Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Titonka Care Center during CMS and state inspections, most recent first.
The facility did not have a licensed Administrator on staff after the previous Administrator left, with the DON applying for provisional status but not yet approved. The former Administrator was only available by phone and had not been present in the building, and the facility was not actively seeking a replacement. The census was 21 residents.
The facility did not maintain an effective Legionella water management program, as maintenance staff were unaware of required procedures and had not monitored hot water system temperatures since the previous administrator's departure. The DON confirmed that staff lacked knowledge of necessary water testing and prevention steps, and there was no documentation of preventive actions.
A resident with a seizure disorder did not receive prescribed evening medications after a nurse left them unattended in the resident's room, resulting in missed doses. The medications were incorrectly documented as given, and a follow-up for an as-needed medication was falsely recorded as effective, contrary to facility policy.
A resident with severe cognitive impairment experienced multiple unwitnessed falls, and staff failed to perform required neurological assessments after seven of these incidents. Despite facility policy mandating neuro checks for all unwitnessed falls unless the resident is alert, oriented, and has a high BIMS score, staff did not complete the assessments, and this was confirmed by the DON.
A resident with multiple chronic conditions was found to have oxygen tubing that was not changed or labeled according to facility policy, despite reporting discomfort and requesting a replacement. The MAR lacked documentation or instructions for staff to change the tubing, and the DON confirmed that standing orders for this task were not transferred to the TAR, resulting in the deficiency.
The facility failed to report PBJ data during the 1st quarter of fiscal year 2024. The data file was rejected due to a mismatch in the reporting period, and the error was not followed up on after the BOM resigned. The DON has since been educated on the PBJ process, and the facility has implemented a PBJ policy.
The facility failed to ensure proper hand hygiene during wound care and colostomy bag management for two residents, and did not complete an annual review of infection control policies. The DON acknowledged these deficiencies.
Failure to Employ Licensed Administrator
Penalty
Summary
The facility failed to employ a licensed Administrator as required by State and local law. According to interviews with the Director of Nursing (DON), the previous Administrator left in October, and since then, the facility has not had a licensed Administrator on staff. The DON reported that she had applied for a Provisional Administrator position but had not yet been approved. The former Administrator was only available by phone and had not been present in the facility since her departure. Additionally, the facility was not actively seeking a replacement Administrator during this period. The facility had a reported census of 21 residents at the time of the deficiency.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement and maintain an effective Legionella water management program as required by its infection prevention and control policy. During interviews, the maintenance staff was unable to explain current procedures for preventing Legionella growth and admitted to not knowing what actions were necessary for the program. The maintenance staff also reported that no hot water system temperatures had been taken since June 2024, following the departure of the previous administrator who was responsible for the Legionella program. Although the maintenance staff occasionally ran water down the drains, there was no documentation of these actions, and he incorrectly believed that city testing for Legionella was sufficient. A review of the facility's Legionella Prevention Policy and Procedure indicated the importance of maintaining building water systems to prevent Legionella growth, specifically mentioning systems such as hot tubs, hot water tanks, large plumbing systems, cooling towers, and decorative fountains. The Director of Nursing confirmed that the maintenance staff was unaware of the required water testing or other necessary steps for Legionella prevention, and only recently obtained information on what should be included in the facility's Legionella policy.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder, hypertension, and peripheral autonomic neuropathy did not receive their prescribed evening medications, including an anticonvulsant, Tylenol, and cold medication. The resident reported that the medications were left on her tray table while she was asleep, and she was not awakened to take them. The following morning, the resident informed a nurse that the medications were still in her room and had not been taken. The Assistant Director of Nursing confirmed that the medications, including the seizure medication, were left in the resident's room and should not have been left for the resident to self-administer. Review of the Medication Administration Record showed that the medications were incorrectly documented as administered, and a follow-up was falsely recorded as effective for the as-needed cold medication. Interviews with nursing staff confirmed that the nurse responsible for the previous evening's medication round did not follow proper procedures for medication administration and documentation. Facility policy requires accountability in the medication system, which was not followed in this instance.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to perform neurological assessments as required following unwitnessed falls for a resident with severe cognitive impairment. Clinical record reviews and incident reports showed that the resident, who had diagnoses including Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, experienced 14 falls since May 2024. Of these, 7 were unwitnessed falls, and the facility did not complete neurological assessments as mandated by their policy. The policy specifies that neurological checks must be performed after any unwitnessed fall, regardless of whether the resident denies hitting their head, unless the resident is alert, oriented, and has a BIMS score of 12 or higher. The resident in question had a BIMS score of 00, indicating severe cognitive impairment, and therefore did not meet the exception criteria. Incident reports for each unwitnessed fall documented the circumstances, such as the resident being found on the floor in various locations, but did not include evidence of completed neurological assessments. Staff interviews confirmed that neurological assessments were not performed for these incidents, and the DON acknowledged the failure to follow the facility's policy. The lack of neurological assessments was not due to any documented clinical judgment or exception, but rather a misunderstanding or disregard of the policy requirements.
