Inspection Reports for
Eagle Point Health Care Center
801 28th Avenue North, Clinton, IA, 527321894
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
71% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance for the survey ending April 3, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective May 3, 2025.
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to review the facility's submission of accurate direct care staffing data for the Payroll Based Journal (PBJ) Staffing Data Report, triggered by concerns of excessively low weekend staffing.
Findings
The facility failed to submit accurate staffing data for the PBJ Staffing Data Report due to the Assistant Director of Nursing and Minimum Data Set nurse hours being recorded as management hours rather than nursing hours on the floor, resulting in a trigger for low weekend staffing.
Deficiencies (1)
Failure to submit accurate direct care staffing information for the PBJ Staffing Data Report.
Report Facts
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Reported on staffing issues related to ADON and MDS nurse hours |
| Assistant Director of Nursing | ADON | Worked shifts due to call offs; hours not included in nursing hours on the floor |
| Human Recourses | HR | Reported payroll processing and submission to Corporate office for PBJ |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from March 31, 2025 to April 3, 2025.
Findings
The facility failed to submit accurate and complete direct care staffing data electronically to CMS as required, resulting in a deficiency related to payroll-based journal reporting and excessively low weekend staffing hours.
Deficiencies (1)
Failure to submit accurate direct care staffing information electronically to CMS based on payroll data in a uniform format.
Report Facts
Census: 53
Date survey completed: Apr 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John W. Steinbeck | Administrator | Signed the statement of deficiencies on 4/25/2025. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
The investigation of complaint #126766-C was conducted from February 19, 2025 to February 20, 2025 to determine the validity of the allegation.
Complaint Details
Complaint #126766-C was investigated and found unsubstantiated.
Findings
The allegation was found to be unsubstantiated and the facility was in substantial compliance at the time of the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The document reports on the department's acceptance of the facility's credible allegation of substantial compliance and Plan of Correction for Eagle Point Nursing and Rehabilitation.
Findings
The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities effective July 6, 2024, based on the department's acceptance of their credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
A complaint investigation for complaints #121756-C was conducted from June 27, 2024 to July 1, 2024.
Complaint Details
Complaint #121756-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Inspection Report
Routine
Census: 52
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to maintaining a safe, clean, and homelike environment, dialysis care, resident transfer documentation, and maintenance operations at Eagle Point Nursing and Rehabilitation.
Findings
The facility failed to maintain a homelike environment in resident rooms, did not conduct required dialysis access site assessments and post dialysis vitals for one resident, and failed to document assessments prior to hospital transfer for another resident. Maintenance processes were described but repairs were not documented as needed. The deficiencies were cited with minimal harm potential affecting some or few residents.
Deficiencies (3)
Facility failed to maintain a homelike environment for resident rooms, including damaged bathroom doors, missing baseboards, and exposed plaster in six rooms.
Facility failed to conduct assessments of the dialysis access site and post dialysis vital signs for 1 of 1 resident requiring dialysis.
Facility failed to document an assessment of a resident prior to transfer to the hospital, including missing documentation of assessment, notification of physician and family, and SBAR form.
Report Facts
Census: 52
Residents affected: 6
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported dialysis residents' schedule and care practices |
| Staff G | Licensed Practical Nurse (LPN) | Reported on nursing documentation practices related to resident hospital transfers |
| Director of Nursing | Director of Nursing (DON) | Explained nursing practices regarding dialysis vitals and hospital transfer documentation |
| Maintenance Supervisor | Described maintenance department operations and repair processes | |
| Administrator | Explained facility's software system for maintenance requests |
Inspection Report
Routine
Census: 52
Deficiencies: 6
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, care planning, dialysis services, medical record documentation, infection prevention, and maintenance.
Findings
The facility was found deficient in maintaining a homelike environment in resident rooms, developing and implementing complete care plans addressing residents' needs, providing safe dialysis care, documenting resident assessments prior to hospital transfers, and implementing infection prevention protocols including proper use of personal protective equipment and catheter care. Additionally, the facility failed to maintain appropriate water temperatures to prevent legionella growth and did not fully comply with enhanced barrier precautions during wound care.
Deficiencies (6)
Failed to maintain a homelike environment for resident rooms with damaged bathroom doors, missing baseboards, and exposed plaster.
Failed to develop and implement complete care plans addressing diabetes mellitus, anticoagulant use, dialysis, and other resident needs for multiple residents.
Failed to conduct assessments of dialysis access site and post dialysis vital signs for a resident receiving dialysis.
Failed to document assessment of a resident prior to hospital transfer including mode of transportation and physician orders.
