Crown Pointe Estates Care Center
Non profit - Corporation
99 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
33/100
#184 of 392 in IA
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Crown Pointe Estates Care Center has a Trust Grade of F, which indicates significant concerns about the quality of care provided. It ranks #184 out of 392 facilities in Iowa, placing it in the top half of the state's nursing homes, and #3 out of 5 in Sioux County, meaning only two local options are better. Unfortunately, the facility is experiencing a worsening trend, with issues increasing from 5 in 2024 to 6 in 2025. Staffing is a strength here, earning a 5/5 star rating and a turnover rate of 37%, which is below the state average, indicating that staff members are generally staying long enough to build relationships with residents. However, the facility has incurred $117,554 in fines, which is concerning as it is higher than 92% of Iowa facilities and suggests ongoing compliance issues. Specific incidents have raised alarms, such as a resident exiting the facility unsupervised during winter, which led to a fall and an emergency room visit, and significant concerns about food safety, including improperly stored food that posed potential health risks. While the staffing levels are commendable, the critical safety oversights and high fines indicate that families should weigh these serious weaknesses when considering this facility for their loved ones.
- Trust Score
- F
- In Iowa
- #184/392
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Iowa's 48% average. Typical for the industry.
- Penalties ✓ Good
- $117,554 in fines. Lower than most Iowa facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Iowa. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Top 46%
Review needed
5 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 6 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Iowa average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Iowa average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 37%
Near Iowa avg (46%)
Typical for the industry
Federal Fines: $117,554
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 21 deficiencies on record
1 life-threatening
Jun 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy review the facility failed to notify the doctor and family after a resident had a fall wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy review the facility failed to notify the doctor and family after a resident had a fall with injury. Resident #143 had a fall around midnight, he was assessed at that time and again at 4:00 AM. At 6:30 AM, the resident was sent to the hospital and found to have a fractured hip. The facility reported a census of 89 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #143 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). At the time of admission, he was independent with transfers and ambulation.
The Care Plan updated on 2/16/25, showed that Resident #142 had weakness, impaired balance and Congestive Heart Failure (CHF). The resident had increased shortness of breath accompanied with cough and lower extremity edema related to CHF. He was at risk for falls due to impaired balance, staff were to monitor vitals and for injuries.
An Event Report dated 3/28/25 at 12:15 AM showed that Resident #143 had an unwitnessed fall in his room. He was found lying on his left side and told the staff that he got dizzy. He did not remember if he had hit his head or not. The initial blood pressure was 105/55. The resident complained of pain in his left leg, was given Tylenol and transferred back into the recliner. The report showed that a Fax was sent to the doctor. (According to the Nursing Notes, the fax was acknowledged by the doctor on 3/31/25 at 4:58PM.)
On 6/24/25 at 10:44 AM, Staff G, Registered Nurse (RN) said that on the overnight shift of 3/28/25, Resident #143 woke up and tried to go to bathroom and fell. The Certified Nurse Aide (CNA) found him on the floor and the two of them transferred him back into the recliner. Staff G said that he checked the Range of Motion (ROM) of his legs and he was moving them but the left one was painful. Staff G administered some Tylenol and the resident said he was feeling okay. Staff G said that they kept checking on him throughout the night and he continued to have some pain. Staff G said that he tried to call the Director of Nursing (DON) at the time but the call didn't go through. He said that he did not contact doctor by phone, but sent a fax. It was his understanding that if it was after 11:00 PM, unless it was an emergency, the nurse in the morning would contact the family.
According to a summary the DON had a conversation with Staff G on 3/28/25 and asked him why he hadn't sent the resident out he said around 5:00 AM they went in to toilet him but the resident was unable to get up he couldn't bear weight on his leg. Educated on decreased ROM, not being able to bear weight to call the ER doc and call the family.
On 6/26/25 at 11:15 AM, the DON and the Administrator agreed that the overnight nurse should have called the doctor and the family sooner.
A facility policy last reviewed 10/2024 titled: Hot Tracking, the charge nurse would assess change in status and the physician and family would be notified if applicable. The doctor would be notified for review of resident's condition as needed to advise nursing if any changes were needed. Notify family of significant change in residents status and care plan if applicable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 1 of 1 residents reviewed (Residents #7). The facility reported a census of 89 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of hypertension, anemia and hyponatremia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment.
Review of Progress Notes revealed the following:
a. On 5/7/25 at 10:38 a.m., resident received orders from the local hospital to be admitted due to high potassium.
b. On 5/10/25 at 4:31 a.m., late entry for 5/7/25 hospital called resident had been admitted for observation. The family gives verbal consent for bed hold.
c. On 5/11/25 at 12:14 p.m., 11:25 a.m., return to the facility with sister.
Review of the bed hold dated 5/7/25 revealed verbal authorization from Resident #7 ' s representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay.
Review of the facility provided policy titled Bed hold with a last revised date of 7/2024 revealed the facility will inform residents and their representatives through written and verbal notice at the time of admission and at the time of transfer for hospitalization or therapeutic leave.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #46) reviewed for PASRR requirements. The facility reported a census of 89 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #46 documented diagnoses of anxiety disorder, and prescribed antipsychotics. The MDS included a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment.
The Medical Diagnosis list for Resident #46 revealed the following diagnoses:
a. Hallucinations
b. Anxiety disorder
c. Dementia with Parkinsonism
The Clinical Orders for Resident #46 revealed the following medications:
a. Depakote extended release 250 milligram (mg) twice a day for aggressive behavior
b. Remeron 7.5 mg at bedtime for depression
c. Seroquel 25 mg at bedtime for dementia with Parkinsonism
The Provider Communication form dated 11/14/24 for Resident #46 showed an order for a behavioral health consult.
The Visit Notes dated 6/10/25 for Resident #46 showed behavior health services received.
In an interview on 6/25/25 at 2:25 PM, the Director of Nursing, (DON) reported she expected the PASSR to be updated and submitted with changes in medication, diagnoses, and behavioral health services related to mental health. The DON reported the facility failed to have a policy related to PASSR.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, chart and policy review the facility failed to ensure that staff provided adequate and timely assessments a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, chart and policy review the facility failed to ensure that staff provided adequate and timely assessments and interventions for 1 of 20 residents reviewed. Resident #143 had a fall on the overnight shift, the staff failed to call the doctor and did not reassess the resident until 4 hours later when he was unable to bear weight on the left leg. Resident #142 was sent to the hospital 7 hours after the fall, and was found to have a fractured hip. The facility reported a census of 89 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #143 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit.) At the time of admission, the resident was independent with sit to lying, chair to bed transfer and toilet transfers.
The Care Plan updated on [DATE], showed Resident #143 had weakness, impaired balance and congestive heart failure. He used a walker for mobility, was independent with transfers, and toileting. The resident had increased shortness of breath, accompanied with cough, lower extremity edema and staff were to monitor for vital signs and injuries.
An Event Report dated [DATE] at 12:15 AM, showed Resident #143 had an unwitnessed fall in his room. He was found lying on his left side and told the staff that he got dizzy. He did not remember if he had hit his head or not. His initial blood pressure after the fall was 105/55. The resident complained of pain in his left leg, was given Tylenol and transferred back into the recliner.
A document titled: Neuro Checks for Resident #143, showed that on [DATE] at 1:13 AM, the pupil reaction was brisk, pupil shape was round, eye movement, tracking and peripheral visual fields were intact. A follow up neuro checks at 4:15 AM, showed the same eye assessment responses and then indicated that the resident was sleeping. The chart lacked vitals during this assessment.
On [DATE] at 12:27 PM, Staff D, Registered Nurse (RN) said that she worked the morning shift on [DATE] and got report from the overnight nurse. The nurse told her that Resident #143 had a fall and he was having hip pain. Staff D went and assessed the resident and when she assessed the range of motion on his left leg, the resident yelled out in pain. Staff D then called the doctor and had the resident sent to the hospital. She told the overnight nurse that if there was any suspected fracture, or if the resident was having pain, staff should have called the on-call doctor for guidance.
According to the Vitals tab in the electronic chart on [DATE] at 6:20 AM, Resident #143 had a blood pressure of 83/45.
