Winslow House Care Center
3456 Indian Creek Road, Marion, IA 52302 · Non profit - Corporation · 50 certified beds · (319) 377-8296 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,360 in federal fines (most recent 2026-01-28)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 | 15.5% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.4% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.1% | 4.2% | 6.5% | better |
| 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 | 3.3% | 3.8% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 16.3% | 16.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 11.2% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.6% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 19.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 73.3% | 79.4% | 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.
Staffing
How full it usually is: this home is certified for 50 beds and averages 46.3 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 2.50 hrs/resident/day on weekends vs 3.29 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.92 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
16 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2026-01-28 · 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
Based on observation, clinical record review, facility policy and staff and resident interviews the facility failed to appropriately transfer a resident from the bed to chair with the use of a mechanical lift in order to prevent a fall with injury for one of three residents reviewed (Resident #4). The full body lift tipped during Resident #4's transfer, and the resident sustained a bruise and skin tear. The facility reported a census of 47 residents.The facility corrected the deficient practice through past-noncompliance through the following actions: *Staff education completed 12/26/25 and 12/29/25 regarding full body lift safety *Removal of the full body mechanical lift pending inspection*Completion of weekly patient lift inspectionFindings include:1.The MDS (Minimum Data Set) dated 10/23/2025 revealed Resident #4 had no cognitive impairment, required substantial/maximum assistance to transfer from one surface to another and had diagnoses including heart failure, diabetes and pressure ulcer left heel.The Care Plan revised on 1/23/2026, identified the resident had a fall risk. It…
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 · Gcited before2024-03-07 · 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, interview, and facility investigation review, the facility failed to maintain an environment as free as possible from hazards when wheelchair foot pedals had been omitted prior to transfer resulting in fracture injury for 1 of 3 residents reviewed for accidents (Resident #200). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #200 required a manual wheelchair for mobility, had lower extremity impairment, and dependent on staff for all transfers. Diagnoses included Heart Failure, Peripheral Vascular Disease (PVD), and polyneuropathy. Resident rated pain at 5 out of 10 that occasionally interfered with sleep and daily activities. The Care Plan, revised 01/19/24, revealed Resident #200 had a risk for falls related to a history of falls, limited mobility, and edema, an intervention informed staff that Resident #200 was non-ambulatory and utilized a wheelchair for locomotion. Care Plan included a focus area…
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 · E2026-01-28 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and Centers for Medicare and Medicaid Services (CMS) 2567 review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to identify previously identified deficiencies, resulting in a repeated deficiency cited on the current survey and cited in the previous survey. The facility reported a census of 47 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 9/25/2025, reflected a deficiency identified for staff failure to use Enhanced Barrier Precautions while doing resident cares for those identified as a risk. During the current complaint survey and facility reported incident survey dated 1/28/26, the team identified the same deficiency, Infection Control (F880).During an interview with the Administrator on 1/28/26 at 2:30 pm she reported she monitors and audits the effectiveness of the QAPI process and confirmed the concern related to the pattern of a deficiency at F880.
- Potential for harm · D2026-01-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical review, staff and resident interviews, and facility policy review, the facility failed to complete wound treatment as ordered for 1 of 5 sampled residents (Resident #1). The facility reported a census of 47 residents. The facility corrected the deficient practice though past-noncompliance through the following actions: *All residents with active treatment orders were assessed and treatments confirmed as completed per physician order*Reeducation of all licensed nursing staff on 1/4/26 and 1/5/26*Post correction audits and weekly audits1.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer, and received pressure ulcer/injury care. The resident required substantial assistance from staff for toileting, bathing, and partial assistance for ambulation. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-28 · 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 observations, clinical review, staff interviews and facility policy review, the facility failed to utilize Enhanced Barrier Precaution (EBP) for 1 of 3 sampled residents reviewed (Resident #1). The facility reported a census of 47 residents.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer (full thickness skin loss), and received pressure ulcer/injury care. The resident required substantial assistance from staff for toileting, bathing, and partial assistance for ambulation. