Good Samaritan - Holstein
505 West Second Street, Holstein, IA 51025 · Non profit - Other · 60 certified beds · (712) 368-4304 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent Aug 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $99,103 in federal fines (most recent 2024-08-17)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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 |
| Short-stay residentsrehab / post-hospital | 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 1 to 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 | 16.9% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.9% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 2.4% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 5.8% | 4.2% | 6.5% | better |
| Long-stay residents who were physically restrained | 2.2% | 0.2% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.4% | 3.8% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.5% | 16.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 36.2% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.2% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 48.6% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 72.0% | 73.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 13.9% | 20.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.3% | 13.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.00 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.26 | 2.08 | 1.80 | better |
‡ 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.
54.2% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 54.2%CMS range 40.2–67.7 | 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 | 10.2%CMS range 5.9–16.8 | 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 | 61.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 78.3% | 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 | 4.3% | 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 | 1.01 | 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 60 beds and averages 52.3 residents a day — about 87% occupied, or roughly 8 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.95 hrs/resident/day on weekends vs 3.51 on weekdays — 16% thinner on weekends. RN hours go from 1.13 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% 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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2024-08-17 · 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, interview and record review the facility failed to ensure that residents were free from abuse for 1 of 1 resident reviewed. Staff F, Certified Nurse Aide (CNA), and Staff E, CNA, used punitive restrictions and restraints to control Resident #1 preventing her from moving about. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, 2024 through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. It was identified during survey Staff I worked 9 times prior to taking course and Staff J worked 12 times prior to taking course. c. Leadership supervision in memory care implemented to include daily…
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 · J2024-08-17 · 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 record, policy and video review, and interviews, the facility failed to report suspected abuse immediately, and failed to separate an alleged abuser from the residents immediately. A staff member witnessed a Certified Nurse Aide (CNA) with her hand covering the mouth of an agitated resident. She failed to report the suspicious activity for over 2 hours. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, 2024 through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. c. Leadership supervision in memory care implemented to include daily oversight of behaviors, staff management and increased activities and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-09 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 2 of 20 residents reviewed (Resident #21 and #51). The facility reported a census of 51 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment.On 4/6/26 at 3:10 PM Resident #21 stated the food was served cold at least once or twice a week. Resident #21 explained does not like cold food. 2. The MDS dated [DATE] revealed Resident #51 had a BIMS of 15 indicating no cognitive impairment.On 4/7/26 at 9:24 AM Resident #51 stated the food is frequently cool and would like it served warm. Resident #51 explained lunch and dinner were the meals that were served cold because his table was the last served. Continuous observation of lunch meal plates for the memory care unit revealed 1st tray placed in heated transport at 12:00 PM, sample plate placed 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.
- Potential for harm · E2026-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, to store food in accordance with professional standards by not dating open food items or disposing of expired food items. The facility reported a census of 51 residents.Findings include: An initial kitchen observation on 4/6/26 at 10:30 AM revealed the 2 door refrigerator had a 3.5 container of cottage cheese with an open date of 4/1/26 and a best by date of 3/26/26, a large plastic container of carrots in water dated 3/31/26, an 8 oz. container of parmesan cheese with a best by date of 11/25 open without an open date, a container of parmesan cheese with a best by date of 7/16/25 open without an open date, a container of barbeque sauce outside of a store bought container with an open date of 2/19/26, a container of strawberry syrup with a best by date of 12/25 open without an open date,…
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 · D2026-04-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, Electronic Health Records (EHR) review, resident interview, resident family interview, staff interviews and policy review the facility failed to provide dignity and respect to a resident when 2 briefs were applied for incontinency to 1 of 3 residents reviewed (Resident #21 ). The facility reported a census of 51 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #21 required partial / moderate assistance with toilet hygiene. Review of Resident #21's EHR titled, Care Plan documented no interventions for utilization of 2 briefs for Resident #21.Review of Resident #21's EHR titled, Progress Note documented no discussions with Resident #21 or Resident #21's Daughter about the use of 2 briefs. Progress Notes documented no indications of trial or previous alternative interventions.On 4/6/26 at 3:17 PM Resident #21 explained the 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.
