Inspection Reports for
Crown Pointe Estates AL Memory Care
1400 7th Avenue SE, Sioux Center, IA, 51250
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
278% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 89
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards following incidents involving resident falls and safety concerns at Crown Pointe Estates Care Center.
Findings
The facility failed to provide timely assessments and interventions after resident falls, including delayed physician notification and inadequate use of safety equipment during transfers. Two residents experienced falls resulting in injury and increased risk due to insufficient supervision and failure to follow established policies.
Deficiencies (2)
F 0684: The facility failed to ensure timely assessment and physician notification after a resident fall, resulting in delayed treatment for a fractured hip and subsequent resident death. Neuro checks and vital signs were not consistently documented as required.
F 0689: The facility failed to use proper safety equipment, specifically gait belts, during resident transfers and ambulation, leading to a resident fall and increased risk of injury. Staff did not adequately monitor a resident with increased weakness and confusion.
Report Facts
Residents Affected: 1
Residents Affected: 1
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Assessed resident after fall and called doctor |
| Staff G | Registered Nurse (RN) | Overnight nurse involved in resident fall care and communication |
| Staff F | Certified Nurse Aide (CNA) | Assisted resident after fall and monitored pain |
| Staff H | Registered Nurse (RN) | Reported resident fall and monitored resident condition |
| Staff I | Certified Medication Aide (CMA) | Assisted resident during ambulation without gait belt |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 6
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure in notifying doctors and families after resident falls, inadequate documentation of bed hold notices, failure to refer residents for PASRR evaluation, inadequate treatment and care following falls, improper use of safety equipment during transfers, and failure to implement infection prevention protocols.
Complaint Details
The investigation was complaint-driven, focusing on failures in notification after falls, documentation of bed hold notices, PASRR referrals, treatment timeliness, safety equipment use, and infection control practices. The facility was found deficient in all these areas.
Findings
The facility failed to notify the doctor and family promptly after a resident fall resulting in a fractured hip and subsequent death. Documentation for bed hold notices was incomplete. The facility did not refer a resident for required PASRR evaluation. Staff failed to provide timely assessments and interventions after falls, did not use gait belts during transfers, and failed to wear Enhanced Barrier Precautions during wound care.
Deficiencies (6)
F 0580: The facility failed to notify the doctor and family after a resident had a fall with injury, delaying hospital transfer and treatment.
F 0628: The facility failed to ensure bed hold notice was signed by residents or their representatives when residents transferred out for hospitalization.
F 0644: The facility failed to refer a resident with a negative Level I PASRR result for Level II evaluation as required by state regulations.
F 0684: The facility failed to provide timely assessments and interventions after a resident fall, resulting in delayed hospital transfer and adverse outcomes.
F 0689: The facility failed to use proper safety equipment, specifically gait belts, during transfers and ambulation for a resident with increased fall risk.
F 0880: The facility failed to wear Enhanced Barrier Precautions during wound care for a resident with an open wound requiring dressing changes.
Report Facts
Residents present: 89
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Named in findings related to delayed notification and assessment after resident fall |
| Staff D | Registered Nurse (RN) | Assessed resident after fall and called doctor for hospital transfer |
| Staff H | Registered Nurse (RN) | Reported on resident fall and confusion, monitoring |
| Staff I | Certified Medication Aide (CMA) | Involved in resident fall due to not using gait belt during transfer |
| Staff B | Registered Nurse (RN) | Observed wound care without Enhanced Barrier Precautions |
| Staff A | Certified Nursing Assistant (CNA) | Observed assisting resident during wound care without Enhanced Barrier Precautions |
| Staff C | Co-Director of Nursing | Interviewed regarding failure to use Enhanced Barrier Precautions |
Inspection Report
Routine
Census: 91
Deficiencies: 5
Date: Aug 1, 2024
Visit Reason
Routine inspection of Crown Pointe Estates Care Center to assess compliance with nursing home regulations including bed hold notices, professional standards of care, dietary services, food storage, and infection prevention.
Findings
The facility failed to complete bed hold notices for residents transferred to hospitals, did not follow physician orders for wound care, served incorrect meal portion sizes, improperly stored food, and failed to maintain proper infection prevention practices during wound and catheter care.
Deficiencies (5)
F 0625: The facility failed to notify residents or their representatives in writing about the duration of bed hold during hospital transfers for 2 of 3 residents reviewed.
F 0658: The facility failed to provide professional standards of quality by not following physician orders for wound dressing changes for 1 of 3 residents reviewed.
