Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Emmetsburg Care Center during CMS and state inspections, most recent first.
Bathing care was not provided as planned for several residents who required assistance. Residents with varying cognitive status and ADL needs had repeated gaps between scheduled baths, including missed or delayed bathing and one refusal entry. A CNA said she was sometimes pulled to the floor and could not complete baths, and the DON verified baths did not always get done as planned due to staffing.
Controlled drug counts were not properly monitored, leading to a temporary inability to reconcile a resident’s morphine when an RN inadvertently took it home in her scrub jacket after administering it to a resident with acute pain from multiple fractures. Camera footage confirmed the medication left the room and facility in the RN’s pocket, and records also showed multiple missing signatures on narcotic shift-to-shift count sheets. Staff interviews indicated counts were sometimes not done together and that controlled substances, including fentanyl patches, were being counted inconsistently.
The facility failed to keep residents free from significant med errors involving insulin, an anticonvulsant, and an antidepressant. One resident with diabetes had blank MAR entries for ordered Lantus and sliding-scale Novolog despite a blood sugar requiring coverage, another resident’s Lacosamide doses were omitted even though they were charted as given, and a third resident repeatedly did not receive Escitalopram because the med was unavailable or not ordered correctly.
Incomplete Care Plan for Catheter and Pressure Ulcer: A resident with paraplegia, kidney disease, and no cognitive impairment had an indwelling suprapubic catheter and a stage 2 pressure ulcer, but the care plan did not address either condition. The CAA noted the catheter should be included to avoid complications and maintain function, and an LPN later verified both the catheter and pressure ulcer should have been on the care plan.
A resident with severe cognitive impairment, stroke, and hallucinations had increased behaviors and paranoia, leading to a physician order for Seroquel and a later dose increase. The MAR showed the antipsychotic was started and then increased, but the care plan did not identify that the resident was receiving antipsychotic medication.
Incontinent Care and UTI Prevention Deficiency: A resident with urine and frequent bowel incontinence, moderate cognitive impairment, diabetes, and BPH did not receive appropriate perineal care during AM hygiene. A CNA wiped the anal area, continued after stool was present on wipes, then cleaned the genital area without changing gloves or performing hand hygiene before applying a clean brief and clothing. The DON stated care should be front to back and gloves should be changed with hand hygiene before moving from back to front.
Inaccurate Pregabalin medication records were found for a resident with a BIMS score of 14 and diabetes. The MAR and medication card conflicted, with the MAR showing 75 mg BID while the physician order and pharmacy documentation reflected 50 mg BID. Staff had continued documenting the 75 mg dose until a CMA questioned the discrepancy, and the DON was unsure how the order was changed.
Failure to use EBP during wound care: an RN and an LPN performed a dressing change for a resident with paraplegia, CKD, and a pressure ulcer after a bath, using the same gloves and gauze to clean the anal area and then the wound. Neither staff member wore gowns during the procedure, and the LPN later stated they forgot to use EBP. The DON stated gowns and gloves should be used for wound care, and the facility policy required gowns and gloves for high-contact care activities including wound care.
A resident with intact cognition, multiple comorbidities, and documented moisture-related skin breakdown on the buttocks had a physician order for barrier cream to be applied with cares each shift. On a morning when the resident reported staff were rushed, she stated no cream was applied and that not all staff had been using her ointment, even though the Treatment Administration Record showed the treatment as completed. A CMA reported being told CNAs had applied the cream, but one CNA only "thought" another applied an unidentified cream from a white tube, and the other CNA denied providing incontinence care or applying any barrier cream. Later that day, an LPN measured an enlarged buttocks wound with additional open areas and applied Desitin, while the resident again confirmed she had not received cream that morning, demonstrating that the ordered treatment was neither consistently provided nor accurately documented.
The facility failed to provide and document scheduled bathing assistance for three residents who required varying levels of help with ADLs, despite care plans and standard twice-weekly bath schedules. One cognitively intact resident with multiple diagnoses went 11 and 7 days between baths, with no record of additional bathing offers, and a family member reported very infrequent bathing. Another cognitively intact resident with cancer, HTN, recent UTI, and CKD experienced 5- and 7-day gaps between baths and reported not having a shower or bath for about two and a half weeks, stating staff only used wipes for perineal care. A third resident with moderately impaired cognition and chronic conditions went 15 days without a bath, despite a preference for whirlpool baths and scheduled twice-weekly bathing, and reported receiving baths only about once a week. The DON and Administrator stated that baths are automatically scheduled twice weekly and documented in the EMR, and facility policy required point-of-care documentation of bathing, but records lacked documentation of missed baths and re-approach attempts.
