Woodland Health and Rehabilitation
701 East Mapleleaf Drive, Mount Pleasant, IA 52641 · For profit - Corporation · 62 certified beds · (319) 385-1400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,807 in federal fines (most recent 2024-07-03)
- 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 | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 2025-06 to 2026-06, this home’s CMS overall rating improved from 2 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 | 10.5% | 17.1% | 15.4% | better |
| 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 | 0.4% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 19.4% | 4.2% | 6.5% | worse |
| 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 | 1.9% | 3.8% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.8% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 34.2% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 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 | 83.3% | 73.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 14.7% | 20.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 31.0% | 13.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.46 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.37 | 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.
47.2% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 47.2%CMS range 35.8–61.9 | 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 | 11.5%CMS range 7.8–17.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.0% | 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 | 72.0% | 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 | 64.0% | 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 | 96.8% | 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 | 3.2% | 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 | 6.8%CMS range 3.2–15.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 62 beds and averages 56.5 residents a day — about 91% occupied, or roughly 6 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.58 on weekdays — 18% thinner on weekends. RN hours go from 0.51 to 0.38 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 unchanged from the previous inspection. 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.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-07-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The MDS assessment dated [DATE] revealed Resident #53 BIMS score 12 out of 15 indicating a moderate cognitive impairment. The MDS revealed the resident dependent with chair/bed to chair transfers and used a wheelchair. The MDS revealed a diagnosis of hemiplegia, unspecified affecting left dominant side. The Care Plan revealed a focus area dated 4/17/24 for ADL (Activities of Daily Living) self-care performance deficit for left-sided hemiplegia. The interventions dated 5/14/24 revealed transfers with an assist of 2 with a mechanical lift and use of a green sling. The EHR (Electronic Health Record) revealed the following Physician Orders: a. Start date 7/2/24- monitor left forearm skin tear and bruising until healed every shift for skin tear and bruising b. Start date 7/2/24- left forearm: gently cleanse ST (skin tears) with NS (normal saline), apply house stock moisturizer or A&D ointment daily u/h (until healed). May cover if needed every day shift for Skin tear During an interview on 7/1/24 at 11:49 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-09-07 · 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 2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented resident used indwelling catheter and received an antibiotic for 6 out of 7 days. The MDS revealed diagnoses of amputation; complete traumatic amputation at the level between knee and ankle, right lower leg, sequela; completed traumatic amputation at level between knee and ankle, left lower leg, sequela; neurogenic bladder; Paraplegia; Depression (other than bipolar); pressure ulcer of other site, Stage 4. The Baseline Care Plan dated 8/1/23 documented resident took antibiotics and did not check the box for nurse monitoring. The Care Plan with revision date 8/16/23 revealed a focus area of required catheterization of a suprapubic catheter due to a diagnosis of neurogenic bladder. The interventions with initiated date 8/3/23 directed staff as follows; monitor and document intake and output per facility…
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 · D2026-04-22 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of Long Term Care Ombudsman notifications of transfers and discharges, and staff interview, the facility failed to notify the Ombudsman of a transfer to the hospital for 2 of 3 residents sampled (Residents #58 and #7). The facility reported a census of 57 residents.Findings included:1. Review of the Minimum Data Set (MDS) assessment for Resident #58, dated 2/27/26, revealed the resident discharged to an acute care hospital on 2/27/26 and was not expected to return to the facility.Review of Notice of Transfer Form to the Long-Term Care (LTC) Ombudsman, dated February 2026, revealed Resident #58 not listed as a hospital transfer/discharge. During an interview on 4/22/2026 at 8:09 AM, the Administrator reported being responsible for sending a monthly notification of resident transfers and discharges to the LTC Ombudsman. The Administrator explained that she did not send notification to the LTC Ombudsman if a resident was sent to the hospital and the resident was expected 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 before2026-04-22 · 