Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emmetsburg Care Center during CMS and state inspections, most recent first.
A resident with intact cognition, multiple comorbidities, and documented moisture-related skin breakdown on the buttocks had a physician order for barrier cream to be applied with cares each shift. On a morning when the resident reported staff were rushed, she stated no cream was applied and that not all staff had been using her ointment, even though the Treatment Administration Record showed the treatment as completed. A CMA reported being told CNAs had applied the cream, but one CNA only "thought" another applied an unidentified cream from a white tube, and the other CNA denied providing incontinence care or applying any barrier cream. Later that day, an LPN measured an enlarged buttocks wound with additional open areas and applied Desitin, while the resident again confirmed she had not received cream that morning, demonstrating that the ordered treatment was neither consistently provided nor accurately documented.
The facility failed to provide and document scheduled bathing assistance for three residents who required varying levels of help with ADLs, despite care plans and standard twice-weekly bath schedules. One cognitively intact resident with multiple diagnoses went 11 and 7 days between baths, with no record of additional bathing offers, and a family member reported very infrequent bathing. Another cognitively intact resident with cancer, HTN, recent UTI, and CKD experienced 5- and 7-day gaps between baths and reported not having a shower or bath for about two and a half weeks, stating staff only used wipes for perineal care. A third resident with moderately impaired cognition and chronic conditions went 15 days without a bath, despite a preference for whirlpool baths and scheduled twice-weekly bathing, and reported receiving baths only about once a week. The DON and Administrator stated that baths are automatically scheduled twice weekly and documented in the EMR, and facility policy required point-of-care documentation of bathing, but records lacked documentation of missed baths and re-approach attempts.
The facility did not provide food prepared in a form tailored to meet the individual needs of residents, resulting in meals that were not consistently modified for specific dietary or physical requirements.
The facility failed to prevent accidents and provide adequate supervision for three residents, resulting in falls both during off-site transport and while using mechanical lifts. One resident fell during a medical transport without required staff assistance or mobility aids, while two others experienced falls from sit-to-stand lifts due to improper sling use, lack of staff education, and failure to follow manufacturer instructions.
Staff did not follow the established portion size guidelines for serving pureed food, using the wrong scoop size and resulting in incorrect portions for four residents on pureed diets. The error was confirmed by the cook and dietary manager, and there was no formal policy in place for the puree process.
Surveyors identified multiple food safety and sanitation deficiencies, including expired and improperly labeled food in storage, unsanitary freezer conditions, and improper food handling during meal service. Staff were observed using bare hands to retrieve utensils and holding plates against dirty uniforms, contrary to facility policy.
Staff did not follow required hand hygiene and infection control protocols while assisting a resident with transfers and toileting. A CNA failed to perform hand hygiene after removing gloves, handled soiled items with bare hands, and placed dirty clothing on the floor, only washing hands at the end of care. These actions did not comply with the facility's infection prevention policy.
A resident with a history of falls and no cognitive impairment experienced multiple falls in the facility. The required neurological assessments following each fall were not completed as per protocol, with several evaluations missed and documented as 'sleeping.' The Regional Nurse Consultant confirmed the assessments should have been completed.
The facility failed to develop comprehensive care plans for two residents, neglecting to address risk factors and interventions for medical conditions and high-risk medications. One resident with multiple diagnoses, including recurrent UTIs, did not have a care plan addressing UTI risks or medication side effects. Another resident on anticoagulant medication lacked a care plan for monitoring potential side effects. The MDS Coordinator acknowledged these omissions, and the facility lacked a policy on comprehensive care planning.
A resident with a history of serious health conditions experienced symptoms of a potential cardiopulmonary issue, including headache, chest pain, and elevated vital signs. Despite these symptoms, the facility failed to conduct a timely follow-up assessment or notify the physician and family. The resident's condition worsened overnight, leading to a delayed transfer to the emergency room the following morning.
A resident with severe cognitive impairment was found with a pillow placed under the fitted sheet, restricting their movement. Staff used the pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan. The MDS Coordinator and DON confirmed this placement constituted a restraint, contrary to facility policy.
A resident requiring substantial assistance for daily baths did not receive consistent bathing due to staffing shortages. The resident, who was cognitively intact and had multiple diagnoses, had baths documented only on select dates over a month. CNAs reported difficulties in providing regular baths due to insufficient staff, and the facility lacked a specific bathing policy.