The facility did not provide food prepared in a form tailored to meet the individual needs of residents, resulting in meals that were not consistently modified for specific dietary or physical requirements.
The facility failed to prevent accidents and provide adequate supervision for three residents, resulting in falls both during off-site transport and while using mechanical lifts. One resident fell during a medical transport without required staff assistance or mobility aids, while two others experienced falls from sit-to-stand lifts due to improper sling use, lack of staff education, and failure to follow manufacturer instructions.
Staff did not follow the established portion size guidelines for serving pureed food, using the wrong scoop size and resulting in incorrect portions for four residents on pureed diets. The error was confirmed by the cook and dietary manager, and there was no formal policy in place for the puree process.
Surveyors identified multiple food safety and sanitation deficiencies, including expired and improperly labeled food in storage, unsanitary freezer conditions, and improper food handling during meal service. Staff were observed using bare hands to retrieve utensils and holding plates against dirty uniforms, contrary to facility policy.
Staff did not follow required hand hygiene and infection control protocols while assisting a resident with transfers and toileting. A CNA failed to perform hand hygiene after removing gloves, handled soiled items with bare hands, and placed dirty clothing on the floor, only washing hands at the end of care. These actions did not comply with the facility's infection prevention policy.
A resident with a history of falls and no cognitive impairment experienced multiple falls in the facility. The required neurological assessments following each fall were not completed as per protocol, with several evaluations missed and documented as 'sleeping.' The Regional Nurse Consultant confirmed the assessments should have been completed.
The facility failed to develop comprehensive care plans for two residents, neglecting to address risk factors and interventions for medical conditions and high-risk medications. One resident with multiple diagnoses, including recurrent UTIs, did not have a care plan addressing UTI risks or medication side effects. Another resident on anticoagulant medication lacked a care plan for monitoring potential side effects. The MDS Coordinator acknowledged these omissions, and the facility lacked a policy on comprehensive care planning.
A resident with a history of serious health conditions experienced symptoms of a potential cardiopulmonary issue, including headache, chest pain, and elevated vital signs. Despite these symptoms, the facility failed to conduct a timely follow-up assessment or notify the physician and family. The resident's condition worsened overnight, leading to a delayed transfer to the emergency room the following morning.
A resident with severe cognitive impairment was found with a pillow placed under the fitted sheet, restricting their movement. Staff used the pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan. The MDS Coordinator and DON confirmed this placement constituted a restraint, contrary to facility policy.
A resident requiring substantial assistance for daily baths did not receive consistent bathing due to staffing shortages. The resident, who was cognitively intact and had multiple diagnoses, had baths documented only on select dates over a month. CNAs reported difficulties in providing regular baths due to insufficient staff, and the facility lacked a specific bathing policy.
A resident with moderate cognitive impairment and dental issues was served a regular pork chop instead of the prescribed mechanical soft ground meat diet. The cook served the regular pork chop based on the resident's preference, despite the dietary order. The facility's policy on ground meat diet orders was not followed, and the staff failed to notify the dietician or update the care plan.
Bathing Care Not Provided as Scheduled
Penalty
Summary
The facility failed to ensure baths were provided as planned for 3 of 4 residents reviewed. Resident #2 had a BIMS score of 14, indicating no cognitive impairment, and required partial/moderate assistance with bathing. The care plan directed staff to assist with showering/bathing per schedule, and the EHR task list documented bathing twice weekly and as needed. The bathing record showed multiple gaps between baths, including intervals of 7, 7, 6, 10, and 7 days, with one entry noting the resident was not available on 3/13/26. Resident #4 had a BIMS score of 8, indicating moderate cognitive impairment, and required supervision/touching assistance with bathing. The care plan directed staff to assist with showering/bathing per schedule, and the EHR task list documented bathing twice weekly and as needed. The bathing record showed several missed or delayed baths, including intervals of 12, 7, 11, 7, 7, and 11 days. Resident #5 had a BIMS score of 13, indicating no cognitive impairment, and required partial/moderate assistance with bathing. The care plan identified assistance with ADLs, and the EHR task list documented bathing twice weekly and as needed. The bathing record showed gaps of 7, 6, 8, 11, 11, 7, and 7 days, including one refusal entry. A CNA stated she did baths but was sometimes pulled to the floor and did not get to do the baths, and the DON verified baths did not always get done as planned due to staffing.
