Good Samaritan - George
324 First Avenue North, George, IA 51237 · Non profit - Corporation · 36 certified beds · (712) 475-3391 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Aug 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,142 in federal fines (most recent 2024-08-29)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- about 18% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 2 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 17.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.0% | 4.2% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.9% | 0.2% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.8% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 6.5% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.1% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.7% | 95.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 1.3% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.7% | 25.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.6% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 7.7% | 2.1% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.80 | 2.08 | 1.80 | typical |
* 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.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 36 beds and averages 32.5 residents a day — about 90% occupied, or roughly 4 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.88 hrs/resident/day on weekends vs 3.53 on weekdays — 19% thinner on weekends. RN hours go from 1.38 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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
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.
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.
21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.
- Immediate jeopardy · J2024-08-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 clinical record review, facility investigation review, staff and resident interviews, and facility policy review the facility staff failed to report an allegation of abuse to a supervisor and the alleged prepetrator continued to work unattended behind closed doors with other residents. On June 27, 2024, the Director of Nursing Services (DNS) learned of a Certified Nurse Aide (CNA) slapping Resident #12 on his upper arm which occurred on June 19, 2024. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 19, 2024 on August 27, 2024 at 2:01 p.m The facility staff removed the IJ on June 27, 2024 through the following actions: a. The local police, residents physician and family/responsible party were notified of the allegation on 6/27/24. An initial report was made to DIAL on…
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.
- Immediate jeopardy · J2023-09-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #31). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 33 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 3, 2023 on September 20, 2023 at 2:30 p.m., The Facility Staff removed the Immediate Jeopardy on May 3, 2023 through the following actions: a. Resident #31 ' s wander guard was checked and working. All other residents who wear a wander guard were checked immediately and all were working. b. Maintenance checked that all doors and alarms were functioning. c. Elopement drill was performed that shift on 5/3/2023, Day shift on 5/4/2023 and continued to be performed until all staff are present for at least…
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.
- Potential for harm · Fcited before2025-08-21 · tag F0851 — widespreadElectronically 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 from Fiscal Quarter 2, 2025 (January 1 through March 31) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in all metrics. The facility reported a census of 31 residents.Findings include:The PBJ Staffing Data Report with a run date of 8/13/25 triggered submitted weekend staffing data excessively low within the quarter.Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. In an interview on 8/21/25 AM at 9:05 AM, the Administrator reported he had no knowledge of how the corporate office submitted staffing data. The Administrator reported the data should reflect that weekend staffing remained the same as during the week. The Administrator reported the facility failed to have a policy regarding PBJ.In an interview on 8/21/25 AM at 9:05 AM, the Director of Nursing (DON) reported the low weekend staffing data error may have occurred when the corporate office…
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.
- Potential for harm · E2025-08-21 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and facility policy review the facility staff failed to serve proper serving amounts for residents. The facility identified a census of 31 residents. Findings include:During an ongoing observation on 8/20/2025 at 11:21 a.m., of Staff A, [NAME] completed the puree process for 2 residents in the facility. Staff A added 3 servings of meat, potatoes, roll and gravy into the blender and added a couple spoons full of thickener and pureed the mixture. When the process was completed, Staff A placed the mixture into the measuring cup and had a total of 3 cups of pureed food. According to the chart the residents were to get 2 #8 scoops of the mixture. Staff A then added 3 servings of spinach to the blender, a couple scoops of thickener and added butter and pureed the mixture until smooth. Once the mixture was smooth Staff A poured the mixture into a measuring cup and the amount was over the 1 cup measurement on the cup. Staff A stated the measurement was 1 and 1/4 cup. When asked how Staff A knew for sure there was 1 and 1/4 cup of food in the measuring…
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.
