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Estherville Community Care Center

2001 First Avenue North, Estherville, IA 51334 · For profit - Corporation · 46 certified beds · (712) 362-3594 Medicare & Medicaid certified

Call the home — (712) 362-3594 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2025Resident-funds citation (F0567)2 actual-harm citations
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 Sep 2025
  • 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 2 actual-harm citations
  • a high number of inspection citations overall (23) — 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)
  • its facility-reported quality-measure rating is low (2/5)

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.

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 2 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
619 2nd Ave N · (712) 362-2404 · Call to confirm hours
Pharmacy
1804 Central Ave · (712) 362-0330 · Call to confirm hours
Grocery
1221 Central Ave · (712) 362-7246 · Call to confirm hours
Park
6TH Ave N · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 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 2 to 1 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 rating1★
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 increased21.6%17.1%15.4%worse
Long-stay residents who lose too much weight13.1%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder3.3%1.5%0.9%worse
Long-stay residents with a urinary tract infection1.6%2.4%2.0%better
Long-stay residents with depressive symptoms7.0%4.2%6.5%typical
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 injury3.7%3.8%3.3%worse
Long-stay residents whose ability to walk worsened15.0%16.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication40.9%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine84.8%95.3%95.3%worse
Long-stay residents with pressure ulcers5.3%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control23.6%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table26.2%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.9%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine30.4%73.3%79.4%worse
Short-stay residents rehospitalized after admission17.7%20.9%22.6%better
Short-stay residents with an outpatient ER visit12.7%13.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.261.491.67better
Long-stay outpatient ER visits per 1,000 resident days2.592.081.80worse

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.

52.7% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.7%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 SNF52.7%CMS range 37.9–64.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 6.5–17.010.7%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 discharge50.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified87.2%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 stay0.0%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 worsened5.1%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 hospitalization9.3%CMS range 5.5–17.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 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

0.91
RN hours/ resident / day
0.59
LPN hours/ resident / day
1.88
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.57
RN hoursweekends
46.2%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 46 beds and averages 39.4 residents a day — about 86% 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.82 hrs/resident/day on weekends vs 3.60 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.04 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-09-25)
4
at the previous standard inspection (2024-12-12)

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2026-06-10 · 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, record review, and staff interview, the facility failed to ensure resident's individualized interventions were in place to prevent falls for 4 of 4 resident's reviewed (Resident #1, #2, #3, and #4). Resident #1 had an alarm to alert staff if she got up so they could assist her. Resident #1 stood up, walked a few steps and fell fracturing her left hip. The resident's alarm did not sound. Resident's #2, #3, and #4 had alarms that failed to sound and alert staff to assist them.The facility reported a census of 36 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 demonstrated long- and short-term memory problems and severely impaired skills for daily decision making. The resident required substantial/maximal assist to transfer and partial/moderate assist to ambulate. Resident #1's diagnoses included primary osteoarthrosis of the right knee, age related physical debility, and unspecified fall, subsequent encounter. The resident used a bed…

    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 before2024-09-06 · 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

    Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent a fall for 1 of 3 residents reviewed (Residents #3). The facility reported a total census of 30 residents. Findings include: Resident #3's clinical record documented diagnoses of anxiety disorder, abnormal weight loss and adult failure to thrive. The Brief Interview for Mental Status (BIMS) score of 15, indicating severe cognitive impairment. Review of facility provided Incident Report dated 9/5/24 at 5:30 p.m. revealed under incident description staff heard someone yelling help help help. Staff ran to the direction of the screaming. Resident was laying down supine on the floor by the ice machine in the hallway. Resident's head was laying on the floor on the right side of the ice machine. Head towards the north wall with her right leg straight out towards the south of the hall. Resident's left leg was rotated out. Resident was screaming in pain that her left hip hurt so bad. Resident description revealed I slipped. Review of resident…