Controlled Drug Counts Not Properly Reconciled
Penalty
Summary
The facility failed to adequately monitor controlled drug records, resulting in a temporary inability to reconcile a controlled medication for one resident and other residents with controlled medications. Resident #1 had a BIMS score of 14 with no cognitive impairment and diagnoses that included fractures and other multiple traumas after a semitruck accident. The resident’s care plan identified acute pain related to multiple fractures, and hospice orders included morphine sulfate 20 mg/ml oral concentrate, 5 mg by mouth or under the tongue every 2 hours as needed for moderate to severe pain or shortness of breath. A medication event incident report documented that the resident’s morphine was missing from the narcotic drawer. Staff searched medication carts and treatment carts without locating the medication, and later learned that an overnight RN had inadvertently taken the morphine home in the pocket of her scrub jacket. The RN returned the medication after discovering it, and the facility reviewed the medication with hospice staff, reconciled the narcotic count, and destroyed the medication per protocol. Camera footage showed the RN leaving the resident’s room with the medication and placing it in her pocket while assisting another resident, and further showed the medication remained in her jacket pocket as she left the facility. Review of the Narcotic and Controlled Substance Shift to Shift Sheets showed multiple missing signatures across February, March, and April 2026 for off-going and on-coming nurses on various shifts. Staff interviews indicated that narcotic counts were not being completed together as required, with staff describing that counts were sometimes signed off without both parties counting together and that patches were counted incorrectly by counting boxes rather than individual patches. The DON stated that the RN and CMA did not count the narcotics and that the off-going and on-coming nurse/CMA should count the narcotics together to assure all medications were accounted for. The facility policy required narcotic counts at the beginning and end of each shift or when medication cart keys were exchanged, with both nurses validating and signing the count.
Significant medication errors involving insulin, anticonvulsant, and antidepressant medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 3 of 4 residents reviewed. One resident with diabetes and no cognitive impairment had orders for Lantus twice daily and Novolog per sliding scale, but the 4/22/26 MAR showed the morning Lantus dose was left blank and the breakfast Novolog dose was also blank despite a blood sugar of 168, which would have required 17 units per the sliding scale. A blood sugar summary contained handwritten notes stating the morning Novolog was held because of the blood sugar and the resident only ate one bowl of cereal, while the resident did receive 20 units of Lantus. The physician stated there was nothing in the record showing the Novolog was held and noted that if medication was being held, staff needed to contact the physician timely. A second resident with a seizure disorder and no cognitive impairment had an order for Lacosamide 150 mg twice daily. The MAR documented the medication as given twice daily in February, but the controlled drug receipt/record/disposition form showed the medication was signed out only once on several dates. A progress note documented that an agency nurse identified omitted doses of Lacosamide on multiple dates and acknowledged the medication was not administered on those dates even though it was documented as given in the medical record. The note also stated the resident remained at baseline with no adverse effects or seizure activity observed during the missed-dose period. A third resident with severe cognitive impairment and depression had an order for Escitalopram 5 mg daily, later changed from morning to bedtime. Progress notes documented repeated days when the medication was not available, including entries stating it was out of stock, no replacement card had been sent, the medication needed to be ordered, and staff were waiting for pharmacy delivery. Another note stated the resident had not received Escitalopram on the listed dates after the schedule change. The facility’s medication pass policy required staff to review the EMAR against the medication label and contact the physician if the order was questioned.
Incomplete Care Plan for Catheter and Pressure Ulcer
Penalty
Summary
The facility failed to develop a comprehensive care plan that identified a resident's needs and described the services to be furnished for an indwelling urinary catheter and a stage 2 pressure ulcer. Resident #5 had diagnoses including paraplegia, injury of kidney, and chronic kidney disease, and the MDS assessment documented a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. The CAA stated the resident had a suprapubic catheter in place and that it would be addressed in the care plan to avoid complications, maintain level of functioning, and minimize risks, but the current care plan with a target date of 5/3/26 did not address the indwelling catheter. A Weekly Pressure Ulcer Progress Report dated 1/13/26 documented that Resident #5 had a stage 2 pressure ulcer and that it continued to be present, but the current care plan only identified the resident at risk for alteration in skin integrity and did not address the pressure ulcer. On 5/7/26 at 7:35 a.m., Staff A, the MDS Coordinator/LPN, verified that both the catheter and the pressure ulcer should have been addressed on the care plan. The facility Care Plan Policy revised 3/25 stated that care plans were to be comprehensive and developed after the comprehensive assessment of a resident, with review and revision by the interdisciplinary team after completion of MDS assessments when applicable and with changes that warranted a care plan revision.
