No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Careage Hills Rehabilitation and Healthcare

725 North Second Street, Cherokee, IA 51012 · For profit - Individual · 44 certified beds · (712) 225-2561 Medicare & Medicaid certified

Call the home — (712) 225-2561 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2024Resident-funds citation (F0567)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
212 E Bow Dr · (712) 225-6431 · Call to confirm hours
Pharmacy
800 N 2nd St · (712) 225-6121 · Call to confirm hours
Grocery
205 W Bluff St · (712) 225-3965 · Call to confirm hours
Park
205 W Bluff St · (515) 269-7899 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.9%17.1%15.4%better
Long-stay residents who lose too much weight16.7%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder3.7%1.5%0.9%worse
Long-stay residents with a urinary tract infection0.0%2.4%2.0%better
Long-stay residents with depressive symptoms17.3%4.2%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.9%3.8%3.3%worse
Long-stay residents whose ability to walk worsened7.0%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.5%20.8%18.9%better
Long-stay residents given the seasonal flu vaccine90.9%95.3%95.3%typical
Long-stay residents with pressure ulcers9.5%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control23.3%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.2%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.7%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine50.0%73.3%79.4%worse
Long-stay hospitalizations per 1,000 resident days0.851.491.67better
Long-stay outpatient ER visits per 1,000 resident days3.622.081.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.7%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
0.62U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.7%CMS range 33.3–58.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 5.5–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened15.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 3.8–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.90
RN hours/ resident / day
0.35
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.15
Total nurse hours/ resident / day
0.65
RN hoursweekends
59.3%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 37.4 residents a day — about 85% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.63 hrs/resident/day on weekends vs 3.36 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.00 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-03-05)
3
at the previous standard inspection (2025-02-06)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent injuries with transfers using a mechanical lift for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Alzheimer's Disease, seizures, cognitive communication deficit and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) was not assessed. The MDS showed the Resident depends on staff for eating, oral care, toileting hygiene, bathing, dressing, personal hygiene, bed mobility and all transfers and the Resident depends on staff for wheelchair movement in and out of the facility. Review of Resident #1's Care Plan revealed the following:1. Resident was unable to ambulate initiated 11/1/23.2. Requires total dependence on staff with locomotion using wheelchair…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to provide proper transfer techniques while transferring a resident to prevent accidents for 1 of 3 residents (Resident #21) reviewed. The facility reported a census of 30 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #21 to have a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS further revealed diagnosis of aphasia (loss of ability to understand or express speech), stroke, hemiplegia (paralysis of one side of the body), difficulty in walking, and need for assistance with personal care. Review of the Electronic Healthcare Record (EHR) tab titled, Progress Notes, revealed and entry from 11/1/23 at 1:44 PM by Staff A Licensed Practical Nurse (LPN) that she was summoned to Resident #21 ' s bathroom and found Resident #21 laying on her back on the floor, with the proper footwear on and no gait belt. Staff A further documented…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2026-03-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents. Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents. Findings include: Observation on 3/4/26 at 12:00 p.m. Staff B, Cook, applied gloves after performing hand hygiene. Staff B with gloved hands grabbed the bread sack and opened the bread sack and poured out about 6 pieces of bread on top of small bowls. Then proceeded to tear up the bread with her soiled gloves and grab the milk jug and pour milk over the bread, then took off the gloves and applied new gloves. Observation on 3/4/25 at 12:30 p.m. Staff B had gloves on and opened the hamburger bun bag and took out the bun with her gloved hand, placed it on the plate, then grabbed the potato chip bag and used her soiled glove hand and grabbed the chips and placed them on the plate. Per the facility Policy…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital and a discharge to home for 2 of 3 residents (Resident #38 and Resident #43) reviewed. The facility reported a census of 38 residents.Findings include: Review of Resident #38's Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was discharged with anticipation to return to the facility. The MDS further revealed a Brief Interview for Mental Status (BIMS) was not completed for this MDS. Review of Resident #38's Electronic Healthcare Record (EHR) revealed an entry dated 11/22/25 at 9:29 a.m. that Resident #38 was sent to the emergency room for evaluation. The hospital later notified the facility, Resident #38 was admitted to the hospital. Review of Resident #43's Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was discharged , return not anticipated. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 15…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 38 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of psychotic disorder, neurocognitive disorder and depression. The MDS included a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The Medical Diagnosis list for Resident #7 revealed the following diagnoses:Delusions, dated 6/6/25,Mild neurocognitive disorder, dated 6/6/25,Major depressive disorder, dated 7/7/25. The Clinical Orders…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility record review and staff interviews the facility failed to document blood sugars and insulin on the medication administration record (MAR) for 1 out of 1 residents reviewed (Resident #4). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of diabetes mellitus, renal insufficiency and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview with Resident #4 stated that he checks his blood sugar through his glucose monitoring device and notifies the nurse. Resident #4 stated the nurses will dial up the insulin pen and then he self administers it. Review of the Physician Orders revealed Resident #4's orders are as followed:Humulin, inject 3 units subcutaneous (insertion of medications beneath the skin ) (SQ) 3 times a day.Humulin, inject 3 units SQ per sliding scale 3 times a day: 151-200=2U; 201-250=4U;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, the facility failed to ensure a safe transfer using a mechanical lift for 1 of 2 residents (Resident #11) according to facility policy and manufacturer guidelines. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of dementia, muscle weakness, and abnormalities of gait and mobility. The MDS showed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident could not complete the BIMS interview. The Care Plan, initiated 7/28/22, for Resident #11 indicated transfers require total dependence with assistance from two staff members using a mechanical lift. Observation on 3/3/26 at 11:55 AM revealed Staff C, Certified Nurse Aide (CNA), and Staff D, CNA, transferred Resident #11 from the bed to the wheelchair using a mechanical lift. During the transfer, Staff C raised the resident from the bed with the mechanical lift while…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) and failed to provide proper hand hygiene after catheter care for 1 out 1 resident reviewed (Resident #2). The facility reported a census of 38 residents. Findings include: Observation on 1/21/26 at 10:19 AM revealed Staff E, Certified Nurse Aide (CNA), performed catheter care and emptied the catheter bag for Resident #2 without donning a gown as part of personal protective equipment (PPE) for EBP. After completing care with soiled gloves, Staff E wiped the urine bag spout with an alcohol wipe, pulled the resident's pants down, and collected the urine colander, barrier, and used alcohol wipe. Staff E opened the bathroom door, discarded the barrier and soiled wipe, turned on water, rinsed the colander, and flushed the toilet. Staff E then wrapped the colander in a clean garbage bag, removed the bag from the receptacle,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-09 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews and facility policy the facility failed to provide an adaptive call light for Resident #4 to call for assistance. The facility reported a census of 33 residents. Observation on 12/3/25 at 3:22 p.m., of Resident #4 transferring from her bed to her wheelchair with a mechanical lift. During the transfer Resident #4 revealed she did not have a call light she was able to operate. Resident #4 verbalized she had a button call light but was unable to operate that due to her multiple sclerosis. Resident #4 revealed the facility had given her a pad call light but sometime last week that broke. Resident #4 explained the facility came and took the call light pad and was going to fix the call light and it has not come back. Observation in the room revealed there was no call light or way for Resident #4 to call for assistance in the room. Interview on 12/3/24 at 3:22 p.m., with Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, staff confirmed Resident #4 did not have a call light. Staff A showed Resident #4 was given a call light…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews and policy review, the facility failed to complete a wound treatment for 1 of 3 residents reviewed (Resident #1) and failed to complete an assessment for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview Mental Status (BIMS) of 15 indicating intact cognition. The MDS revealed diagnoses including type 1 diabetes, pressure ulcer of the right buttock and sacral region. The MDS further revealed the resident was dependent on staff for toileting assistance and personal hygiene. The Care Plan for Resident #1 initiated [DATE] revealed the resident had actual pressure ulcer development and directed staff to administer treatments as ordered. Review of Physician Orders for Resident #1 revealed an order effective [DATE] to treat left ischium (lower and back of the hip bone) with 1/2 strength peroxide and 1/2…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety for 1 meal. The facility reported a census of 35 residents. Findings include: During observation on 2/5/25 at 11:07 a.m. the Dietary Supervisor (DS) removed his gloves, washed his hands and applied new gloves. The DS and started serving the noon meal, touching plates, utensils, covers on the steam table, diet cards and menus. During the service the DS retrieved a bun out of it's bag wearing the same gloves. He used tongs to put a hamburger on the bun. After sending the hamburger out, he changed his gloves without washing his hands. The DS continued to serve, touching multiple surfaces. He paused to make a peanut butter sandwich wearing the same gloves. He retrieved a package of cheese from the refrigerator and removed a slice wearing the same gloves. He served additional hamburgers handling the buns with gloves on that he had touched other surfaces with. On 2/6/25 at 2:14 p.m. the Dietician confirmed gloves that touched other surfaces could…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to obtain bed hold notifications for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 35. Findings include: Review of Resident #6's Electronic Healthcare Record (EHR) revealed Resident #6 was in the hospital from [DATE] to 5/16/24 and 5/17/24 to 5/18/24. Further review of the EHR page titled, Clinical Census confirmed the Resident was in the hospital on these dates. Review for bed hold notification for Resident #6 revealed there was no bed hold form to review for the dates of hospitalization. During an interview on 2/6/25 at 12:49 PM the Administrator stated these two bed holds were missed. The Administrator stated we had started a Performance Improvement Program (PIP) after our last annual survey. The Administrator stated that she was the person auditing the bedholds at that time and that they were missed and weren't followed back up on. She stated that the process is anyone that goes out needs to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2025-02-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the facility policy, the facility failed to follow the facility policy regarding significant weight loss in 1 out of 1 residents reviewed for nutrition needs (Resident #33). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 documented diagnoses of diabetes mellitus, cerebrovascular accident, and Non-Alzheime's dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of Resident #33's clinical record reviewed the following information: On 12/9/2024, the resident weighed 149.4 pounds (lbs). On 1/8/2025, the resident weighed 128.0 pounds which is a -14.3% Loss. Review of Resident #33's weights showed the last weight taken on 1/8/2 5was 128 lbs. There were no weights taken after this date. Review of facility Weight Committee Progress Notes dated 1/8/25 at 8:56 PM revealed the Resident had a weight loss of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents were free from abuse for 1 of 4 residents. Resident #1 fell to the floor and sustained a hematoma on the back of his head after another resident pushed him down. The facility reported a census of 33 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficit). The resident required set up assistance with eating, and was independent with walking, transfers and toileting. His diagnosis included benign prostatic hyperplasia (BPH), Diabetes Mellitus, and non-Alzheimer's dementia. During observation on 11/4/24 at 12:40 PM, Resident #1 had just finished his lunch. He was pacing the hallway near his room and the door to the outside where the residents took their smoke breaks. He went back into the dining room and in and out of his room several times. At 12:58 PM he was sitting in chair near a large fish tank,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-05 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to thoroughly investigate alleged abuse for 1 of 3 residents, and failed to investigate an injury of unknown origin for 1 of 1 resident reviewed. The facility reported a census of 33 residents Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficit). The resident required set up assistance with eating, and was independent with walking, transfers and toileting. His diagnosis included benign prostatic hyperplasia (BPH), Diabetes Mellitus, and non-Alzheimer's dementia. The Care Plan updated on 7/1/24, showed that Resident #1 was allowed to smoke during designated smoking times that were offered 4 times a day. He participated with psychiatric services for evaluation and response to psychotropic medications. Resident #1 had impaired cognitive function with short term memory loss and had periods of agitation. According to an Incident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policy review the facility failed to ensure that residents were properly supervised, and interventions were utilized to prevent accidents for 5 of 5 residents reviewed, (Residents #1, #2, #3, #4 and #5), . Staff failed to use safe transfer practices for Residents #1, and #5. Resident #3 slid off of the [NAME] pool seat, and