- Potential for harm · Ecited before2025-08-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 31 residents.Findings include: On 8/18/2025 at 10:49 a.m., during the initial walkthrough in the kitchen was conducted and following concerns were noted. The following items were in the kitchen open and ready for use:a. open container of Cheerios with no label and no open dateb. open container of rice cereal with no label and no open datec. open bottle or raspberry syrup with no label and no open dated. open container of oatmeal with no label and no open date e. open box of cornstarch with no label and no open date. The following items were in the refrigerator read for use:a. 32 servings of cake uncovered on a tray b. open carton of liquid egg with no open datec. open carton of heavy whipping cream with no open dated. open gallon of white milk with no open datee. pitcher of orange juice with no open datef. pitcher of apple juice with no open dateg. open carton of thickened water with no open…
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.
- Potential for harm · D2025-08-21 · tag F0628 — isolatedProvide 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, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 1 of 1 residents reviewed (Residents #7). The facility reported a census of 31 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of hypertension, anemia and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. Review of Resident #7's Census tab revealed the following information:11/7/24- no pay hospital leave11/8/24- active12/10/24- no pay hospital leave12/12/24- active Review of Progress Notes revealed the following:On 11/7/24 at 8:47 p.m., resident will be admitted to hospital for observation. On 11/8/24 at 5:07 p.m., resident arrived back at the facility. On 12/10/24 at 9:02 a.m., resident left facility to hospital for hip surgery.On 12/12/24 at 1:13…
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.
- Potential for harm · D2025-08-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 observations, record review, interviews and policy reviews, the facility failed to provide staff with current continuous positive airway pressure (CPAP) machine settings, failed to enter the faxed order into the electronic chart, and failed to enter CPAP information into the care plan for 1 of 12 residents reviewed (Resident #6). The facility reported a census of 31 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of renal insufficiency, diabetes and anemia. The MDS failed to indicate Resident #6 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. In an interview on 8/19/2025 at 11:03 AM, Resident #6 reported using a CPAP nightly.Observation on 8/19/25 at 1:48 PM revealed a CPAP on Resident #6's bedside table. The faxed Physician's Order dated 6/19/25 for Resident #6 showed an order for a CPAP.The Order Summary Report 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.
- Potential for harm · Ecited before2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the menu, observation, and staff interviews the facility failed to serve the full portions of food and failed to consistently fill and empty scoop utensils when preparing meals for residents. The facility identified a census of 27 residents. Findings include: In an interview on 8/28/24 at 11:35 AM, the Dietary Manager (DM) reported the meals for 8/27/24 and today were partially switched due to meat not being completely thawed. The following replacement meal served to residents per the DM: a. 4 ounces (oz.) pork loin b. 2 oz. pork gravy c. 4 oz. mashed potatoes d. 4 oz. corn e. Bun with margarine Residents on a pureed diet received: a. 4 oz. minced pork loin b. 2 oz. pork gravy c. 4 oz. mashed potatoes d. 4 oz. minced buttered broccoli florets e. Bun with margarine pureed During meal service the DM failed to completely fill and empty the scoop when serving corn and minced pork. When asked if scoops should be completely filled and emptied when plating food, the DM reported yes, but thought the scoop used to serve corn looked too big. The DM reviewed the information…
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.
- Potential for harm · Ecited before2024-08-29 · tag F0851 — patternElectronically 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 (January 1-March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 27 residents. Findings include: The PBJ Staffing Data Report run date 8/21/24 triggered for excessively low weekend staffing- submitted weekend staffing data is excessively low and failed to have licensed nursing coverage 24 Hours/Day - four or more days within the Quarter with <24 Hours/Day Licensed Nursing Coverage. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. No issues for nursing coverage found. In an interview on 8/26/24 at 8:57 AM, the Administrator and Director of Nursing reported incorrect payroll data resulted from the amount of hours the employees were not punched in for breaks and worked to correct the issue. The facility planned to check with CMS to see if the change impacted the most…
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.
- Potential for harm · D2024-08-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents reviewed from physical abuse, (Resident #12). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident Report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm as he yelled out. Review of Resident #12 ' s Progress Notes revealed on 6/27/24 at…
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.
- Potential for harm · D2024-08-29 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #12). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident Report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm…
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.