Care Plan Not Updated for Antipsychotic Use
Penalty
Summary
The facility failed to update the comprehensive care plan to reflect that Resident #8 was receiving an antipsychotic medication. Resident #8 had severe cognitive impairment on the MDS, with diagnoses including stroke and hallucinations, and the record showed no antipsychotic medications at the time of the assessment. On 3/24/26, staff documented increased behaviors and paranoia and contacted the physician to request a medication review; later that day, a signed order was received for Seroquel 25 mg twice daily. The MAR showed Seroquel was started on 3/24/26 and increased to 50 mg twice daily on 3/30/26 for dementia with mood disturbance, but the care plan with a target date of 6/21/26 did not identify that the resident was receiving antipsychotic medication.
Incontinent Care and Infection Prevention Deficiency
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to prevent urinary tract infections for a resident who was incontinent of urine and frequently incontinent of bowel. The resident had a BIMS score of 8 indicating moderate cognitive impairment, depended on staff for toileting hygiene, and had diagnoses including diabetes and benign prostatic hyperplasia. The care plan identified the resident needed assistance with ADLs, including assist of 1 for toilet transfers and cares using a front wheeled walker and belt. During morning incontinent care, two CNAs assisted the resident to stand and removed the incontinent pad. One CNA wiped the resident's anal area with a gloved hand and continued wiping after stool was present on the wipe. After asking an LPN for wipes, multiple wipes had stool on them. When stool was no longer found, the CNA did not change gloves and used a washcloth from a basin to wipe the front genital area, handling the cloth with both hands and turning it with the same gloves. The CNA then applied a new incontinent pad and shorts while still wearing the same gloves, and removed the gloves only after the resident was seated in the wheelchair. The DON stated incontinent care should be done front to back, and if care starts in the back, gloves should be changed with hand hygiene before cleaning the front. The facility's incontinence care policy also directed staff to remove feces, discard soiled materials and gloves, and apply clean brief/incontinent pad/undergarment.
Inaccurate Pregabalin Medication Record
Penalty
Summary
The facility failed to maintain an accurate medication record for one resident whose MDS assessment showed a BIMS score of 14, indicating no cognitive impairment, and whose diagnoses included diabetes. The MAR for March 2026 documented Pregabalin 50 mg twice daily, but the order was changed on 3/14/26 to 75 mg twice daily. During med pass on 4/10/26, staff identified a discrepancy between the medication card, which read Pregabalin 50 mg twice daily, and the MAR, which read 75 mg twice daily. The nurse held the morning dose pending clarification and contacted the pharmacy and provider; the provider’s nurse stated the resident was to continue Pregabalin 50 mg BID and that the transcription error was corrected on the MAR. A note to the physician documented that a nurse had changed the order from 50 mg twice daily to 75 mg on 3/13/26, while nursing staff had continued giving 50 mg twice daily even though the MAR stated 75 mg twice daily. The note also stated the pharmacy never documented a 75 mg order and had the correct 50 mg dose as ordered by the physician. The physician responded that the issue had already been addressed, stating the chart documentation from 2/19/26 showed 50 mg twice daily, clarified with the pharmacy, and that the dose had not changed and had never been 75 mg. The DON later stated she was unsure how the Pregabalin order was changed and confirmed the facility had continued documenting the 75 mg dose until the CMA questioned it.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during wound care for Resident #5, who had diagnoses including paraplegia, injury of kidney, chronic kidney disease, and a pressure ulcer. During a dressing change, Staff J RN and Staff A LPN performed wound care after the resident had just had a bath. Staff J used gauze sponges saturated with Vashe cleanser, used one sponge to wipe the anal area, then used another sponge to clean the ulcer while wearing the same gloves and wiped over the ulcer again with the same gauze. Staff A measured the wound at 2.2 cm by 1.2 cm by 0.3 cm. Staff J then washed her hands and changed gloves before applying the collagen dressing and silicone dressing. Neither staff member wore gowns during the procedure for enhanced barrier precautions. Staff A later stated they forgot to use EBP during the wound care, and the DON stated gowns and gloves should be used with wounds and that a new pair of gloves would be appropriate when moving from the anal area to a wound. The facility's Enhanced Barrier Precautions policy revised 3/2024 stated gowns and gloves should be used during high contact resident care activities including wound care for any skin opening requiring a dressing.
