Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crown Pointe Estates Care Center during CMS and state inspections, most recent first.
A resident with impaired balance and CHF suffered an unwitnessed fall during the night, resulting in leg pain and later diagnosis of a hip fracture. The overnight RN assessed the resident, administered Tylenol, and sent a fax to the physician, but did not make a phone call or notify the family. The physician did not acknowledge the fax until days later, and the family was not informed at the time of the incident, contrary to facility policy requiring prompt notification after significant changes in condition.
A resident with severe cognitive impairment was transferred to a hospital, and although verbal consent for a bed hold was obtained from the representative, the facility did not secure the required signature or specify the daily bed hold rate as mandated by policy.
A resident with a negative initial PASRR result was not referred for a Level II PASRR evaluation after developing new or possible serious mental health conditions, despite having diagnoses such as anxiety disorder, hallucinations, and dementia with Parkinsonism, and receiving behavioral health services and related medications. The DON confirmed that PASRR updates were expected with such changes, but the facility lacked a related policy.
Staff did not use required Enhanced Barrier Precautions, such as gown and gloves, while providing wound care and personal care to a resident with an open wound. Despite facility policy and available supplies, both a CNA and an RN performed dressing changes and toileting assistance without following EBP protocols.
A resident with a history of heart failure and impaired balance experienced an unwitnessed fall overnight. Staff did not promptly notify the physician or family, and failed to reassess the resident or document vital signs in a timely manner despite ongoing pain and inability to bear weight. The resident was not sent to the hospital until the morning shift, where a hip fracture, hypotension, and sepsis were diagnosed, leading to rapid decline and death. Facility policy for post-fall assessment and notification was not followed.
A resident with recent increased confusion and weakness, identified as high risk for falls, experienced two falls in one day. Despite facility policy requiring gait belt use for assisted ambulation and transfers, staff failed to use a gait belt while helping the resident, resulting in a second fall when the staff member let go to adjust a chair cushion.
The facility failed to store food properly for all residents. Surveyors found cooked ground beef dated a week prior and undated, open bags of chicken and pork in the freezer. The kitchen supervisor confirmed that opened food should be dated and leftovers are only good for 3 to 5 days. The facility's policy required food to be covered, labeled, and dated, but no policy on leftover storage duration was provided.
The facility failed to provide bed hold notices to two residents or their representatives during hospital transfers. One resident with severe cognitive impairment and another with no cognitive impairment were transferred to the hospital without receiving the required bed hold documentation. The facility's policy mandates informing residents and their representatives about bed hold policies at admission and transfer, which was not adhered to in these cases.
A resident with severe cognitive impairment did not receive wound care as per physician orders, which required a silver foam dressing to be changed three times a week. During an observation, it was found that the dressing had not been changed for five days. Staff interviews confirmed the dressing schedule, but the facility lacked a policy to ensure compliance with physician orders.
Two residents with severe cognitive impairments were served incorrect meal portions due to the use of a soup spoon instead of the required measuring devices. The facility's dietary guidelines specified portion sizes for an IDDSI level 6 diet, but Staff E estimated the portions due to a lack of measuring tools. The facility lacked a policy to ensure adherence to dietary guidelines.
A facility failed to adhere to infection prevention practices during wound and catheter care for a resident with severe cognitive impairment and an indwelling catheter. Staff did not maintain proper gown usage, as sleeves were pushed up during care, contrary to Enhanced Barrier Precautions (EBP) policy. Observations showed lapses in maintaining gown sleeve coverage and hand hygiene, which are crucial for residents with indwelling medical devices.
Failure to Notify Physician and Family After Resident Fall with Injury
Penalty
Summary
The facility failed to notify both the physician and the family after a resident experienced a fall with injury. The resident, who had a moderate cognitive deficit and was at risk for falls due to impaired balance and congestive heart failure, was found on the floor in his room after an unwitnessed fall around midnight. He complained of pain in his left leg and was given Tylenol before being transferred to a recliner. Although a fax was sent to the physician, there was no immediate phone contact, and the fax was not acknowledged by the physician until several days later. The family was also not notified at the time of the incident. Staff interviews revealed that the overnight nurse did not call the physician or the family, believing that unless it was an emergency, the morning nurse would handle family notification. The resident continued to experience pain and was unable to bear weight on his leg during subsequent checks. He was eventually sent to the hospital in the morning, where a fractured hip was diagnosed. Facility policy required notification of the physician and family in the event of a significant change in status, but this was not followed in this case.
