Titonka Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Sep 16, 2021

  Based on observations, facility policy review, resident interviews, and staff interviews the facility failed to properly use isolation precautions while providing care, or delivering meals to Resident #22. Observations of meal trays being passed throughout the facility showed staff not wearing correct isolation precaution equipment and lacked hand hygiene before delivering trays to other residents not in isolation before and after delivering to Resident #22. The findings constituted an immediate jeopardy (IJ) to resident health and safety.The facility failed to ensure the ice cooler was covered when staff weren't present. The laundry room staff failed to follow proper procedures with keeping clean and dirty laundry separated in the laundry room. […]

• No harm, potential for more than minimal, widespreadF836Apr 17, 2025

  Based on facility record review and staff interviews, the facility failed to employ a licensed Administrator. The facility reported a census of 21 residents. Findings include: During an interview on 4/14/25 at 10:31 AM, the Director of Nursing (DON) reported she has applied for Provisional Administrator and has not been approved yet. She reported the prior Administrator had left back in October around 18th-21st but not sure of the date. During an interview on 4/17/25 at 9:11 AM, the DON reported the former Administrator was available by phone if they would need her but she was not employed by the facility and had not been in the building since October 20th. She reported the facility was not actively looking for an Administrator and has not been.

• No harm, potential for more than minimal, widespreadF880Apr 17, 2025

  Based on observation, infection control policy and staff interview, the facility failed to initiate a legionella water program for the facility. The facility reported a total census of 21 residents. Findings include: During interview on 4/17/25 at 10:30 AM., with Staff A, Maintenance, was unable to explain what the facility was currently doing to prevent Legionella growth in the facility. Staff A stated he wasn't sure what needed to be done for the legionella water program. Staff A stated the previous Administrator was in charge of the Legionella water program. Staff A stated this person left the facility in June 2024. Staff A stated there has not been any temperatures taken of the hot water system since June of 2024. […]

• No harm, potential for more than minimal, widespreadF851May 2, 2024

  Based on record review and staff interview, the facility failed to report Payroll Based Journal (PBJ) during the 1st quarter of fiscal year 2024. The facility reported a census of 13 residents. Findings include: Review of the PBJ report provided by the Center of Medicare and Medicaid Services (CMS) for Fiscal year (FY) 2024 quarter one, indicated the facility did not submit PBJ data. Review of CMS Submission Report titled PBJ on Demand Final File Validation Report dated 2/12/24 revealed the data file was rejected as the reporting period selected on the upload screen did not match submitted XML. On 4/30/24 at 3:28 PM, the Director of Nursing (DON) reported the previous Business Office Manager (BOM) submitted the PBJ data on 2/12/24 but there was a fatal error and the file was rejected. […]

• No harm, potential for more than minimal, widespreadF880May 2, 2024

  Based on observations, 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 2 of 2 residents reviewed (Residents #1, #8). The facility failed to complete hand hygiene after removing gloves and did not complete an annual review of the infection control policies/procedures. The facility reported a census of 13 residents. Findings include: 1. Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS identified Resident #1 was independent with bed mobility and required substantial/maximal assistance with transfers and toileting. […]