Failure to Provide and Accurately Document Ordered Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to accepted standards of clinical practice for a resident with intact cognition who was dependent for transfers and required assistance with bed mobility. The resident had diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease, and was care planned as being at risk for altered skin integrity due to frequent urinary incontinence and need for bed mobility assistance. A health status note documented moisture breakdown on the left inner buttocks with specific measurements, and a physician order directed staff to apply barrier cream with cares every shift to promote healing; however, the order did not specify the location for application or the type of barrier cream to be used. The facility’s policy required active physician orders to be followed and carried out as written. On the morning in question, the resident reported that staff were in a hurry, that her bottom was hurting, and that no cream had been applied that morning, despite having ointment available in her bedside table and a treatment order in place. She stated not all staff had been using the cream. The Treatment Administration Record showed the barrier cream treatment as signed off as completed for that morning shift. A CMA reported he was told the barrier cream was applied with morning cares by two CNAs. One CNA stated she thought the other CNA applied a cream from a white tube but did not know what it was or where it came from, while the other CNA reported she did not assist with changing the resident’s brief that morning and did not apply any barrier cream. Later that day, an LPN measured the wound on the left buttocks and found it had increased in size with two small open areas, and applied Desitin ointment. The resident again verified she had not received any cream or treatment for the wound during the morning shift, indicating the ordered treatment was not provided as documented.
Failure to Provide and Document Scheduled Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance according to residents’ assessed needs, care plans, and scheduled bathing routines for three residents. One resident with intact cognition and diagnoses including cancer, hypertension, non-Alzheimer’s dementia, anxiety disorder, and schizophrenia was care planned to receive staff assistance with showers/bathing per schedule. Task forms showed this resident received only four baths/showers over a 30-day period, with gaps of 11 days and 7 days between baths. The clinical record did not contain documentation of other attempts to offer or encourage bathing, and the resident’s sister reported that bathing was very infrequent and seemed to occur about every two weeks, often when she was present. A second cognitively intact resident with diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease required setup or cleanup assistance for bathing and was also care planned for scheduled showers/bathing. Task forms showed this resident received four baths/showers over 30 days, with gaps of 5 days and 7 days between baths, and no documentation of additional offers or encouragement for bathing. This resident reported believing she had not had a shower or bath for about two and a half weeks and stated that staff only used wipes to clean her bottom. A third resident with moderately impaired cognition and diagnoses including hypertension, diabetes mellitus, depression, and overactive bladder required substantial/maximal assistance for bathing, preferred showers, and was scheduled for twice-weekly bathing. Task forms showed this resident had a 15-day gap without a bath, and the clinical record lacked documentation of other bathing attempts. This resident reported liking whirlpool baths, described the shower as gross, and stated he received a bath about once a week but would like more frequent baths. The DON and Administrator reported that baths are scheduled twice weekly and documented in the electronic record, and the DON acknowledged concerns with bathing documentation and lack of insight into why baths were not done, while facility policy required documentation of completed showers/baths in point-of-care charting.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures. The report does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention for three residents reviewed for falls. One resident, who had a history of falls, generalized weakness, and required substantial assistance for mobility and toileting, experienced a fall outside the facility during transport to a medical appointment. The resident, who was known to have diarrhea and was on a blood thinner, was not accompanied by facility staff as required by his care plan, and did not use his prescribed mobility aids. The fall occurred when the resident attempted to use a restroom at a gas station with only the transport driver assisting, resulting in a head injury and hospitalization. Two other residents experienced falls during transfers using a mechanical sit-to-stand lift. One resident, with moderate cognitive impairment and significant physical limitations, slipped out of the sling during a transfer when the safety features were not properly utilized. Staff interviews revealed a lack of education and awareness regarding the use of a hip sling as a preventive measure, and there was no evidence of follow-up training after the incident. Observations showed that staff did not consistently use the correct sling or ensure that safety straps were properly tightened during transfers. Another resident, who was non-ambulatory and required maximal assistance, was involved in a fall when the sling used with the sit-to-stand lift was not manufactured for use with that specific lift, contrary to the operator's instructions. Staff failed to double-check the straps and did not use all required safety features, resulting in the resident being lowered to the floor after the sling became detached. Observations confirmed that mismatched slings were in use and that staff did not always adjust or tighten safety belts as required. The facility lacked consistent adherence to manufacturer instructions and did not provide adequate staff education or supervision to prevent these incidents.