The Emergency Department Note dated [DATE] at 7:10 AM, showed that the resident had a closed intertrochanteric fracture of left hip and hypotension. The patient had been struggling with worsening of his heart failure and dyspnea on exertion. He'd had a drastic decline since moving to nursing home. The resident was admitted to the hospital for possible surgery.
The Hospital History and Physical dated [DATE] at 2:16 PM, showed the Assessment and Plan indicated Resident #143 had sepsis, hypotension, and a closed intertrochanteric fracture of left hip. On [DATE] at 3:48 PM, the hospital report showed Resident #143 was critically ill with worsening hypoxemia (low oxygen) hyperkalemic (high potassium) and was in rapid deterioration. He was sent to the Intensive Care Unit and expired on [DATE] at 8:28 AM.
On [DATE] at 10:44 AM, Staff G, Registered Nurse (RN) said that on the overnight shift of [DATE], Resident #143 woke up and tried to go to bathroom and fell. The Certified Nurse Aide (CNA) found him on the floor and the two of them transferred him back into the recliner. Staff G said that he checked the Range of Motion (ROM) of his legs and he was moving them but the left one was painful. Staff G administered some Tylenol and the resident said he was feeling okay. Staff G said that they kept checking on him throughout the night and he continued to have some pain. Staff G said that he tried to call the Director of Nursing (DON) at the time but the call didn't go through. He said that he did not contact doctor by phone, but sent a fax. It was his understanding that if it was after 11:00 PM, unless there was an emergency, the morning nurse would contact the family.
On [DATE] at 9:28 AM, Staff F, CNA, said that Resident #143 was getting up to go to the bathroom by himself and ended up falling backwards. She and Staff G went in when they heard a thud, the nurse assessed him and they transferred him back into the recliner. The resident said that he was having leg pain so the nurse gave him something. Staff F said that she checked on him throughout the night and around 4:00 AM, he said he had more pain. She and Staff G tried to get him up to clean him because he was wet, but the resident could not stand because he had too much pain in the left leg at that time.
According to a summary of a conversation between the DON and Staff G, the DON asked the nurse why he hadn't sent the resident to the hospital when he was unable to bear weight. Staff G was then educated that when a resident had decreased ROM, and unable to bear weight, staff should call the emergency room doctor, and call the family.
According to the policy titled: Falls Follow up Documentation last review 8/2024, for an unwitnessed fall or fall with suspected heard injury, staff would complete vital signs and neurologic checks to be done at the time of the fall, then neuro checks every 4 hours x 24 hours then each shift x48 hours. Vital signs were to be obtained every shift x72 hours.
On [DATE] at 11:15 AM, the DON and the Administrator agreed that the overnight nurse should have called the doctor and the family sooner. When asked about the falls follow up policy, and standards of care for vitals and neuro checks after unwitnessed falls, they said that policy had been in place for a while but they would revisit it to see if they needed to make any changes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review the facility failed to use proper safety equipment to ensure safe transfers and amb...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review the facility failed to use proper safety equipment to ensure safe transfers and ambulation for 1 of 3 residents reviewed. Resident #38 had a change in status with increased weakness, and fell at 4:40 AM on 5/17/25. Later that morning, staff failed to use a gait belt while assisting the resident with ambulation and transfers, and the resident had another fall. The facility reported a census of 89 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #38 had a Brief Interview for Mental Status score of 15 (intact cognitive ability.) She was independent with toileting, dressing, walking and transferring.
The Care Plan updated on 1/21/25, showed Resident #38 had pain related to a fracture, and ovarian cancer. She was independent with transfers and ambulation with the use of a walker. The resident was admitted to Hospice on 4/14/25. On 5/17/25 she had an unwitnessed fall in the bathroom, and was reminded to use her call light for assistance. After a second fall on 5/17/25, staff attached a sign to her walker to call for assistance, and staff were instructed to use a gait belt and keep her oxygen in place.
An Incident Report dated 5/17/25 at 4:40 AM, showed Resident #38 was a high risk for falls and she was found on the floor after attempting to go to the bathroom. She was supine with feet facing the bathroom door and her walker was in front of her near her feet. The resident had been very confused throughout the night and had not slept, and many times she attempted to get out of her recliner. She had an acute change in mental status.
The Incident Report dated 5/17/25 at 9:45 AM, showed Resident #38 was assisted back to her room from dining room following breakfast. Her gait was unsteady and she fell backwards. All staff were made aware of change to ambulation assist of one with gait belt and walker in room. The aide had momentarily let go of the resident to straighten pad on the chair, that's when she fell. Due to new confusion and fall earlier in day, staff had been educated on the increased fall risk.
On 6/25/25 at 12:00 PM, Staff H, Registered Nurse (RN) said that the night shift reported Resident #38 had a fall earlier that morning and was more confused. Staff H was checking very frequently. Resident #38 eventually wanted to come out to the dining room. She said she asked Staff I to assist the resident back to her room. When they were in the room getting ready to sit down Staff I reached down to adjust something in the chair, and turned from her. That was when she fell. The med aide was not using a gait belt and the staff had been directed to monitor her closely.
On 6/25/25 at 11:09 AM Staff I Certified Medication Aide (CMA) said it had been passed on in morning report that Resident #38 had been very weak that morning. She came out for breakfast and Staff I helped her walk to the table for breakfast. She walked her back to her room. They got to the room, and the resident leaned over to straighten the cushion in her chair before sitting. Staff I said that she would do it for her and momentarily let go of the resident and turned away from her. That's when she fell. The resident had her walker in front of her and was holding onto the handle with one hand. Staff I said she was holding onto the back of her pants and did not use a gait belt. After that fall, the resident was instructed to call for assistance, and they tried to keep eye on her. She said that they had discussed with the nurse that morning that the resident had a change in status and needed close monitoring.
On 6/26/25 at 11:15 AM the Director of Nursing and Administrator agreed that Resident #38 had a change in status and staff should have used a gait belt while assisting with ambulation and transfers.
According to a facility policy titled: Gait Belt Usage, last reviewed 9/2024 showed that gait belts would be used by all employees with any resident and/or patient who needed assistance with ambulating and/or transferring.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, infection control policy and staff interview, the facility failed to wear Enhanced Barrier Precautions (EBP) with wound care with 1 of 4 residents (Resident #66) observed for wou...
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Based on observation, infection control policy and staff interview, the facility failed to wear Enhanced Barrier Precautions (EBP) with wound care with 1 of 4 residents (Resident #66) observed for wound care. The facility reported a total census of 89 residents.
Findings include:
Observation on 6/24/25 at 1:52 p.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, Registered Nurse (RN) providing toileting assistance for Resident #66. Staff A assisted Resident to a standing position using a mechanical lift. Staff B removed mepelix dressing off of the resident's coccyx area. Area observed and noted to have an open wound under the dressing. Staff B cleansed the area and reapplied a mepelix dressing to the area. Staff A finished assisting resident with toileting and dressing. Staff A and Staff B did not wear any EBP during personal cares and wound dressing with Resident #66.
Interview on 6/24/25 at 2:17 p.m., with Staff B revealed the open wound was found on 6/18/25 and was addressed by the physician and stated dressing changes twice weekly were ordered.
Review of the facility provided policy titled Transmission Based Precautions and Enhanced Barrier Precautions with a last reviewed date of 10/10/24 revealed EBP are used during high contact resident care activities for the following residents and should be implemented as facilities are able include wound requiring a dressing, regardless of MDRO status. If this applies a gown and gloves must be used during high contact resident care activities including, dressing, transferring, providing hygiene, changing briefs or assisting with toileting and wound care (any wound requiring a dressing).
Interview on 6/25/25 at 12:29 p.m., with the Staff C, Co-Director of Nursing revealed Resident #66 should be on EBP as she put the supplies in the room and did not know why the sign was not on the door and why EBP was not being used as it should be.
Aug 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview and facility policy, the facility failed to complete a bed hold notice with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview and facility policy, the facility failed to complete a bed hold notice with the resident or resident's responsible person when residents transferred out of the facility for 1 of 3 residents reviewed (Residents #29 and #45). The facility reported a census of 91 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 documented diagnoses of renal failure and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment.