- Potential for harm · Dcited before2024-08-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during urinary catheter care for 1 of 1 resident (Resident #16). The facility reported a total census of 27 residents. Findings include: Observation on 8/28/24 at 1:09 PM, Staff E, Certified Nursing Assistant (CNA) donned personal protective equipment (PPE) then retrieved the urine colander out of the closet. Staff D placed the colander in the bathroom, removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff D lowered Resident #16's pants then assisted the resident to sit in the recliner. Staff D removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff A cleansed the leg bag urine catheter drainage spout, drained the urine, cleansed the drainage spout then placed the spout back into the holder. Staff D emptied urine from the colander into the toilet, removed and discarded gloves, failed to complete hand hygiene then donned new gloves. Staff D then assisted the resident to pull up and fasten pants. 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.
Show the remaining 9 citations
- Potential for harm · E2023-09-21 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, facility policy, and staff interview, the facility failed to revise care plans with medication changes for 4 of 12 residents reviewed (Residents#6, #11, #2, and #24). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of duchenne or [NAME] muscular dystrophy, chronic pain, pain in right and left toes, and low back pain. The MDS revealed the resident did not receive routine or PRN (as needed) pain medication, reported occasional pain that did not interfere with sleep or daily activities. The Care Plan Intervention revised 2/19/23 revealed: WARNINGS #5: Refer to black boxed warnings in the orders for oxycodone. The Order Summary Report signed by a physician on 8/14/23 lacked an order for oxycodone. The Care Plan- R/S (Rehabilitation and Skilled), LTC (Long Term Care), Therapy &…
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.
- Potential for harm · Ecited before2023-09-21 · tag F0880 — failed to prevent and control infections — patternProvide 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, facility policy, Centers for Disease Control and Prevention (CDC), and staff interview, the facility failed to perform hand hygiene when assisting residents during meals and cover clean laundry cart when laundry was delivered and failed to cover a laundry when transporting clean laundry in the facility. The facility reported a census of 33 residents. Findings include: 1. Observation on 9/18/23 at 12:14 PM of Staff A, Certified Nurse Assistant (CNA), assisted Resident #17 eat lunch. After Staff A assisted Resident #17, she assisted Resident #20 without performing hand hygiene. Observation on 9/19/23 at 12:00 PM of Staff A assisted Resident #17 eat lunch. After Staff A assisted Resident #17, she assisted Resident #11 without performing hand hygiene. Observation on 9/19/23 at 12:09 PM of Staff B, CNA assisted Resident #20 eat lunch, she then assisted Resident #5 eat lunch without performing hand hygiene. The CDC Hand Hygiene Guidance last reviewed 1/30/20 accessed 9/19/23 at https://www.cdc.gov/handhygiene/providers/guideline.html revealed: a. The Core Infection…
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.
- Potential for harm · D2023-09-21 · tag F0623 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 1 residents reviewed who transferred to the hospital (Resident #23). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 documented diagnoses of heart failure, respiratory failure and lymphoma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #23 ' s Progress Notes revealed the following information: On 7/18/23 at 5:46 p.m., resident being admitted to the hospital. On 7/31/23 at 1:40 p.m., resident returns to facility via private vehicle. Review of Resident #23 ' s Census tab revealed the following: 7/18/23- paid hospital leave The facility lacked documentation that the facility submitted information to the LTC Ombudsman for July 2023. Review of facility provided policy titled Omudsman with a revision date of 12/13/22 revealed 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.
- Potential for harm · D2023-09-21 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person, when residents transferred out of the facility for 1 of 4 residents reviewed (Residents #38). The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 documented diagnoses of heart failure, respiratory failure and lymphoma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #23 ' s Progress Notes revealed the following information: On 7/18/23 at 5:46 p.m., resident being admitted to the hospital. On 7/31/23 at 1:40 p.m., resident returns to facility via private vehicle. Review of Resident #23 ' s Census tab revealed the following: 7/18/23- paid hospital leave The clinical record lacked a signed bed hold for the hospitalization for July. Review of the facility provided policy titled 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.
