Westbrook Acres
605 Garfield Street, Gladbrook, IA 50635 · For profit - Corporation · 54 certified beds · (641) 473-2016 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)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 14.0% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.9% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.3% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 8.8% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.4% | 3.8% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.3% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.4% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.8% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.7% | 2.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 59.1% | 73.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 34.8% | 20.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.4% | 13.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.43 | 1.49 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.38 | 2.08 | 1.80 | worse |
* 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.
48.7% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 48.7%CMS range 34.1–62.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.6–15.0 | 10.7% | Oct 2022–Sep 2024 | no 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 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.62 | 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 54 beds and averages 38.6 residents a day — about 71% occupied, or roughly 15 beds typically open. It usually has some room. 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.00 hrs/resident/day on weekends vs 3.71 on weekdays — 19% thinner on weekends. RN hours go from 0.64 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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.
15 citations, most serious first — scroll within the box to see all.
- Actual harm · G2026-06-03 · 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 and hospital record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure a safe transfer and ambulation with the use of a gait belt as determined necessary by the care plan during Resident #1's staff-assisted transfer and ambulation on 3/13/26 for one of three residents reviewed for falls (Resident #1). Resident #1 fell to the floor, sustained a hip fracture with 7 out of 10 pain level, and required hospitalization with surgical repair. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam. which indicated the resident had moderately impaired cognition. Per this assessment, the resident required partial/moderate assistance to walk 10 feet, and for chair/bed to chair transfer. The MDS assessment further revealed the resident used a walker and wheelchair. The MDS…
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.
- Actual harm · G2023-09-28 · 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 observation, record review, resident and staff interviews, and facility policy review, the facility failed to implement safety measures and interventions to protect residents on the Chronic Confusion and Dementing Illness (CCDI) Unit from resident to resident physical abuse from Resident #3, for 2 of 19 residents reviewed (Residents #2 and #7) that resided on the CCDI unit. Resident #3 had a history of physical violence directed at staff and resident's that included: On 7/8/23 alleged to have hit Resident #3 in the chest that caused an 8 X 10 centimeter (cm) purple bruise. On 7/10/23 Resident #3 was sent to the local emergency room (ER) for behavioral health placement before return to the facility. Resident #3 was described by facility on transfer documents as angry, agitated, with a history of physical aggression to residents and staff, raises fists to everyone. The resident returned to facility at 7:00 p.m. that same day and the facility implemented 15-minute checks. On 7/11/23 at 8:30 a.m. 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.
- Potential for harm · D2026-03-12 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review and facility policy review, the facility failed to obtain consent to administer psychotropic medications taken by 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 12/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included Alzheimer's Disease, Cerebrovascular Accident (CVA or stroke), seizure disorder, anxiety disorder, and psychotic disorder. Resident #9 used the following high-risk medications: antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of the Care Plan initiated 3/12/25 revealed a Focus area for psychotropic medication use related to diagnoses of anxiety, dementia, frontal lobe meningioma (brain tumor), and psychotic disorder. The Care Plan indicated that Resident #9 was currently took Buspirone (medication used to treat anxiety disorders).…
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 · D2026-03-12 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility policy review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days unless the prescribing practitioner documented a rationale to extend medication for 1 of 5 residents reviewed for unnecessary medications (Resident #34). The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of the resident's diagnoses per the MDS included cancer, non-Alzheimer's dementia, Cerebrovascular Accident (CVA or stroke), anxiety disorder, and adult failure to thrive. Review of the Care Plan Focus area initiated on 12/30/25 for Resident #34's use of the psychotropic medication revealed the following: The resident used Lorazepam, related to anxiety disorder, with times of yelling out to peers/staff, insomnia, non-sensical…
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 · D2026-03-12 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/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, staff interview and policy review the facility failed to complete a comprehensive assessment and evaluation of a resident for readmission to the facility after hospitalization for 1 of 3 residents reviewed for discharge (Resident #48). The facility reported a census of 40 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 revealed the resident admitted to the facility on [DATE]. The MDS assessment dated [DATE] for Resident #48 documented an unplanned discharge to a short term general hospital, with return not anticipated. Diagnoses included urinary tract infection over last 30 days, depression and vascular dementia.A Baseline Care plan initiated 1/9/26 documented Resident #48 admitted from the hospital with the goal to return home after therapy goals were met. Resident #48 was alert and oriented to self, and confused. The discharge goal revealed to remain