Review of Resident #29's Progress Notes revealed the following information:
On 9/10/23 Resident #29 taken to the emergency department per family request for increased swelling in the left lower calf. The resident left the facility at 7:10 PM.
On 9/12/23 Resident #29 returned to the facility at 1:48 PM.
Review of the Resident #29's Census tab revealed the following information:
9/10/23 hospital start date.
9/12/23 hospital end date.
Review of Resident #29's clinical record revealed the facility lacked a bed hold notice for the hospital admission on [DATE].
2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 documented diagnoses of heart failure, renal failure and Diabetes Mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment.
Review of Resident #45's Progress Notes revealed the following information:
On 11/29/23 at 12:58 PM resident leaves on stretcher with EMS at 12:57 PM.
On 11/29/23 at 6:12 PM the charge nurse notified of Resident #45 admission to hospital at 5:51 PM.
Review of the residents #45's Census tab revealed the following information:
11/29/23 hospital start date.
12/4/23 hospital end date.
Review of Resident #45's clinical record revealed the facility lacked a bed hold notice for the hospital admission on [DATE].
The Bed Hold policy last reviewed July 2024 identified the facility will inform residents and their representatives through written and verbal notice at the time of the admission and at the time of transfer for hospitalization or therapeutic leave, of the duration of the state bed hold policy, during which the resident is permitted to return and resume residence in the nursing facility, the bed hold payment policy, and the nursing facilities policies regarding bed hold periods.
In an interview on 07/29/24 at 2:10 PM, the Administrator reported she expected staff to complete bed hold forms with the resident and/or representative for hospital transfers. When asked what happened, the Administrator stated, we previously noticed an issue, and are now auditing the bed hold notices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Electronic Health Records (EHR), staff interview, and observation the facility failed to provide a professional standar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Electronic Health Records (EHR), staff interview, and observation the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #22). The facility reported a census of 91 residents.
Findings include:
1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment.
Review of Physician's Order dated 3/5/24 for Resident #22 documented silver foam bordered to wound on coccyx 3x's a week and PRN.
Review of order detail in Resident #22's EHR revealed Physicians Order written 3/6/24 that reads silver foam bordered to wound on coccyx 3x's a week and PRN- May use silver foam resident already has cut to fit. Found in her cupboard outside of her room. To be changed every Sunday, Wednesday, and Friday at 7am.
During a continuous observation on 7/31/24 at 12:34 PM Staff A, Certified Nursing Assistant (CNA) and Staff B CNA completed catheter care and peri care on Resident #22. Staff A removed a dressing with feces on the bottom that was dated 7/26/24.
On 7/31/24 at 12:45 Staff A stated the dressing had a date of 7/26/24 after removing from Resident #22.
On 7/31/24 at 1:01 PM Staff C, Licensed Practical Nurse (LPN) stated the dressing on Resident #22's coccyx was to cover a pressure area. Staff C stated Resident #22's dressing was to be changed Sunday, Wednesday, and Friday.
On 7/31/24 at 3:00 PM Staff D RN/ADON stated that if the order read to change Sunday, Wednesday, and Friday that the dressing would have been changed at those times. Staff D stated the facility had no policy on following physician orders or completion of physician orders. Staff D stated the facility's expectation was that professional standards would be followed and the dressing would have been changed according to the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide a well ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 2 of 26 residents reviewed (Resident #22 and 41) The facility reported a census of 91 residents.
Findings include
1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment.
An observation on 7/31/24 at 1:18 PM of Staff E, AM [NAME] serving Resident #22's lunch plate revealed Staff E scooped 3 spoonful of noodles and 3 spoonful of beef onto Resident #22's plate with a soup spoon.
Review of a Physician's Order for Resident #22's diet documented a diet of International Dysphagia Diet Standardisation Initiative (IDDSI) 6 soft and bite-sized diet.
2. The Minimum Data Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 1 indicating severe cognitive impairment.
An observation on 7/31/24 at 12:20 PM of Staff E, AM [NAME] serving Resident #41's lunch plate revealed Staff E scooped 3 spoonful of noodles and 3 spoonful of beef onto Resident #41's plate with a soup spoon.
Review of a Physician's Order for Resident #41's diet documented a diet of International Dysphagia Diet Standardisation Initiative (IDDSI) 6 soft and bite-sized diet.
On 7/31/24 at 1:20 PM Staff E stated he ran out of measuring devices for the IDDSI 6 diets and just used a soup spoon. Staff E stated he should have used a 3 oz scoop for the beef tips and 1/2 cup or 4 oz scoop for the noodles. Staff E stated when he does not have enough measuring devices he will just estimate because he pretty much knows what 3 oz and 4 oz are just by eyeing the amount. Staff E stated he used the soup spoon when he served Resident #22 and Resident #41's lunch plate.
Review of document titled, CPCC Menu A 2024 - Week 4 documented IDDSI level 6 should be served 3 oz of beef tips and 4 oz of noodles for the date 7/31/24.
On 7/31/24 at 3:31 PM Staff F, Certified Dietary Manager (CDM) stated the facility's expectation was the appropriate scoop size would have been used to serve the IDDSI level 6 diets.
Request for a policy with regards to following the menu and utilization of appropriate scoop sizes resulted in no policy provided by facility management or administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing wound care and catheter care for 1 of 1 residents (Resident #22). The facility reported a census of 91 residents.
Findings include:
1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. MDS also indicated Resident #22 utilized an indwelling catheter.
An observation on 7/30/24 at 9:02 AM of Staff G changing Resident #22's right knee dressing revealed Staff G completed hand hygiene, donned gown and gloves. Staff G removed Resident #22's old dressing on the right knee. Staff G removed gloves and applied new gloves. Staff G then cleansed the area around the wound on Resident #22's right knee. Staff G removed gloves and applied new gloves. Staff G then applied a date to the new dressing and applied the new dressing to the right knee of Resident #22. Staff G removed gloves and applied new gloves. Staff G applied a lidocaine patch to the area above Resident #22's right knee. Staff G removed gloves, completed hand hygiene, and applied new gloves. Staff G applied artificial tears to bilateral eyes. Staff G applied the fall mat to the floor. Staff G collected garbage, removed the gown, and removed gloves. Staff G completed hand hygiene when she left the room with hand sanitizer outside of the door.
An observation on 7/31/24 at 12:34 PM of Staff A completing catheter care and peri care on Resident #22 revealed Staff A closed the window shade, completed hand hygiene, donned gown, and gloves. Staff A removed brief and completed peri care, and catheter care on Resident #22. Staff A removed gloves, pushed sleeve up, completed hand hygiene, and applied new gloves. Staff A completed peri cares on Resident #22's buttocks. Staff A removed gloves, completed hand hygiene and applied new gloves. Staff A applied a new brief to Resident #22. Staff A removed gown, removed gloves and completed hand hygiene. Staff A's sleeves remained up throughout all cares after the first glove removal.
On 7/31/24 at 12:59 PM Staff A stated she typically wears the gown with her sleeves covering her wrist but when she washed her hands she pushed them up and forgot to push them back down during care with Resident #22.
On 7/31/24 at 3:00 PM Staff D Registered Nurse (RN) / Assistant Director of Nursing (ADON) stated she expected hand hygiene would have been completed every time gloves were soiled, after going from dirty to clean, and when gloves were changed. Staff A stated when wearing a gown related to enhanced barrier precautions (EBP) she would expect the sleeves of the gown would remain in place through all gown required contact with the resident.
Review of policy titled, Transmission Based Precautions and Enhanced Barrier Precautions documented EBP were used during high contact resident care activities for residents with indwelling medical devices regardless of MDRO status such as urinary catheters. Hand hygiene would be completed upon entering the residents room, leaving the residents room, and after removal of personal protective equipment (PPE).
Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/11/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, and policy review, the facility failed to store food in accordance with professional standards for 91 of 91 residents. The facility reported a census of 91 resi...
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Based on observation, staff interviews, and policy review, the facility failed to store food in accordance with professional standards for 91 of 91 residents. The facility reported a census of 91 residents.