- Potential for harm · Dcited before2026-04-09 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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, document review, Electronic Health Record (EHR) review, family interviews, staff interviews and policy review.The facility failed to protect a resident from the use of a physical restraint that the resident could not consistently remove on their own for 1 of 2 residents reviewed (Resident # 9). The facility reported a census of 51 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment . The MDS reported Resident #9 utilized a trunk restraint in the wheelchair. The MDS also documented Resident #9 had diagnoses of anxiety disorder, bipolar disorder, impulse disorder and unspecified intellectual disability. Review of a document provided by the facility on 4/6/26 titled, CMS 802 (Resident Matrix) documented use of a restraint for Resident #9. Review of Resident #9's EHR titled, Care Plan documented the resident utilized a seatbelt for physical restraints related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Health Records (EHR) review, policy review and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, that was on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #9) and with missed opportunities for hand hygiene when personal cares were completed for 1 of 3 reviewed (Resident #21). The facility reported a census of 51 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented Resident #9 had a feeding tube in place.Review of Resident #9's EHR titled, Order Summary Report documented a physician's order to flush PEG tube with 200cc of tap water daily to maintain patency. Review of Resident #9's EHR titled, Care Plan documented Resident #9 required EBP related to peg tube placement with an initiation…
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 · D2025-06-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 review, staff interview and facility policy the facility failed to update the resident ' s care plan to accurately reflect the resident for 3 of 3 residents reviewed (Resident #1, #2, and #4) The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnosis of heart failure, renal insufficiency, diabetes mellitus, and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS also indicated Resident #1 was in hospice care. Review of the clinical census indicated that Resident #1 was admitted into Hospice care on 3/8/25. Review of the Care Plan for Resident #1 with a date initiated as of 7/23/24 revealed the facility failed to update the care plan to reflect Resident #1 was admitted to hospice care. 2. The MDS assessment dated [DATE] for Resident #2 documented diagnosis of heart failure, renal insufficiency, peripheral vascular…
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 · D2025-03-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview, the facility failed to implement or follow through with advanced directives per resident directive upon admission for 1 of 21 residents reviewed (Resident #206). The facility reported a census of 49. Findings include: The entry Minimum Data Set (MDS) dated [DATE] indicated Resident #206 entered the facility on [DATE]. The Care Plan for Resident #206, implemented [DATE] did not document if the resident wanted cardiopulmonary resuscitation (CPR) should he require it. A review of clinical records and files on [DATE] showed they failed to document Resident #206 had a code status or advanced directive of any kind. His Electronic Health Record (EHR) lacked documentation the resident required CPR and did not indicate the resident was indicated as a do not resuscitate (DNR). In an interview on [DATE] at 3:54 PM with Resident #206, he was asked directly if he wanted CPR in the event he should need it. He was able to voice that yes, he wants CPR. In 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 · D2025-03-20 · 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 review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 3 out of 21 residents (Resident #10, #16, #31) reviewed for comprehensive care plans. The facility reported a census of 49 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident #10's MDS included diagnoses of diabetes mellitus, non-alzheimer's dementia, anxiety and depression. The MDS documented Resident #10 was taking insulin injections during the 7 day look back period. A Physician Order dated 9/25/24 directed staff to obtain a FSBS (Finger Stick Blood Sugar) daily in the morning related to type 2 diabetes mellitus. A Physician Order dated 10/14/24 directed staff to administer Basaglar Insulin 100 unit/ml (milliliter) to inject 14 units subcutaneously (fatty tissue below the skin) one time a day related…
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 · D2025-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on direct observation, clinical record review, and staff interview, the facility failed to provide adequate oral cares for 2 of 2 residents reviewed (Resident #22, #24). The facility reported a census of 49. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #22, dated 12/9/2024, documented the resident's Brief Interview for Mental Status (BIMS) score as 00, indicating the resident was rarely/never understood. It documented the resident required substantial/maximal assistance to perform oral hygiene. The Care Plan for Resident #22, last revised 12/15/2024, documented the resident had his own teeth. It instructed staff to assist the resident with oral cares every AM and PM shift. Review of the Plan of Care Response History, printed 3/20/2025 at 10:08 AM, contained no documentation of oral cares performed in the last 30 days, the maximum look back period of the plan of care response history. 2. The MDS for Resident #24, dated 1/29/2025, documented the residents BIMS score as 03, indicating severely impaired cognition. It documented Resident #24 was fully…
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 before2025-03-20 · 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, observations, and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed for falls (Resident #46). The facility also failed to ensure a wander guard (a monitoring bracelet with activated alarm when exiting) was working for resident safety on a daily basis for 1 of 1 resident reviewed for risk for elopement (Resident #49). The facility reported a census of 49 residents. Findings include: 1. Resident #46's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The MDS identified Resident #46 required supervision/touching assistance with bed mobility and ambulation. The MDS identified Resident #46 required partial/moderate assistance for transfers. Resident #46's MDS included diagnoses of non-alzheimer's dementia, depression, hypothyroidism and other abnormalities of gait and mobility.…