    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 · D2026-03-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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, observation, staff and resident interview, along with facility policy review, the facility failed to provide a call light system within reach for which the call light was caught in the hinge of the side rail and was not able to be triggered when pulled for 1 of 3 residents (Resident #5) reviewed. The facility reported a census of 38 residents. Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 for which indicated intact cognitive decisions, was able to be understood and understand others. The MDS addressed the resident as dependent for toileting, hygiene, showers/bathing, lower body dressing, sit to lying, sit to standing and transfers. The MDS included diagnosis of hypertension (when the pressure in your blood vessels is too high) anxiety, depression, after-care following replacement of total knee, weakness and need for assistance of personal cares. The Care Plan Focus…

    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 · D2026-03-19 · 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 and family interview along with policy/procedure review, the facility failed to ensure that discharge instructions were documented in the residents medical record with the necessary information to the resident/resident representative that is easy to understand in a written form and language for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 38 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognitive decisions, is able to be understood and understand and no behaviors present. The MDS addressed that the resident is independent in the facility with all activities of daily living (dressing, personal hygiene, transfers, ambulation) and a walker is used for mobility. The MDS included diagnoses of cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis…

    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 · D2025-09-25 · 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 clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from financial exploitation of dependent adult abuse for 3 of 3 residents reviewed (Resident #32, #41 and #43).The facility reported a census of 33 residents. Findings include:A. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #41 documented diagnoses of cancer, anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment.The Clinical Census report for Resident #41 documented a discharge date of 4/4/25.In an interview on 9/16/25 at 2:08 PM, the son of Resident #'41 reported several months after the resident transferred from the facility, Resident #41's bank notified him of fraudulent charges to a debit card account. The charges started during the time Resident #41 resided at the facility. The fraudulent charges totaled over $13,000. The son reported Resident #41 had a debit card on her person…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-09-25 · 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 clinical record review, staff interviews and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 2 of 2 residents reviewed (Resident #7 and #18). The facility reported a census of 33 residents. Findings include: 1. Resident #7's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of bilateral primary osteoarthritis of knee, colon cancer, anemia, chronic obstructive pulmonary disease, and atrial fibrillation. The MDS further documented the bed rails used as a physical restraint (any manual method, physical, or mechanical device, material or equipment attached or adjacent to the resident's body the individual cannot remove easily which restricts freedom of movement or normal access to one's body). Resident #7's Care Plan documented that she could go from lying to sitting on the edge of bed independently. The intervention 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · 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, policy and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #3). The facility reported a census of 33 residents. Findings Include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnosis of depression, anxiety, Psychotic Disorder and Post Traumatic Stress Disorder (PTSD). Resident #3's Level 1 PASRR dated 6/19/24 lacked a diagnosis of Psychotic disorder and PTSD. Resident #3's clinical record lacked a PASRR after 6/19/24. On 9/17/2025 at 10:30 AM, the Director of Nursing (DON) verbalized she submitted PASRR submissions. She reported she did not complete a new one for Resident #3 because the doctor keeps changing her medications around. She was not aware of the PASRR lacked the diagnoses of Psychotic Disorder and PTSD.…

    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 · D2025-09-25 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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, staff interview and policy review, the facility failed to provide trauma informed care with PTSD (Post Traumatic Stress Disorder) and was not assessed for potential triggers that could cause re-traumatization for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS included diagnoses of anxiety, depression, PTSD, and psychotic disorder. Resident #3's behavioral health psych visit notes documented the resident had childhood trauma and history of suicidal attempts in the past. It further documented Resident #3 was grieving the loss of her husband who died a year ago. Resident #3's Care Plan lacked documentation of PTSD, history of suicidal history and loss of her husband. It further lacked potential triggers that could cause the re-traumatization and possible triggers that would cause…

    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 · D2025-09-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 were offered and received the pneumonia vaccine for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 33 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The MDS documented the resident was not up to date with the pneumonia vaccine, and it was not offered. The Clinical-Immunizations page lacked an entry for a pneumonia vaccine. A Pneumococcal Vaccine Consent dated 6/28/24 documented the resident e-signed that she had been educated on the risks and benefits of the pneumonia vaccine and gave permission for receiving the vaccine. The clinical record lacked documentation the resident received the pneumonia vaccine. According to the MDS assessment dated [DATE] the resident was not up to date with the pneumonia vaccine, and it was not offered. On 9/17/25 at 2:34 PM the…

