Emmetsburg Care Center

In the surveyor’s words

From the most serious findings on record at Emmetsburg Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Jul 28, 2025

  Based 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. […]

• Actual harm, isolatedF689Jul 28, 2025

  Based 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. Findings include: 1. Resident #2’s Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, patternF677May 11, 2026

  Based 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.Findings include:1. 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. The resident required partial/moderate assistance with bathing. Resident #2's diagnoses included anemia, inflammatory bowel disease, and diabetes.The current Care Plan with goal target dates of 5/31/26 identified Resident #2 required assistance with Activities of Daily Living (ADL's) related to generalized weakness and neuropathy to lower extremities. […]

• No harm, potential for more than minimal, patternF755May 11, 2026

  Based 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.Findings include:According to the Minimum Data Set Assessment (MDS) dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #1's diagnoses included fractures and other multiple traumas. […]

• No harm, potential for more than minimal, patternF760May 11, 2026

  Based 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.Findings include:1. 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 and the resident received insulin daily.The current Care Plan with a goal target date of 5/31/26 identified Resident #2 at risk for complication related to Diabetes Mellitus. Interventions included encouraging compliance with diet and medication regimen, and medication as ordered. […]