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Embassy Rehab and Care Center

206 Port Neal Road, Sergeant Bluff, IA 51054 · For profit - Limited Liability company · 60 certified beds · (712) 943-3837 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0744)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
319 Sergeant Square Dr · (712) 943-2500 · Call to confirm hours
Pharmacy
Grocery
700 1st St · (712) 943-9325 · Call to confirm hours
Park
300 Crystal Ct · (712) 943-5800 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.9%17.1%15.4%typical
Long-stay residents who lose too much weight0.7%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.5%0.9%better
Long-stay residents with a urinary tract infection9.2%2.4%2.0%worse
Long-stay residents with depressive symptoms1.9%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.5%3.8%3.3%better
Long-stay residents whose ability to walk worsened12.6%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.2%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine97.7%95.3%95.3%typical
Long-stay residents with pressure ulcers1.9%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control18.6%25.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table30.8%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.6%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine70.0%73.3%79.4%worse
Short-stay residents rehospitalized after admission25.5%20.9%22.6%worse
Short-stay residents with an outpatient ER visit16.8%13.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.951.491.67worse
Long-stay outpatient ER visits per 1,000 resident days1.062.081.80better

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.

34.6%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 34.6% 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 26 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.6%56.6%Oct 2024–Sep 2025CMS 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 discharge15.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge23.1%50.0%Oct 2024–Sep 2025CMS 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 identified92.1%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS 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

0.77
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.60
RN hoursweekends
54.2%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 43.7 residents a day — about 73% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 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 2.87 hrs/resident/day on weekends vs 3.78 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.83 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-05-21)
10
at the previous standard inspection (2025-06-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and policies reviewed the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility failed to provide hygiene practices during food preparation, prevent cross contamination during meal service, complete temperature logs for resident snack refrigerator, and serve food at the appropriate temperatures.The facility reported a census of 42 residents. Findings include: Observed on 5/18/26 at 11:40 AM Staff A, cook, modify turkey with a roll, green bean casserole, pumpkin pie, and sweet potatoes to a pureed consistency. Staff A completed hand hygiene and donned gloves prior to the initiation of the processing. With the completion of each portion of the meal, the staff removed the components of the Robo Coup (food processor) and took them with the spatula to the dish area, placed them in the dish machine, and started it. The staff demonstrated inconsistency when removing the gloves, whether it was before placement of the dirty items in the dish machine or after placement in the dish machine.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and policy review, the facility failed to maintain an effective infection prevention and control program and provide specific policies related to all employees' hand hygiene during meal service (Resident #5, #24 and #25). The facility reported a census of 42 residents.indings include:1. Observations on 5/19/26 at 12:24 PM showed that Staff F, Dietary Aide, wore the same pair of gloves during the entire dining room service. Staff F picked up food plates and cups from resident tables and placed the dishware into the dirty dish room. Staff F then immediately returned to the dining room and failed to remove the soiled gloves or perform hand hygiene. During the observation, Staff F touched the residents' cups before asking if they were finished. Staff F also retrieved condiments for the residents while still wearing the same gloves.2. Observation on 5/20/26 at 7:43 AM showed the following:Staff C, a Certified Nursing Assistant (CNA), played with Resident #25's hair, failed to perform hand hygiene, then obtained two coffee cups. Staff C then pulled 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    Based on observations, facility policy review and staff interview the facility failed to provide dignity with speaking to residents in the dining room and provide privacy during resident treatments. The facility reported a census of 42 residents. Findings include: 1. Observation on 5/18/2026 at 1:11 p.m., of Staff D, Certified Nursing Assistant (CNA) sitting at table with a resident while she was eating. Staff D said residents name to Resident #25 sitting 2 tables