at Long Term Care (LTC) setting. Resident #48 required assist of one with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-06 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on time card review, schedule review, and staff interview, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. The facility reported a census of 44 residents. Finding include: Review of all Nursing Schedules from 7/1/2024 thru 9/30/2024 and Time Card Punches from 7/1/2024 thru 8/18/2024 revealed the facility failed to staff an RN for 8 consecutive hours on the following dates: 7/6/24, 7/7/24, 8/4/24, 8/17/24, and 8/18/24. During an interview on 3/5/25 at 2:47 PM, the Administrator revealed the facility uses an accounting company to submit all Payroll Based Journal staffing data. The accounting company emailed the Administrator a report reflecting the staffing data submitted. A Review of the Payroll Based Journal Quarterly Analysis from the accounting company for the period of 7/1/2024 to 9/30/2024 submitted documented the total number of days with no RN coverage for the quarter to be 5 days. The identified dates are 7/6/2024, 7/7/2024, 8/4/2024, 8/17/2024 and 8/18/2024. On 3/6/25…
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 · D2025-03-06 · tag F0851 — isolatedElectronically 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 review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024 - September 30, 2024, facility staffing reports, and staff interviews the facility failed to submit accurate staffing reports for the PBJ Staffing Data Report. The facility reported a census of 44 residents. Findings include: The PBJ Staffing Data Report with a run date of 2/26/25 triggered for excessively low weekend staffing (submitted weekend staffing data is excessively low). A review of the schedules for the months of July 2024, August 2024, and September 2024 revealed nursing shifts covered by facility employee and outside staffing agencies. During an interview on 3/5/24 at 2:47 PM, the Administrator revealed the facility utilized an outside accounting company to submit the PBJ staffing data. The Administrator acknowledged data provided to the accounting company comes from the Administrator and a corporate administrative assistant. The Administrator revealed prior to the accounting company submitting the data, a preliminary…
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 · D2025-03-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 clinical record review, policy review, and staff interview the facility failed to follow the Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule for pneumococcal vaccination for 1 of 5 residents sampled (Resident #31). Findings include: Resident #31 Electronic Healthcare Record (EHR) Census documented admission to the facility on [DATE]. Resident #31 EHR Immunization Record showed Resident #31 received the pneumococcal polysaccharide (PPSV) 23 vaccination on 11/01/21 at the age of 53. A review of the EHR Progress Notes, Miscellaneous documentation and paper medical chart lacked documentation of receiving a pneumococcal conjugate (PCV) 15, 20 or 21 vaccination. A Pneumococcal Vaccine Informed Consent Form signed by Resident #31's family member on 10/25/22 documented consent for the facility to administer a Pneumococcal Conjugate (PCV) 20 vaccination. The CDC 2025 Adult Immunization Schedule for Pneumococcal Vaccination for adults age [AGE] or over directed when PPSV23 is 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 · D2024-04-18 · 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 observations, interviews, and record review, the facility failed to follow a physician's order for 1 of 1 residents reviewed with a tube feeding (Resident #39). Resident #39 was ordered to have water every 2 hours through her PEG (percutaneous endoscopic gastrostomy) tube (a flexible feeding tube inserted through the abdominal wall and into the stomach for nutritional support). This resident received the water every hour. The facility reported a census of 51 residents. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #39's diagnoses included Cerebral Palsy, seizure disorder and gastrostomy status. It documented that Resident #39 had a feeding tube. A Routine Medication record dated 4/1/24 to 4/30/24, directed staff that Resident #39 was to have her PEG tube flushed every 2 hours. It documented to auto flush through the pump. admission Orders dated 2/25/24, directed staff to flush PEG tube with 30 cc (cubic centimeters) every 2 hours. Auto flush with pump. A Progress Note…
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 before2024-04-18 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage daily (in a 24 hour period). The facility reported a census of 51 residents. Findings include: On 4/17/24 at 12:42 p.m., reviewed March 2024 and April 1-19/2024 schedules. Noted 3 days (4/6/24, 4/13/24 and 4/14/24) did not have 8 consecutive hours of RN coverage. On 4/17/24 at 12:50 p.m., the Licensed Nursing Home Administrator (LNHA), stated that the RN scheduled for 8 hours on 4/6/24, had to leave at 11:00 a.m., and was relieved by a Licensed Practical Nurse (LPN). The LNHA stated that the RN worked from 6:00 a.m. to 11:00 a.m. which left the facility short of the 8 hour RN coverage for that day. The LNHA stated that on 4/12/24 an agency nurse came in at 10:00 p.m. and worked through the night until 6:00 a.m. on 4/13/24. She stated the agency RN worked 6 hours from midnight (12:00 a.m.) on 4/13/24 to 6:00 a.m (6 hours), but that still left them short of the required 8 hours of RN coverage on 4/13/24. On 4/14/24, the LNHA stated there was no RN coverage for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, staff interviews, Pharmacist interview, facility investigation review, and facility policy review, the facility failed to ensure 1 of 3 resident's reviewed (resident #1) remained free from misappropriation of Tramadol, a narcotic pain medication. The facility reported a census of 51 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #1 dated 4/12/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition and identified diagnosis which included Non-Hodgkin's Lymphoma. The pain assessment interview identified no pain or hurting at any time in the last 5 days. A Physician's Telephone Order Audit, dated 3/14/23, documented Tramadol 50 milligrams (mg) with directions to give 1 by mouth every 6 hours as needed for pain. Review of a Pharmacy Delivery Packing Slip documented on 3/14/23, 15 Tramadol, 50 mg tablets were signed as received from the local pharmacy by Staff A, Licensed Practical Nurse (LPN) for Resident #1. 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.