    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 · F2024-12-12 · 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 the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, employee time cards review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 36 residents. Findings include: The PBJ Staffing Data Report with run date 12/4/24 triggered for failing to have licensed nursing coverage 24 hours/day - 4 or more days within the quarter with <24 hours/day licensed nursing coverage with specific infraction dates. The report reflected 7 dates with failure to provide 24 hour/day nursing coverage during August and September. Review of the Nurse Schedule for the infraction dates revealed nursing shifts covered by the Director of Nursing (DON), Staff C, Licensed Practical Nurse (LPN), Staff D, LPN, Staff E, Registered Nurse (RN), Staff F, RN, and Staff G, RN for 7/7 dates. Review of time cards for the infraction dates revealed nursing services were provided for 24 hours/day. On 12/11/24 at 2:19…

    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 · E2024-12-12 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, staff interviews, and policy review, the facility failed to complete comprehensive assessments within required time frames for 7 of 7 residents (Residents #4, #7, #8, #15, #18, #189, and #190). The facility reported a census of 36. Findings include: On 12/10/24 at 9:31 AM, multiple record reviews revealed seven (7) past-due Comprehensive Assessments (Minimum Data Sets - MDS) and were documented as follows: 1) Resident #4's MDS included an Assessment Reference Date (ARD - last day of observation period) of 11/04/24 with an in-progress status. It indicated 22 days past due. 2) Resident #7's MDS included an ARD of 10/07/24 with an in-progress status. It indicated 50 days past due. 3) Resident #8's MDS included an ARD of 11/05/24 with an in-progress status. It indicated 22 days past due. 4) Resident #15's MDS included an ARD of 10/14/24 with an in-progress status. It indicated 41 days past due. 5) Resident #18's MDS included an ARD of 10/03/24 with an in-progress status. It indicated 54 days past due. 6) Resident #189's MDS included an ARD of 10/29/24 with an…

    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 · D2024-12-12 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review the facility failed to notify the Long Term Care (LTC) Ombudsman of a transfer to a hospital for 1 of 2 residents (Resident #190) reviewed. The facility reported a census of 36 residents. Findings include: Review of Resident #190's Clinical Census in the Electronic Health Record (EHR) revealed Resident #190 had a hospital unpaid leave from 10/30/24 to 11/6/24. Review of the facility document, Notice of Transfer Form to Long Term Care Ombudsman, for the month of 10/24 revealed there was no notification for the Resident 190's hospitalization beginning on 10/30/24. During an interview on 12/11/24 at 1:42 PM the Administrator acknowledged Resident #190 was neither on the Discharge Report nor the Notice of Transfer to Long Term Care Ombudsman Report. The Administrator stated the resident had been missed on his transfer to the hospital. The Administrator indicated she completed the Ombudsman notifications. On 12/12/24 at 8:00 AM the Administrator stated the expectation was for residents transferred to acute hospitals to be on the…

    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 11 citations
  • Potential for harm · D2024-12-12 · 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 observations, clinical record review, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during mealtimes, catheter management, and laundry delivery. The facility reported a census of 36. 1) On 12/09/24 at 12:11 PM, Staff A, Certified Nurse Aide (CNA) put on a pair of gloves, picked a fork off the floor with her right hand, and placed it on the table. She walked behind a resident (Resident #34) seated in a tilt-chair, repositioned the resident to face the right side of the table, sat down to the right of the resident, and began feeding the resident. She wiped the resident's mouth with a napkin in her right gloved hand, picked up the resident's milk cup from the top with her gloves, and gave the resident some milk. She did not perform hand hygiene or change gloves throughout the process. A policy titled Handwashing/Hand Hygiene revised 10/22 indicated employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-17 · tag F0567 — failed to protect residents' money held by the home — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews and facility policy review the facility failed to provide residents with the ability to have access to their funds when requested for 2 out 4 residents reviewed (Resident #2 & #4). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of anxiety disorder, anemia and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Interview on 10/15/24 at 2:44 p.m., with Resident #2 revealed she is unable to get money on the weekends if she asked for it. Resident #2 explained the facility always is waiting for a check to come to the facility and then they have to go get the money before they can give it to us. She has had to wait a couple of days to be able to get her money. 2. The MDS assessment dated [DATE] for Resident #4 documented diagnoses of anxiety disorder, hypertension and neurogenic bladder.…