away from her. Resident #25 did not acknowledge Staff D. Staff D then repeated Resident #25's name. The resident again did not acknowledge her. Staff D then whistled at Resident #25 to get her attention. Resident #25 looked at Staff D and she proceeded to ask her in the dining room loudly if she was going to need to go to the bathroom. Staff D proceeded to say if she did she should go back to her room and turn on the light for us to help you. Resident #25 just looked at Staff D and never responded or moved her wheelchair. Interview on 5/21/2026 at 9:02 a.m., with the Administrator revealed the staff should not have been…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-21 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to address dementia care for 1 out of 4 residents reviewed (Resident #5). The facility reported a census of 43 residents.Findings include:The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of non-Alzheimer's Dementia. The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed active diagnosis of Non-Alzheimer's Dementia.Review of Resident #5's active diagnosis list revealed alcohol dependence with alcohol- induced persisting dementia. Review of Resident #5's care plan with a revision date of 5/8/26 lacked information regarding dementia care. Interview on 5/20/26 at 1:52 p.m., with the Director of Nursing (DON) revealed dementia should be addressed on the care plan if they have a diagnosis.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility provided policy the facility failed to maintain accurate and verified documentation of task completion. Specifically, staff signed off on assigned duties as complete without actually performing the work or communicating with assigned personnel to confirm completion. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of non- Alzheimer's Dementia, arthritis and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of facility provided documentation titled Follow Up Question Report on Toilet Transfer dated 5/1/26-5/20/26 revealed Staff G, Assistant Director of Nursing (ADON) completed documentation not assigned to her on 15 separate occasions. Staff G was not the employee assigned to these tasks. Review of facility provided documentation titled follow up question report 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from physical abuse for 1 of 3 (Resident #1) residents. The facility reported a census of 45 residents. Findings Include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of neurogenic bladder, anxiety disorder and dementia with other behavioral disturbances. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.The Progress Note dated 7/5/25 at 6:45 AM for Resident #1 showed Staff C, Registered Nurse (RN) documented the following: At about 3:45 AM one of the night CNA's notified me that she met another CNA yelling, restraining and hitting a resident inappropriately in his room during rounds. According to her this happened while they were trying to get a resident changed. I was notified and immediately went and assessed the resident. There were no physical injuries on the resident. No bruises…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2025-06-05 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, staff interviews and policy review the facility failed to provide a clean homelike environment free from offensive odors. The facility reported a census of 45. Findings include: 1. Observation on 6/2/25 at 10:12 a.m., noted upon entrance into the building a strong urine odor. 2. Observation on 6/3/25 at 11:41 a.m., urine odor noted in hallways throughout the building. 3. Observation on 6/3/25 at 3:33 p.m., urine odor noted in hallways throughout the building and around the nursing station. 4. Observation on 6/4/25 at 9:36 a.m., urine odor noted in hallways throughout the building and around the nursing station. Interview on 6/4/25 at 12:09 p.m., with the Administrator revealed the hallways should not have urine smell and the facility will be working on the right away.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-05 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility. The bed hold notice also failed to notify the amount per day the resident or representative agreed to pay for 2 of 4 residents reviewed (Residents #13, # 21 and #40). The facility failed to notifiy the Long Term Care Ombudsman of discharge from facility for 1 of 4 residents reviewed (Resident #46). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented reentry to the facility on 4/11/25 for a short term hospital stay. Review of the Clinical Census report for Resident #21 revealed the following information: a. 12/15/24- hospital b. 12/20/24- active c. 4/4/25- hospital d. 4/11/25- active Review of the Progress Notes for Resident #21 revealed the following: a. On 12/15/24 at 5:58 PM, Resident admitted…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-05 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to post accurate nurse staffing data in a prominent location and visible to residents and visitors. The facility reported a census of 45 residents. Findings include: 1. Observation on 6/2/25 at 12:49 p.m., lacked a daily staffing sheet visible for residents and public to locate. 2. Observation on 6/3/25 at 2:19 p.m., lacked a daily staffing sheet visible for residents and public to locate. 