Failed to implement infection prevention and control program including improper handling of urinary catheter bags, failure to use enhanced barrier precautions during wound care, and inadequate PPE use when handling contaminated linens.
Failed to maintain appropriate water temperatures to prevent legionella growth and lacked clear guidance on correct water temperature ranges.
Report Facts
Residents affected: 52
Dialysis frequency: 3
Urinary catheter emptying observations: 2
Water temperature: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Licensed Practical Nurse (LPN) | Reported on care plan updates and hospital transfer documentation deficiencies |
| Staff E | Certified Nurse Aide (CNA) | Observed emptying urinary catheter bags improperly |
| Staff D | Certified Nurse Aide (CNA) | Reported proper catheter bag emptying procedures |
| Staff F | Certified Nurse Aide (CNA) | Reported proper catheter bag emptying procedures and PPE use |
| Staff I | Registered Nurse (RN)/Infection Preventionist | Observed failing to use enhanced barrier precautions during wound care |
| Staff B | Laundry/Housekeeping | Observed handling contaminated linens without gown or mask |
| Staff C | Housekeeping Supervisor | Explained laundry PPE policies |
| Director of Nursing | Director of Nursing | Provided explanations on care plan responsibilities, hospital transfer documentation, and infection control expectations |
| Administrator | Administrator | Provided information on water temperature management and maintenance practices |
| Maintenance Supervisor | Maintenance Supervisor | Reported maintenance procedures and repair request processes |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported on care plan and infection control observations |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 7
Date: Jun 3, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of complaints #117947-C, #119027-C, #120121-C, and #121235-C from June 3, 2024 to June 6, 2024.
Complaint Details
Complaint #120121-C was substantiated. Complaints #119027-C and #121235-C were substantiated without deficiency. Complaint #117947-C was not substantiated.
Findings
The facility was found not in compliance with multiple federal requirements including maintaining a safe, clean, and homelike environment, developing and implementing comprehensive care plans, dialysis care, resident records confidentiality and documentation, and infection prevention and control. Several residents were affected by deficiencies in these areas.
Deficiencies (7)
Facility failed to maintain a safe, clean, comfortable, and homelike environment for resident rooms.
Facility failed to develop and implement comprehensive care plans with proper diagnoses, goals, and interventions for residents.
Facility failed to ensure proper post dialysis assessments and vitals for residents receiving dialysis.
Facility failed to maintain resident records that are complete, accurately documented, confidential, and systematically organized, including documentation of assessments prior to hospital transfers.
Facility failed to establish and maintain an infection prevention and control program, including failure of staff to wear gowns when handling soiled linens and failure to maintain appropriate water temperatures to prevent legionella growth.
Facility failed to use proper barriers and infection prevention procedures when emptying urinary catheter drainage bags.
Facility staff failed to don gowns during treatment of residents requiring enhanced barrier precautions.
Report Facts
Total census: 52
Residents affected: 5
Residents affected: 4
Resident affected: 1
Resident affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John W. Steinbrook | Administrator | Signed the initial comments section of the inspection report. |
| Staff G | Licensed Practical Nurse (LPN) | Reported on care plan updates and resident assessments. |
| Staff A | Licensed Practical Nurse (LPN) | Reported on dialysis residents' post dialysis procedures. |
| Staff B | Observed failing to wear gown during linen transfer. | |
| Staff C | Housekeeping Supervisor | Educated laundry staff on PPE use. |
| Staff D | Certified Nursing Assistant (CNA) | Reported on urinary catheter bag handling. |
| Staff E | Certified Nursing Assistant (CNA) | Observed emptying urinary catheter bag without proper barrier. |
| Staff F | Certified Nursing Assistant (CNA) | Reported on urinary catheter bag handling and infection control training. |
| Staff H | Certified Nursing Assistant (CNA) | Observed handling of urinary collection bag. |
| Director of Nursing | Reported on care plan updates, infection control procedures, and audits. | |
| Assistant Director of Nursing (ADON) | Reported on resident medication orders and wound care. |
Inspection Report
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a standard survey to assess compliance with health and safety regulations at Eagle Point Nursing and Rehabilitation.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
A Focused Infection Control Survey and a Complaint Survey of intake 113231-I were completed from September 19 to 25, 2023.
Complaint Details
Intake #113231-I was not substantiated.
Findings
The facility was found to be in substantial compliance and the complaint intake #113231-I was not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective March 9, 2023.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive care planning, medication labeling, and hospice service coordination at Eagle Point Nursing and Rehabilitation.