    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 · E2023-10-05 · 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 file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff A, Registered Nurse (RN) documented a hire date of 1/7/23. Review of Employee Termination Report revealed Staff A was terminated on 4/19/23 with a hire date of 1/7/23. The personnel file for Staff A revealed documention of an criminal background check and dependent adult and child abuse registry check was completed on 1/27/23 at 3:56 p.m The file lacked documentation of the Iowa Criminal Background Check and dependent adult/child abuse registry check prior to hire. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed the Criminal Background Check/Nurse Aid Registry Check - In states where…

    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 · E2023-10-05 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and staff interview the facility failed to verify professional nursing licensure prior to hire for 1 of 2 staff members reviewed (Staff A). The facility reported a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff A, Registered Nurse (RN) documented a hire date of 1/7/23. Review of Employee Termination Report revealed Staff A was terminated on 4/19/23 with a hire date of 1/7/23. The personnel file for Staff A revealed a nurse license verification report was completed with a date and time of 10/26/22 at 12:40 p.m Review of Staff A personnel file lacked a license verification report dated prior to rehire date. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed when a potential new employee is considered for hire, each of the following steps should be taken to assure that the applicant is suitable for hire. Verification of License/Certificate - Verification of licensure or certification and identification of previous disciplinary…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-05 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy the facility failed to have the Director of Nursing Services, Medical Director and Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 28. Findings include: Review of the facility document titled Quality Assurance Process Improvement (QAPI) Committee: a. Document dated 11/3/22 lacked the signature of the Director of Nursing Services. b. Document dated 1/2023 lacked the signature of the Medical Director, Director of Nursing Services and Infection Preventionist. Review of the facility provided policy titled Quality Assurance Process Improvement Management dated January 2023 revealed the Administrator of this facility shall be the chairperson and shall appoint all representatives to the QAPI Committee. Additionally, any vacancies occurring on the committee shall be filled by the facility's Administrator. According to the Federal OBRA nursing home guidelines [§483.75(o)(l)(i-iii)], the QAPI Committee must include the Director of Nursing…

    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 · E2023-10-05 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review, facility policy review and staff interview the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff B). The facility identified a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff B, Certified Nursing Assistant (CNA) documented a hire date of 3/22/23. Review of Staff B personal file revealed a Dependent Adult Abuse Training certificate dated 10/2/23. Review of Staff B time card dated 9/17/23-9/30/23 revealed Staff B worked on 9/23/23, 9/27/23, and 9/28/23. Review of time cared dated 10/1/23-10/14/23 revealed Staff B did not work. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed to create an educated awareness of resident abuse, the facility standard of Freedom of Abuse, Neglect and Exploitation covers types of abuse, abuse reporting and abuse investigation. This information shall be reviewed during orientation with each new employee and reviewed with staff…

    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 · D2023-10-05 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review and staff interview, the facility failed to give 2 day notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 for 1 of 3 sampled residents. (Residents #184). The facility reported a census of 28 residents. Findings Include: Record review for Resident #184 revealed form CMS 10123-NOMNC with a services end date of 5/10/23. Resident #184 signed 5/9/23. Centers for Medicare and Medicaid website titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 visited on 10/4/23 at 12:56 p.m., revealed the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Interview on 10/4/23 at 1:14 p.m., with the Administrator revealed it should be a 2 days notice unless they waive it.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · 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 record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 3 of 12 residents reviewed (Resident #4, #8, and #11). The facility reported a census of 28 residents. Findings include: 1) According to the MDS assessment dated [DATE] Resident #4 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included depression and schizophrenia. The MDS indicated the resident was not considered to have a mental illness by the state Level 2 Preadmission Screening and Record Review (PASRR) process. The resident admitted to the facility on [DATE]. A facility referral from the hospital dated 8/17/23 documented the PASRR would be faxed once completed, it was under review. A Notice of PASRR Level 1 Screen Outcome dated 8/17/23 documented the resident needed referral for a Level 2 screen onsite. On 10/3/23 at 2:40 p.m. the DON stated they had not had the Level 2 done. The hospital should have…