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, clinical record review and staff interview, the facility failed to ensure staff administered medicated inhalers per physician order for 2 of 3 sampled residents (Residents #24 and #7). The facility reported a census of 57 residents. Findings included: 1. Review of the Minimum Data Set (MDS) Assessment for Resident #24, dated 4/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated a severe cognitive impairment, and a diagnosis of dementia. Review of the Physician Order List for Resident #24 revealed an order, dated 11/5/25, for Asmanex Inhaler (an inhaled corticosteroid medication) 200 micrograms (mcg) per actuation, two puffs inhaled orally two times per day for chronic obstructive pulmonary disease (COPD) with acute exacerbation. Rinse mouth with water and spit (after use). Review of the Medication Administration Record (MAR) for Resident #24, dated February 2026, revealed an order for Asmanex Inhaler two puffs two times per day and to rinse mouth…
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 · D2025-04-09 · 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, facility policy review, and staff interview, the facility failed to accurately obtain and implement advanced directives per resident and family directives upon admission for 1 of 1 residents (Resident #202) reviewed. The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #202 had been admitted to the facility on [DATE] from a short term general hospital. Review of Resident #202's Order Summary Report, dated [DATE], revealed a verbal order for CPR, effective [DATE]. Review of Resident #202's electronic health record (EHR) revealed a lack of a signed document, by Resident #202, Resident Representative, or physician, to confirm Resident #202's wishes for life sustaining measures. During an interview on [DATE] at 11:28 AM, the Director of Nursing (DON) retrieved a binder which included the resident's Iowa Physician Orders for Scope of Treatment (IPOST). An IPOST is a document that allows a person to communicate…
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 before2025-04-09 · 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 observations, clinical record review, and staff interviews, the facility failed to ensure 2 foot pedals used when a staff pushed a resident in their wheelchair for 1 of 7 (Resident #17) reviewed for accidents. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored a 00 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated resident impaired on one lower extremity. The MDS indicated resident used a manual wheelchair and walker. The MDS revealed medical diagnoses for non-Alzheimer's dementia; hemiplegia or hemiparesis; arthritis; and hip fracture. The Care Plan revealed a focus area dated 10/10/24 for anytime ambulation program- increased risk for impaired physical mobility related to decreased strength, endurance, and chronic illness, as evidenced by generalized weakness ADL (Activities of Daily Living) self performance level and support level…
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 · E2024-11-14 · 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 — an excerpt from the official record, may be distressing
Based on Centers for Medicare and Medicaid Services (CMS) Certification and Survey Provider Enhanced Reports Reporting (CASPER) system, review of the facility Quality Assurance Performance Improvement (QAPI) Policy, and staff interview the facility failed to ensure effective measures had been taken to correct deficiencies that continue. The facility reported a census of 50 residents. Findings include: A review of the facility CASPER report revealed the facility cited for F641 (Accuracy of Assessments) in February 2024 and will be cited during the current recertificaton survey. A review of Resident #49 and #18 Minimum Data Set (MDS) Comprehensive Assessments showed both coded as no, for use of tobacco in Section J Health Conditions. On 11/13/24 at 4:49 PM, the Director of Nursing acknowledged that Resident #49 and Resident #18 currently smoked at the facility. On 11/13/24 at 4:52 PM Staff A, MDS Coordinator acknowledged both Resident #49 and #18 were coded wrong and she would be submitting (MDS) corrections. Staff A stated they have a policy for MDS accuracy. During an interview 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 · D2024-11-14 · 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, clinical record review, policy review, resident, guardian, and staff interviews, the facility failed to notify the legal guardian of laboratory refusals and resident change in condition for 1 of 5 resident reviewed for medication use (Resident #7). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 7/04/24, for Resident #7 listed diagnoses included schizophrenia, diabetes mellitus, stroke, aphasia (a disorder that affects a person's ability to understand and express language, including reading and writing), hemiplegia (paralysis or weakness on side of the body), and anxiety disorder. A Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated a moderate cognitive impairment. The MDS listed medications taken seven days a week which included insulin, antipsychotic, and an antidepressant. The MDS identified Resident #7 as not exhibiting rejection of care during the review period. A clinical record review revealed 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 · D2024-11-14 · 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