Findings include:
A continuous observation on 7/29/24 between 10:40 AM - 11:00 AM during the initial kitchen tour revealed cooked ground beef in a metal steam table container dated 7/22/24. Small fried food freezer with a bag of chicken strips, a bag of chicken patties, and a bag of breaded pork all undated and open.
On 7/29/24 at 11:15 AM the Kitchen Supervisor stated all the food open in bags in the mini café freezer should be dated when the bags were opened, stated the hamburger with the date of 7/22/24 should have been thrown away by now stated leftover food is only good for 3 or 5 days after being prepared when stored.
Review of policy titled, Departmental Services: Nutrition Services revised 7/24 documented food should be covered, labeled, and dated when stored. Prepared food that needs to be stored will be cooled per food code guidelines.
Request for a policy with regards to acceptable number of days for stored leftovers resulted in no policy provided by facility management or administration.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to use a mechanical stand to avoid hazards and prevent a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to use a mechanical stand to avoid hazards and prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 87 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] for Resident #1 identified the Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS indicated Resident #1 totally dependent on staff for transfers, bed mobility, personal hygiene, and toileting. The MDS included a diagnosis of stroke and hemiplegia or paralysis of one side of the body.
The Care Plan dated 1/6/23 identified Resident #1 required a mechanical stand, also known as a mechanical aide, and the assistance of 2 staff members for all transfers.
The Nurse Note dated 6/24/23 for Resident #1 documented resident lowered to the ground this morning at 0700. CNA was getting her ready for the day and the resident refused to use stand aid or hoyer and wanted pivot transfer. Resident was unable to pivot well and CNA lowered the resident to the floor. The note went on to document the CNA education on the importance of using the stand lift with assistance of two staff members.
In an interview on 9/6/23 at 3:21 PM, Staff A, Certified Nurse ' s Assistant (CNA), reported Resident #1 refused to use the mechanical stand on the morning of 6/24/23. Staff A explained Resident #1 requested assistance to stand and pivot from the bed to the wheelchair. Staff A then failed to follow the care plan by then attempting to transfer Resident #1 independently. Staff A stated, it didn' t work, the resident became weak, so I lowered her to the ground. Staff #1 reported that she usually followed the care plan but now couldn' t remember what the care plan instructed for Resident #1 related to transfers. Staff A added, I don' t think the care plan said anything, otherwise I would have followed it. When asked if she received education after this incident regarding what action should be taken if a resident refused the mechanical lift, Staff A stated, yes in a meeting.
In an interview on 9/11/23 at 2:06 PM, Staff B, Registered Nurse (RN), Care Coordinator, reported that they managed Resident #1' s care plan. Staff B explained Resident #1 required the mechanical stand for transfers. When asked if the care plan at any time instructed staff to pivot the resident, Staff B stated, not that I can remember. When asked if Staff A should have pivoted Resident #1 independently, Staff B responded, no. Staff B further explained if a resident refused the mechanical lift the next step would be for the CNA to report the nurse. The nurse would then be expected to talk with the resident about using the mechanical stand for safe transfers.
In an interview on 9/11/23 at 3:32 PM, Resident #1 reported that she could not recall the details of this incident but could recall that she refused the mechanical lift in the past. Resident #1 reported that she now uses the mechanical lift to prevent harm to herself and staff.
In an interview on 9/21/23 at 3:57 PM the Administrator reported staff received education regarding mechanical lifts and directions for when a resident refused a mechanical lift transfer.The Administer further explained if a resident refused a mechanical lift transfer the CNA should not transfer the resident. The CNA is then required to inform the nurse who will speak with the resident about safety precautions regarding the use of mechanical lifts. The Administrator reported the CNA received education immediately upon the incident, other staff received education during morning huddles and education was added to the Daily Communication Book.
In an interview on 9/25/23 at 2:29 PM, the DON reported she expected staff to follow the care plan when transferring residents. The DON explained if the resident refused, the CNA is required to inform the nurse who would then be expected to talk with the resident. When asked about a policy, the DON explained the facility lacked a policy with specific information regarding a resident' s refusal to use a mechanical stand.
May 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on clinical record, Medicare manual, resident representative interview, and staff interview, the facility failed to include all required information on Advanced Beneficiary Notice of Non-Coverag...
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Based on clinical record, Medicare manual, resident representative interview, and staff interview, the facility failed to include all required information on Advanced Beneficiary Notice of Non-Coverage (ABN) and Notice of Medicare Provider Non-Coverage (Skilled Care) (NOMNC) when telephone call was used for resident representative notification and failed to mail the form to resident representatives for 3 of 3 residents reviewed (Resident #9, #30, and #230). The facility reported a census of 82 residents.
Findings include:
The ABN and NOMNC for Resident #9 revealed verbal: Talked with resident's representative agrees/understands 4/28/23 1:26 PM.
The ABN for Resident #30 revealed called POA. Verbal: consent 3/23/23 signed by the Business Office Manager BOM.
The NOMNC for Resident #30 revealed verbal: Called POA and she was in cooperation with stopping skilled care. Called at 12:55 PM 3/23/23. BOM 3/23/23.
The NOMNC for Resident #230 revealed verbal consent given by resident's representative on 12/29/22 and in agreement. An illegible signature was present.
In an interview on 5/10/23 at 10:05 AM, Resident #30's representative reported that she did not receive the Medicare forms in the mail that she discussed with the BOM about the resident's Medicare coverage at the facility.
In an interview on 5/10/23 at 11:02 AM, Resident #9's representative reported she did not receive the Medicare forms in the mail that she discussed with the BOM about the resident's Medicare coverage at the facility.
The Medicare Claims Processing Manual revised 1/21/22 revealed:
1. ABNs
a. ABNs should be delivered in-person and prior to the delivery of medical care which is presumed to be non- covered. In circumstances when in-person delivery is not possible, notifiers may deliver an ABN using another method. Examples include:
1. Direct telephone contact
2. Mail
3. Secure fax machine
4. Internet e-mail.
b. All methods of delivery require adherence to all statutory privacy requirements under HIPAA. The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery.
c. When delivery is not in-person, the notifier must verify that contact was made in his/her records. In order to be considered effective, the beneficiary should not dispute such contact.
d. Telephone contacts should be followed immediately by either a hand-delivered, mailed, emailed, or a faxed notice.
1. The beneficiary should sign and retain the notice and send a copy of this signed notice to the notifier for retention in the patient ' s record. The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice.
2. If the beneficiary does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself.
2. NOMNC
a. Note - Exceptions to in person notice delivery. If the NOMNC must be delivered to a
representative not living with the beneficiary, the provider is not required to make off-site
in- person notice delivery to the representative. The provider must complete the NOMNC as required and telephone the representative at least two days prior to the end of covered services. The provider should inform the representative of the beneficiary ' s right to appeal a coverage termination decision.
The information provided should include the following:
.The beneficiary ' s last day of covered services, and the date when the beneficiary ' s liability is expected to begin.
.The beneficiary ' s right to appeal a coverage termination decision.
· A description of how to request an appeal by a QIO.
·The deadline to request a review as well as what to do if the deadline is missed.
·The telephone number of the QIO to request the appeal.
The date the provider communicates this information to the representative, whether by
telephone or in writing, is considered the receipt date of the NOMNC.
The NOMNC must be annotated with the following information on the day that the
provider makes telephone contact:
Reflect that all of the information indicated above was communicated to the
representative;
Note the name of the staff person initiating the contact, the name of the representative
contacted by phone, the date and time of the telephone contact, and the telephone number
called.
A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiary ' s medical file.
If the provider chooses to communicate the information in writing, a hard copy of the NOMNC must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g. FedEx, UPS) The burden is on the provider to demonstrate that timely contact was attempted with the representative and that the notice was delivered.
The date that someone at the representative ' s address signs (or refuses to sign) the receipt
is considered the date received. Place a copy of the annotated NOMNC in the beneficiary ' s medical file.
If both the provider and the representative agree, providers may send the notice by fax or e-mail, however, providers fax and e-mail systems must meet the The Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security requirements.
