Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Estherville Community Care Center during CMS and state inspections, most recent first.
A cognitively intact but physically dependent resident, identified as at risk for falls and requiring assistance with toileting and transfers, was found on the floor after attempting to obtain help when needing the bathroom. The resident’s care plan required a call light within reach, but the call light cord had become caught in a bed rail hinge, preventing activation despite appearing to be within reach from the recliner. Unable to trigger the call light, the resident walked without a walker to retrieve a cell phone that was not within reach, resulting in a fall. Facility leadership and policy acknowledged that call lights were expected to be accessible, functional, and not wrapped around bed rails, but this was not achieved at the time of the event.
A cognitively intact, largely independent resident with multiple diagnoses, including CVA and hemiplegia, had an established goal and ongoing discussions about returning home, culminating in a provider order for discharge home. On the day of discharge, the family reported that no written discharge instructions or orders were reviewed or provided when they arrived and took the resident home. The DON later stated she had reviewed discharge instructions with the resident but acknowledged they were not signed and were instead mailed after discharge, and an RN confirmed that no discharge paperwork was given to the resident or family at the time of discharge. This occurred despite facility policy requiring residents to receive proper written notice and documented discharge planning.
Failure to Protect Residents from Financial Exploitation The facility failed to keep residents safe from financial abuse involving a CNA and missing money/cards. A resident with cancer, anxiety, and depression had debit card fraud totaling over $13,000 while living at the facility, and law enforcement confirmed criminal charges against the CNA. Another resident with bipolar disorder, spinal stenosis, and muscle weakness had fraudulent credit card activity tied to a missing card kept in a purse in the room, with police confirming evidence of the CNA attempting to withdraw money. A third resident with cancer and reduced mobility had cash and a credit card missing from a purse kept in the room, with the husband reporting repeated losses and the facility reimbursing $50.
A facility failed to accurately complete MDS assessments for two residents. One resident’s bed rails were coded as a physical restraint even though the resident could move independently and the siderail was documented as a transfer assist rail, while another resident’s MDS omitted antianxiety medication use despite the care plan and MAR showing Buspirone (Buspar) use for anxiety and a later MDS modification changing the coding.
The facility failed to submit an updated PASRR for a resident whose MDS listed depression, anxiety, Psychotic Disorder, and PTSD. The resident’s Level 1 PASRR did not include Psychotic Disorder or PTSD, and no later PASRR was found in the clinical record. The DON stated she did not complete a new PASRR because the MD was changing medications and she was unaware the PASRR was missing those diagnoses.
A resident with anxiety, depression, PTSD, and psychotic disorder had psych notes documenting childhood trauma, prior suicidal attempts, and grief over a spouse’s death, but the care plan did not include these issues or identify triggers, goals, or interventions related to the mental health diagnoses. The MDS Coordinator said care plans were based on meds and that psych notes were not reviewed, and she was not aware trauma needed to be assessed and care planned.
Failure to offer and document a pneumonia vaccine for a resident with no cognitive impairment. The MDS showed the resident was not up to date on the pneumococcal vaccine and that it was not offered, the immunization record had no vaccine entry, and although the resident signed consent after being educated on the risks and benefits, there was no documentation the vaccine was given. The IP could not find any record of the vaccine, and the DON stated the admission packet did not inform her that the resident had consented.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, indicating a lack of 24-hour licensed nursing coverage on seven dates. However, a review showed that nursing services were provided around the clock by the DON, LPNs, and RNs. The issue arose from staff hours not being transferred correctly for submission, which the Corporation was aware of and investigating.
The facility failed to complete comprehensive assessments within required time frames for seven residents, with delays ranging from 22 to 54 days. Despite a policy mandating timely assessments, the MDS for these residents were not completed within the 14-day requirement from the ARD. The deficiency was identified through record reviews, staff interviews, and policy review.
The facility failed to notify the LTC Ombudsman of a resident's transfer to a hospital, as required by policy. The resident's hospitalization was not included in the Discharge Report or the Notice of Transfer to the Ombudsman Report. The Administrator acknowledged the oversight, noting the resident was missed in the transfer notification process.
The facility failed to implement proper infection control practices during mealtimes, catheter management, and laundry delivery. A CNA did not perform hand hygiene after picking a fork off the floor before feeding a resident. A resident with an indwelling catheter was seen with the catheter bag and tubing dragging on the floor. Additionally, a Laundry Aide transported both clean and dirty laundry in uncovered carts, contrary to facility policy.
Two residents were unable to access their funds promptly due to the facility's lack of petty cash and reliance on corporate checks, which contradicted the policy of 24/7 access. One resident, with no cognitive impairment, experienced delays on weekends, while another, with moderate cognitive impairment, waited weeks for a $50 request. The administrator confirmed the issue, citing a two-day processing delay for corporate checks.