- No harm found · B2025-03-06 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 document review, policy review, and staff interview, the facility failed to utilize a grievance form to address missing resident items for 1 of 2 residents sampled (Resident #40). The facility reported a census of 44 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS documented Resident #40 with adequate vision and hearing and able to understand others and be understood. The 1/23/25 Resident Council Meeting Note detailed Resident #40 missing a Black Iowa Select hooded sweatshirt. The 2/11/25 Resident Council Meeting Note documented Resident #40 continued to be missing a Black hooded Iowa Select sweatshirt. During an interview on 3/4/25 at 1:41 PM the Administrator reported they review for lost items during the Resident Council Meetings, then work with laundry to go through all residents' closets to search for the missing items. She reported Resident #40…
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.
- No harm found · B2025-03-06 · tag F0623 — patternProvide 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 inform the Long-Term Care (LTC) Ombudsman office of a resident hospitalized for 2 of 2 residents reviewed (Resident #4 and Resident #46). The facility reported a census of 44 residents. Findings include: 1. Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. The MDS listed diagnoses of non-traumatic brain dysfunction (damage to the brain by internal factors), diabetes mellitus, and Non-Alzheimer's Dementia. A review of the Electronic Health Record Census Detail page for Resident #4 revealed Resident #4 had been hospitalized from [DATE] to 12/27/2025 and from 1/31/2025 to 2/6/2025. A Progress Note dated 12/24/2024 a 10:44 PM, documented the hospital called to inform the facility that Resident #4 had been admitted . On 12/27/24 at 3:44 the Progress Notes revealed Resident #4 had been readmitted to the facility. A Progress…
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.
- No harm found · B2025-03-06 · tag F0641 — patternEnsure 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, Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Vaccination Schedule, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of 1 of 5 residents reviewed for pneumococcal immunizations (Resident #31). The facility identified a census of 44 residents. Findings include: Resident #31 Electronic Health Record (HER) Census documented admission to the facility on [DATE]. Resident #31 EHR Immunization Record showed Resident #31 received the pneumococcal polysaccharide (PPSV)23 vaccination on 11/01/21 at the age of 53. The Immunization Record lacked documentation of any other Pneumococcal Vaccination received by the resident. The CDC 2025 Adult Immunization Schedule for Pneumococcal Vaccination for adults age [AGE] or over directed when PPSV23 is the only pneumococcal vaccination received, then one dose of PCV15,…
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.
- No harm found · B2024-04-18 · tag F0625 — patternNotify 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 — the official record, unedited, may be distressing
Based on interviews and record reviews, the facility failed to provide the bed hold policy for 1 of 2 residents reviewed (Resident #39). On 12/8/23 Resident #39 was sent to the hospital for seizures. A bed hold policy was not discussed/given to Resident #39's representative. The facility reported a census of 51 Residents. Findings include: A Census page for Resident #39 documented to stop billing on 12/8/23. A Progress Note dated 12/8/23 at 1:00 p.m., documented that this resident was loaded into the ambulance for seizure activity. A Progress Note dated 12/11/23 at 2:35 p.m., documented that this resident returned to the facility on a stretcher after an acute hospital stay. On 4/16/24 at 1:46 p.m., the Licensed Nursing Home Administrator (LHNA), stated they do not have a bed hold for 12/8-11/23 hospital stay for Resident #39. She stated that the nurse working was an agency nurse and must have missed it. An undated Bed Hold Policy, directed staff that the charge nurse would notify the resident's power of attorney, guardian or next of kin of transfer and the Bed Hold form.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVEN, CRYSTAL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 07/01/2013 |
| LANGE, RANDALL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 10/01/1998 |
| BARKER, MOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/05/2024 |
| BRUBAKER, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/22/2021 |
| SCURR, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/26/2025 |
| THOMSEN, BRETT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/24/2018 |
| THOMSEN, KEYA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/18/2020 |
| WRIGHT, MARCEE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/16/2005 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CARESERV TECHNOLOGIES LLC | Organization | ADP OF THE SNF | — | since 02/02/2018 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL CONSULTING LLC | Organization | ADP OF THE SNF | — | since 09/30/2022 |
| CATTAIL INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| DENMAN CPA LLP | Organization | ADP OF THE SNF | — | since 12/01/2011 |
| ECSI INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| FOX REHAB OT IA LLC | Organization | ADP OF THE SNF | — | since 06/30/2024 |
| FOX REHAB PT IA PLLC | Organization | ADP OF THE SNF | — | since 06/30/2024 |
| FOX REHAB SLP IA PLLC | Organization | ADP OF THE SNF | — | since 06/30/2024 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| PM ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 03/31/2022 |
| BROOME, SHARON | Individual | ADP OF THE SNF | — | since 04/01/2019 |
| JOHNSRUD, THOMAS | Individual | ADP OF THE SNF | — | since 03/31/2022 |
CMS files one row per role, so the 28 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
12 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $124K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 165446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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.