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. Review of the Care Plan dated 9/8/25 indicated the resident needed Enhanced Barrier precautions due to a wound. The Goal section informed staff the precautions would reduce the spread of infectious agents and minimize 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 before2025-09-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, staff interviews and facility policy review the facility failed to utilize Enhanced Barrier Precaution (EBP) for 4 out of 4 encounters with residents (Resident #3 and Resident #32) and their environment, and failed to personal protective equipment (PPE) while handling dirty laundry. The facility reported a census of 48 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #3 dated 8/1/25, listed diagnoses of pressure ulcer of the left heel, and diabetes mellitus (DM) The MDS listed the Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The Care Plan for Resident #3 dated 10/3/25 reflected she needed for EBP related to wound care.On 9/22/2025 at 10:25 AM Staff K, Certified Nurse Aide (CNA) reported the EBP sign on the door of Resident #3's room because of her wound.1. On 9/23/2025 at 2:03 PM Staff A, Certified Nurse Aide entered Resident#3's room washed her hands. The Care Coordinator stood back to observe. Staff A applied gloves. Staff B, CNA entered the room,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-25 · 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 observation, record review, interviews, and policy review the facility failed to maintain code status records for 1 of 3 residents reviewed (Resident #21). The facility was unable to locate code status documentation after a resident's return from the hospital. The facility reported a census of 48 residents. Findings include:The Minimum Data Set, dated [DATE] for Resident #21 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status exam (BIMS), which indicated intact cognition. The MDS further indicated diagnoses of coronary artery disease, mild persistent asthma with acute exacerbation, and obstructive sleep apnea.The resident's Care Plan did not include the resident's preference for Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR).The resident's Electronic Health Record (EHR) did not include the resident's preference for CPR or DNR.The resident's paper chart did not include the resident's preference for CPR or DNR.On [DATE] at 3:01 PM Staff H, Licensed Practical…
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 · D2025-09-25 · 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 record review and staff interviews, the facility failed to accurately code all diagnoses and Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for Minimum Data Set (MDS) assessments (Resident #7). The facility reported a census of 48 residents. Findings include: Record review of Resident #7's Notice of PASRR Level II Outcome dated 5/22/2024 revealed the resident had short term approval until 5/22/2025, and determined to be a Level II (a comprehensive, in-depth evaluation for individuals determined to have a Serious Mental Illness (SMI), Intellectual Disability (ID), or related condition that requires specialized services.) The PASRR documented the resident had the diagnosis of schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder). The PASRR also included the following direction to the facility: The facility should document yes to the following question on the MDS Is the resident currently considered…
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 · D2025-09-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and clinical record review, the facility failed to obtain a resident's Level II Preadmission Screen and Resident Review (PASRR), failed to implement Level II requirements, and failed to resubmit the Level I after expiration for one out of one resident reviewed (Resident #7). The facility reported a census of 48 residents. Findings include:The Minimum Data Set assessment for Resident #7 dated [DATE] included diagnoses of Bipolar disorder and cancer. The Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15, which indicated moderately impaired cognition. Review of Resident #7's Preadmission Screen and Resident Review (PASRR) dated [DATE] reflected following determination: Level 1 positive, No status change, and further documented did not require further PASRR evaluation due to lack of significant change since previous PASRR Level II evaluation. PASARR paperwork revealed the resident's previous summary of findings remained valid for the resident's stay at the nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-25 · 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 observation, record review, interviews, and policy review the facility failed to provide a resident unable to carry out Activities of Daily Living (ADLs) independently the necessary services to maintain adequate personal hygiene and grooming (Resident #28). The resident was admitted to the facility 9/4/25 and was bathed/showered 1 time between 9/4/25 and 9/25/25. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) for Resident #28 dated 9/10/25 documented diagnoses of stroke, non-Alzheimer's dementia, and depression. Section GG indicated the resident required supervision or touch assistance with tub/shower transfers and bathing. The resident's Brief Interview for Mental Status score was 2/15 which indicated severe cognitive impairment.The Care Plan for Resident #28 indicated she was at risk for skin breakdown due to incontinence and impaired mobility. It further documented her ability to complete Activities of Daily Living (ADLs) had deteriorated related to dementia and impaired mobility. An intervention dated 9/17/25 indicated 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 · E2025-04-01 · 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, staff and resident interviews, and facility policy and clinical record review, the facility failed to ensure an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered for four of four residents reviewed. (Residents #1, #5, #6, & #7). The facility reported a census of 44 residents. Findings include: 1. The MDS (Minimum Data Set) dated 2/5/2025 revealed Resident #1 had intact cognitive skills, transferred with assistance, had diagnoses including diabetes, chronic pain, and heart disease. The MDS indicated the resident had frequent pain rated at #8 on a scale of 1-10. The Care Plan identified the resident had pain and directed staff to administer medications as ordered and assess effectiveness. The physician's order's included an order for Hydrocodone-Acetaminophen Tablet 5-325 mg (milligrams). Give one tablet by mouth every 12 hours as needed for pain dated 12/11/2024. On 12/26/2024 the physician changed the order 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 · D2024-08-29 · 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
Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to ensure comprehensive Care Plans were reviewed and revised in a timely manner for 2 of 12 residents reviewed. Resident #27's Care Plan lacked goals, triggers, and interventions related a diagnosis of schizophrenia. Resident #25's Care Plan lacked goals and interventions related to hearing impairment. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #27 dated 7/25/24 documented a Brief Interview for Mental Status score (BIMS) of 15/15 indicating intact cognition. Diagnoses included depression, schizophrenia, and schizoid personality disorder. During an interview with the resident on 08/26/24 at 10:40 AM, the resident confirmed the diagnosis of schizophrenia and indicated he had it for 'a long time.' He said staff didn't do anything about it. On 08/26/24 at 12:27 AM observed resident in the dining room, raising his hand for assistance. Staff responded in less than a minute. At about 12:32 PM the resident put his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-29 · tag 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, staff interviews, record review, and policy review the facility failed to follow professional standards of medication administration for 1 of 1 resident that required medications via gastric tube (Resident #20). Medications were given late without physician notification, an extended release tablet was crushed and Enhanced Barrier Precautions (EBP) were not followed appropriately. The facility reported a census of 46 residents. Findings include: The MDS dated [DATE] for Resident #20 was coded for a feeding tube. The Care Plan completed 6/6/24 for Resident #20 documented: Resident NPO status referred to nothing by mouth, directed to provide tube feeding and administer medications as ordered. The Medication Administration Record (MAR) dated August 2024 for Resident #20 documented the following medications to be given at 8:00 AM, enterally or per gastric tube: Potassium chloride solution, give 15 milliliter (ML) via gastric tube Omeprazole suspension, give 10 ML liquid via gastric tube…
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 · D2024-03-07 · 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, record review, interview, and facility policy review the facility failed to treat 2 out of 3 residents reviewed with dignity during meals (Residents #42 and #21). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #42 dated 2/22/24 included diagnoses of non-Alzheimer's dementia, gastroesophageal reflux disease without esophagitis (GERD), and Parkinsonism. The Brief Interview for Mental Status (BIMS) documented the resident was not able to complete the Brief Interview for Mental Status with staff documenting inattention and disorganized thinking. The MDS recorded the resident as dependent for eating with the helper completing the activity. The Care Plan for Resident #42, revised 10/11/23, documented a focus area of potential for variable intake and significant weight change due to Parkinson's with severe dementia, anxiety, depression, and GERD. Interventions included assistance at meals with setup, cuing, encouragement, 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 before2024-03-07 · 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
Based on observation, interviews, record review, and facility policy the facility failed to administer medications within the facility scheduled time frame 15 times in 15 days for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) for Resident #10 dated 12/27/23 documented diagnoses of chronic obstructive pulmonary disease with acute exacerbation (COPD), encounter for palliative care, and heart failure. Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Section D, Mood, revealed a Resident Mood Interview (PHQ-2 to 9) score of 7 which indicated moderate depression. A Care Plan focus area revised 1/2/24 documented the resident had impaired cognition related end stage COPD. Interventions included medications administered as ordered and the resident's routine should be kept consistent to decrease confusion. A focus area revised 1/2/24 documented resident complained of pain related to COPD, scoliosis, spondylosis…
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 · C2025-09-25 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interviews the facility failed to update as needed and provide current daily staffing information for residents and visitors. The facility reported a census of 48 residents. Findings include: During an observation on 9/22/2025 at 9:17 AM, the facility's staffing posting on the wall at the main facility entrance was observed to be dated 9/19/25. Review of Daily Staff Posting records from September 1 to September 23, 2025 had no edits or changes in staffing for the month. During an interview on 9/24/25 at 2:40 PM Staff D, Registered Nurse (RN) and Staff E, RN informed they did not have anything to do with the Daily Staff Posting and the Director of Nursing (DON) completed them. During an interview on 9/24/25 at 2:45 PM with the DON, informed it was on the night nurses responsibilities to change them over. During a follow up interview on 9/25/25 at 12:20 PM with the DON, informed she was the only one that updated the Daily Staff Posting records. She also revealed she had had new night shift nurses who were supposed to change it over, 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$18,360 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $5,597 — penalty dated 2026-01-28
- $12,763 — penalty dated 2026-01-28
- Medicare payment denial — starting 2024-03-29 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165440. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.