Failure to Obtain Signed Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to ensure that the required bed hold notice was properly signed by either the resident or the resident's responsible person when a resident was transferred out of the facility. Clinical record review showed that a resident with severe cognitive impairment, as indicated by a BIMS score of 01 and diagnoses including hypertension, anemia, and hyponatremia, was transferred to a hospital due to high potassium levels. Documentation revealed that while verbal consent for the bed hold was obtained from the resident's representative, the bed hold notice lacked both the required signature and the amount per day that the resident or representative agreed to pay. Facility policy requires written and verbal notice at admission and at the time of transfer, but this was not followed in this instance.
Failure to Refer for Level II PASRR Evaluation After Change in Mental Health Status
Penalty
Summary
The facility failed to refer a resident, who initially had a negative Level I Preadmission Screening and Resident Review (PASRR) result, for a Level II PASRR evaluation after new or possible serious mental disorder, intellectual disability, or other related conditions became evident. Clinical record review showed that the resident had diagnoses including anxiety disorder, hallucinations, and dementia with Parkinsonism, and was prescribed medications such as Depakote, Remeron, and Seroquel for behavioral and mental health conditions. The resident also received behavioral health services, as documented in visit notes. Despite these changes in diagnosis, medication, and behavioral health interventions, the facility did not update or submit a new PASRR referral as required. During staff interview, the DON acknowledged the expectation to update PASRR with such changes and reported the absence of a facility policy related to PASRR.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during wound care and personal care activities for a resident with an open wound. During an observation, a CNA and an RN assisted the resident with toileting and performed a dressing change on a coccyx wound without wearing the required gown and gloves, despite the facility's policy mandating EBP for any wound requiring a dressing. The open wound had been identified several days prior and was being treated per physician orders. The facility's policy clearly states that EBP, including gown and gloves, must be used during high-contact care activities such as dressing changes, toileting, and hygiene for residents with wounds requiring dressings, regardless of MDRO status. Staff interviews confirmed that EBP supplies were available, but the precautions were not followed during the observed care.
Failure to Provide Timely Assessment and Intervention After Resident Fall
Penalty
Summary
Staff failed to provide adequate and timely assessment and intervention following a resident's unwitnessed fall during the overnight shift. The resident, who had a history of congestive heart failure, impaired balance, and moderate cognitive deficit, was found on the floor after attempting to go to the bathroom. Initial assessment noted pain in the left leg, and Tylenol was administered. However, the nurse did not contact the on-call physician or the family, and the resident was transferred back to a recliner without further immediate medical evaluation. Subsequent monitoring throughout the night revealed ongoing pain and an inability to bear weight on the left leg, but no additional vital signs were documented during a follow-up assessment, and the physician was not notified until the morning shift. The nurse reported attempting to contact the DON but did not reach them and instead sent a fax to the physician. The resident's condition deteriorated, with a significant drop in blood pressure recorded in the early morning. It was only after the morning nurse assessed the resident and found severe pain with range of motion that the physician was contacted and the resident was sent to the hospital. At the hospital, the resident was diagnosed with a closed intertrochanteric fracture of the left hip, hypotension, and sepsis. The resident's condition rapidly declined, leading to admission to the ICU and subsequent death. Facility policy required immediate and ongoing neuro checks and vital signs after unwitnessed falls, as well as prompt physician notification for suspected fractures or significant pain, but these procedures were not followed in this case.
Failure to Use Gait Belt During Resident Transfer and Ambulation
Penalty
Summary
A resident with a history of ovarian cancer and a recent fracture, who was independent with transfers and ambulation using a walker, experienced a change in status with increased confusion and weakness. On the morning in question, the resident had an unwitnessed fall in the bathroom and was subsequently identified as high risk for falls. Despite this change in condition and the facility's policy requiring the use of gait belts for residents needing assistance with ambulation or transfers, staff failed to use a gait belt when assisting the resident later that morning. During this assistance, the staff member momentarily let go of the resident to adjust a chair cushion, resulting in the resident falling backwards. Interviews with staff confirmed that the resident was more confused and weak than usual, and that the need for close monitoring and use of a gait belt had been communicated. However, the staff member assisting the resident did not use a gait belt and instead held onto the back of the resident's pants. The facility's policy, last reviewed in September 2024, clearly stated that gait belts should be used for any resident requiring assistance with ambulation or transfers, but this protocol was not followed, directly contributing to the resident's second fall.