Failure to Change and Label Oxygen Tubing as Required
Penalty
Summary
A deficiency occurred when the facility failed to change and label oxygen tubing for a resident with diagnoses of heart failure, hypertension, and diabetes mellitus. The resident, who was cognitively intact, was observed to have oxygen tubing without a date indicating when it was last changed. During medication administration, the resident reported to the nurse that the tubing was hard, causing a sore in his nose, and requested a new set, stating he wears it nightly and believed it had not been changed in the last thirty days. Despite this request, the tubing had not been changed or labeled as of later that day. Review of the Medication Administration Record (MAR) for the relevant months showed no documentation or instructions regarding changing the oxygen tubing. The facility's policy on oxygen therapy required weekly changes of the mask, cannula, and bottle, but this was not reflected in the MAR or Treatment Administration Record (TAR), leaving staff without guidance. The DON confirmed that the standing orders for changing oxygen tubing should have been included on the TAR to direct staff, but this was missed.
Failure to Report PBJ Data
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) data during the 1st quarter of fiscal year 2024. The facility, which reported a census of 13 residents, did not submit the required PBJ data. The PBJ report provided by CMS indicated that the data file was rejected because the reporting period selected on the upload screen did not match the submitted XML. The Director of Nursing (DON) reported that the previous Business Office Manager (BOM) submitted the PBJ data, but the file was rejected due to a fatal error. The BOM resigned shortly after, and the error was not followed up on. The DON has since been educated on the PBJ process and now has access to it. The facility did not have a PBJ policy at the time of the incident but has since implemented one.
Infection Control Deficiencies
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for two residents. For Resident #1, who had severe cognitive impairment and an open wound on the left shoulder, the facility did not ensure proper hand hygiene during wound care. The RN did not complete hand hygiene after removing gloves multiple times during the dressing change, which involved handling wound care supplies and applying bacitracin ointment. This lapse in protocol occurred despite the presence of a wound culture revealing Staphylococcus Aureus and a physician's order for antibiotic treatment. For Resident #8, who had intact cognition and a colostomy, the RN also failed to perform hand hygiene after removing gloves while emptying the colostomy bag. The RN adjusted the resident's brief and handled the graduate with stool contents without washing hands between glove changes. Additionally, the facility did not complete an annual review of its infection control policies and procedures, with several policies lacking revision or review dates. The DON acknowledged the deficiencies in hand hygiene and the incomplete review of infection control policies, noting that the policies were a work in progress and had not been reviewed by the Medical Director.
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What surveyors actually found near you
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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 Titonka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Bancroft | 9.1 mi | ★★★★★ | 0 | 0 |
| Timely Mission Nursing Home | 11.5 mi | ★★★★★ | 1 | 0 |
| Algona Manor Care Center | 14.3 mi | ★★★★★ | 0 | 0 |
| Westview Care Center | 15.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan - Algona | 15.4 mi | ★★★★★ | 4 | 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.