Inspection Reports for The Village of Ackley
502 Butler Street, IA, 506011730
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 8, 2025, found the facility in substantial compliance with no specific deficiencies detailed. Earlier inspections showed a mixed pattern, with some substantiated complaints related to abuse and neglect in late 2025, and multiple deficiencies in resident care, notification practices, and staffing issues identified in prior years. Complaint investigations included substantiated cases involving failure to notify families and physicians of significant resident condition changes, inadequate supervision, and issues with abuse reporting, while many other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports, though an Immediate Jeopardy was identified and later removed in 2023 related to inadequate supervision and accident hazards. The facility’s record shows some improvement over time, with recent inspections indicating substantial compliance following earlier citations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
32 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 8, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility will be certified in compliance with health requirements effective November 25, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 25, 2025
Visit Reason
A complaint investigation for complaints #2673973-C was conducted on November 24th and 25th, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2673973-C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Report Facts
Complaint number: 2673973
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Nov 20, 2025
Visit Reason
The inspection was conducted as a result of complaints #2593979-A, investigating allegations of abuse, neglect, and failure to report incidents at The Village of Ackley.
Findings
The investigation found deficiencies related to abuse and neglect, including failure to ensure residents were free from abuse and failure to report allegations of abuse within required timeframes. Specific incidents involving Resident #2 were documented, including a fall and staff neglect in reporting and assisting the resident.
Complaint Details
The deficiencies resulted from investigation of complaints #2593979-A conducted from October 16, 2025 to November 20, 2025. Complaints were substantiated with findings of abuse and neglect.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents are free from abuse, neglect, misappropriation of property, and exploitation. | D |
| Failure to report allegations of abuse within required timeframes to appropriate authorities. | D |
Report Facts
Census: 32
MDS assessment date: 61825
Staff training date: 10232025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to neglect and failure to report Resident #2's fall |
| Staff B | Registered Nurse (RN) Nurse Mentor | Reported Resident #2 needed help and notified Director of Nursing |
| Director of Nursing (DON) | Director of Nursing | Notified of Resident #2's fall and staff neglect |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance with health requirements effective March 21, 2025.
Findings
The facility was found to be in substantial compliance with health requirements based on the accepted Plan of Correction; no specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 4
Feb 27, 2025
Visit Reason
The inspection was conducted due to the facility's annual recertification survey and investigation of complaint intakes #125919-C and #126090-I.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements, including failure to treat residents with dignity and respect, failure to notify the Long-Term Care Ombudsman of resident transfers, failure to submit accurate PASRR evaluations, and failure to submit accurate Payroll Based Journal (PBJ) staffing data.
Complaint Details
Complaint #125919-C was unsubstantiated. Facility reported incident #126090-I was substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to treat residents with dignity and respect, evidenced by staff using inappropriate language and behavior toward Resident #14. |
| Failure to provide required notification to the Office of the State Long-Term Care Ombudsman for resident transfers and discharges. |
| Failure to submit a Level II PASRR evaluation for Resident #19 with a new mental health diagnosis. |
| Failure to submit accurate and complete Payroll Based Journal staffing data, including failure to reflect licensed nursing coverage and failure to submit accurate staff reports. |
Report Facts
Resident census: 28
Days with failure to notify for 24 hours/day nursing coverage: 26
Date survey completed: Feb 27, 2025
Date of training meeting: Mar 21, 2025
Plan of correction completion date: May 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Named in finding for inappropriate language and behavior toward Resident #14. |
| Staff A | Certified Nursing Assistant (CNA) | Reported Staff B's inappropriate behavior and assisted Resident #14. |
| Director of Nursing | Director of Nursing (DON) | Documented call regarding incident with Resident #14 and acknowledged staffing and PBJ reporting issues. |
| Administrator | Facility Administrator | Acknowledged failures in notification to LTC Ombudsman, PBJ reporting, and staffing data validation. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Met with Staff B regarding inappropriate behavior. |
| Staff C | Quality Life Services MDS Coordinator | Signed MDS indicating completion on 12/16/24. |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 26, 2024
Visit Reason
This was an onsite revisit inspection following a prior survey ending July 11, 2024, to verify compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Grand Ji Vante Nursing Home was found to be in substantial compliance effective August 10, 2024. The discretionary denial of payment for new admissions did not take effect.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 6
Jul 11, 2024
Visit Reason
The inspection was conducted due to a substantiated complaint #121835-C investigated from July 8, 2024 to July 11, 2024, focusing on compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with requirements related to notification of changes, safe and clean environment, accident supervision, nutrition/hydration, rehab services, and resident records. Deficiencies were identified involving failure to notify physicians and family of significant resident condition changes, inadequate environment cleanliness, insufficient accident prevention and supervision, and failure to provide timely therapy services and proper documentation.
