Emmetsburg Care Center

Inspectors wroteBased on record review and staff interview, the facility failed to ensure baths as planned for 3 of 4 residents reviewed (Resident #2, #4 and #5). The facility reported a census of 41 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a record of controlled drugs was adequately monitored allowing for the temporary inability to reconcile a controlled medication for 1 resident (Resident #1) and other residents with controlled medications. The facility reported a census of 41 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were free of significant med errors for 3 of 4 residents reviewed (Resident #2, #6 and #7). The facility reported a census of 41 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to develop a comprehensive care plan identifying a resident's needs and describing services to be furnished for a pressure sure and catheter for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 41 residents. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The resident's diagnoses included paraplegia, injury of kidney, and chronic kidney disease. Resident #5 had an indwelling urinary catheter. The Care Area Assessment (CAA) documented the resident had a suprapubic catheter in place, and it would be addressed in the care plan to avoid complications, maintain level of functioning, and minimize risks. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to update the care plan to reflect a resident on an antipsychotic for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 41 residents. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 7 on the Brief Interview for Mental Status indicating severe cognitive impairment. Resident #8's diagnoses included a stroke and hallucinations. The resident received 0 antipsychotic medications. The Progress Notes dated 3/24/26 at 9:25 a.m. documented a communication with the physician about Resident #8 having increased behaviors and paranoia, and requesting a review of her medication for possible update or review. At 2:27 p.m. received a signed order for Seroquel (antipsychotic) 25 mg 2 times a day. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 41 residents. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 8 on the BIMS indicating moderate cognitive impairment. The resident depended on staff for toileting hygiene. The resident was incontinent of urine and frequently incontinent of bowel. Resident #4's diagnoses included diabetes and benign prostatic hyperplasia (enlarged prostate). The current Care Plan with goal target dates of 6/15/26 identified Resident #4 required assistance with Activities of Daily Living (ADL's) related to difficulty in walking, generalized weakness, and obesity. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate medication record for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 41 residents. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #2's diagnoses included diabetes. The Medication Administration Record (MAR) for March 2026 documented Resident #2 took Pregabalin 50 mg 2 times a day. On 3/14/26 the order changed from 50 mg to 75 mg 2 times a day. The Progress Notes dated 4/10/26 at 11:54 a.m. documented during med pass the med aid alerted the nurse of a discrepancy in medication dosage. The Medication card read: Pregabalin 50 mg 2 times a day and the MAR read: 75 mg 2 times a day. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to implement appropriate infection control practices during wound care for 1 resident reviewed (Resident #5). The facility reported a census of 41 residents.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 3 residents reviewed (Residents #2). The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, family interview, resident interviews, staff interviews and policy review the facility failed to provide bathing assistance for 3 of 3 residents reviewed for bathing (Residents #1, #2, #3). The facility reported a census of 39 residents.

Inspectors wroteBased on diet orders, staff interviews, clinical record review, hospital record review and facility policy review the facility failed to serve the appropriate therapeutic diets to meet resident's needs according to their diet orders for 1 of 6 residents reviewed (Resident #3). The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/24/25 at 11:27 AM that began as of 7/17/25. The Facility Staff removed the IJ on 7/24/25 through the following actions:-Education to the nursing staff started on 7/24/25 to ensure they confirm the diet order and serve the appropriate diet and diet modifications. -Like residents include residents with orders for modified or altered diets. An audit was completed for residents with orders for modified or altered diets to ensure the diets are correct. [...]

Inspectors wroteBased on clinical record review, staff and resident interviews, facility policy review, and observations. The facility failed to provide adequate nursing supervision to prevent accidents and injuries for 3 out of 7 residents reviewed for falls. Resident #2 experienced a fall outside of the facility and was not receiving an appropriate level of assistance. Resident #4 and #37 had a fall from a mechanical stand. The facility failed to use the correct harness and provide the correct level of assistance with transfers. The facility reported a census of 43.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 4 of 4 residents reviewed (Residents #18, #19, #21, #23). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure food was discarded after product expiration date, ensure freezers were clean/sanitized and prevent cross contamination during meal service. The facility identified a census of 43 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident with a history of pressure sores received adequate repositioning to prevent a new pressure sore from developing for 1 resident with a pressure sore (Resident #4). The facility reported a census of 43 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed (Resident #37). The facility reported a census of 43 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to perform adequate assessments following falls for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to protect resident from the use of physical restraint that the resident could not remove on their own (Resident #28). The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to develop a care plan to address risk factors and interventions for 2 out of 14 residents (Residents #35 and #6) reviewed for comprehensive care plans. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, resident and staff interview and facility record review the facility failed to provide bathing assistance per resident preference for 1 of 8 residents reviewed for bathing (Resident #2). The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 14 residents reviewed (Resident #18). The facility failed to complete a follow up assessment after the resident had complaints of headache, chest pain, jaw pain with an increased blood pressure and pulse. The facility also failed to notify the Physician and family of the condition change in a timely manner. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, resident and staff interviews the facility failed to ensure residents received the proper diet texture to meet the residents needs in 1 of 1 residents reviewed (Resident #31). The facility reported a census of 39 residents. Finding Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #31 revealed the Brief Interview for Mental Status (BIMs) score of 12, indicating moderate cognitive impairment. Resident #31 had diagnoses of hypertension (high blood pressure), renal insufficiency and difficulty in walking. The MDS revealed the resident was coded for a mechanically altered diet. The Care Plan with a target date of 12/20/24 identified Resident #31 to have a mechanical soft ground meat diet. Physician Orders dated 2/7/24 included an order for general diet, mechanical soft ground meat only texture, regular fluid consistency. [...]