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 12 citations
- Potential for harm · D2025-03-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to complete a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications, (Resident #21). The facility also failed to include nonpharmacological interventions and targeted behaviors for which staff were to monitor and/or redirect for 1 out 5 residents (Resident #31). The facility reported a census of 49 residents. Findings include: 1. Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. The MDS identified Resident #21 was independent transfers and ambulation. Resident #21's MDS included diagnoses of Alzheimer's, non-alzheimer's dementia, seizure disorder, and psychotic disorder. The MDS documented Resident #21 was taking an antipsychotic medication during the 7 day look back period. The Care Plan with a target date 9/17/24 documented Resident #21 received Seroquel…
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 before2025-03-20 · 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 direct observation, staff observation, and facility document review, the facility failed to serve food to residents in a safe and hygienic manner. The facility reported a census of 49. Findings include: A direct observation on 3/17/2025 at 12:21 PM revealed Staff J, Registered Nurse (RN), assisting two residents simultaneously with eating assistance. There was no witnessed hand hygiene as she transferred from resident to resident. A continued observation on 3/17/2025 at 12:22 PM revealed Staff J appearing to touch their face before continuing to assist both residents with eating, no hand hygiene was performed. A direct observation on 3/18/2025 at 12:31 PM revealed Staff J, RN, offer eating assistance to two residents again. No hand hygiene was observed as she switched from resident to resident. A direct observation on 3/18/2025 at 12:39 PM revealed Staff K, Certified Nurse Aide (CNA), assisting a resident to take a bite of a cake. While assisting the resident to take a bite of the cake she appeared to make direct contact with the tines of the fork, and then assisted 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 · E2024-08-17 · tag F0741 — failed to have staff trained for behavioral health — patternEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, video, record and policy review, the facility failed to ensure staff displayed competent dementia care and safe interventions for 1 of 1 resident reviewed. Staff F, Certified Nurse Aide (CNA), and Staff E, CNA, used punitive restrictions and restraints to control Resident #1 preventing her from moving about. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. c. Leadership supervision in memory care implemented to include daily oversight of behaviors, staff management and increased activities and interaction with residents. d.All…
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 before2024-06-17 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure accurate accounting of Scheduled II medications for 2 of 6 residents (#3 and #4). The facility also failed to ensure that medications were securely locked in the cart and storage room. The facility reported a census of 57 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive deficit). The resident was totally dependent on staff for eating, toileting, dressing. Her diagnoses included cancer, anemia, anxiety disorder, secondary malignant neoplasm of brain, adult failure to thrive. The Care Plan updated on [DATE] showed Resident #3 had alteration in gastrointestinal status related to malignant neoplasm on the abdomen. She had communication problem related to difficulty forming words and self-care deficit related to weakness. The resident was on high risk medications prescribed for pain, depression and anxiety. 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 · Ecited before2023-12-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record, and policy review the facility failed to keep residents safe from preventable accidents and hazards for 5 of 6 residents reviewed (Residents #49, #31, #50, #22, and #9). Resident #49 required two persons with the use of a mechanical lift for transfers. On two occasions, as one staff member assisted Resident #49, he fell from the lift as they transferred him. Resident #31 had a fall from her wheelchair when staff put her in the wrong wheel chair and failed to secure a safety belt. An observation revealed Resident #50 smoking a cigarette with her oxygen tank nearby. An observation revealed the staff transferring Resident #22 without the use of a gait belt, and Resident #9 sustained a skin tear to her hand when an unleashed dog jumped up into her lap unexpectedly. Findings include: 1. Resident #49's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive deficit. The resident had limited…
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 · E2023-12-21 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews with staff and administration, and policy review the facility failed to provide training or orientation to temporary nursing staff for 2 of 2 staff reviewed (Staff M and N). The facility reported a census of 57 residents. Findings include: On 12/21/23 at 11:28 AM, Staff M, Licensed Practical Nurse (LPN), said that she worked for an agency and had worked at the facility since November on a full-time basis. She said that she did not get orientation when she started, and they just put her on the floor with a full load of residents. She said that she worked at other facilities that provided some orientation and that did help her to transition better. On 12/21/23 at 3:14 PM, Staff N, Certified Nurse Aide (CNA), said that he worked for an agency and had a contract with the facility. He said that he did not get formal training or have an orientation checklist completed before the facility expected him to work independently with the residents. On 12/20/23 at 3:45 PM, the Director of Nursing (DON) said that she did not know they needed to have an orientation checklist 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 · E2023-12-21 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietitian. The facility reported a census of 57 residents. Findings include: On 12/20/2023 at 11:30 a.m., the Dietary Manager (DM) reported she did not have her Certified Dietary Manager certification. The DM explained she enrolled in a class that starts on 1/8/24. The DM reported she worked with the facility and recently transitioned into the DM role on 9/24/23. The Director of Nursing (DON) explained the facility could not find a policy regarding Dietary Manager. On 12/21/2023 at 12:00 p.m., the DON verified the DM's registration to take an Iowa Food Manager Certification Course. On 12/20/2023 at 3:00 p.m., the Administrator confirmed that the DM enrolled for the class on 1/8/24.