F 0800: The facility failed to provide a well-balanced diet meeting nutritional and special dietary needs by serving incorrect portion sizes for 2 of 26 residents reviewed.
F 0812: The facility failed to store food in accordance with professional standards, including undated and improperly stored food items.
F 0880: The facility failed to provide appropriate infection prevention practices during wound and catheter care for 1 resident with an indwelling catheter.
Report Facts
Residents reported in census: 91
Residents reviewed for bed hold notice deficiency: 3
Residents reviewed for wound care deficiency: 3
Residents reviewed for dietary portion deficiency: 26
Residents affected by food storage deficiency: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed providing catheter and peri care with infection prevention issues |
| Staff C | Licensed Practical Nurse (LPN) | Provided statements regarding wound dressing changes |
| Staff D | Registered Nurse (RN) / Assistant Director of Nursing (ADON) | Provided statements on wound care standards and infection prevention expectations |
| Staff E | AM Dietary Staff | Observed serving incorrect portion sizes for IDDSI level 6 diets |
| Staff F | Certified Dietary Manager (CDM) | Provided statements on dietary portion expectations |
| Staff G | Observed performing wound care and infection prevention practices | |
| Administrator | Reported expectations for bed hold notice completion and auditing | |
| Kitchen Supervisor | Provided statements on food storage and dating requirements |
Inspection Report
Original Licensing
Census: 15
Deficiencies: 0
Date: May 21, 2024
Visit Reason
Initial certification visit conducted to determine compliance with certification rules for an Assisted Living Program for People with Dementia (ALP/D).
Findings
No regulatory insufficiencies were cited during the initial certification visit. An investigation (#118803-I) was also completed with no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 13
Total census: 15
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to use a mechanical stand to prevent accidents for a resident requiring assistance with transfers.
Complaint Details
The complaint investigation found that Resident #1 was not transferred using the mechanical stand as required, resulting in a fall to the floor. Staff failed to follow the care plan and did not have a clear policy on handling resident refusal of mechanical lifts. Education was provided post-incident. The complaint was substantiated with few residents affected.
Findings
The facility failed to follow the care plan for Resident #1 by not using the required mechanical stand during transfers, resulting in the resident being lowered to the floor. Staff education was provided after the incident, but the facility lacked a specific policy on resident refusal of mechanical stand use.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards by not using a mechanical stand for Resident #1 during transfers, contrary to the care plan. This failure led to the resident being lowered to the floor when the mechanical stand was refused.
Report Facts
Resident census: 87
Inspection Report
Census: 82
Deficiencies: 6
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with Medicare/Medicaid regulations including notification requirements, staffing postings, dental service assistance, food safety, and infection control practices.
Findings
The facility failed to provide required Medicare notices to resident representatives, notify the Long Term Care Ombudsman of resident hospital transfers, post daily nurse staffing on paper, assist a resident with dental service transportation, enforce kitchen staff hair net policy, and ensure proper hand hygiene during medication administration.
Deficiencies (6)
F 0582: The facility failed to mail Advanced Beneficiary Notice of Non-Coverage and Notice of Medicare Provider Non-Coverage forms to resident representatives after verbal consent for 3 residents.
F 0623: The facility failed to notify the Long Term Care Ombudsman of hospital admissions for 3 residents and lacked a policy on such notifications.
F 0732: The facility failed to post a paper copy of daily nurse staffing in each unit as required.
F 0791: The facility failed to provide needed assistance for dental appointments and transportation for one resident.
F 0812: The facility failed to ensure kitchen staff wore hair nets as required by policy.
F 0880: The facility failed to perform hand hygiene before and after glove use and allowed medication to be touched with bare hands during administration.
Report Facts
Residents census: 82
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene and touching medication with bare hands |
| Staff H | Registered Nurse (RN), Care Coordinator | Interviewed regarding dental service assistance for Resident #47 |
| Staff I | Social Worker | Interviewed regarding dental service transportation policy and Resident #47 |
| Staff E | Certified Medication Assistant (CMA) | Reported no paper copy of daily staff posting for residents |
| Staff F | Licensed Practical Nurse (LPN) | Reported no paper copy of daily staff posting for residents |
| Staff J | Assistant Director of Nursing (ADON) | Reported on daily printed nursing staff posting and uncertainty about posting location |
| Business Office Manager | Interviewed regarding issuance of Medicare notices and verbal consent process | |
| Registered Dietician | Reported expectation that kitchen staff wear hair nets | |
| Administrator | Interviewed regarding Ombudsman notification and dental transportation policies |
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