Complaint Details
Complaint #121835-C was substantiated based on clinical record review, staff interviews, and policy review. The complaint involved failure to notify physician and family of significant condition changes for residents #1 and #4.
Severity Breakdown
Level D: 4
Level G: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify physician and family for significant change in resident condition for 2 of 4 residents reviewed. | Level D |
| Failure to provide a safe, clean, comfortable, homelike environment for 1 of 4 residents reviewed. | Level D |
| Failure to provide adequate supervision to prevent accidents and injuries for 1 of 4 residents reviewed. | Level G |
| Failure to maintain adequate nutrition and hydration status for 1 of 4 residents reviewed. | Level G |
| Failure to provide specialized rehabilitative services timely for 1 of 1 resident reviewed. | Level D |
| Failure to maintain resident records with required documentation and confidentiality for 1 of 4 residents reviewed. | Level D |
Report Facts
Resident census: 32
Weight loss percentages: 9.1
Weight loss percentages: 11.8
Weight loss percentages: 10.4
Fall risk assessment score: 17
Fall risk assessment score: 19
Fall risk assessment score: 15
Meal intake percentages: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Scott Kramer | Administrator | Signed Plan of Correction |
| Staff B | Registered Nurse | Reported concerns about Resident #1's fall and communication with family |
| Staff C | Regional Nurse Consultant | Confirmed lack of family notification for Resident #4's bruise |
| Staff J | Housekeeping Supervisor | Acknowledged room cleanliness issues |
| Staff D | Licensed Practical Nurse | Reported Resident #1's worsening condition and communication with family |
| Staff A | Certified Nurse Aide | Notified nurse about Resident #1's discoloration and assisted with care |
| Staff E | Certified Nurse Aide | Reported Resident #1's oral care and feeding difficulties |
| Staff F | Certified Nurse Aide | Reported Resident #1's decline and hospice consideration |
| Staff G | Certified Nurse Aide | Reported Resident #1's appetite and feeding issues |
| Staff H | Registered Nurse | Reported on Resident #1's mouth condition and care |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation for complaint #120102-C from May 21, 2024 to May 23, 2024, including an onsite revisit of the survey ending April 9, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. All deficiencies were corrected and the complaint was not substantiated.
Complaint Details
Complaint #120102-C was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 16
Apr 9, 2024
Visit Reason
The inspection was conducted following the facility's annual recertification survey and a complaint investigation #118905-C from April 1 to April 9, 2024.
Findings
The facility was found out of compliance with federal regulations related to multiple deficiencies including inconsistent code status documentation between hospice and facility, failure to timely notify family of resident condition changes, delayed transmission of discharge MDS assessments, failure to invite residents to care conferences, inadequate infection prevention practices, failure to ensure therapeutic monitoring of anticoagulant medications, improper food service and sanitation practices, lack of annual staff evaluations, incomplete hospice care planning, incomplete QAPI committee membership, and failure to maintain a comprehensive water management program.
Complaint Details
Complaint #118905-C was substantiated.