A resident with moderate cognitive impairment and dental issues was served a regular pork chop instead of the prescribed mechanical soft ground meat diet. The cook served the regular pork chop based on the resident's preference, despite the dietary order. The facility's policy on ground meat diet orders was not followed, and the staff failed to notify the dietician or update the care plan.
Failure to Provide and Accurately Document Ordered Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to accepted standards of clinical practice for a resident with intact cognition who was dependent for transfers and required assistance with bed mobility. The resident had diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease, and was care planned as being at risk for altered skin integrity due to frequent urinary incontinence and need for bed mobility assistance. A health status note documented moisture breakdown on the left inner buttocks with specific measurements, and a physician order directed staff to apply barrier cream with cares every shift to promote healing; however, the order did not specify the location for application or the type of barrier cream to be used. The facility’s policy required active physician orders to be followed and carried out as written. On the morning in question, the resident reported that staff were in a hurry, that her bottom was hurting, and that no cream had been applied that morning, despite having ointment available in her bedside table and a treatment order in place. She stated not all staff had been using the cream. The Treatment Administration Record showed the barrier cream treatment as signed off as completed for that morning shift. A CMA reported he was told the barrier cream was applied with morning cares by two CNAs. One CNA stated she thought the other CNA applied a cream from a white tube but did not know what it was or where it came from, while the other CNA reported she did not assist with changing the resident’s brief that morning and did not apply any barrier cream. Later that day, an LPN measured the wound on the left buttocks and found it had increased in size with two small open areas, and applied Desitin ointment. The resident again verified she had not received any cream or treatment for the wound during the morning shift, indicating the ordered treatment was not provided as documented.
Failure to Provide and Document Scheduled Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance according to residents’ assessed needs, care plans, and scheduled bathing routines for three residents. One resident with intact cognition and diagnoses including cancer, hypertension, non-Alzheimer’s dementia, anxiety disorder, and schizophrenia was care planned to receive staff assistance with showers/bathing per schedule. Task forms showed this resident received only four baths/showers over a 30-day period, with gaps of 11 days and 7 days between baths. The clinical record did not contain documentation of other attempts to offer or encourage bathing, and the resident’s sister reported that bathing was very infrequent and seemed to occur about every two weeks, often when she was present. A second cognitively intact resident with diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease required setup or cleanup assistance for bathing and was also care planned for scheduled showers/bathing. Task forms showed this resident received four baths/showers over 30 days, with gaps of 5 days and 7 days between baths, and no documentation of additional offers or encouragement for bathing. This resident reported believing she had not had a shower or bath for about two and a half weeks and stated that staff only used wipes to clean her bottom. A third resident with moderately impaired cognition and diagnoses including hypertension, diabetes mellitus, depression, and overactive bladder required substantial/maximal assistance for bathing, preferred showers, and was scheduled for twice-weekly bathing. Task forms showed this resident had a 15-day gap without a bath, and the clinical record lacked documentation of other bathing attempts. This resident reported liking whirlpool baths, described the shower as gross, and stated he received a bath about once a week but would like more frequent baths. The DON and Administrator reported that baths are scheduled twice weekly and documented in the electronic record, and the DON acknowledged concerns with bathing documentation and lack of insight into why baths were not done, while facility policy required documentation of completed showers/baths in point-of-care charting.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures. The report does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention for three residents reviewed for falls. One resident, who had a history of falls, generalized weakness, and required substantial assistance for mobility and toileting, experienced a fall outside the facility during transport to a medical appointment. The resident, who was known to have diarrhea and was on a blood thinner, was not accompanied by facility staff as required by his care plan, and did not use his prescribed mobility aids. The fall occurred when the resident attempted to use a restroom at a gas station with only the transport driver assisting, resulting in a head injury and hospitalization. Two other residents experienced falls during transfers using a mechanical sit-to-stand lift. One resident, with moderate cognitive impairment and significant physical limitations, slipped out of the sling during a transfer when the safety features were not properly utilized. Staff interviews revealed a lack of education and awareness regarding the use of a hip sling as a preventive measure, and there was no evidence of follow-up training after the incident. Observations showed that staff did not consistently use the correct sling or ensure that safety straps were properly tightened during transfers. Another resident, who was non-ambulatory and required maximal assistance, was involved in a fall when the sling used with the sit-to-stand lift was not manufactured for use with that specific lift, contrary to the operator's instructions. Staff failed to double-check the straps and did not use all required safety features, resulting in the resident being lowered to the floor after the sling became detached. Observations confirmed that mismatched slings were in use and that staff did not always adjust or tighten safety belts as required. The facility lacked consistent adherence to manufacturer instructions and did not provide adequate staff education or supervision to prevent these incidents.