Based on observation, clinical record review, and staff interviews the facility failed to ensure resubmission of the a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for 1 of 1 residents reviewed (Resident #21). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) for Resident #21, dated 9/26/24, included the following diagnoses: anxiety disorder; major depressive disorder, moderate, recurrent; pervasive developmental disorder; adjustment disorder; and psychotic disorder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, included intact cognition. The clinical record revealed Resident #21's diagnoses list with date added to the record. The list reflected Major Depressive Disorder, single episode, unspecified 5/28/19; Anxiety Disorder unspecified 5/28/19; Pervasive Developmental Disorder 5/28/19; Generalized Anxiety Disorder 5/28/19; Adjustment Disorder unspecified 5/28/19; Major Depressive Disorder, recurrent, moderate 7/1/24; and Unspecified Psychosis not due to a substance or…
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 · D2024-11-14 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident and staff interviews, the facility failed to complete post dialysis assessments for 1 of 1 residents sampled (Resident #12). The facility identified a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 11/01/24, for Resident #12 documented a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive loss. The MDS identified Resident #12 received dialysis for a diagnosis of end stage renal disease. The Care Plan, Date Initiated: 9/8/24 included a Focus area to address Dialysis at [provider name redacted] on M-W-F (Monday-Wednesday-Friday) at 10 AM and transportation via [provider name redacted] transport. A review of the October 2024 Electronic Registered Nurse/Licensed Practical Nurse Medication Administration Record (RN/LPN MAR) revealed an order, dated 9/6/24, Vital Signs prior to sending and returning from dialysis two times a day every Mon, Wed, and Fri. The vital signs documented at 0700 (7:00 AM) and 1500 (3:00 PM) included: BP (blood pressure), Temp (temperature),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · 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 resident and staff interviews, clinical record review, and facility policy the facility failed to ensure the dignity of one of three reviewed (Residents #37). The facility reported a census of 54 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #37 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and had the following diagnoses: Amputation, Coronary Artery Disease and Heart Failure. The MDS also identified Resident #37 required extensive staff assistance with bed mobility, locomotion on and off the unit, dressing and toileting. The MDS documented that Resident #37 was totally dependent on staff for transfers and bathing. In an interview on 8/27/23 at 10:30 AM, Resident #37 reported staff will leave him to sit on his feces in the bedpan. This causes it to burn and break down the skin. Resident #37 stated to be left on the bedpan for 45 minutes, that's the most inhumane thing to do to a person. On 11/17/21, the Care Plan with initiated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, staff and resident interviews and facility policy review the facility failed to prevent the misappropriation of resident money for one out of one residents reviewed (Resident #10). The facility reported a census of 54 residents. Findings include: The Significant Change Minimum Data Set (MDS) Assessment for Resident#10 dated 4/7/23, included diagnoses of Parkinson's disease and anxiety disorder. The MDS listed the Brief Interview for Mental Status (BIMS) as 15 which indicated intact cognition. The Care Plan for Resident#10 dated 4/2/23, reflected independent for transfers, use assist of one staff with transfers and ambulation in room as requested by resident when not feeling well. A Bank slip dated 7/3/23, reflected two hundred dollar withdrawn. The Progress Notes for Resident#10 dated 7/2/23 through 7/30/23, failed to identify any incident or concern related to the Resident#10's money. The facility investigation report dated 7/13/23, reflected Resident#10 reported missing money. The report written by the Administrator reflected, Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2023-09-07 · 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
Based on observation clinical record review, staff and resident interviews and facility policy review the facility failed to initiate the investigation immediately after the resident report the missing money to staff (Resident #10). The facility reported a census of 54 residents. Findings include: The Significant Minimum Data Set (MDS) Assessment for Resident#10 dated 4/7/23, included diagnoses of Parkinson's disease and anxiety disorder. The MDS listed the Brief Interview for Mental Status (BIMS) as 15, (intact cognition). The Care Plan for Resident #10 dated 4/2/23, reflected independent for transfers, use assist of one staff with transfers and ambulation in room as requested by resident when not feeling well. The facility investigation dated 7/13/23, reflected Resident#10 reported missing money. The file failed to document the date and time Resident#10 reported the money missing. On 8/28/23 at 1:13 PM, Resident#10 sat on the side of her bed, dressed well and clean. Resident#10 reported she held about one hundred dollars in her purse, and she failed to know who took 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.