- Potential for harm · D2023-12-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to notify the physician when a resident did not get her scheduled medication for 1 of 4 residents reviewed (Resident #50). Resident #50 had an order for Lexapro daily, when she ran out of her pills, the staff failed to replenish the supply. In addition, the facility failed to notify the phsyician regarding a significant change in weight for 1 of 2 residents reviewed (Resident #55). Resident #55 had a significant loss in weight in 6 months (greater than 10%) of 11.2%. Findings include: 1. Resident #50's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment). Resident #50 used a walker and/or a wheelchair for mobility with all transfers. The MDS indicated that she could walk independently for 150 feet. The MDS listed Resident #50 as independent with eating, oral hygiene, toilet hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. 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.
- Potential for harm · Dcited before2023-12-21 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents consented to the use of a restraint and failed to obtain a physician's order for restraint use, for 1 of 1 resident reviewed (Resident #31). Resident #31 had a diagnosis of traumatic brain injury with limited mobility. Staff used a seatbelt in her wheelchair to prevent her from sliding out and failed to get a consent from the family. Findings include: Resident #31's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive deficit. The resident required total dependence from two staff for transfers, dressing, locomotion, and hygiene. She used a wheelchair for mobility. The MDS did not indicate that she required the use of a restraint to prevent her from sliding from the wheelchair. The Incident Report dated 10/13/23 at 4:50 PM, indicated a visitor alerted staff of Resident #31 sliding from her wheelchair. By the time staff got to her, she fell on the floor.…
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 · D2023-12-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review the facility failed to ensure that the Minimum Data Set (MDS) included resident specific information for 1 of 21 resident reviewed (Resident #31). Resident #31 had diagnosis of traumatic brain injury with limited mobility. Staff were using a seat belt in her wheel chair to prevent her from sliding out. The MDS lacked information regarding the use of restraints for Resident #31. Findings include: According to the MDS dated [DATE], Resident #31 had a BIMS score of 4 (severe cognitive deficit). Resident #31 was totally dependent on two staff for transfers, dressing, locomotion, and hygiene. She used a wheelchair for mobility. The MDS lacked the use of a restraint to prevent her from sliding from the wheelchair. The Care Plan updated on 12/4/23 showed that Resident #31 had a traumatic brain injury with limited mobility, she was chair fast, did not ambulate, and required the use of a full-body mechanical lift (Hoyer lift) for transfers. She used a wheelchair with a seatbelt in…
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 · D2023-12-21 · 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 observation, interview and record review the facility failed to ensure that a resident received her scheduled medication for 1 of 4 residents reviewed (Resident #50). Resident #50 had an order for Lexapro daily, when she ran out of medication, the staff failed to follow through and replenish the supply. Findings include: Resident #50's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment). Resident #50 used a walker and/or a wheelchair for mobility with all transfers. The MDS indicated that she could walk independently for 150 feet. The MDS listed Resident #50 as independent with eating, oral hygiene, toilet hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. The MDS included diagnoses of chronic obstructive pulmonary disease (chronic lung disease), hypertension (high blood pressure), and anxiety disorder. Resident #50 had shortness of breath with exertion (walking, bathing, transferring), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately document, monitor the use, and the storage of narcotic medications for 1 of 5 residents reviewed (Resident #1). The nursing staff failed to sign off on the accuracy of the narcotic counts between all shifts. The Individual Resident Narcotic Record (IRNR) for Resident #1 did not match with the amount in the bottle. Another IRNR sheet for Resident #1 reflected a total of 5.25 milliliters (ml) of morphine missing. Findings include Resident #1's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive deficits. He had impairment on both sides of his lower extremities and used a wheelchair for mobility. He was on Hospice care and was almost constantly in pain. The care plan initiated on 6/14/19, showed that Resident #1 had limited mobility related to a cerebral vascular attack with right sided paralysis. The resident was taking medication for convulsions,…
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
$99,103 in federal fines across 1 penalty.
- $99,103 — penalty dated 2024-08-17
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 | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| 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; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; 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 |
| ANDERSON, TROY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/14/2020 |
| LUFT, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2020 |
| 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 07/16/2023 |
| DTN STAFFING INC | Organization | ADP OF THE SNF | — | since 08/02/2024 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/13/2018 |
CMS files one row per role, so the 55 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 $883K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 165207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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 →
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