A resident with severe cognitive impairment fell and fractured her hip after slipping on water near an ice machine in the hallway. Staff interviews confirmed the presence of a small puddle of water, and the resident was wearing shoes without tread. The facility's policy emphasizes the importance of addressing environmental hazards like wet floors to prevent falls.
Failure to Ensure Accessible and Functional Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident had a functional call light system within reach, as required by the resident’s care plan and facility policy. The resident had an MDS BIMS score of 14, indicating intact cognition, and was dependent on staff for toileting, hygiene, bathing, lower body dressing, and transfers. The care plan identified the resident as at risk for falls related to a recent hospitalization and specified that the call light must be within reach. On the morning of the incident, staff heard someone calling for help and found the resident sitting on the floor with her back against her room door and feet extended. The resident reported she had attempted to use her call light for assistance to the bathroom, but the call light cord was caught in the hinge of the bed rail and could not be triggered when pulled. The incident documentation and subsequent interviews confirmed that, although the call light appeared to be within reach from the resident’s recliner, the cord had fallen and become entrapped under the bed grab bar, preventing activation. The resident then attempted to walk without her walker to retrieve her cell phone, which was charging on the sink counter, in order to call the facility for help, and she fell. Later observation showed the resident’s cell phone on a table across the room under a window, with a long cord attached but not within reach. The DON acknowledged that staff were expected to ensure call lights were within reach and not wrapped around bed rails, and the facility’s policy stated that all resident call lights must be accessible, functional, and answered promptly to maintain resident safety, dignity, and well-being. Despite these expectations and care plan interventions, the resident’s call light was not effectively accessible at the time assistance was needed.
Failure to Provide and Document Written Discharge Instructions at Time of Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that discharge instructions were documented in the medical record and provided in written form to a resident and/or the resident’s representative at the time of discharge. The resident had an MDS showing intact cognition (BIMS 14), independence with ADLs using a walker, and diagnoses including cerebrovascular accident, hemiplegia, anxiety, depression, and schizophrenia. The care plan and multiple care conference notes documented an ongoing goal and discussions about the resident’s wish to return home, with family expressing that discharge home remained a possibility and later anticipating a return home in the spring. On 2/24, a provider order was received for discharge home on 2/28, and the resident was discharged that day. Following discharge, the resident’s family reported that no discharge instructions or orders were reviewed or given to the resident or family when they arrived to take the resident home, stating they simply packed belongings and left. The Administrator confirmed the family had called to arrange discharge home, and the DON stated she went over discharge instructions with the resident prior to discharge but acknowledged that the discharge instructions were not signed by the resident. The DON further confirmed that discharge instructions were mailed to the resident several days after discharge for signature and had not been returned. Staff A, an RN, stated that no discharge paperwork was given to the resident or family at the time of discharge. This sequence of events occurred despite a facility policy stating that residents will receive proper written notice consistent with federal regulations and that discharge planning must include documentation of all planning activities.
Failure to Protect Residents from Financial Exploitation
Penalty
Summary
The facility failed to provide a safe environment free from financial exploitation of dependent adult abuse for 3 of 3 residents reviewed. Resident #41 had diagnoses of cancer, anxiety disorder, and depression, with a BIMS score of 14 indicating no cognitive impairment. After the resident discharged from the facility, the resident’s son reported the bank notified him of fraudulent debit card charges that began while the resident was still living at the facility and totaled over $13,000. A local law enforcement officer confirmed criminal charges against a CNA, Staff A, in connection with fraudulent purchases made using Resident #41’s debit card information, with additional charges pending investigation. The Administrator reported Staff A had been terminated after law enforcement removed the staff member from the facility and after learning of another resident’s missing money and debit card. Resident #43 had diagnoses of bipolar disorder, spinal stenosis, and muscle weakness, and a BIMS score of 14 indicating no cognitive impairment. The resident’s husband reported charges on the resident’s credit card account after discharge, and the resident stated she kept her debit card in her purse in the closet of her room while she was frequently away at therapy. The bank statement showed the first fraudulent charge attempt occurred while the resident was still at the facility, with transactions continuing after discharge. The incident report documented that law enforcement was notified, and a local law enforcement officer later confirmed evidence of Staff A attempting to withdraw money from Resident #43’s bank account at a drive-through window, with criminal charges filed and further investigation ongoing. Resident #32 had diagnoses of cancer, need for assistance with personal cares, and reduced mobility, with a BIMS score of 15 indicating no cognitive impairment. The resident and her husband reported cash and a credit card missing from a purse kept in the resident’s room, with money disappearing on more than one occasion. The husband described placing cash in the purse for personal expenses and later finding bills missing, along with a missing credit card. The Administrator reported the incident to law enforcement and reimbursed the resident $50. The facility policy defined abuse and misappropriation of a resident’s property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent.