Failure to Follow Pureed Diet Portion Sizes for Residents
Penalty
Summary
Staff failed to prepare and serve pureed food in accordance with the facility's established portion sizes and procedures for four residents on pureed diets. During meal preparation, the cook used a #10 scoop to serve pureed pork tenderloin instead of the required #12 and #16 scoops as indicated on the Pureed Diet Portion Sizes/Scoop Chart. This resulted in incorrect portion sizes being served, with leftover pureed meat remaining after meal service, despite only four servings being prepared for four residents. The cook acknowledged the error in scoop size and portioning, and the Certified Dietary Manager confirmed that the correct scoop sizes should have been used. The Administrator stated there was no formal policy on the puree process, and the facility relied on the portion size chart.
Food Safety and Sanitation Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards as evidenced by multiple observations during a kitchen tour and meal service. Expired food items, including two large containers of cream cheese past their expiration date and an undated open container, were found stored in the refrigerator. Additionally, a container of chicken broth was dated but not properly labeled with a use-by date. Freezers were found to be in unsanitary condition, with food debris present in all units, a broken plastic container with dried/frozen residue, ice build-up, and a damaged freezer door seal. These conditions were not in compliance with the facility's own policies regarding food storage, labeling, and sanitation. During meal service, improper food handling practices were observed. A staff member was seen holding plates of food against a dirty uniform while cutting pork tenderloin for multiple residents, and handled a serving utensil with bare hands after it fell into a pan of potatoes, then continued to use the same utensil to serve food. The Certified Dietary Manager confirmed that these actions were inappropriate and not in line with facility policy, which requires the use of gloves or utensils when handling ready-to-eat foods and mandates proper sanitation procedures. These deficiencies were identified during a survey with a facility census of 43 residents.
Failure to Follow Hand Hygiene and Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the care of a resident with multiple diagnoses, including hypertension, diabetes mellitus, cerebral palsy, and anxiety disorder. The resident required substantial to maximal assistance for transfers and toileting. During an observed transfer to the commode using a sit-to-stand lift, a CNA applied compression socks and braces to the resident's lower legs while wearing gloves, then removed the gloves without performing hand hygiene. The CNA and another staff member continued with the transfer process, including removing the resident's incontinence brief and placing it in the commode with bare hands, again without performing hand hygiene afterward. Further, the CNA handled the resident's clothing and placed soiled garments directly on the floor, donned new gloves without prior hand hygiene, and continued to assist the resident without following proper infection control protocols. Hand hygiene was only performed at the end of the care episode, after multiple opportunities were missed. The facility's policy required hand hygiene before and after direct resident contact, after glove removal, and after contact with soiled items, but these procedures were not followed during the observed care.
Inadequate Post-Fall Assessments for Resident
Penalty
Summary
The facility failed to perform adequate assessments following falls for a resident, identified as Resident #2, who was at risk for falls due to generalized weakness and difficulty in walking. The resident, who had no cognitive impairment and a history of falls, experienced multiple falls within the facility. After each fall, the facility was required to follow a specific neurological assessment protocol, which included frequent evaluations and documentation over a 72-hour period. However, the facility did not complete the required neurological assessments as per the protocol, with several instances of missed evaluations documented as the resident was 'sleeping.' The first incident on 1/9/25 involved the resident attempting to transfer to the bathroom without assistance, resulting in a fall. The neurological assessments were not completed at several required intervals. A subsequent fall on 1/12/25 was similarly followed by incomplete assessments, with multiple time slots marked as 'sleeping.' Another fall on 1/31/25 also showed a lack of completed assessments, with only two out of nine required evaluations documented. The Regional Nurse Consultant confirmed that the facility should have been completing the neurological assessments as per the protocol.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #35, with a BIMS score indicating intact cognition, had multiple diagnoses including anemia, atrial fibrillation, congestive heart failure, and recurrent urinary tract infections (UTIs). Despite receiving diuretic and opioid medications, the care plan did not address the risk factors for UTIs or the side effects of the high-risk medications. The MDS Coordinator acknowledged the oversight, noting that the care plan did not include interventions for UTIs or monitoring for medication side effects. Similarly, Resident #6, also with intact cognition, had diagnoses of atrial fibrillation, hypertension, and renal disease, and was receiving anticoagulant medication. The care plan failed to address the anticoagulant medication, its potential side effects, and necessary monitoring. The MDS Coordinator confirmed the omission, stating that high-risk medications should have been included in the care plan. The facility lacked a policy on comprehensive care planning, contributing to these deficiencies.
