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Lakeside Lutheran Home

301 North Lawler Street, Emmetsburg, IA 50536 · Non profit - Corporation · 55 certified beds · (712) 852-4060 Medicare & Medicaid certified

Call the home — (712) 852-4060 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20251 actual-harm citation1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — 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 facility-reported quality-measure rating is low (1/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 1 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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3201 1st St · (712) 852-5555 · Call to confirm hours
Pharmacy
2216 Main St · (712) 852-2886 · Call to confirm hours
Grocery
2008 12th St · (712) 852-2455 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
703 Broadway St · (712) 852-4450

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 1 of 5
Long-stay residentspeople who live here 1 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 fell from 3 to 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 increased17.5%17.1%15.4%worse
Long-stay residents who lose too much weight3.5%4.6%5.4%better
Long-stay residents with a catheter left in their bladder4.6%1.5%0.9%worse
Long-stay residents with a urinary tract infection6.1%2.4%2.0%worse
Long-stay residents with depressive symptoms0.0%4.2%6.5%check this — see note marked star below the table
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 injury5.7%3.8%3.3%worse
Long-stay residents whose ability to walk worsened13.1%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.9%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers1.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control21.8%25.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.7%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.9%2.1%1.4%worse
Long-stay hospitalizations per 1,000 resident days1.861.491.67worse
Long-stay outpatient ER visits per 1,000 resident days3.902.081.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

51.4% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.4%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
0.11U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF51.4%CMS range 36.3–63.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 6.5–15.710.7%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 identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

0.76
RN hours/ resident / day
0.35
LPN hours/ resident / day
3.00
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.53
RN hoursweekends
37.2%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 55 beds and averages 37.6 residents a day — about 68% occupied, or roughly 17 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 is at or above 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 3.80 hrs/resident/day on weekends vs 4.24 on weekdays — 10% thinner on weekends. RN hours go from 0.86 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as 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

2
deficiencies at the latest standard inspection (2026-02-26)
8
at the previous standard inspection (2025-01-23)

Deficiencies are fewer than at the previous inspection — improving. 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.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2025-01-23 · 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 interviews, and facility record review, the facility failed to provide adequate fall follow up and pain assessments after a fall for 1 of 1 residents reviewed (Residents #35). The facility reported a total census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 documented diagnoses of non-Alzheimer ' s Dementia, non-traumatic brain dysfunction (a complex condition that occurs when the brain is damaged by internal factors, rather than an external force to the head), restlessness and agitation. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognition. The MDS revealed Resident #35 was independent with transfers, was substantial/maximal (helper does more than half the effort, helper lifts or holds trunk or lungs and provides more than half the effort) with upper and lower body dressing, and partial/moderate (helper does less than half the effort. helper lifts, holds, or supports…

    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 · D2026-02-26 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 record review and staff interview, the facility failed to ensure residents who used psychotropic drugs received a Gradual Dose Reduction (GDR), unless clinically contraindicated, 2 times the first year, in 2 separate quarters (with at least one month between the attempts) unless the provider documented the rationale for 1 of 5 residents (Resident #5) and once a year after for 1 of 5 residents (Resident #1). The facility reported a census of 39 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included anxiety disorder. The resident received multiple high risk medications including an antianxiety.The Care Plan revised 7/19/25 identified Resident #1 used anti-anxiety medication related to anxiety disorder. The interventions included giving anti-anxiety medications ordered by the physician and monitoring/documenting side…

    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 · D2026-02-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, record review and staff interview, the facility failed to complete the Minimum Data Set (MDS) assessment accurately for 2 of 13 residents reviewed (Resident #19 and #31). The facility reported a census of 39 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #19 scored 6 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included heart failure, renal insufficiency, and chronic respiratory failure. The MDS documented the resident had an indwelling urinary catheter.On 2/23/26 at 3:30 p.m. Resident #19 sat in her recliner and had no catheter.The Care Plan dated 2/23/26 identified Resident #19 had mixed bladder incontinence related to diuretic therapy. Interventions included the resident used disposable briefs.The Care Plan lacked documentation the resident had a catheter.The Progress Notes dated 9/12/25 documented Resident #19 admitted skilled after right hip fracture repair, with…

    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 · Ecited before2025-05-22 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 record review and staff interview the facility failed to immediately separate an alleged abuser from all potential victims. The facility reported a census of 34 residents. Finding's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she applied the bath chair safety belt. Staff A refused to turn the jets on. She also jammed the toothbrush in her mouth. Staff B went to the charge nurse, who was from a temp agency.…