Failure to Store Food Properly
Penalty
Summary
The facility failed to store food in accordance with professional standards for all 91 residents. During a kitchen tour, surveyors observed cooked ground beef in a metal steam table container dated a week prior, which should have been discarded according to the kitchen supervisor. Additionally, the small fried food freezer contained undated and open bags of chicken strips, chicken patties, and breaded pork. The kitchen supervisor acknowledged that all opened food bags should be dated and that leftover food is only good for 3 to 5 days after preparation. The facility's policy on nutrition services required food to be covered, labeled, and dated when stored, but no specific policy on the acceptable number of days for storing leftovers was provided by the facility management or administration.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives when residents were transferred out of the facility for hospital admissions. This deficiency was identified for two residents. Resident #29, who had severe cognitive impairment with diagnoses of renal failure and heart failure, was transferred to the emergency department due to increased swelling in the left lower calf. The resident was absent from the facility from September 10, 2023, to September 12, 2023. However, the clinical record lacked documentation of a bed hold notice for this hospital admission. Similarly, Resident #45, who had no cognitive impairment and was diagnosed with heart failure, renal failure, and Diabetes Mellitus, was transferred to the hospital on November 29, 2023, and returned on December 4, 2023. The facility also failed to provide a bed hold notice for this resident's hospital admission. The facility's bed hold policy, last reviewed in July 2024, requires that residents and their representatives be informed in writing and verbally about the bed hold policy at the time of admission and transfer. The Administrator acknowledged the expectation for staff to complete bed hold forms and mentioned ongoing audits to address the issue.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following physician orders for a resident with severe cognitive impairment. The resident had a physician's order for a silver foam dressing to be applied to a wound on the coccyx three times a week and as needed. The dressing was to be changed every Sunday, Wednesday, and Friday at 7 am. However, during an observation, it was found that the dressing had not been changed as per the schedule, as it was dated five days prior to the observation. Staff interviews revealed that the dressing was intended to cover a pressure area and should have been changed according to the physician's order. Despite this, the facility lacked a policy on following or completing physician orders, relying instead on the expectation that professional standards would be followed. This oversight resulted in the dressing not being changed as required, indicating a failure to meet the professional standards of care for the resident.
Failure to Provide Correct Meal Portions for Residents
Penalty
Summary
The facility failed to provide a well-balanced diet that meets the nutritional and special dietary needs of two residents, as observed during a survey. Resident #22 and Resident #41, both with severe cognitive impairments as indicated by their Brief Interview for Mental Status (BIMS) scores, were served incorrect portion sizes for their meals. Specifically, Staff E used a soup spoon to serve three spoonfuls of noodles and beef to each resident, instead of using the appropriate measuring devices as per the dietary requirements. The physician's orders for both residents specified an International Dysphagia Diet Standardisation Initiative (IDDSI) level 6 soft and bite-sized diet, which required specific portion sizes of 3 oz of beef tips and 4 oz of noodles. Staff E admitted to running out of measuring devices and resorted to estimating the portion sizes by eye, which led to the incorrect serving sizes. The facility's menu documentation confirmed the required portion sizes for the IDDSI level 6 diet, and the Certified Dietary Manager (CDM) stated that the expectation was to use the appropriate scoop sizes. However, the facility was unable to provide a policy regarding the adherence to menu guidelines and the use of proper measuring tools, indicating a lack of procedural guidance in ensuring dietary compliance.
Infection Control Deficiency in Wound and Catheter Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during wound care and catheter care for a resident with severe cognitive impairment and an indwelling catheter. During an observation, a staff member was seen changing the resident's right knee dressing. The staff member performed hand hygiene and donned a gown and gloves before removing the old dressing. However, the staff member did not maintain proper gown usage, as the sleeves were pushed up and not returned to cover the wrists during care. This was contrary to the facility's policy on Enhanced Barrier Precautions (EBP), which requires gown sleeves to remain in place during resident contact. Another observation revealed a staff member performing catheter and peri care on the same resident. The staff member initially followed proper hand hygiene and PPE protocols but failed to maintain gown sleeve coverage after washing hands. The facility's policy and CDC guidelines emphasize the importance of maintaining gown coverage and performing hand hygiene when changing gloves, especially for residents with indwelling medical devices. The staff member admitted to forgetting to adjust the gown sleeves, which was not in compliance with the expected infection prevention practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sioux Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Ridge Care Center | 7.1 mi | ★★★★★ | 0 | 0 |
| Pleasant Acres Care Center | 8.7 mi | ★★★★★ | 14 | 0 |
| Hegg Memorial Health Center | 11.5 mi | ★★★★★ | 4 | 0 |
| Hillcrest Health Care Center | 16.3 mi | ★★★★★ | 30 | 0 |
| Good Samaritan - Lemars | 18.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.