3. Observation on 6/4/25 at 9:27 p.m., lacked a daily staffing sheet visible for residents and public to locate. Interview on 6/4/25 at 9:29 a.m., with Staff C, Licensed Practical Nurse (LPN) and Staff D, Registered Nurse (RN) revealed the staffing book on the counter is where the sheet is kept. Staff D opened the book to reveal the daily sheet. Staff C verified this is the only place where the hours are posted and all of the daily sheets are kept in the office after they are changed out. Review of facility provided policy titled Posting of Daily Nursing Hours Policy with a revision date of March 2019 revealed it is the policy 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area. The facility identified a census of 45 residents. Findings included: The initial kitchen walk through on 6/2/25 at 10:55 AM with the Dietary Manager (DM) revealed the following: A clean dish cart contained a variety of scattered food debris. Three food preparation tables with shelving underneath showed a thick layer of grease build-up on the shelves, pans and food containers. The floor contained an accumulation of food debris and a variety of dried liquid. The freezer units with a variety of food debris in the bottom of the units. The refrigerator units with debris with a variety of food debris in the bottom of the units. The top of the dishwasher not visible due to a layer of white, crusty material. The snack cart with food debris build-up. The warming table pan covers found with dried food debris and dried liquid. Back splash of oven wall covered with multiple large food debris and dried liquid. During the initial walkthrough the DM…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 12 residents (Resident #34) reviewed from physical abuse. The facility reported a census of 45 residents. The deficiency cited at F600 is considered past non-compliance. The Workplace Violence, HIPAA, Abuse Recap facility education and sign-in sheets dated 4/2/25 showed the facility performed education regarding abuse. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of dementia, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The facility Incident Report dated 3/25/25 at 8:45 AM for Resident #34 documented the following: At 8:45 AM this nurse was approached by CNA (Certified Nursing Assistant), and CNA attempted to block the swing and made contact with the resident causing a scratch…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-06-05 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #13 and #38). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of hypertension, heart failure, anemia.The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication during the review period. Review of the Medication Review Report dated 6/3/25 revealed the following orders: a. Aripiprazole tablet (antipsychotic medication) with an order and start date of 5/8/25 b. Buspirone tablet (antianxiety medication) with an order and start date of 5/8/25 c. Trazodone tablet (antidepressant medication) with an order and start date of 5/8/25.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #34). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of dementia, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The facility Incident Report dated 3/25/25 at 8:45 AM for Resident #34 documented the following: At 8:45 AM this nurse was approached by CNA (Certified Nursing Assistant), and CNA attempted to block the swing and made contact with the resident causing a scratch to the bridge of nose and left cheek per CNA. When asked what happened she was unable to describe what happened. The 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record and chart review the facility failed to accurately update a physician's order in the electronic chart and failed to update the resident's chart to show a diagnosis of anxiety for 1 of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents. Findings include: The MDS assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Clinical Orders for Resident #39 showed on 3/9/25 the physician ordered hydroxyzine 25 milligrams (MG) every eight hours as needed for anxiety. The order indicated the end date as indefinite. The Consultant Report for Resident #39 showed on 4/1/25 the pharmacy recommended either to stop the hydroxyzine or to continue for 90 days for anxiety. The physician marked that they agreed to continue for 90 days but then also wrote, okay 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents (Resident #38 and #39) reviewed for PASRR requirements. The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Clinical Physician Orders dated 3/10/25 for Resident #39 showed hydroxyzine ordered for anxiety. The Consultation Report dated 4/3/25 for Resident #39 showed hydroxyzine…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to address dementia/Alzheimer's Disease care for 1 out of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #39 documented diagnoses of dementia with other behavioral behaviors, depression, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The Medical Diagnosis report for Resident #39 showed a diagnosis of dementia dated 2/27/25. The Care Plan for Resident #39 lacked information regarding the physical, mental and psychosocial needs to support the highest practical level of well being for a resident with Alzheimer's Disease or dementia. In an interview on 6/4/25 at 3:52 PM, the Director of Nursing (DON) reported she expected dementia to be included in the care plan for Resident #39.