Inspection Reports for
The Village of Ackley

The complaint involved neglect of Resident #2 after a fall on 8/16/25 when Staff D failed to assist or report the fall and left the facility. The allegation of neglect was substantiated. The facility also failed to report the abuse allegation to DIAL within the required timeframe.

The facility failed to ensure Resident #2 was free from neglect after a fall and failed to timely report the allegation of abuse to the Iowa Department of Inspection, Appeals, and Licensing (DIAL). Staff D left the resident unattended after the fall and did not notify nursing staff. The facility's policy lacked clear direction for staff on reporting falls.

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.

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.

The investigation was complaint-driven, focusing on allegations of resident mistreatment, failure to notify the LTC Ombudsman of resident transfers, failure to submit required PASRR evaluations, and inaccurate staffing data submissions. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to treat a resident with dignity and respect, failed to notify the LTC Ombudsman of resident transfers, failed to submit a required Level II PASRR evaluation for a resident with a new mental health diagnosis, and failed to submit accurate Payroll Based Journal staffing data reports.

The complaint involved Staff B telling Resident #14 to 'shut the fuck up' and stating 'your mom is fucking dead' during care. The complaint was substantiated, and Staff B was terminated.

The facility failed to treat Resident #14 with dignity and respect, as Staff B used inappropriate and offensive language during care. Staff B was removed from the floor and terminated. The facility also failed to provide documentation of training Staff B received on Resident Rights.

Complaint #125919-C was unsubstantiated. Facility reported incident #126090-I was substantiated.

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.

The facility failed to notify physicians and families timely regarding significant changes in residents' conditions, failed to provide a safe and clean environment, did not provide adequate nursing supervision to prevent falls, failed to provide appropriate nutritional and hydration support, and did not provide ordered speech therapy services. Incident reports and medical records were incomplete or inaccurate.

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.

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.

The facility had multiple deficiencies including failure to ensure congruent code status with hospice, delayed family notifications, incomplete resident assessments, inadequate medication monitoring for anticoagulants, improper dietary management, insufficient infection control measures, incomplete staff evaluations, and lack of updated care plans for hospice residents.

The facility failed to provide appropriate urinary tract infection prevention care for one resident, failed to manage psychotropic medications within required timeframes for one resident, and failed to ensure timely dependent adult abuse mandatory training recertification for two staff members.

Complaint #118905-C was substantiated.

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.

The investigation was complaint-driven, focusing on failure to notify physician and family about weight loss, failure to assess and intervene for weight loss, and inadequate nursing staff coverage. The facility reported a census of 33 residents. The complaint was substantiated based on clinical record reviews and staff interviews.

The facility failed to notify the physician and family of significant weight loss for one resident, failed to assess and investigate the cause of weight loss and implement interventions, and failed to provide 24/7 professional nursing coverage as required.

Complaint #116399-C was substantiated. Facility reported incident #115461-1 was substantiated.

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.

The complaint investigation was triggered by an elopement incident on 5/2/23 where Resident #1 left the facility unnoticed and was found by a community member outside. The facility was unaware of the elopement until contacted. The investigation confirmed failures in supervision, alarm system reactivation, and risk assessment.

The facility failed to provide adequate supervision and assistive devices to prevent elopement for 5 residents at risk. Resident #1 eloped unnoticed, exposing her to environmental hazards. The facility's door alarm system was slow to reactivate, and staff did not ensure it was reactivated before leaving the area. Four other residents at risk did not have wander guard sensors at the time.

The complaint investigation was triggered by an elopement incident on 5/2/2023 involving Resident #1, who left the facility unnoticed and was found by a community member. The facility was unaware of the elopement until contacted. The investigation confirmed failures in supervision, alarm system management, and risk assessment.

The facility failed to ensure adequate nursing supervision and assistive devices to prevent elopement for 5 residents at risk. Resident #1 eloped unnoticed, exposing her to environmental hazards. The facility's door alarm system was slow to re-engage, and staff did not consistently ensure alarms were active. Four other residents at risk lacked wander guard sensors at the time.

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.

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.

Facility reported incidents #109962-I and #110253-I were investigated and found not substantiated.

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.

The facility had multiple deficiencies including failure to notify the ombudsman of resident discharge, failure to provide bed hold policy notification, medication administration errors, inadequate assessments after change of condition, insufficient pressure ulcer care, and poor kitchen sanitation and food handling practices.

Complaint #85865-C was not substantiated. Facility reported incident #96006-I was substantiated.

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.