In an interview on 5/10/23 at 2:04 PM, the Business Office Manager reported that she issues ABNs and NOMNCs to resident representatives at her previous employer and was trained to continue this practice at this facility; she was not aware that if a verbal consent was obtained from a resident representative that the ABN and/or NOMNC needed to be mailed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Emergency Department notes dated 2/13/23 revealed Resident #71 needed to be admitted to the hospital for empiric in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Emergency Department notes dated 2/13/23 revealed Resident #71 needed to be admitted to the hospital for empiric intravenous antibiotics and further work-up.
Review of Resident #71 ' s progress notes revealed the following information:
a. On 2/13/23 at 5:49 p.m., Resident #71 admitted to acute care hospital per hospital staff.
b. On 2/17/23 at 12:03 p.m., Resident #71 returned to the facility following hospital stay.
Review of the facility provided document titled Notice of Transfer form to Long Term Care Ombudsman dated February 2023 lacked documentation of Resident #71 ' s hospitalization to the Long Term Care Ombudsman.
The facility lacked a policy on notification of transfer to the Long Term Care Ombudsman.
Interview on 05/10/23 at 10:21 a.m., with the Administrator revealed the ombudsman notification got missed since January 2023. There are no notifications from January 2023 until April 2023.
Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 3 of 3 residents reviewed who transferred to the hospital (Resident #59, #61 and #71). The facility reported a census of 82 residents.
Findings include:
1. A Progress Note dated 3/10/23 at 4:15 PM identified Resident #59 admitted to Hospital due to pneumonia.
A ED Progress Note dated 3/10/22 identified Resident #59 admitted to Hospital for left lower lobe pneumonia.
The Minimum Data Set, dated [DATE] for Resident #59 showed a reentry date to the facility from an acute hospital stay that occurred on 3/13/23.
Review of the Notice Of Transfer Form To Long Term Care Ombudsman dated March 2023 showed the facility failed to notify the Ombudsman of Resident #59 ' s admission to the hospital on 3/10/23.
2. A Progress Note dated 3/6/23 at 11:55 AM identified Resident #61 admitted to Hospital due to low sodium and low potassium.
A ED Progress Note dated 3/6/22 identified Resident #61 admitted to Hospital for acute kidney injury, leukocytosis and low sodium and low potassium.
The Minimum Data Set, dated [DATE] for Resident #61 showed a reentry date to the facility from an acute hospital stay that occurred on 3/13/23.
Review of the Notice Of Transfer Form To Long Term Care Ombudsman dated March 2023 showed the facility failed to notify the Ombudsman of Resident #61 ' s admission to the hospital on 3/6/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, and policy review the facility failed to provide needed assistance in making appointments and arranging for transportation to and from dental services for...
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Based on resident interview, staff interview, and policy review the facility failed to provide needed assistance in making appointments and arranging for transportation to and from dental services for 1 of 1 residents (Resident #47). The facility reported a census of 82 residents.
Findings include:
1. Record review of the Minimum Data Set (MDS) for Resident #47, dated 4/1/2023 documented a Brief Interview of Mental Status of 15 indicating no cognitive impairment.
On 5/8/23 at 1:19 PM Resident #47 had stated he needed to get to the dentist and get lower dentures. Resident #47 stated the closest place is Sioux City. Resident #47 stated getting to Sioux City can be difficult. Resident #47 said he doesn't know if the van goes that far. Resident #47 stated the facility only transport in town. Resident #47 stated it is hard to eat without lower dentures. Resident #47 stated he has a top plate but doesn't have a bottom. Resident #47 stated he asked nursing and HR people for help.
On 5/9/23 at 3:41 PM, Staff H, Registered Nurse (RN), Care Coordinator, stated if a resident wanted a new set or needed a new set of dentures the resident would speak to a charge nurse, the care coordinator, or social worker. Staff H stated she started in November of that year. Staff H stated at that time Resident #47 talked about getting dentures with cousins help. Staff H stated Resident #47 decided at that time dentures were too expensive. During the care conference it was decided by Resident #47 he would wait for someone local because payment and transportation could pose a problem.
On 5/9/23 at 8:37 AM Staff I, Social Worker, stated Resident #47 looked at Nebraska first for lower denture plate. Staff I stated obtained information that dentures can be completed in Orange City with current insurance. Staff I stated it is not the facility ' s responsibility to transport residents to appointments outside the city of Sioux Center. Staff I stated Resident #47 ' s family lives in a different town and do not visit often. Staff I stated Resident #47 ' s family do not want to be called until death. Staff I stated Resident #47 is his own POA.
On 5/10/23 at 2:46 PM the Administrator stated the facility is not responsible for transportation. Administrator stated residents are notified with the policies and procedures upon entry.
Document titled facility name Policies and Procedures provided by the Administrator revealed ;
a. Doctor appointments outside of Sioux Center, Family is responsible for transport and assistance.
Document titled Care Conference Summary provided by the Administrator revealed;
a. Waiting on lower dentures will need teeth pulled and would like to stay local, payment source may pose a problem related to Resident #47 ' s insurance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, facility policy, and staff interview, the facility failed to perform hand hygiene during medication administration and touch a resident's medication with bare hands. The facility...
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Based on observation, facility policy, and staff interview, the facility failed to perform hand hygiene during medication administration and touch a resident's medication with bare hands. The facility reported a census of 82 residents.
Findings include:
Observation on 5/10/23 at 8:37 AM revealed Staff G, Licensed Practical Nurse (LPN):
1. Put gloves on in a resident's room without performing hand hygiene.
2. Staff G administered an insulin injection and then took her gloves off.
3. Staff G did not perform hand hygiene and placed the insulin pen on the medication cart.
4. While at the medication cart, Staff G touched a 3 ring binder, computer mouse, entered the medication cart, retrieved medication cards, prepared oral medication to be administered, and placed the insulin pen in the medication cart on top of a compartment of covered needles.
5. Touched an oral medication with her bare hands to break it in half per resident request.
6. Administered both oral and nasal medications.
7. Touched the end of a drinking straw to place it in a cup, resident drank from this end of the drinking straw.
8. Put the nasal medication in the medication cart.
The Hand Hygiene policy last revised 2/23 revealed:
1. Purpose:
a. To cleanse hands to prevent the spread of infection.
b. To provide a clean and healthy environment for patients, residents, staff, and visitors.
2. HH (hand hygiene), either with soap and water or with alcohol based hand rub (ABHR)
a. Immediately before touching a patient or resident.
b. After removing gloves.
In an interview on 5/11/23 at 10:15 AM, both Assistant Directors of Nursing (ADON) reported that hands hygiene should be performed before gloves are put on and after gloves are removed, oral medication should not be touched with bare hands.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, facility policy, and staff interview, the facility failed to post a paper copy of daily staffing in each unit of the facility. The facility reported a census of 82 residents.
Fin...
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Based on observation, facility policy, and staff interview, the facility failed to post a paper copy of daily staffing in each unit of the facility. The facility reported a census of 82 residents.
Findings include:
Observation on 5/9/23 at 3:24 PM of each of the 3 facility units, 2 of the units had daily nursing department staffing handwritten written on reusable white boards and not posted on paper.
In an interview on 5/9/23 at 3:23 PM, Staff E, Certified Medication Assistant (CMA) reported there was no paper copy of the daily staff posting out for residents to see.
In an interview on 5/9/23 at 3:27 PM, Staff F, Licensed Practical Nurse (LPN) reported there was no paper copy of the daily staff posting out for residents to see.
In an Electronic Mail (email) on 5/10/23 at 8:31 AM, the Administrator reported we don ' t have a policy for the daily posting of census and nursing hours.
In an interview on 5/11/23 at 10:50 AM, Staff J, Assistant Director of Nursing (ADON), reported that each unit receives a daily printed copy of nursing staff posting and this is posted in each unit. Staff J reported she was unsure where the paper copy of the daily nurse staffing was posted since this is a newer unit. The information from these paper copies was used to write the staffing information the white boards.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, facility policy, and staff interview, the facility failed to have kitchen staff wear hair nets in the kitchen. The facility reported a census of 82 residents.
Findings include:
O...