Failure to Follow Pureed Diet Portion Sizes for Residents
Penalty
Summary
Staff failed to prepare and serve pureed food in accordance with the facility's established portion sizes and procedures for four residents on pureed diets. During meal preparation, the cook used a #10 scoop to serve pureed pork tenderloin instead of the required #12 and #16 scoops as indicated on the Pureed Diet Portion Sizes/Scoop Chart. This resulted in incorrect portion sizes being served, with leftover pureed meat remaining after meal service, despite only four servings being prepared for four residents. The cook acknowledged the error in scoop size and portioning, and the Certified Dietary Manager confirmed that the correct scoop sizes should have been used. The Administrator stated there was no formal policy on the puree process, and the facility relied on the portion size chart.
Food Safety and Sanitation Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards as evidenced by multiple observations during a kitchen tour and meal service. Expired food items, including two large containers of cream cheese past their expiration date and an undated open container, were found stored in the refrigerator. Additionally, a container of chicken broth was dated but not properly labeled with a use-by date. Freezers were found to be in unsanitary condition, with food debris present in all units, a broken plastic container with dried/frozen residue, ice build-up, and a damaged freezer door seal. These conditions were not in compliance with the facility's own policies regarding food storage, labeling, and sanitation. During meal service, improper food handling practices were observed. A staff member was seen holding plates of food against a dirty uniform while cutting pork tenderloin for multiple residents, and handled a serving utensil with bare hands after it fell into a pan of potatoes, then continued to use the same utensil to serve food. The Certified Dietary Manager confirmed that these actions were inappropriate and not in line with facility policy, which requires the use of gloves or utensils when handling ready-to-eat foods and mandates proper sanitation procedures. These deficiencies were identified during a survey with a facility census of 43 residents.
Failure to Follow Hand Hygiene and Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the care of a resident with multiple diagnoses, including hypertension, diabetes mellitus, cerebral palsy, and anxiety disorder. The resident required substantial to maximal assistance for transfers and toileting. During an observed transfer to the commode using a sit-to-stand lift, a CNA applied compression socks and braces to the resident's lower legs while wearing gloves, then removed the gloves without performing hand hygiene. The CNA and another staff member continued with the transfer process, including removing the resident's incontinence brief and placing it in the commode with bare hands, again without performing hand hygiene afterward. Further, the CNA handled the resident's clothing and placed soiled garments directly on the floor, donned new gloves without prior hand hygiene, and continued to assist the resident without following proper infection control protocols. Hand hygiene was only performed at the end of the care episode, after multiple opportunities were missed. The facility's policy required hand hygiene before and after direct resident contact, after glove removal, and after contact with soiled items, but these procedures were not followed during the observed care.
Inadequate Post-Fall Assessments for Resident
Penalty
Summary
The facility failed to perform adequate assessments following falls for a resident, identified as Resident #2, who was at risk for falls due to generalized weakness and difficulty in walking. The resident, who had no cognitive impairment and a history of falls, experienced multiple falls within the facility. After each fall, the facility was required to follow a specific neurological assessment protocol, which included frequent evaluations and documentation over a 72-hour period. However, the facility did not complete the required neurological assessments as per the protocol, with several instances of missed evaluations documented as the resident was 'sleeping.' The first incident on 1/9/25 involved the resident attempting to transfer to the bathroom without assistance, resulting in a fall. The neurological assessments were not completed at several required intervals. A subsequent fall on 1/12/25 was similarly followed by incomplete assessments, with multiple time slots marked as 'sleeping.' Another fall on 1/31/25 also showed a lack of completed assessments, with only two out of nine required evaluations documented. The Regional Nurse Consultant confirmed that the facility should have been completing the neurological assessments as per the protocol.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #35, with a BIMS score indicating intact cognition, had multiple diagnoses including anemia, atrial fibrillation, congestive heart failure, and recurrent urinary tract infections (UTIs). Despite receiving diuretic and opioid medications, the care plan did not address the risk factors for UTIs or the side effects of the high-risk medications. The MDS Coordinator acknowledged the oversight, noting that the care plan did not include interventions for UTIs or monitoring for medication side effects. Similarly, Resident #6, also with intact cognition, had diagnoses of atrial fibrillation, hypertension, and renal disease, and was receiving anticoagulant medication. The care plan failed to address the anticoagulant medication, its potential side effects, and necessary monitoring. The MDS Coordinator confirmed the omission, stating that high-risk medications should have been included in the care plan. The facility lacked a policy on comprehensive care planning, contributing to these deficiencies.