Inaccurate MDS Coding for Bed Rail Use and Antianxiety Medication
Penalty
Summary
The facility failed to accurately document and submit resident MDS assessments for 2 of 2 residents reviewed. For Resident #7, the MDS dated [DATE] documented a BIMS score of 13, indicating intact cognition, and listed diagnoses including bilateral primary osteoarthritis of the knee, colon cancer, anemia, COPD, and atrial fibrillation. The MDS also coded bed rails as a physical restraint, while the care plan documented that the resident could move from lying to sitting on the edge of the bed independently and that a transfer assist rail on the right side of the bed was requested to maintain independence and mobility. During interview, the MDS Coordinator stated she had marked it wrong, had not completed a modification yet, and said the siderail did not restrict the resident’s movement and therefore should not have been coded as a restraint. For Resident #18, the MDS dated [DATE] documented long- and short-term memory problems and severely impaired daily decision-making skills, with diagnoses including non-Alzheimer’s dementia, anxiety disorder, depression, and psychotic disorder. The MDS identified antipsychotic and antidepressant use but did not indicate antianxiety medication use, even though the care plan identified Buspar for anxiety and the MARs for June and July 2025 documented Buspirone 5 mg twice daily during the lookback period. The MDS Coordinator stated she did not know why Buspar was not included, then later stated she fixed the MDS related to the resident’s Buspar use, and a modification MDS dated 7/2/25 changed antianxiety use to yes on 9/17/25.
PASRR Not Updated for New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for one resident with a new mental health diagnosis. Resident #3’s MDS assessment documented a BIMS score of 15, indicating intact cognition, and listed diagnoses of depression, anxiety, Psychotic Disorder, and PTSD. However, the resident’s Level 1 PASRR dated 6/19/24 did not include Psychotic Disorder or PTSD, and the clinical record contained no PASRR after that date. During interview, the DON stated she had submitted PASRRs but did not complete a new one for Resident #3 because the doctor kept changing medications, and she was not aware the PASRR lacked the Psychotic Disorder and PTSD diagnoses. The facility policy titled Pre-admission Screening and Resident Review, revised 11/2016, did not provide direction for a resident with a newly identified mental health diagnosis.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma informed care for Resident #3, who had diagnoses of anxiety, depression, PTSD, and psychotic disorder and a BIMS score of 15 indicating intact cognition. Record review showed behavioral health psych visit notes documenting childhood trauma, a history of suicidal attempts, and grief related to the death of the resident’s husband about a year earlier. The resident’s care plan did not include PTSD, the history of suicidal behavior, or the loss of the husband, and it also lacked potential triggers that could cause re-traumatization or suicidal ideations, as well as goals and interventions for the mental health diagnoses. The MDS Coordinator stated she builds care plans based on medications and does not review psych notes, and she was not aware that trauma needed to be assessed and care planned. The facility policy for comprehensive care plans stated that trauma informed care incorporates knowledge about trauma into care plans and practices to avoid re-traumatization.
Failure to Offer and Document Pneumonia Vaccination
Penalty
Summary
The facility failed to ensure that Resident #3 was offered and received the pneumonia vaccine. The resident’s MDS assessment documented a BIMS score of 15, indicating no cognitive impairment, and also noted that the resident was not up to date with the pneumonia vaccine and that it was not offered. The clinical record’s immunization page did not contain an entry for a pneumonia vaccine, and although a Pneumococcal Vaccine Consent dated 6/28/24 showed the resident e-signed after being educated on the risks and benefits and giving permission to receive the vaccine, there was no documentation that the vaccine was actually administered. During record review, the Infection Preventionist stated she could not find anything on the pneumonia vaccine for the resident, and the DON stated that when the admission packet was completed, they did not tell her the resident had consented to the pneumonia vaccine.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter from July 1 to September 30. The PBJ report indicated that the facility did not provide licensed nursing coverage 24 hours a day on seven specific dates in August and September. However, a review of the nurse schedule and time cards for these dates showed that nursing services were indeed provided around the clock by the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). The Business Office Manager (BOM) mentioned that missed punches were submitted to Weblock and then uploaded to a folder in Teams for the Corporation to handle. The Administrator acknowledged that during this period, the previous Corporation was responsible for submitting hours to PBJ, and there was an issue with staff hours not being transferred correctly for submission, which the Corporation was aware of and investigating.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments within the required time frames for seven residents. Record reviews revealed that the Minimum Data Sets (MDS) for these residents were past due, with delays ranging from 22 to 54 days. The assessments were in-progress but not completed within the 14-day requirement from the Assessment Reference Date (ARD). The residents affected included those with ARDs dating back to early October and November, indicating a significant backlog in completing these assessments. The facility's policy, revised in August 2022, mandates that comprehensive assessments be conducted within 14 days of admission, upon significant changes in condition, quarterly, and annually. Despite this policy, the assessments were not completed in a timely manner, as confirmed by the facility's administrator, who acknowledged the expectation for timely completion. The deficiency was identified through record reviews, staff interviews, and policy review, highlighting a systemic issue in adhering to the assessment schedule.