    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 · D2025-05-22 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 record review and staff interview, the facility failed to ensure residents were allowed to choose schedules, clothing, or bathing preferences for 2 of 4 residents reviewed (Resident #1 and #4). The facility reported a census of 34 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Care Plan identified the resident had an activity of daily living self care performance deficit. The interventions included she required one staff assistance for completion of bathing. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower and making her wait on her jewelry, commenting she didn't have time to pamper her…

    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 · Dcited before2025-05-22 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 record review and staff interview, the facility failed to notify the physician, and the resident's representative immediately of a resident's allegation of rough treatment for 1 resident (Resident #1). The facility reported a census of 34 residents. Findings's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide (Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower (her breast got pinched with a gait belt, and jammed toothbrush in her mouth). The resident also complained of pain in her breast radiating to the back of her shoulder, feeling weak, and unable to walk. The resident assisted to her room via wheelchair. Vital Signs…

    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 · Dcited before2025-05-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 record review and staff interview the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of an allegation of potential abuse within the required time frame for 1 resident reviewed (Resident #1). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she…

    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 before2025-05-22 · 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 record review and staff interview the facility failed to ensure appropriate transfer techniques to prevent injury for 1 of 3 resident's reviewed (Resident #6). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required partial to moderate assistance with sitting to standing. The resident's diagnoses included cancer, anemia, atrial fibrillation, and heart failure. The Care Plan dated 7/24/24 identified the resident had an activity of daily living self care performance deficit related to weakness and cancer. The interventions included the resident had chronic pain at varied levels, and having 2 staff present with cares and mobility, may help with gentle moving and tasks to alleviate pain. The Progress Notes dated 10/7/24 at 11:06 a.m. documented Resident #6 had skin tears to his right forearm The surrounding…

    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 · F2025-01-23 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel time card records and staff interview, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data. The facility reported a census of 39 residents. Findings include: The facility Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter 4 2024 (July 1 - September 30) showed an area of concern triggered. The facility failed to have licensed nursing coverage 24 hours a day on 7/5, 7/6, 7/7, 8/2, 8/10, 8/11, 8/15, 8/24, 8/25, 9/7, 9/8, and 9/22/24. The facility provided time card information for facility staff working the days above, and agency staffing invoices documenting agency staff working the same day above, showing the facility had a nurse on 24 hours per day. On 1/22/25 at 5:02 p.m. the Administrator provided documentation they had 24 hour staffing on the days that were lacking on the PBJ report. She understood this needed to be reported…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-23 · tag F0607 — failed to have anti-abuse policies — pattern
    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 record review, staff interviews and policy review the facility failed to provide appropriate screening prior to employment for 2 of 5 employees reviewed for background checks. The facility did not receive approval for the employee to work after the criminal background check revealed the employees had a past criminal history. The facility reported a census of 39 residents. Findings include: 1. The personnel file for Staff E, (Certified Nursing Assistant) documented a start date of 7/29/24. The Single Contact License and Background Check (SING) dated 7/15/24 indicated a criminal history record was found and required further research. The Iowa Criminal History results revealed Staff E had been charged with operating while intoxicated, 1st offense. The personnel file for Staff E lacked documentation that a record check evaluation was conducted and an approval to work was obtained through the Iowa Department of Human Services. Review of current nursing schedules revealed Staff E was an active CNA at the facility. 2. The personnel file for the active DON (Director 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · 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

    Based on clinical record review, staff interviews and policy review, the facility facility failed to protect a resident from verbal and physical abuse by a staff member for 1 of 12 residents reviewed for abuse (Resident #24). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #24 dated 12/10/24 identified a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. The MDS identified Resident #24 was dependent on staff for bed mobility, toileting and transfers. The MDS documented Resident #24 had physical and verbal behavioral symptoms directed toward others 1 to 3 days per week. The MDS included diagnoses of hypertension (high blood pressure), pneumonia, diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia (stroke affecting one side), non-Alzheimer's dementia, anxiety, depression and adjustment disorder with mixed disturbance of emotions and conduct. The Care Plan with a revised date of 12/4/24 documented Resident #24 had behavior problems related 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2025-01-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, personnel record review, facility investigation review, and policy review the facility failed to notify DIAL (Department of Inspection, Appeals and Licensing) of an alleged verbal and physical abuse for Resident #24 that occurred on 1/6/25 at 7:00 AM in a timely manner. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25. The DON denied being told or hearing of the allegation of abuse. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL entered the facility and notified the DON of the allegations. The facility reported the incident to DIAL on 1/16/25 at 3:34 PM. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head…

    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 before2025-01-23 · 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