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-20 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1-March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 38 residents. Findings include: The PBJ Staffing Data Report run date 6/13/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low. Review of Facility Daily Assignment Sheets revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. On 6/19/24 at 3:42 PM, the Administrator stated she spoke with the home office. In the future office staff working in resident care areas will use different time clock codes to ensure the correct amount of hours are reflected in the data reported to CMS.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, document review, policy review, and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents at the facility on regular diets. The facility reported a census of 38 residents. Findings include: A continuous observation of the lunch service on 6/19/24 from 11:50 AM - 1:10 PM revealed Staff A, [NAME] utilize a 1/3 cup green scoop #12 to serve Brussel sprouts, a 3/8 cup #10 ivory scoop used for noodles, a 2/3 cup #6 scoop white handled used for serving beef stroganoff to all the regular diets. Review of document titled, Diet Spreadsheet Week 3 Day 18 documented scoop size for beef stroganoff 6 oz or 2/3 cup, noodles 4 oz or 1/2 cup, and brussel sprouts 4 oz or 1/2 cup to be utilized when serving a regular diet. Review of color chart titled, Scoop Size Matters documented the green scoop #12 was equal to 1/3 cup and the ivory scoop #10 was equal to 3/8 cup. Review of document titled, Food Preparation Guidelines dated 4/1/24 documented the cook, or designee, shall prepare menu items following the 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 interview, policy review, and staff interview the facility failed to provide snacks to residents who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 6/17/24 at 12:02 PM Resident #12 stated snacks are not dropped off during the day or in the evening. Resident #12 stated snacks used to be dropped off but he was no longer given a snack. On 6/18/24 at 1:51 PM Staff C, Certified Nursing Assistant (CNA) stated she worked the AM shift but frequently stayed 2pm - 8pm. Staff C stated she had not taken the snack cart around and had not seen anyone on pm shift when she was working drop snacks off to the residents. On 6/18/24 at 2:26 PM Staff D stated she usually worked the 2pm - 10pm shift. Staff D stated the facility staff park the snack carts at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open items of food. The facility reported a census of 38 residents. Findings include: On 6/17/24 from 9:30 AM - 10:00 AM a continuous observation during the initial kitchen tour revealed: a. The dry storage freezer chest had cinnamon rolls in a bag open and undated. b. The dry storage room had cornbread mix and baking powder open and undated. c. The stand up refrigerator had a 3.5 pound butter spread container, a 5 pound cottage cheese container, a 5 pound sour cream container, and a 16 oz. beef base container open and undated. On 6/17/24 at 10:10 AM Staff B, Certified Dietary Manager (CDM) acknowledged the cinnamon rolls, cornbread mix, baking powder, butter spread, cottage cheese, sour cream, and beef base was open and undated. Staff B threw these items away in the garbage. Staff B stated the facility's expectation was the opened food should have been dated when the container was opened. Review of the facility policy for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    Based on observation, staff and resident interview the facility failed to provide privacy during incontinence care and dressing change for 1 out of 4 residents reviewed (Resident #4). The facility reported a census of 38 residents. The findings include: 1. The Minimum Data Set (MDS) for Resident #39, dated 4/11/2024 documented the presence of gastrostomy feeding tube (G-tube). The MDS identified Parkinson's disease and renal insufficiency. Observation on 6/18/24 at 1:25 PM showed after Resident #4 received incontinence care, Staff G, CNA (Certified Nursing Assistant) and Staff H, CNA failed to cover the resident ' s exposed area from mid abdomen to mid thighs before Staff G opened the door to retrieve the nurse. Seconds later the door drifted approximately half way open before Staff H crossed the room to shut the door. Resident #4 remained exposed as Staff G and Staff F, Licensed Practical Nurse, (LPN) entered the room. Seconds later the door drifted partially open before Staff G turned to shut the door again. The resident remained exposed during this time. In 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health records review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents reviewed (Resident #8, and #10). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. Review of Resident #8 ' s electronic health records revealed Resident #8 was hospitalized [DATE], 12/25/23, 2/13/24, 4/25/24, and 6/4/24. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #10 ' s electronic health records revealed Resident #10 was hospitalized [DATE] and 7/7/23. On 6/20/24 at 8:34 AM the Administrator stated for Resident #8 and Resident #10 there are no ombudsman notifications. The Administrator stated the ombudsman notifications were not…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents reviewed (Residents #8 and #10). The facility reported a census of 38 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. Review of Resident #8 ' s electronic health records revealed Resident #8 was hospitalized [DATE], 12/25/23, 2/13/24, 4/25/24, and 6/4/24. 