnover of their entire nursing department in 1/2025. Prior to this, the previous ADON was part of the plan of correction in 9/2024, and it took a long time to fill the ADON position. The Administrator reported she had only worked at the facility since 4/22/24. The facility had worked on staff hiring and retention strategies, as well as staff education to address resident concerns.
A Quality Assurance and Performance Improvement Plan (QAPI)) Plan updated 5/23/23 revealed the QAPI is a systematic approach for improving quality of care and services provided to the residents. The QAPI focused on systems and processes, identified system gaps, and identified root causes of concern as well as opportunities for improvement, which lead to improvement in the lives of residents, through continuous attention to quality of care, quality of life, and resident safety. The Root Cause Analysis was used to identify improvement opportunities and understand how to improve on them. The QAPI Committee monitored progress and ensured interventions or actions were implemented, and effective and sustained improvements were made. 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/08/2025 Accura Healthcare of Pleasantville, LLC 909 North State Street Pleasantville, IA 50225 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34817 Based on record review, observations, staff interviews, and policy review the facility staff failed to change gloves when performed cares and then touched other objects for one of four residents sampled for cares (Resident #18). The facility staff also failed to disinfect a mechanical lift after use for one of three residents observed for transfers. The facility reported a census of 45 residents.
- 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #18 had diagnoses
- 2. During continuous observations on 4/30/25 at 2:01 PM, Staff H, CNA wore gloves as she pushed a
- 1. A CNA-CMA Roster revealed Staff G, CNA, had a hire date 5/20/21, Staff M, CNA, had a hire date of
of cerebrovascular accident (CVA)(stroke), hemiplegia (paralysis on one side of the body) and neurogenic bladder (loss of bladder control). The MDS recorded the resident had an indwelling catheter. The MDS documented the resident required partial to moderate assistance for toileting hygiene and substantial to maximum assistance for lower body dressing.
The Care Plan revised 2/17/25 revealed the resident required Assistance with activities of Daily Living (ADL's) related to cerebral infarction and hemiplegia and had a catheter. The Care Plan revealed the resident transferred and moved in bed independently and required staff assistance as needed. The Care Plan directed staff to use enhanced barrier precautions related to the catheter.
During observations on 5/1/25 at 10:25 AM, Staff G, Certified Nursing Assistant (CNA) and Staff B, Certified Medication Aide (CMA) washed their hands, then donned a gown, mask with a face shield, and gloves. Staff G removed Resident #18's brief tabs, then took disposable wipes as Staff B handed the wipes to her and cleansed the resident's peri-area and groin. Staff assisted the resident to roll onto his right side. Staff G changed her gloves, then took disposable wipes and cleansed the buttocks area. Staff B placed a clean brief under the resident and staff assisted the resident to roll onto his left side. Staff G continued to wear the same gloves and touched the back of the resident's shirt as she supported the resident and as Staff B cleansed the buttocks. The resident rolled onto his back and the brief tabs were attached. Staff G placed a blanket over
the resident, placed the call light by the resident, then handed the resident a grabber device. Staff B picked up a beverage mug and offered the resident a drink of water. Staff G and Staff B removed their gown and gloves. Staff B then reached into her uniform pocket and applied hand sanitizer to her hands. The Assistant Director of Nursing stood in the room and observed staff with the surveyor.
In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse (LPN) reported gloves changed whenever staff did cares and went and did something else.
In an interview 5/6/25 at 11:30 AM, the Director of Nursing (DON) reported she expected staff changed gloves before and after cares, and anytime staff went from a dirty to a clean task or area.
In an interview 5/7/25 at 2:40 PM, the Administrator confirmed no other policy for glove changes found.
08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/08/2025 Accura Healthcare of Pleasantville, LLC 909 North State Street Pleasantville, IA 50225 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
A Using Gloves policy updated on 11/13/24 revealed gloves worn to prevent contamination of the employee's hands whenever services provided to the resident. Gloves must be replaced as soon as practical when contaminated.
mechanical lift out of room [ROOM NUMBER] into the hallway. Staff H parked the mechanical lift along the hallway railing, then told the resident to have a good nap. Staff H walked back into the room and removed
the gloves from her hands. At 2:03 PM, a hospice CNA took the mechanical lift and pushed the lift into room [ROOM NUMBER]. The mechanical lift was not disinfected before or after use.
In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse (LPN) reported equipment such as a mechanical lift needed to be disinfected after use.
In an interview 5/6/25 at 11:30 AM, the DON reported equipment such as mechanical lifts needed disinfected
before and after use.
An untitled facility policy updated on 11/13/24 under Miscellaneous revealed equipment cleaned and sanitized prior to using in other areas. 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/08/2025 Accura Healthcare of Pleasantville, LLC 909 North State Street Pleasantville, IA 50225 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Based on employee roster review, education transcript review and staff interviews, the facility staff failed to complete a minimum of 12 hours of regular in-service education for 3 of 4 Certified Nursing Assistants (CNAs) sampled who had worked at the facility greater than 1 year (Staff G, Staff M, and Staff N). The facility identified a census of 45.
10/9/23 and Staff N, CNA, had a hire date 7/6/22.
The Relias Education Transcripts reviewed 5/2024 - 4/2025 revealed the education and number of hours completed for the following: Staff G =8.95 hours completed Staff M = 1.0 hours completed Staff N = 0 hours completed
During interview on 5/6/25 at 11:30 AM, the Director of Nursing reported mandatory staff in-services held monthly and education courses set up on Relias for staff to complete. The DON reported staff needed to complete at least 12 hours of education each year.
During an interview on 5/7/25 at 11:10 AM, the Administrator reported the staff who worked nights don't attend the staff meetings and in-service training. She tried to get the staff to attend the meetings/in-services but when they worked nights, it was hard. 08/27/2025