- Potential for harm · D2023-09-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, staff and resident interview and facility policy review the facility failed to complete a through investigation for an allegation from a resident that reported missing money for one of of one residents reviewed (Resident 10). The facility reported a census of 54 residents. Findings include: The Significant Change Minimum Data Set (MDS) Assessment for Resident#10 dated 4/7/23, included diagnoses of Parkinson's disease and anxiety disorder. The MDS listed the Brief Interview for Mental Status (BIMS) as 15 which indicated intact cognition. The Care Plan for Resident#10 dated 4/2/23, reflected independent for transfers, use assist of one with transfers and ambulation in room as requested by resident when not feeling well. The Daily Assignment Sheet dated 7/3/23, listed 19 nursing staff worked over the 24 hour period. The facility investigation dated 7/13/23, included documentation of 10 staff interviewed. The staff interviewed included the Social Services (S.S.) and Human Recourses Director (H.R). The investigation file failed to include…
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 before2023-09-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the resident received only his prescribed medication and the resident received his antibiotic as prescribed for 1 of 11 residents reviewed for standards of practice for medication administration (Resident #18). The facility reported a census of 54. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented resident used indwelling catheter and received an antibiotic for 6 out of 7 days. The MDS documented diagnoses including neurogenic bladder (bladder lacks control due to nerve problems), and paraplegia (paralysis of the legs and lower body). The Care Plan dated 8/16/23 revealed a focus area of required catheterization of a suprapubic catheter due to a diagnosis of neurogenic bladder. The interventions dated 8/3/23 directed staff as follows; monitored 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 · D2023-09-07 · 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, policy review and staff interview the facility failed to time limit the use of a new as needed (PRN) anti-anxiety medication to 14 days and failed to implement interventions to try prior to administration of the medication for 1 of 5 resident reviewed for psychotropic medication use (Resident #49). The facility identified a census of 54 residents. Findings include: 1. Resident #49 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The Resident required extensive assistance with bed mobility, transfer, toileting, dressing and personal hygiene. The MDS listed diagnoses of anxiety and depression and documented Resident #49 received 4 days of anti-anxiety medications during the seven day lookback period. The MDS lacked documentation of current mood or behaviors that had occurred during the assessment look-back period. A Hospital Medication Discharge Report, run date 8/02/23, ordered 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.
- No harm found · B2024-11-14 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, resident and staff interviews, the facility failed to complete the Minimum Data Set to accurately reflect the tobacco status for 2 of 2 residents reviewed for smoking (Resident #49 and #18). The facility identified a census of 50 residents. Findings include: 1. A Minimum Data Set (MDS) assessment, dated 9/30/24, for Resident #49 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. MDS Section J Health Conditions indicated Resident #49 did not utilize tobacco. MDS Section V Assessment Administration documented I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare 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
$33,807 in federal fines across 2 penalties.
- $10,842 — penalty dated 2024-07-03
- $22,965 — penalty dated 2023-09-07
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 THE ENSIGN GROUP — 342 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 | 3.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; 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 |
|---|---|---|---|---|
| ARBOR COURT INVESTMENTS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 10/01/2020 |
| GREINER, NATHAN | Individual | W-2 MANAGING EMPLOYEE | — | since 04/14/2023 |
| BIENSTOCK, JUDAH | Individual | CORPORATE OFFICER | — | since 10/01/2020 |
1 organizational owner 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 $317K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 165478. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.