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident's transfer to a hospital. The deficiency was identified through a review of records, staff interviews, and policy review. Specifically, the facility did not notify the Ombudsman about a resident's hospitalization from October 30 to November 6, as required by their policy. The resident was not included in the Discharge Report or the Notice of Transfer to the Ombudsman Report. The Administrator acknowledged the oversight during an interview, stating that the resident had been missed in the transfer notification process. The facility's policy mandates that a copy of the transfer or discharge notice should be sent to the Ombudsman and noted in the record, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene, Catheter Management, and Laundry Handling
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during mealtimes, catheter management, and laundry delivery. During an observation, a Certified Nurse Aide (CNA) was seen picking a fork off the floor, repositioning a resident, and feeding the resident without performing hand hygiene or changing gloves, contrary to the facility's hand hygiene policy. The Director of Nursing (DON) confirmed that staff should not pick utensils off the floor and then assist a resident with eating. Additionally, a resident with moderate cognitive impairment and an indwelling catheter was observed self-propelling her wheelchair with the catheter bag and tubing dragging on the floor, which was against the facility's policy that required catheter equipment to be kept off the floor. The Infection Preventionist (IP)/DON and the Administrator both stated that catheter bags and tubing should be kept in dignity bags and not on the floor. Furthermore, a Laundry Aide was observed transporting both clean and dirty laundry in uncovered carts throughout the facility, which was against the facility's policy that required laundry carts to be covered during transportation to prevent microbial contamination. The IP/DON and the Administrator confirmed that laundry should be covered at all times when transported in the facility.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their funds upon request, as evidenced by the experiences of two residents. Resident #2, who has no cognitive impairment, reported being unable to access her money on weekends due to the facility waiting for a check to arrive. This delay resulted in her having to wait several days to obtain her funds. Similarly, Resident #4, who has moderate cognitive impairment, requested $50 from the administration weeks prior and had not received it. He was informed that the facility needed to wait for a check to arrive, as there was no money available in the building. The facility's policy states that residents should have access to their funds 24/7, yet the administrator confirmed that the facility was out of petty cash and had to wait for a corporate check, which took two days to process. This situation led to residents being unable to access their funds promptly, contrary to the facility's policy. The administrator acknowledged the issue and mentioned working with the corporate office to find a solution, but the deficiency was evident in the delay experienced by the residents.
Resident Fall Due to Environmental Hazard
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent a fall for a resident, resulting in a health deficiency. The resident, who had diagnoses of anxiety disorder, abnormal weight loss, and adult failure to thrive, was found to have a Brief Interview for Mental Status (BIMS) score of 15, indicating severe cognitive impairment. The incident occurred when the resident slipped on water in front of an ice machine in the hallway, leading to a fall that resulted in a left hip fracture. The fall was not witnessed, and the resident was subsequently transported to the emergency department for evaluation and hospitalization for surgery. Interviews with staff members revealed that they heard the resident yelling for help and found her lying on the floor by the ice machine. The resident reported slipping on water, and staff confirmed the presence of a small puddle of water near the fall site. The resident was wearing shoes without tread at the time of the incident, which may have contributed to the fall. The facility's policy on fall management highlights the importance of addressing environmental hazards, such as wet floors, to reduce the risk of falls and injuries. The Director of Nursing (DON) confirmed that staff should clean up any spilled ice by the ice machine immediately and ensure the floor is dry. The facility's failure to address the environmental hazard of a wet floor in a timely manner contributed to the resident's fall and subsequent injury. The incident underscores the need for vigilant supervision and prompt attention to potential hazards to prevent accidents in the facility.
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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 Estherville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Estherville | 0.4 mi | ★★★★★ | 11 | 0 |
| Accura Healthcare Of Spirit Lake | 15.4 mi | ★★★★★ | 9 | 0 |
| Valley Vue Care Center | 16.5 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Jackson | 17.9 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Milford | 18 mi | ★★★★★ | 0 | 0 |
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