Failure to Timely Assess and Notify in Cardiopulmonary Event
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident experiencing symptoms indicative of a potential cardiopulmonary issue. The resident, who had a history of cancer, anemia, heart failure, hypertension, and non-Alzheimer's dementia, reported symptoms including headache, chest pain, and jaw pain, along with elevated blood pressure and pulse. Despite these symptoms, the facility did not conduct a follow-up assessment or notify the physician and family in a timely manner. On the evening of the incident, the resident's vital signs indicated elevated blood pressure and pulse, and the resident reported a pain level of 7 out of 10. The LPN on duty asked the resident if they wanted to go to the emergency room, but the resident declined. The following morning, the resident's condition had worsened, with increased pain and discomfort, elevated pulse, and decreased oxygen saturation. It was only then that the facility contacted the emergency room and sent the resident for further evaluation. The clinical record lacked documentation of any follow-up assessments or notifications to the resident's family or physician on the evening of the initial symptoms. The MDS Coordinator and DON both acknowledged the delay in sending the resident to the emergency room and the lack of timely notification to the physician and family. The facility's policy required immediate notification of the resident's responsible party and physician in the event of a change in medical condition, which was not adhered to in this case.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to protect a resident from the use of a physical restraint that the resident could not remove on their own. The resident, who had diagnoses of Alzheimer's Disease, anxiety disorder, and a history of falling, was observed with a pillow placed under the fitted sheet on their right side. This method of placement restricted the resident's movement, as confirmed by staff interviews and the facility's policy on physical restraint usage. Staff members, including CNAs, reported using the body pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan or ordered for use. The MDS Coordinator acknowledged that the pillow was not on the care plan and confirmed that its placement under the fitted sheet constituted a restraint. The Director of Nursing also confirmed that the pillow should not be placed under the fitted sheet, as it restricts movement, and stated that staff had been educated on the correct placement of the body pillow.
Failure to Provide Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide bathing assistance according to the preferences of a resident who required substantial assistance. The resident, who was cognitively intact and had diagnoses of diabetes, major depressive disorder, and anxiety disorder, was documented to need extensive assistance for daily baths. However, the electronic health record showed that baths were only completed on specific dates over a month-long period, with no documentation of attempts to encourage bathing or records of refusals. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that staffing shortages were a significant barrier to providing regular bathing assistance. CNAs reported that they often had to reschedule baths due to insufficient staff, leading to residents not receiving baths as needed. The facility lacked a specific policy on bathing, and the Director of Nursing confirmed that all bath records were maintained electronically without additional documentation forms.
Failure to Provide Prescribed Diet Texture
Penalty
Summary
The facility failed to ensure that a resident received the proper diet texture as prescribed. Resident #31, who has moderate cognitive impairment and is on a mechanically altered diet due to having very few teeth, was observed being served a regular pork chop instead of the prescribed mechanical soft ground meat. The cook, Staff C, acknowledged serving the regular pork chop because the resident preferred it this way, despite the dietary order. The resident confirmed that she liked her pork chop cut up and reported that she is on a ground meat diet due to her dental condition. The facility's policy on ground meat diet orders aims to provide appropriate texture meat products for residents with chewing or swallowing problems. However, the staff did not adhere to this policy, as they did not notify the dietician or update the care plan to reflect the resident's preference. The Director of Nursing (DON) reported that the Certified Dietary Manager (CDM) was educated on the need to notify the physician if a resident disagrees with the diet order, but this was not done in this instance.
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We read the 111 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Emmetsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Lutheran Home | 1.1 mi | ★★★★★ | 6 | 0 |
| Palo Alto County Hospital | 1.3 mi | ★★★★★ | 0 | 0 |
| Ruthven Community Care Center | 11.2 mi | ★★★★★ | 2 | 0 |
| West Bend Health And Rehabilitation | 15.5 mi | ★★★★★ | 0 | 0 |
| Laurens Care Center | 19.7 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.