Severity Breakdown
Level D: 12
Level E: 4
Level J: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure code status between the facility and hospice were congruent for 1 of 2 residents reviewed for advanced directives (Resident #10). | Level D |
| Failed to provide family notification in a timely manner when changes occurred in the resident's physical or mental condition for 1 of 1 resident reviewed (Resident #23). | Level D |
| Failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for 1 of 1 resident reviewed (Resident #32). | Level D |
| Failed to invite a resident or a resident's representative to an initial Care Conference for 1 of 1 resident (Resident #38). | Level D |
| Failed to provide appropriate treatment and services to prevent a urinary tract infection for 1 of 3 residents (Resident #23). | Level D |
| Failed to ensure residents who use Coumadin (blood thinner) received therapeutic monitoring as ordered by the physician for 3 of 3 residents reviewed (Residents #5, #13, #16). | Level J |
| Failed to evaluate and manage an as needed psychotropic medication between fourteen days of use for 1 of 1 resident sampled (Resident #34). | Level D |
| Failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. | Level D |
| Failed to follow the approved diet menu and failed to measure accurate servings for residents who received pureed diets. | Level E |
| Failed to provide food served by a method to maintain a safe and appetizing temperature. | Level E |
| Failed to maintain sanitary practices by improperly storing food, failing to maintain correct dishwasher operation, and failing to prevent cross contamination during food service. | Level E |
| Failed to conduct annual staff evaluations for 5 of 5 employee records reviewed. | Level D |
| Failed to update a resident's Care Plan following their admission to Hospice Services for 1 of 1 resident reviewed (Resident #23). | Level D |
| Failed to ensure the required members were present at quarterly Quality Assurance Performance Improvement (QAPI) meetings. | Level D |
| Failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. Failed to provide hand hygiene supplies for each resident and/or visitor. | Level E |
| Failed to ensure Dependent Adult Abuse Mandatory Training recertification training was completed timely for 2 of 5 staff personnel files reviewed (Staff B, RN and Staff C, Maintenance Supervisor). | Level D |
Report Facts
Deficiencies cited: 17
Resident census: 34
Lab draw delay: 6
Missed warfarin doses: 8
PRN psychotropic medication days: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Named in findings related to code status discrepancy, family notification, infection prevention, anticoagulant monitoring, and abuse training. |
| Staff C | Maintenance Supervisor | Named in findings related to infection prevention, water management, and abuse training. |
| Staff G | Registered Nurse | Named in findings related to failure to conduct annual staff evaluations. |
| Staff H | Licensed Practical Nurse | Named in findings related to failure to conduct annual staff evaluations. |
| Staff I | Registered Nurse | Named in findings related to failure to conduct annual staff evaluations. |
| Staff A | Dining Services Manager | Named in findings related to dietary management and food service deficiencies. |
| Chief Clinical Officer | Named in findings related to infection prevention, food service, and psychotropic medication management. | |
| Director of Nursing | Named in findings related to anticoagulant monitoring, family notification, MDS transmission, and staff evaluations. | |
| Assistant Director of Nursing | Named in findings related to code status, anticoagulant monitoring, family notification, and MDS transmission. | |
| Regional Director of Quality and Clinical Services | Named in findings related to multiple deficiencies and facility expectations. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 17, 2023
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and approval of the facility's Plan of Correction, resulting in certification of compliance effective November 17, 2023.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Oct 30, 2023
Visit Reason
The inspection was conducted as a result of investigation of facility reported incident #115461-1 and complaint #116399-C, both of which were substantiated.
Findings
The facility failed to notify the physician and family of a significant weight loss for one resident, failed to recognize and investigate the cause of weight loss, and did not provide sufficient nursing staff coverage. The Director of Nursing acknowledged staffing issues and weight discrepancy concerns.
Complaint Details
Complaint #116399-C was substantiated. Facility reported incident #115461-1 was substantiated.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify physician and family of significant weight loss for Resident #2. | Level D |
| Failure to recognize, assess, and investigate cause of weight loss for Resident #2. | Level D |
| Failure to provide sufficient nursing staff with appropriate competencies to assure resident safety and care. | Level E |
Report Facts
Census: 33
Weight record: 146.8
Weight record: 132.3
Weight record: 59.4
Date: Sep 2, 2023
Time: 30
Time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged leaving the facility unattended and being the only nurse on duty on 9/2/23 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding weight discrepancy and staffing issues |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 15, 2023
Visit Reason
A revisit of the survey ending May 16, 2023 was conducted on June 15, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective 5/17/23.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
May 16, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and an investigation of complaint #112135-C and facility reported incident #112711-I, conducted from 5/8/23 to 5/16/23.
Findings
The facility was found to be in compliance with CDC recommended COVID-19 practices. However, a deficiency was identified related to accident hazards and supervision, specifically regarding Resident #1's elopement due to inadequate nursing supervision and failure to ensure the environment was free of hazards. The facility was notified of Immediate Jeopardy which was later removed after corrective actions were implemented.
Complaint Details
Complaint #112135-C was not substantiated. Facility reported incident #112711-I was substantiated. Immediate Jeopardy was identified beginning 5/2/23 and removed on 5/10/23 after education and corrective actions.