    Based on staff interviews, facility investigation review, time card detail, and policy review the facility failed to separate a staff member from dependent residents accused of alleged physical and verbal abuse that occurred on 1/6/25 at 7:00 AM for Resident #24. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25 and the DON denied being told or hearing of the allegation of abuse. The staff member worked full shifts on 1/6/25, 1/7/25, 1/9/25, 1/11/25, 1/12/25, 1/15/25 and a partial shift on 1/16/25. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL (Department of Inspections, Appeals and Licensing) entered the facility and informed the DON of the alleged abuse. Two staff members interviews reflected inappropriate behavior with the nurse and Resident #24. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 record review and staff interview, the facility failed ensure residents on antibiotics were re-evaluated for excessive duration, for 2 of 3 residents reviewed (Resident #7 and #8). The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including cardiorespiratory conditions and anxiety. The Care Plan revised 5/7/24 identified Resident #7 on routine antibiotic therapy for preventative measures secondary to a history of chronic urinary tract infections (UTI's). Interventions included administering medication as ordered, and taking Cephalexin daily at bedtime for prevention. Antibiotics were non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Observe the resident for…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review and policy review the facility failed to give medications according to manufacturer's instructions for 1 out of 6 residents observed during medication pass (Resident #8). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #8 dated 1/13/25 identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS identified Resident #8 was independent with bed mobility, transfers and walking. The MDS included diagnoses of cerebral palsy, non-alzheimer's dementia, seizures and moderate intellectual disabilities. The January 2025 Medication Administration Record (MAR) directed staff to administer Fosamax (used to treat or prevent osteoporosis) 70 MG (milligrams) one tablet by mouth one time a week in the AM on Thursday related to specified disorders of bone density and structure. The order lacked specific directions on how the medication should be administered. On 1/23/25 at 7:58 AM, observed Resident #8 sitting at the dining room…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 interviews, the facility failed to ensure resident ' s current code status was available for 1 out of 15 residents reviewed (Resident #42). The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The clinical record review revealed Resident #42 was admitted to the facility on [DATE]. Review of a form titled Iowa Physician Orders Scope of Treatment (IPOST) revealed Resident #42 ' s legal representative chose Resident #42 to be DNR status (Do Not Attempt to Resuscitate) with comfort measure only. The IPOST documented comfort measures included the use of medications by any route, positioning, wound care…

    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 · Dcited before2024-02-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 notify the physician regarding a significant weight loss in 1 out of 1 residents reviewed for nutritional needs (Resident #17). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 documented diagnosis of Alzheimer's disease, renal insufficiency, and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS indicated that Resident #17 was coded for weight loss and not on physician prescribed weight loss regimen. Review of Care Plan with a revised date of 1/9/24 revealed Resident #17 had potential for nutritional problems related to a therapeutic diet, variable intake by mouth and cognitive deficits. Review of Resident #17 ' s clinical record reviewed the following information: On 11/21/2023, the resident weighed 153.6 pounds. On 12/26/2023, the resident weighed 145.4 pounds which…

    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 · D2024-02-15 · 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 clinical record review and staff interviews the facility failed to develop a care plan to address risk factors and interventions for 1 out of 15 residents (Residents #42) reviewed for comprehensive care plans.The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The MDS documented Resident #42 received anticoagulant (blood thinner) medication for 7 days during the lookback period. A Physician Order dated 1/23/24 directed staff to administer Warfarin Sodium (Coumadin) (anticoagulant) 1.5 mg (milligrams) by mouth in the evening every Monday and Friday and 3 mg in the evening on Tuesday, Wednesday, Thursday, Saturday and Sunday for…

    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 · D2024-02-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, staff interview, and clinical record review the facility failed to provide appropriate catheter care for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 41 residents. Findings include: Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility and substantial/maximal assistance with chair/bed to chair transfers. The MDS identified Resident #1 was dependent on staff with transfer to the toilet. The MDS indicated that Resident #1 has an indwelling catheter. Resident #1 ' s MDS included diagnoses of heart failure, hypertension, neurogenic bladder, diabetes mellitus, and schizophrenia. The Care Plan with revised date of 8/15/23 identified Resident #1 had an indwelling catheter due to atonic bladder (muscle in bladder loses it ability to contract, making emptying the bladder difficult)…

