Estherville Community Care Center

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure resident's individualized interventions were in place to prevent falls for 4 of 4 resident's reviewed (Resident #1, #2, #3, and #4). Resident #1 had an alarm to alert staff if she got up so they could assist her. Resident #1 stood up, walked a few steps and fell fracturing her left hip. The resident's alarm did not sound. Resident's #2, #3, and #4 had alarms that failed to sound and alert staff to assist them. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, observation, staff and resident interview, along with facility policy review, the facility failed to provide a call light system within reach for which the call light was caught in the hinge of the side rail and was not able to be triggered when pulled for 1 of 3 residents (Resident #5) reviewed. The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, staff and family interview along with policy/procedure review, the facility failed to ensure that discharge instructions were documented in the residents medical record with the necessary information to the resident/resident representative that is easy to understand in a written form and language for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 38 residents.

Inspectors wroteBased on clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from financial exploitation of dependent adult abuse for 3 of 3 residents reviewed (Resident #32, #41 and #43). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 2 of 2 residents reviewed (Resident #7 and #18). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, policy and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #3). The facility reported a census of 33 residents. Findings Include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnosis of depression, anxiety, Psychotic Disorder and Post Traumatic Stress Disorder (PTSD). Resident #3's Level 1 PASRR dated 6/19/24 lacked a diagnosis of Psychotic disorder and PTSD. Resident #3's clinical record lacked a PASRR after 6/19/24. On 9/17/2025 at 10:30 AM, the Director of Nursing (DON) verbalized she submitted PASRR submissions. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to provide trauma informed care with PTSD (Post Traumatic Stress Disorder) and was not assessed for potential triggers that could cause re-traumatization for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 33 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were offered and received the pneumonia vaccine for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 33 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, employee time cards review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 36 residents.

Inspectors wroteBased on record reviews, staff interviews, and policy review, the facility failed to complete comprehensive assessments within required time frames for 7 of 7 residents (Residents #4, #7, #8, #15, #18, #189, and #190). The facility reported a census of 36.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to notify the Long Term Care (LTC) Ombudsman of a transfer to a hospital for 1 of 2 residents (Resident #190) reviewed. The facility reported a census of 36 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during mealtimes, catheter management, and laundry delivery. The facility reported a census of 36. 1) On 12/09/24 at 12:11 PM, Staff A, Certified Nurse Aide (CNA) put on a pair of gloves, picked a fork off the floor with her right hand, and placed it on the table. She walked behind a resident (Resident #34) seated in a tilt-chair, repositioned the resident to face the right side of the table, sat down to the right of the resident, and began feeding the resident. She wiped the resident's mouth with a napkin in her right gloved hand, picked up the resident's milk cup from the top with her gloves, and gave the resident some milk. [...]

Inspectors wroteBased on record review, staff and resident interviews and facility policy review the facility failed to provide residents with the ability to have access to their funds when requested for 2 out 4 residents reviewed (Resident #2 & #4). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent a fall for 1 of 3 residents reviewed (Residents #3). The facility reported a total census of 30 residents.

Inspectors wroteBased on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 28 residents.

Inspectors wroteBased on document review and staff interview the facility failed to verify professional nursing licensure prior to hire for 1 of 2 staff members reviewed (Staff A). The facility reported a census of 28 residents.

Inspectors wroteBased on record review, interview, and facility policy the facility failed to have the Director of Nursing Services, Medical Director and Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 28.

Inspectors wroteBased on personnel file review, facility policy review and staff interview the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff B). The facility identified a census of 28 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to give 2 day notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 for 1 of 3 sampled residents. (Residents #184). The facility reported a census of 28 residents. Findings Include: Record review for Resident #184 revealed form CMS 10123-NOMNC with a services end date of 5/10/23. Resident #184 signed 5/9/23. Centers for Medicare and Medicaid website titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 visited on 10/4/23 at 12:56 p.m., revealed the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Interview on 10/4/23 at 1:14 p.m., with the Administrator revealed it should be a 2 days notice unless they waive it.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 3 of 12 residents reviewed (Resident #4, #8, and #11). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility completed a Preadmission Screening and Resident Review (PASRR) for Level I, but failed to Refer for Level II evaluation for (Resident #4, #8 and #22). The facility reported a census of 28 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a baseline care plan for 3 of 5 residents reviewed (Resident #5, #8, and #14). The facility reported a census of 28 residents.