Severity Breakdown
K: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to provide adequate nursing supervision and assistive devices to ensure the environment was free of accident hazards for residents at risk of elopement, as evidenced by Resident #1 eloping unnoticed and the removal of her wander guard sensor. | K |
Report Facts
Total Residents: 34
Immediate Jeopardy duration: 8
Time for door alarm to close and lock: 114
Elopement drills frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay DeBerg | CEO | Signed the report and responsible for plan of correction |
| Staff A | Registered Nurse (R.N.) | Nurse on duty during elopement event and interviewed regarding incident |
| Staff B | Certified Nursing Assistant (CNA) | Staff on duty after Staff A left, interviewed about resident wandering |
| Director of Nursing | Director of Nursing (DON) | Conducted elopement evaluation and interviewed about door alarm and wander guard issues |
| Maintenance Supervisor | Maintenance Supervisor | Demonstrated door alarm system operation and interviewed about door alarm functionality |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 17, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on February 17, 2023, related to facility certification compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective February 17, 2023. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 6
Jan 17, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of reported incidents #109962-I and #110253-I from January 10 to January 17, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify the Office of the State Long-Term Care Ombudsman of resident discharge, failure to provide bed hold policy upon discharge, failure to follow accepted nursing practices during medication administration, inadequate quality of care assessments, failure to prevent and treat pressure ulcers, and failure to ensure proper food safety and sanitation practices. The facility reported a census of 34 residents during the inspection.
Complaint Details
Facility reported incidents #109962-I and #110253-I were investigated and found not substantiated.
Deficiencies (6)
| Description |
|---|
| Failure to notify the Office of the State Long-Term Care Ombudsman of discharge for 1 of 2 residents reviewed for hospitalization. |
| Failure to provide a bed hold policy upon discharge to a resident or resident representative. |
| Failure to follow accepted nursing practices during medication administration for 2 of 3 residents reviewed. |
| Failure to carry out adequate assessments after a change of condition for 1 of 2 residents reviewed. |
| Failure to create and/or carry out care plan interventions and treatments to prevent or heal pressure ulcers for 2 of 4 residents reviewed. |
| Failure to ensure proper food safety and sanitation practices including dishwasher function and kitchen cleanliness. |
Report Facts
Resident census: 34
Inspection dates: 8
Number of residents reviewed for medication administration deficiency: 3
Number of residents reviewed for pressure ulcer deficiency: 4
Number of residents reviewed for discharge notification deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in medication administration deficiency for not priming insulin pen. |
| Staff B | Certified Medication Assistant (CMA) | Named in medication administration deficiency related to medication orders and supervision. |
| Staff C | Dietary Staff | Named in food safety deficiencies related to glove use and food handling. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding deficiencies and corrective actions. |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 4
Jun 10, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaint #85865-C and facility reported incident #95006-I.
Findings
The facility was found deficient in posting survey results, notifying the Long-Term Care Ombudsman of resident transfers, maintaining a safe environment free of accident hazards, and ensuring proper food temperature and coverage during delivery. Several residents and staff interviews, observations, and record reviews supported these findings.
Complaint Details
Complaint #85865-C was not substantiated. Facility reported incident #96006-I was substantiated.
Deficiencies (4)
| Description |
|---|
| Facility did not have survey results accessible to residents as required. |
| Facility failed to notify the Long-Term Care Ombudsman of transfers/discharges for 3 of 3 residents reviewed. |
| Facility failed to maintain a safe environment by leaving hot electric griddle and steam table unattended. |
| Facility failed to maintain proper food temperatures and cover food during delivery to residents. |
Report Facts
Census: 45
Residents transferred without notification: 3
Residents interviewed: 6
Residents with wandering behaviors: 7
Food temperatures observed: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karla Dewey-Lawrence | Provisional Administrator | Signed the report and noted in plan of correction. |
| Director of Nursing | Director of Nursing | Interviewed regarding survey results posting and Ombudsman notifications; involved in plan of correction. |
| Staff A | Observed leaving hot steam table and electric griddle unattended; involved in food service observations. | |
| Staff B | Certified Nursing Assistant | Observed passing drinks to residents. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food temperature policies and supervision of steam table and griddle. |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Nov 18, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 45
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 37
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