Findings
The facility failed to develop comprehensive person-centered care plans for three residents, ensure medication labels matched physician orders for two residents, and coordinate hospice care plans adequately for two residents. Deficiencies were noted in care plan completeness, medication order accuracy, and hospice service coordination.
Deficiencies (3)
Failed to develop a comprehensive person-centered care plan for three residents, missing care plans for schizophrenia, hospice care, and multiple chronic conditions.
Failed to ensure medication labels matched physician orders for two residents, including discrepancies in insulin and levothyroxine administration instructions.
Failed to ensure coordinated hospice plans of care were completed between the facility and hospice provider for two residents, with missing details on wound care, symptom management, and measurable goals.
Report Facts
Residents reviewed for care plans: 27
Residents reviewed for medication labeling: 9
Residents reviewed for hospice services: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan requirements and medication labeling discrepancies. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan omissions and hospice admission timing. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Observed administering medications and interviewed about medication label discrepancies. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Observed administering medications and interviewed about medication administration timing. |
| Director of Clinical Services | Director of Clinical Services | Phone interview regarding hospice admission nurse responsibilities for coordinated care plans. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaints #108957-C and #109578-C from February 6 to February 9, 2023.
Complaint Details
The inspection included investigation of Complaints #108957-C and #109578-C.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for residents, proper labeling and administration of drugs and biologicals, and coordination of hospice services with incomplete hospice care plans and lack of communication between hospice and facility staff.
Deficiencies (3)
Failed to develop a Comprehensive Person-Centered Care Plan for three residents, missing care plans for antipsychotic medication, hospice care, and multiple diagnoses.
Failed to ensure residents' medication labels matched physician orders and proper administration times were followed for two residents.
Failed to ensure coordinated hospice care plans were completed and maintained between the facility and hospice provider for two residents.
Report Facts
Residents reviewed for care plans: 27
Residents reviewed for medication labeling: 9
Residents affected by care plan deficiencies: 3
Residents affected by medication labeling deficiencies: 2
Residents affected by hospice care plan deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Stauweck | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and medication labeling deficiencies |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan deficiencies |
| LPN1 | Licensed Practical Nurse | Observed administering medications and interviewed about medication label discrepancies |
| LPN2 | Licensed Practical Nurse | Observed administering medications and interviewed about medication administration times |
| Director of Clinical Services | Director of Clinical Services | Phone interview regarding hospice care plan responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
A complaint investigation was conducted for Complaints #103962-C, #105138-C, #106362-C, #106400-C and Facility Self-Reported Incidents #101944-I, #101949-I, #102085-I and #102680-I from August 29, 2022 to September 8, 2022.
Complaint Details
Investigation involved multiple complaints and self-reported incidents; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 1
Date: Jul 29, 2021
Visit Reason
The inspection was conducted as part of the Recertification Survey and investigation of Complaint #96242 completed 7/26-7/29/2021.
Complaint Details
Complaint #96242 was investigated and found not substantiated.
Findings
The facility failed to complete proper assessments for residents receiving dialysis, specifically Residents #41 and #19, including pre and post dialysis assessments and monitoring of dialysis access sites. Documentation was lacking for pre dialysis assessments and every shift checking of bruit and thrill.
Deficiencies (1)
Facility failed to complete proper assessments for residents receiving dialysis, including pre and post dialysis assessments and monitoring of access sites.
Report Facts
Resident census: 49
Complaint number: 96242
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Stansheck | Administrator | Signed plan of correction dated 8/20/2021 |
| J. McWhorter | Director of Nursing | Informed Dialysis Unit of new binder and communication tool on 7/30/2021 |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis weight checks |
| Staff B | Assistant Director of Nursing (ADON) | Interviewed regarding dialysis assessment expectations |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted in conjunction with an investigation of Complaints #93579 and #94935 by the Department of Inspections and Appeals from 12/17/20 through 12/23/20.
Complaint Details
Complaints #93579 and #94935 were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaints #93579 and #94935 were not substantiated.
Report Facts
Total Residents: 56
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #92912 and #92959 were conducted by the Department of Inspections and Appeals from 9/8 to 10/20.
Complaint Details
Complaints #92912 and #92959 were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. All complaints were not substantiated.
Report Facts
Total residents: 49
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #89356, #89944, and #92558 was conducted by the Department of Inspections and Appeals on 8/17-8/19/20.
Complaint Details
Investigation of Complaints #89356, #89944, and #92558; all complaints not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. All complaints were not substantiated.
Report Facts
Total residents: 56
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/15/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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