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Based on observation, facility policy, and staff interview, the facility failed to have kitchen staff wear hair nets in the kitchen. The facility reported a census of 82 residents.
Findings include:
Observation on 5/9/23 at 10:45 AM revealed Staff A, Nutrition and Food Service Assistant; Staff B, Baker; Staff C, Cook; Staff D, Cook. All 4 staff were in the kitchen, not wearing hair nets. Staff B wore a baseball cap, Staff C and Staff D wore mesh topped skull style caps.
The Dress Code and Appearance policy last approved date of 4/23 revealed:
1. Purpose to outline a code of dress that provides direction in promoting and enhancing a professional and respectful image of the facility as well as to remain in compliance with issues such as infection control, safety, and security.
2. Hair nets that confine all hair, including bangs and beard, are required for all employees when in food preparation areas. If desired, team members may wear the approved mesh skull cap over the hair net.
In an interview on 5/10/23 at10:41 AM, the Registered Dietician (RD) reported that she would expect all staff to wear hair nets in the kitchen.
Feb 2023
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, facility policy review and physician interview, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, facility policy review and physician interview, the facility failed to assure that staff provided appropriate nursing supervision for one resident who exited the facility unsupervised on two separate occasions,(Resident #1). This failure resulted in exposure to subzero winter elements and a fall that resulted in injury and one visit to an emergency room for treatment for the resident, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The facility also failed to maintain the safety and security of one resident during the transfer process which resulted in a serious injury.(Resident #8).
The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on December 24, 2022 on January 12, 2023 at 12:15 A.M and was given the IJ template. The Facility Staff corrected the Immediate Jeopardy on January 13, 2023 through the following actions:
a. Placement of new and more audible alarms on the exit doors in the resident's neighborhood.
b. Staff education on the different types of alarms and the audible sounds of each.
c. Moving the resident to a more secured area of the neighborhood and close to the nurse's station.
The scope was lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures.
The facility identified a census of 76 residents.
Findings Include:
During an interview with the State Climatologist on 1/10/22 at 8:41 a.m. the temperature on 12/24/22 registered -4 degrees Fahrenheit (F), humidity at 76%, winds [NAME] to North [NAME] (NW) at 14 miles per hour (mph) gusting to 20 mph so wind chill registered at -24 degrees F with no clouds.
The weather conditions on 12/29/22 at 2:42 a.m. registered 34 degrees F, humidity 93%, winds NW at 9 mph so the wind chill registered at 27 degrees F with a cloud cover low and mid- level with snow in the area at the time of the elopement. On 12/26/22 the office registered four (4) inches of snow on the ground.
1. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 with diagnosis that included Parkinson's Disease, Alzheimer's, Arthritis and Peripheral Vascular Disease (PVD). The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills)and required extensive assistance of 1 staff member with ambulation and locomotion with a walker.
A MDS BIMS interview form dated 11/2/22 at 12:40 p.m. documented the resident with a score of 8 (moderately impaired cognitive skills).
An Elopement Risk form dated 11/2/22 at 3 p.m. documented the resident jokingly stated he planned to leave out the back door of the facility however the scale indicated no risk for elopement.
A Care Plan documented the resident as admitted to the facility on [DATE] at 1:37 p.m. The Care Plan identified the following problem areas and interventions as dated:
a. Activities of Daily Living (ADL) status related to a diagnosis of Dementia and an unsteady gait. Dated 11/2/22 at 1:37 p.m The interventions included the following:
1. Transferred with 1 staff assistance, a four wheeled walker (4 WW) and a gait belt assistive device. Dated 11/2/22 at 10:25 a.m
2. Ambulation/locomotion with 1 staff assistance, 4 WW and a gait belt. Dated 11/2/22 at 10:25 a.m.
b. Cognitive status as evidenced by a short term memory problem, long term memory problem, impaired decision making, problem understanding others and a diagnosis of mixed Alzheimer's with vascular dementia. Dated 11/2/22 at 1:02 p.m.
c. Fall risk related to a diagnosis of Dementia, history of falls and a diagnosis of an unsteady gait. Dated 11/2/22 at 1:32 p.m.
1. 12/29/22: Staff told the nurse the resident's call light had been on and the door alarm sounded in the other hallway as she observed that information on the monitor at the Certified Nursing Assistant (CNA) desk. Staff hurried to the hallway and found the resident as he sat on the ground outside and leaned against the wall approximately 10 feet from the outside door. When asked what he had done he indicated he planned to get his pickup and go to his daughter's house. He had been able to state his name but not where he had been located or the time of day. With the assistance of 4 staff members and gait belt staff transferred him to a wheel chair and brought him inside. He wore a t-shirt, pajama pants and gripper socks. Once inside staff assessed skin tears to his right arm as bruising started to appear.
A Long Term Care (LTC) Provider Communication form dated 12/24/22 at 12:34 p.m. included the following documentation: Resident found outside near entrance by visitors at approximately 10:30 a.m. with long sleeved shirt, long pants, sock and shoes as he walked with a front wheeled walker (FWW). Visitors guided the resident to their car then called the facility at 10:40 a.m. Staff applied coat and assisted the resident back into the facility with a FWW. The resident noted to have been more confused than normal. Brought w/c to resident in the service hallway near the loading dock entrance where he rested on a bench and warmed up. Brought him back to his neighborhood and wrapped in a blanket. Temperature at 11 a.m. registered 95.4 degrees F. The facility notified his daughter and suggested he had been outside for 10-15 minutes.
An Emergency Department (ED) note dated 12/24/22 at 12:22 p.m. documented the resident's body temperature at 97.7 degrees F.
An Assessment and Plan form from the local hospital dated 12/25/22 at 1:37 p.m. included the following documentation: An [AGE] year old man with Alzheimer's, Vascular Dementia, Coronary Artery Disease, Type II Diabetes Mellitus (DM), presented with cold exposure of unknown duration. He apparently wore long sleeved clothing with no coat. He exhibited swelling of is left distal pinky and with bilateral swollen feet however it had been difficult to say if that was caused from his heart failure or from the cold.
A Nurse Note dated 12/25/22 at 5:14 p.m. documented the resident returned from an overnight observation at the local hospital after hypothermia with frost bite on the left finger.
During an interview on 1/11/23 at 4:30 p.m. the visiting Pastor confirmed he observed the resident outside on 12/24/22 with just a T-shirt, pants but no coat, hat or gloves. The resident appeared confused and not located near any door to the facility but rather in the parking lot. The Pastor told him he wanted to get him inside so they walked towards the nonfunctional front door because of a big snow drift in front of the door. By the time the Pastor noticed the functionality of the front door he retrieved his car and helped the resident into the car for warmth. The Pastor drove the resident to a door to get him inside but by that time another person came up and called the facility to get the resident. The Pastor stated he acted immediately because the resident appeared not fit. The Pastor asked the resident where he planned to go and the resident said something about a pick up and going somewhere but the resident had not looked like he had the ability to drive and the Pastor just wanted to make sure he warmed up. The Pastor confirmed the resident had a walker with him and he was actually first located at the bottom of an incline and up against the curb where there was snow.
During an interview on 1/11/23 at 4:26 p.m. the other resident's family member who assisted the Pastor with the resident indicated she came around the corner and observed a visiting Pastor and the resident as they walked outside and she found that different because of the cold weather and the fact the resident wore a shirt and sweat pants but no jacket or hat. This family member called the nurse in the facility and informed her of the situation because the front door of the facility remained locked at that time.
During an interview on 1/11/23 at 7:45 a.m. the facilities Senior Services Officer indicated she investigated the elopement herself and was able to track the resident's footsteps out the door at the end of hall 900 to where he was located by a Pastor coming to visit some of his parishioners. Additionally, another resident's family member assisted the resident into the Pastor's car and back to the building where staff greeted him, positioned him in a w/c and given a blanket. To date she had been unable to retrieve the time of exit from the facilities door alarm system due to a malfunction however she knew he returned around 10:40 a.m. The Senior Services Officer indicated there were 3 nursing staff who worked that day however no staff member heard the door alarm due to having been behind other resident's closed doors as they provided care. However a kitchen personal heard the alarm but assumed it was a delivery person and failed to appropriately respond and/or communicate the sounding alarm to nursing staff.
