Estherville Community Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 16, 2022

  Based on observation, clinical record review, resident representative interview, staff interviews, facility policy, and facility record review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 2 residents reviewed for elopement (Resident #35). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 29 residents. Findings include: Observations of the switch turned to the off position for the front door alarm for the following dates and times: a. 08/01/22 at 01:18 PM b. 08/02/22 at 07:43 AM c. […]

• Actual harm, isolatedF689Jun 10, 2026

  Based 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.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 demonstrated long- and short-term memory problems and severely impaired skills for daily decision making. […]

• Actual harm, isolatedF689Sep 6, 2024

  Based 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. Findings include: Resident #3's clinical record documented diagnoses of anxiety disorder, abnormal weight loss and adult failure to thrive. The Brief Interview for Mental Status (BIMS) score of 15, indicating severe cognitive impairment. Review of facility provided Incident Report dated 9/5/24 at 5:30 p.m. revealed under incident description staff heard someone yelling help help help. Staff ran to the direction of the screaming. Resident was laying down supine on the floor by the ice machine in the hallway. […]

• No harm, potential for more than minimal, widespreadF851Dec 12, 2024

  Based 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. Findings include: The PBJ Staffing Data Report with run date 12/4/24 triggered for failing to have licensed nursing coverage 24 hours/day - 4 or more days within the quarter with <24 hours/day licensed nursing coverage with specific infraction dates. The report reflected 7 dates with failure to provide 24 hour/day nursing coverage during August and September. […]

• No harm, potential for more than minimal, widespreadF727Jun 2, 2021

  Based on staff schedules, time cards, and staff interview, the facility failed to provide a Registered Nurse (RN) for eight hour per day, seven days per week. The facility reported a census of 27 residents. Findings include: Review of staffing schedules showed a RN did not work for 4 out of 30 days; 4/27/21, 5/14/21, 5/15/21, and 5/23/21. During an interview on 5/26/21 at 9:48 AM, the Administrator, stated she had challenges with staffing RNs. The Administrator commented her request for assistance from the corporation that owned the facility in applying for a waiver for the requirement to have a RN scheduled eight hours per day for seven per week was denied.