Resident #4 sustained a broken toe when a staff's dog tripped her. Staff failed to follow care plan interventions established to prevent further falls for Resident #2. The facility reported a census of 38 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 was admitted on [DATE] and did not have a Brief Interview for Mental Status (BIMS) assessment because she was rarely/never understood. She was totally dependent on staff for toileting, dressing, hygiene and transfers. Her diagnoses included Alzheimer's Disease, malnutrition, anxiety disorder, lack of coordination and parkinsonism. A Care Plan updated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow interventions established in the care plan to prevent falls for 1 of 5 residents reviewed. Resident #2 had a history of falls and observations revealed that staff failed to implement two of those interventions. The facility reported a census of 38 residents Findings include. According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive deficits). She used a walker and wheelchair for mobility and required substantial assistance with lower body dressing and footwear. The resident required supervision/touch assistance with sit to stand, toilet transfer and sit to lying. She was frequently incontinent of urine, and occasionally incontinent of bowel. Her diagnoses included renal insufficiency, non-Alzheimer's dementia, unspecified fracture fifth lumbar vertebra and muscle weakness. The Care Plan showed Resident #2 had confusion/disorientation, weakness, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews and policy review the facility failed to have ready and reasonable access to personal funds upon request for 2 of 12 residents reviewed (Resident #25 and #30). The facility reported a census of 30. Findings Included: In an interview on 3/25/24 at 1:32 PM, Resident #30 stated, We can't get money when we want it because the person isn't here. We can plan for the weekend and they will leave money but only if we make plans. In an interview on 3/25/24 at 1:59 PM, Resident #25 stated, I haven't asked for money because that staff isn't here on the weekend. If I need money I would have to call my son. In an interview on 3/26/24 at 1:13 PM, the Operations Manager (OM) reported personal funds were available to residents after business hours and weekends by making predetermined arrangements with the social worker. In an interview on 3/26/24 at 2:47 PM, the Social Worker (SW) reported residents with the proper cognitive ability could use funds from their envelope located at the nurse ' s station. The SW explained residents could get up to $10 of their…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file reviews, staff interviews, and policy reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 2 of 5 employees reviewed (Staff E and Staff F). The facility census was 30. Findings include: On 3/26/24 Staff E, LPN's personnel file did not contain the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information. Staff E was rehired on 7/18/22. On 3/26/24 Staff F, CNA ' s personnel file did not contain the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information. Staff F was rehired on 10/11/22. On 3/26/24 at 2:19 PM the Business Office Manager completed an online verification via the facility ' s SING account for Staff E and F ' s background checks. The Business Office Manager stated the facility failed to complete background checks for both Staff E and Staff F prior to rehire. On 3/26/24 at 1:04 PM the Executive Director…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Residents #21) reviewed. The facility reported a census of 30. Findings include: Review of Resident #21 ' s Electronic Healthcare Record (EHR) revealed Resident #23 was in the hospital from [DATE] through 11/4/23. Further review of the EHR page titled, Clinical Census, confirmed the Resident was in the hospital on this date. Review for bed hold notification for Resident #21 revealed there was no bed hold form to review for the dates of hospitalization. During an interview 3/26/24 at 2:30 PM the Administrator revealed there was no bed hold for Resident #21 going to the hospital 11/1/23. During a follow up interview 3/26/24 at 2:47 PM with the Director of Nursing (DON) and the Administrator revealed their expectation would be to get a bed hold every time a resident is transferred or discharged from the facility. Review of a facility provided policy titled, Bed Hold, with a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.2-1.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
HELENTHAL, TARAIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 02/03/2016
BURNAM, SOONIndividualCORPORATE OFFICERsince 07/18/2011

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.7M
Net patient revenuemost recent cost report
+4.4%
Operating marginrevenue minus expenses
$388K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 6%Other / private 34%

This home reported $388K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$268per resident / day
operating cost
$8,134per month
≈ monthly operating cost
$280per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.

Typical monthly cost in Iowa
$9,277/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,381/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165428. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next