    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 before2023-10-05 · 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 completed a Preadmission Screening and Resident Review (PASRR) for Level I, but failed to Refer for Level II evaluation for (Resident #4, #8 and #22). The facility reported a census of 28 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 documented diagnosis of depression, schizophrenia and paranoid schizophrenia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the PASRR Level 1 Screening Outcome dated 7/6/23 for Resident #22 revealed PASRR Level I Determination Refer for Level II Onsite. Review of the clinical chart lacked a Level II PASRR evaluation. The Progress Notes dated 8/16/23, and 6/30/23 for Resident #22 revealed follow up psychiatric visits related to schizophrenia. The Pre-admission Screening and Resident Review (PASRR) policy dated October 2023 revealed: PASRR is a review required under the State Medicaid program…

    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 · D2023-10-05 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to develop and implement a baseline care plan for 3 of 5 residents reviewed (Resident #5, #8, and #14). The facility reported a census of 28 residents. Findings include: 1) The Progress Notes dated 2/6/23 at 5:53 p.m. documented at 2 p.m. Resident #5 admitted to the facility. He entered in a wheelchair, from the hospital at skilled level of care with diagnosis of acute diastolic heart failure. The resident oriented to the facility, mealtimes and staff. The resident needed 1-2 assist with a gaitbelt and front wheeled walker. The resident had left sided weakness from a previous stroke. The resident needed assistance with activities of daily living (ADL's), and was legally blind. A seat alarm applied at all times. Lungs sounded clear bilaterally, heart rate regular and oxygen saturations 97% on room air. The resident had edema to his left lower leg with shin discoloration noted, and encouraged elevation of his extremities. He was alert and oriented but had mild dementia with short term memory loss. Physical Therapy 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 · D2023-08-31 · 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 interviews, and record review, and clinical policy review the facility failed to thoroughly investigate bruising of unknown origin for 1 of 3 residents reviewed (Resident #2). On 4/3/23 Resident #2 was discovered with bruising around the left eye that was not explained or investigated. The facility reported a census of 29 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnosis for Resident #2 included severe intellectual disabilities, seizure disorder, Schizophrenia, psychotic disorder and anxiety. A Brief Interview for Mental Status indicated severely impaired cognitive functioning. This resident required extensive assist of 2 for bed mobility, transfers, dressing and toileting and had unclear speech. A Progress Note dated 4/3/23 at 4:40 p.m. created by Staff A Licensed Practical Nurse (LPN) documented Resident #2 continued with hospice level of care. Bruise noted to the eye measuring 5 cm by 5 cm. Noted that resident usually slept with left eye flat on pillow, might…

    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

“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.

Who owns this facility

Owner / managerTypeRoleSince
GS ESTHERVILLE HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
GOLDBERGER, SHELDONIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
KUGLER, AARONIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
GENSTAR HEALTHCARE MGMTOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
KABRICK, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
PRABHAKARAN, MADHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
YAGER, SALLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
ESTHERVILLE PROPCO, LLCOrganizationADP OF THE SNFsince 11/01/2025

CMS files one row per role, so the 18 rows in the source record cover these 8 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.

3 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.

$2.9M
Net patient revenuemost recent cost report
-13.4%
Operating marginrevenue minus expenses
$319K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 10%Other / private 22%

This home reported $319K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$321per resident / day
operating cost
$9,761per month
≈ monthly operating cost
$283per 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 165523. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, 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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