- Potential for harm · D2023-09-21 · tag F0644 — isolatedCoordinate 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, facility policy, and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) when changes occurred for 2 of 2 residents reviewed (Resident #6 and #11). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had a diagnosis of duchenne or [NAME] muscular dystrophy. The (PASRR) dated 3/22/23 revealed: a. The section to list mental health diagnoses revealed that the resident had no mental health diagnosis was known or suspected. b. The section that listed mental health medications listed Zoloft (anti-depressant medication) 50 milligrams (mg) per day, current status, diagnosis of dysthimia. The Order Summary Report signed by a physician on 8/14/23 revealed an order for Zoloft 50 mg one time daily for dysthimia with a start date of 1/5/23. 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.
- Potential for harm · D2023-09-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, facility policy, and staff interview, the facility failed to develop a care plan when a resident had new pressure ulcers for 1 of resident reviewed (Resident #32). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed a Brief Interview of Mental Status score of 8 which indicated moderately impaired cognition. The MDS revealed the resident had diagnoses of essential tremor and hypertension (high blood pressure). The MDS revealed the resident did not have pressure ulcers. The Health Status Note on 8/7/2023 at 2:30 PM revealed Resident found to have unstageable pressure sores to bilateral heels as well as an open area on the back of left leg. Therapy believes the open area may be due to the amount of edema in BLE (bilateral lower extremities). Resident does have 2+ edema in BLE. Fax was sent to provider informing them of skin issues as well as requesting treatment orders. The Care Plan Focus Area 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.
- Potential for harm · D2023-09-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 interviews the facility failed to provide professional standards of care by administering medications without a current physician order for 1 of 6 residents reviewed (Resident #24). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 24 documented diagnoses of diabetes mellitus, depression, atrial fibrillation and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the admission Orders signed 8/22/23 revealed an order for bumetanide (diuretic medication) daily hold until seen by primary care physician (PCP). Review of the August and September 2023 Medication Administration Record (MAR) revealed an order for bumetanide oral tablet with a start date of 8/30/23. Review of the September MAR revealed bumetanide was administered September 6-20, 2023. Review of the clinical chart lacked a current order for bumetanide.…
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.
- Potential for harm · D2023-09-21 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 interview, the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 1 residents reviewed in the closed record sample (Resident #34). The facility reported a census of 33 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 34 documented diagnoses of hypertension, arthritis, and anxiety disorder . The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of Resident #34 ' s Census tab revealed Resident #34 was discharged on 9/1/23 at 11:00 a.m. Review of Resident #34 ' s Progress Notes revealed on 9/1/23 at 2:03 p.m., resident was discharged . Review of Resident #34 ' s medical record lacked a completed discharge summary including a recapitulation of the resident ' s stay. Facility later provided a Discharge summary dated [DATE]. Review of the MDS list revealed a MDS completed on 9/1/23 discharge returned not anticipated. Review 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.
- Potential for harm · D2023-09-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, observation, facility policy, and staff interview, the facility failed to provide treatment to pressure ulcers for 1 of 1 resident reviewed (Resident #32). The facility reported a census of 32 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full…
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.
“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.
- 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.
Fines & penalties
$18,142 in federal fines across 2 penalties.
- $8,827 — penalty dated 2024-08-29
- $9,315 — penalty dated 2023-09-21
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.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.0 | +2.0 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 5 of 5 | 2.8 | +2.2 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 10/01/2022 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| CHAUDHARY, IKRAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/07/2024 |
| DEJONG, CHESTER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/02/2018 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| SANDGREN, DEEANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2020 |
| DTN STAFFING INC | Organization | ADP OF THE SNF | — | since 08/02/2024 |
| FOCUSONE SOLUTIONS | Organization | ADP OF THE SNF | — | since 03/04/2024 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/13/2014 |
CMS files one row per role, so the 54 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
This home reported $626K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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
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
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.
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 165247. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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.