    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 · D2024-02-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, and staff interviews, the facility failed to assure a medication error rate of less than 5%. During observation the facility had 2 errors out of 28 opportunities for error resulting in an error rate of 7.14% (Resident #14). The facility reported a census of 41 residents. Findings include: A Physician order dated 10/6/2019 for Resident #14 directed staff to administer Cholecalciferol (vitamin d3) 5000 units one tablet by mouth in the morning for supplement. A Physician order dated 3/3/2022 for Resident #14 directed staff to administer Calcium 500 mg (milligrams) with Vitamin D 200 units one tablet by mouth one time a day for supplement. On 2/14/23 at 7:13 AM observed Staff B, Licensed Practical Nurse (LPN) administer the following medications to Resident #14 during morning medication pass: A. Calcium 600 mg with Vitamin D3 400 international units (IU) one tablet B. Vitamin B-12 500 mcg (microgram) one tab by mouth On 2/14/24 at 12:00 PM, Staff B LPN acknowledged and verified she did not give the correct medications during morning…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 record review and staff interview, the facility failed to assure resident's were free of significant medication errors for 1 of 8 residents reviewed (Resident #6). The facility reported a census of 41 residents. Finding's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes, non-Alzheimer's dementia, a seizure disorder, and anxiety disorder. The Care Plan identified the resident used psychotropic medications (meds) of antipsychotic and antianxiety medication secondary to diagnosis of Schizophrenia and Anxiety disorder. The care plan identified the resident at risk of altered mood state and adverse side effects to psychoactive medication use. The resident sometimes displayed dissatisfaction with other residents behavior or protocol's within the facility. The interventions included administering medications as ordered,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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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, facility document review, and staff interviews, the facility failed to conduct regular inspections of side rails as part of a regular maintenance program for 1 out of 15 residents (Resident #21). The facility reported a census of 41 residents. Findings include: Resident #21 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 07, indicating moderately impaired cognition. The MDS indicated Resident #21 required substantial/maximal assistance with bed mobility and was dependent with assistance of 2 persons with transfers. Resident #21 ' s MDS ' s documented diagnoses of hypertension (high blood pressure), non-Alzheimer ' s dementia, depression, osteoarthritis, and chronic pain syndrome. The MDS documented Resident #21 had bed rails used less than daily on the bed. On 2/12/24 at 3:31 PM observed Resident #21 lying in bed. Resident #21's bed had upper bilateral metal side rails, quarter length in size. 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.

    Environmental 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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-02-19 for 5 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
IOWA TRUST & SAVINGS BANKOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST50%since 10/23/2013
BARBER, JOANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2018
BURDOF, EDWINIndividualCORPORATE DIRECTORsince 10/19/2023
EVANS, MARKIndividualCORPORATE DIRECTORsince 01/01/2023
MERRILL, KATHYIndividualCORPORATE DIRECTORsince 01/01/2023
MORLOCK, FREDERICKIndividualCORPORATE DIRECTORsince 10/01/2019
SONSKEN, LARRYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2019
VELTRI, FRANKIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/01/2016
WOLF, JOHNIndividualCORPORATE DIRECTORsince 01/01/2023
KINNETZ, WILLIAMIndividualCORPORATE OFFICERsince 01/01/2023
LAKESIDE LUTHERAN HOMEOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/1968
ANDERSON, HALLIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2024
BODLE, JERIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/13/2024
GETTA, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2016
JENKINS, KATELYNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/02/2024
LARA, JESUSIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/21/2024
MCEWEN, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/22/2022
WEIR, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2019
BCG HOLDINGS INCOrganizationADP OF THE SNFsince 10/21/2025
BLUE STONE THERAPY INCOrganizationADP OF THE SNFsince 12/01/2015
BRIGHTON CONSULTING GROUP LLCOrganizationADP OF THE SNFsince 10/01/2024
CATTAIL BCG LLCOrganizationADP OF THE SNFsince 10/21/2025
CATTAIL INCOrganizationADP OF THE SNFsince 10/21/2025
ECSI INCOrganizationADP OF THE SNFsince 10/21/2025
HUGHES PHARMACY SERVICES INC.OrganizationADP OF THE SNFsince 01/31/2012
IOWA HEALTH CARE ASSOCIATIONOrganizationADP OF THE SNFsince 10/21/2025
VISUAL EDGE IT INCOrganizationADP OF THE SNFsince 11/09/2015
WINTHER STAVE & CO LLPOrganizationADP OF THE SNFsince 10/17/2012
ERICKSON-WELTER, SHAWNIndividualADP OF THE SNFsince 01/01/2012
HOYMAN, GREGORYIndividualADP OF THE SNFsince 01/31/2012
HOYMAN, STEVENIndividualADP OF THE SNFsince 01/31/2012

CMS files one row per role, so the 37 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted.

12 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$4.7M
Net patient revenuemost recent cost report
+12.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 62%Medicare 3%Other / private 35%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$283per resident / day
operating cost
$8,590per month
≈ monthly operating cost
$323per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 165492. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, 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.

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