During an interview on 1/11/23 at 10:35 a.m. the Senior Services Officer reviewed the facility map and identified the resident went out the 900 exit door on the NW corner of the building went around the building and up 2 stairs with walker. The Senior Services Officer indicated there had been very little if any ice but due to slightly blown snow she tracked the resident's footsteps.
During an interview on 1/11/23 at 9:11 a.m. Staff A, Certified Medication Aide (CMA)/CNA indicated on the date of 12/24/22 the facility had been short a CNA. At 10:15 a.m. she told another CNA she planned to bath a resident on the 800 hallway so she planned to answer resident call lights and assist the last resident up for the day. At the same time Resident #1 sat at the dining room table right in front of the serving table. She had been unable to hear the door alarm sound because when located in the whirlpool room staff could not hear anything outside of the room. At 10:35 a.m. the staff member finished up in the whirlpool room and the nurse asked for a w/c but she could not safely leave the resident she cared for at that time. Around 10:40-10:45 a.m. when left she left the whirlpool room she could still hear the 900 door exit alarm as it sounded.
During an interview on 1/12/23 at 10:36 a.m. Staff D, Registered Nurse (RN) confirmed she worked 12/24/22. The staff member indicated when she first knew about situation had been when she received a call from a daughter of another resident in the parking lot who informed her a male resident had been located in the parking lot without a coat. She responded right away and asked him what he had been doing but she could tell he needed to get back into the facility due to the fact his head shook and he failed to speak to anyone The staff member asked the Pastor, who had him in a car to back him to the loading dock so they could return him into the building. The staff member removed her coat and placed it around the resident, entered the building, sat him down and placed his hands under his armpits. The staff member then called for a w/c as they waited for about 5-10 minutes and tried to get him warmed up. Then took him to nurse's station, assessed his vitals and she thought his temperature registered 95 degrees F at that time and he had been in the building for approximately 10 minutes at that point however his skin remained cold and red.
During an interview on 1/12/23 at 9 a.m. Staff B, CNA confirmed she worked 12/24/22 but failed to hear the door alarm when Resident #1 exited the facility unattended as she cared for another resident at the time. Staff C indicated Staff D, RN asked Staff C, Dietary about the alarm as she had been aware of the sound. Staff B stated when she completed her cares with a resident at the end of the 800 hallway she faintly heard the alarm. The staff member confirmed she failed to hear any alarms as they went off but she had been located down the 800 hallway as she checked other resident's vital signs which she completed around 10:30 a.m. and returned to the nurse's station when she heard a faint sound and asked Staff C, dietary if she had something in her oven or something. The dietary staff member denied cooking so Staff S went to the galley station and heard the alarm. Both of the staff members went down the 900 hallway, shut off the alarm, went out of building almost to the corner but observed no tracks so they returned into the facility. Staff D returned to the nurse's station at which time she received the call from another resident's daughter.
During an interview on 1/12/23 at 8:21 a.m. the Dietary Manager (DM) stated the dietary staff member who originally heard the alarm had currently been in [NAME] but she had spoken with her following the event. The staff member stated she left the kitchenette to go to the main dining room of he facility at which time the resident sat at an unknown dining room table. When she returned the resident had no longer been present so she thought someone took him back to his room. The DM confirmed when in the main dining area a staff member could not hear an alarm if it sounded in a neighborhood. The DM had been unaware if Staff C heard the alarm sound however the Senior Services Officer had been the person who formally interviewed Staff C.
During an interview on 1/11/23 at 12:29 p.m. the resident's daughter stated that she shared with the facility staff upon admit that he had episodes when he lived with her of a fluctuating cognitive function. The daughter indicated her father had another episode a couple times after this said event where he got to the door and out, the door alarm sounded and staff responded however she had been unsure if those had been an witnessed event.
A typed statement from the Senior Services Officer started on 12/24/22 included the following documentation in addition to the above documented information on the resident's Care Plan: The resident set off the 800-door alarm on 12-29-22, at 2:40 a.m., but staff responded quickly, and returned right back into the household.
2. A MDS assessment form dated 10/18/22 documented Resident #8 with diagnosis that included Alzheimer's dementia, hip and knee replacements and a displaced intertrochanteric fracture of the left femur. The assessment documented the resident with a short and long term memory deficit, moderately impaired cognitive skills, dependent on 2 staff with bed mobility, extensive assistance of 1 staff with transfers and a fall risk.
A Care Plan addressed a problem with ADL status dated 10/12/22 at 12:51 a.m. The interventions included the following: a. Transferred with 1 staff assistance and a gait belt.
A Fall Risk Assessment form dated 1/12/23 documented the resident at a high risk fall precautions.
An Incident Report form dated 1/15/23 at 12:05 a.m. documented while staff assisted the resident out of bed she sustained a laceration to her right shin that measured 15 centimeters (cm), staff transferred the resident to the emergency room for repair and admission.
An emergency room report dated 1/15/23 at 12:15 a.m. documented the resident presented in the ER via the ambulance service with a significant bleed/stellate laceration to the right lower leg that measured 15 cm. The physician had been able to repair the area with quite a bit of pressure and there had been tearing of the skin.
A Care Assessment form dated 1/17/23 at 11:10 a.m. documented the resident with an L shaped, upside down,wound with sutures not well approximated at that time. The wound appeared open, purple and red and measured 8 centimeters (cm) by (x) 14.5 cm with entire wound area that measured 116.0 cm. The surrounding tissue appeared purple, bruised, edematous and moist with the surrounding tissue erythema measured greater than 2.5 cm. The site appeared with a small amount of serosanguinous to bright red blood with a mild odor.
A typed statement dated 1/15/23 (no time) from the Senior Services Director included the following documentation:
Staff E, Registered Nurse (RN) and Staff F, Certified Nursing Assistant (CNA) shared different versions of what happened in the resident's room prior to the discovery of her skin tear. Photos were taken of the resident's room and her wheel chair as well as the charting desk where she sat prior the transfer to her room for the night. The Senior Services Director asked the physician the measurement from the distance of the laceration to the bottom of the resident's foot and it measured 16 inches which matched directly to the part of the wheel chair that the leg rests attached to the wheel chair with blood noted on top outer edge on the top pin base at the connector site.
Staff F explained to the Senior Services Director that when they transferred the resident from the bed to her wheel chair for an observation of the cause of the small drops of blood on the resident's sheets, Staff E turned the wheel chair towards the resident from behind her, but the resident's right foot became caught behind the wheel at the time the resident said ouch. The resident and the Senior Services Director measured in similar heights so when the Director stood where Staff F said her foot had been located and the chair turned, that rough spot on the top pin base went right across my leg at the same spot.
The discrepancies in the staff statements included the following:
1. When her leg started bleeding (for a laceration that large, it couldn't have happened before she laid down, or the bed pad would have more blood on it.
According to an email dated 2/8/23 at 4:08 p.m. the Senior Services Director confirmed staff failed to use a gait belt assistive device during the transfer.
During an interview on 1/15/23 (no time documented) the Director interviewed Staff F which included the following information: I took Resident #8 to her room. I lowered the bed down to be level with the wheel chair. I said give me a hug and she responded some type of remark, but raised her arms up. I transferred her to her bed without any fussing. All in one motion by pivot transfer and laid her down on her back and her legs on the bed. I saw the nurse in the dining room, as she came into the resident's room. The resident's feet had been positioned on top of her covers. When I moved the covers from under her feet, the nurse had already been in the room at the foot of the bed, the resident cried out, just hollered. When I picked her feet up I saw the blood stain on the chux, I laid her feet down and said, she is bleeding from somewhere. I pulled her right leg up to her knee and there noticed no blood, then I looked at the left and noted no blood. I remembered she had a bandage on her right leg that she picked at, so I checked it, but noted no blood. The nurse said, well lets just get her up and I will take her with me. I said that is good, then I can get caught up. The resident's left leg had moved closer to the wall, so I pulled her legs around and as the resident reached for the railing and pulled herself up as I stood at the foot of the bed. The resident sat on the edge of the bed calmly with her feet on the floor. The nurse reached for the back of the resident's pajamas slacks, I had my right arm extended, we said 1, 2,3 and transferred her. The nurse turned the chair around and I saw her foot was behind one of the wheels, I then saw blood on her foot, said stop, pulled her pants up and saw the blood. I'm sure that during the transfer the wheel chair, the spot where the foot pedals attached to the wheel chair cut her shin/leg. I think the turn during the transfer caught an edge of the chair and cut her leg. She hollered, owie, then became calm.