Failure to Timely Assess and Notify in Cardiopulmonary Event
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident experiencing symptoms indicative of a potential cardiopulmonary issue. The resident, who had a history of cancer, anemia, heart failure, hypertension, and non-Alzheimer's dementia, reported symptoms including headache, chest pain, and jaw pain, along with elevated blood pressure and pulse. Despite these symptoms, the facility did not conduct a follow-up assessment or notify the physician and family in a timely manner. On the evening of the incident, the resident's vital signs indicated elevated blood pressure and pulse, and the resident reported a pain level of 7 out of 10. The LPN on duty asked the resident if they wanted to go to the emergency room, but the resident declined. The following morning, the resident's condition had worsened, with increased pain and discomfort, elevated pulse, and decreased oxygen saturation. It was only then that the facility contacted the emergency room and sent the resident for further evaluation. The clinical record lacked documentation of any follow-up assessments or notifications to the resident's family or physician on the evening of the initial symptoms. The MDS Coordinator and DON both acknowledged the delay in sending the resident to the emergency room and the lack of timely notification to the physician and family. The facility's policy required immediate notification of the resident's responsible party and physician in the event of a change in medical condition, which was not adhered to in this case.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to protect a resident from the use of a physical restraint that the resident could not remove on their own. The resident, who had diagnoses of Alzheimer's Disease, anxiety disorder, and a history of falling, was observed with a pillow placed under the fitted sheet on their right side. This method of placement restricted the resident's movement, as confirmed by staff interviews and the facility's policy on physical restraint usage. Staff members, including CNAs, reported using the body pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan or ordered for use. The MDS Coordinator acknowledged that the pillow was not on the care plan and confirmed that its placement under the fitted sheet constituted a restraint. The Director of Nursing also confirmed that the pillow should not be placed under the fitted sheet, as it restricts movement, and stated that staff had been educated on the correct placement of the body pillow.
Failure to Provide Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide bathing assistance according to the preferences of a resident who required substantial assistance. The resident, who was cognitively intact and had diagnoses of diabetes, major depressive disorder, and anxiety disorder, was documented to need extensive assistance for daily baths. However, the electronic health record showed that baths were only completed on specific dates over a month-long period, with no documentation of attempts to encourage bathing or records of refusals. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that staffing shortages were a significant barrier to providing regular bathing assistance. CNAs reported that they often had to reschedule baths due to insufficient staff, leading to residents not receiving baths as needed. The facility lacked a specific policy on bathing, and the Director of Nursing confirmed that all bath records were maintained electronically without additional documentation forms.
Failure to Provide Prescribed Diet Texture
Penalty
Summary
The facility failed to ensure that a resident received the proper diet texture as prescribed. Resident #31, who has moderate cognitive impairment and is on a mechanically altered diet due to having very few teeth, was observed being served a regular pork chop instead of the prescribed mechanical soft ground meat. The cook, Staff C, acknowledged serving the regular pork chop because the resident preferred it this way, despite the dietary order. The resident confirmed that she liked her pork chop cut up and reported that she is on a ground meat diet due to her dental condition. The facility's policy on ground meat diet orders aims to provide appropriate texture meat products for residents with chewing or swallowing problems. However, the staff did not adhere to this policy, as they did not notify the dietician or update the care plan to reflect the resident's preference. The Director of Nursing (DON) reported that the Certified Dietary Manager (CDM) was educated on the need to notify the physician if a resident disagrees with the diet order, but this was not done in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Emmetsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Lutheran Home | 1.1 mi | — | 6 | 0 |
| Palo Alto County Hospital | 1.3 mi | — | 0 | 0 |
| Ruthven Community Care Center | 11.2 mi | — | 2 | 0 |
| West Bend Health And Rehabilitation | 15.5 mi | — | 0 | 0 |
| Laurens Care Center | 19.7 mi | — | 8 | 0 |
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