During an interview on 1/15/23 (no time documented) the Director interviewed Staff E which included the following information: I responded to the resident as she yelled, Stop it and went to her room but never witnessed the alleged event. Staff E went into the resident's dark room. I saw the CNA as he moved her legs over and said lay on down. I turned on the light as the resident sat on her bed. I said she would not stay in bed while he covered her legs with her comforter. I replied we could get her up and she could have been a one on one with me until you finished your rounds. At this point the resident already pushed the comforter off of her legs with her hands when I saw blood as it dripped from her right shin and went down her left side of her leg. I asked where is the blood came from. Staff F said I don't know. Then he lifted both her legs and I didn't see right away where the blood came from as she had long pink silky pajama pants on. Then we got her up into the wheel chair as I stood behind her and he stood in front of her. We got her into the wheel chair and the pajama pant came up and I saw the blood and the wound. I said Oh my God, how did this happen? as the blood gushed out of the wound. I ran and got gauze and Kerlix and wound cleanser. I came back and applied pressure.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, staff interview and physician interview the facility failed to notify one resident's physician concerning a change in condition that warranted notificatio...
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Based on observation, clinical record review, staff interview and physician interview the facility failed to notify one resident's physician concerning a change in condition that warranted notification which resulted in a delay in medical treatment.
(Resident #3) The facility identified a census of 76 residents
Findings include:
The Minimum Datat Set with assessment reference date 12/27/22 showed Resident #3 had a Brief Interview for Mental Status score of 12, which indicated moderately impaired decision making skills. The residents diagnosis included hypertension, diabetes and cirrhosis of the liver.
Physical Therapy (PT) notes dated 10/30/22 (no time documented) included the following information: Patient reported continued stomach aches, diarrhea and just not feeling well.
PT notes dated 10/31/22 (no time documented) included the following information: Patient displayed some difficulty as she processed cueing, needed demonstration and frequent cues.
PT notes dated 11/1/22 (no time documented) included the following information: Patient displayed some difficulty as she processed cueing, needed demonstration and frequent cues. Nursing stated no changes in medication or medical status at that time.
Review of the facilities Vitals form revealed the following blood pressures, that measured low according to the form, as dated. The facility failed to notify the resident's physician related to the low reads.
a. 10/30/22 at 11:40 a.m. - 94/59
b. 10/30/22 at 9 p.m. - 103/61
c. 10/31/22 at 6:30 p.m. - 104/66
d. 11/1/22 at 6:30 a.m. - 108/74
e. 11/1/22 at 6:30 p.m. - 100/58
f. 11/2/22 at 6 a.m. - 100/54
g. 11/2/22 at 6:30 p.m. - 84/41
Review of the facilities Nurse's Notes from 10/30/22 thru 11/2/22 failed to address physician notification related to the resident's change in condition.
During an interview on 2/3/23 at 12:29 p.m. a family member indicated two weeks before the resident ended up in the hospital the therapy services noted her as confused, documented that in their notes and informed the nursing staff but they failed to follow through appropriately. It had not been until that Thursday when the resident could not recall her name the facility notified family of the condition change.
During an interview on 2/9/23 at 11:30 a.m. Staff G, LPN Clinical Nursing Coordinator indicated that nursing staff failed to contact the Physician with the resident ' s change of condition and low blood pressures. The labs on 11/7/22 were also missed because the nurse failed to document them in the computer to have been drawn on 11/9/22. Staff also failed to administer the Lactulose or Albumin per order and they failed to contact the Physician. The staff member confirmed the facility lacked a policy related to physician notification of a change of condition however that is nursing 101.
During an interview on 2/9/23 at 10:10 a.m. the Director of Senior Services indicated the facility had no policy on Physician notification with a condition change.
During an interview on 2/8/23 at 3:40 p.m. the resident's Physician confirmed the facility first informed him of the resident ' s confusion on 11/3/23 and he would have expected the staff to have notified him of a condition change when the confusion and low blood pressure had been initially identified on 10/31/22.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview, family interview and Physician interview, the facility failed to follow Physician orders for one resident on 2 separate occasions which resulted in he...
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Based on clinical record review, staff interview, family interview and Physician interview, the facility failed to follow Physician orders for one resident on 2 separate occasions which resulted in her continued change in medical condition, (Resident #3). The facility identified a census of 76 residents.
Findings include:
The Minimum Datat Set with assessment reference date 12/27/22 showed Resident #3 had a Brief Interview for Mental Status score of 12, which indicated moderately impaired decision making skills. The residents diagnosis included hypertension, diabetes and cirrhosis of the liver.
A Physician's Order form for Rsident #3 dated 11/7/22 (no time identified) included the following orders:
a. Complete Blood Count (CBC) with automatic differential.
b. Comprehensive Metabolic Panel (CMP).
c. C-Reactive Protein (CRP) test.
A Physician's Order form dated 11/10/22 at 4 p.m. included the following orders:
a. Albumin 25% IV (intravenous) 25 grams (g) three (3) (TID) times a day for (x) 48 hours.
b. Basic Metabolic Panel (BMP) rechecked on 11/14/23.
c. Lactulose 20 g TID.
During an interview on 2/9/23 at 11:30 a.m. Staff G, LPN Clinical Nursing Coordinator confirmed the physician orders for labs on 11/7/22 were missed because the nurse failed to document them in the computer to have been drawn on 11/9/22. Staff also failed to administer the Lactulose or Albumin per order and they failed to contact the physician. The staff member confirmed the facility lacked a policy related to physician notification of a change of condition however that is nursing 101.
During an interview on 2/3/23 at 12:29 p.m. a family member stated a physician wrote orders which included labs however the facility failed to follow through with those orders. Additionally, she spoke to a Nurse Practitioner (NP) who said they planned to start Albumin and Lactulose on that Thursday afternoon and the facility failed to start those medications so the resident went 5 days without those orders.
During an interview on 2/8/23 at 3:40 p.m. the resident's Physician confirmed he would have expected staff to follow his orders and/or that of his NP.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 37% turnover. Below Iowa's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $117,554 in fines, Payment denial on record. Review inspection reports carefully.
- • 21 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $117,554 in fines. Extremely high, among the most fined facilities in Iowa. Major compliance failures.
- • Grade F (33/100). Below average facility with significant concerns.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Crown Pointe Estates Care Center's CMS Rating?
CMS assigns Crown Pointe Estates Care Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Crown Pointe Estates Care Center Staffed?
CMS rates Crown Pointe Estates Care Center's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 37%, compared to the Iowa average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Crown Pointe Estates Care Center?
State health inspectors documented 21 deficiencies at Crown Pointe Estates Care Center during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 20 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Crown Pointe Estates Care Center?
Crown Pointe Estates Care Center is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 91 residents (about 92% occupancy), it is a smaller facility located in Sioux Center, Iowa.
How Does Crown Pointe Estates Care Center Compare to Other Iowa Nursing Homes?
Compared to the 100 nursing homes in Iowa, Crown Pointe Estates Care Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (37%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Crown Pointe Estates Care Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Crown Pointe Estates Care Center Safe?
Based on CMS inspection data, Crown Pointe Estates Care Center has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Iowa. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Crown Pointe Estates Care Center Stick Around?
Crown Pointe Estates Care Center has a staff turnover rate of 37%, which is about average for Iowa nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Crown Pointe Estates Care Center Ever Fined?
Crown Pointe Estates Care Center has been fined $117,554 across 2 penalty actions. This is 3.4x the Iowa average of $34,254. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Crown Pointe Estates Care Center on Any Federal Watch List?
Crown Pointe Estates Care Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.