2. The MDS dated [DATE] documented Resident #10 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #10 ' s electronic health records revealed Resident #10 was hospitalized [DATE] and 7/7/23. Review of the facility policy for bed holds revealed there was no policy. On 6/20/24 at 8:34 AM the Administrator stated for Resident #8 and Resident #10 there are no bed holds. The Administrator stated bed holds were not being completed per regulations related to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing hand hygiene during resident care and failed to follow guidelines for enhanced barrier precautions for 2 out of 4 resident reviewed (Resident #4 and #39). The facility reported a census of 38 residents. Finding include: 1. The Minimum Data Set (MDS) for Resident #39, dated 4/11/2024 documented the presence of gastrostomy feeding tube (G-tube). The MDS identified Parkinson's disease and renal insufficiency. The Care Plan for Resident #39 dated 10/17/23 showed G-tube placement for medications and feedings. Observation of Resident # 39 ' s door showed a sign that instructed the nurse to ask before entering the room. A bin for Personal Protective Equipment (PPE) also noted to be present. In an interview on 6/17/24 at 10:34 AM, Staff E, Registered Nurse (RN) reported the sign on Resident #39 ' s door meant anyone providing close contact for 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 2. On 1/16/24 at 12:11 PM observed the staff pass the lunch in the dining room. The observation revealed the staff placing a fluted cup of butterscotch pudding on the plate with other food. The butterscotch touched the food ready for consumption, the staff continued to serve the meal to the residents. The Food Preparation policy revised September 2017 instructed to prepare all foods in accordance with the Food & Drug Administration (FDA) Food Code. Interview on 1/17/24 at 11:11 AM, the Administrator reported the pudding cup should not be on the dinner plate. 3. On 1/16/24 at 12:39 PM, witnessed the linen cart in the hallway with the front cover up and clean linen laying in the cart. Staff A, Housekeeping, walked up to the linen cart and pushed it down to the next room with the linen cover up exposing the clean linen. Staff A removed clean linen out of the cart, walked down the hallway to the previous room to speak to a coworker, as the clean linens touched Staff A's clothing. Staff A walked back to the linen…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 record review, facility policy review, resident, and staff interviews, the facility failed to maintain the resident's dignity by not providing bathroom assistance in a timely manner to prevent incontinence for 2 out of 3 residents reviewed (Residents #1 and #3). Findings included: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated the Resident #1 required maximal assistance for transfers and toilet hygiene. The MDS included diagnoses of difficult walking and muscle weakness. The Care Plan revised 12/29/23 identified Resident #1 required assistance of 1 person for toilet use and to stand-pivot transfer with a front-wheeled walker. The Interventions instructed to encourage Resident #1 to use the call light for assistance. In an interview on 1/11/23 at 1:01 PM, Resident #1 reported they waited for someone to answer their call light for over 15 minutes at least once a day. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-18 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 facility record review and resident and staff interviews, the facility staff do not consistently answer call lights within a reasonable amount of time. Residents reported having to wait for staff to answer their call light for over 15 minutes for 2 of 3 resident reviewed (Residents #1 and 3#). Findings included: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated the Resident #1 required maximal assistance for transfers and toilet hygiene. The MDS included diagnoses of difficult walking and muscle weakness. The Care Plan revised 12/29/23 identified Resident #1 required assistance of 1 person for toilet use and to stand-pivot transfer with a front-wheeled walker. The Interventions instructed to encourage Resident #1 to use the call light for assistance. In an interview on 1/11/23 at 1:01 PM, Resident #1 reported they waited for someone to answer their call light for over 15…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LANTIS ENTERPRISES — 5 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 →

RatingThis homeChain avg
Overall 1 of 51.6-0.6 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 4 of 52.8+1.2 vs chain
Quality measures 1 of 51.6-0.6 vs chain
The other 4 homes this chain runs (chain average 1.6★, per CMS)

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 / managerTypeRoleSince
KISMET HD LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2018
KISMET HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2018
LANTIS, CAMMYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2018
LANTIS, MARYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
LANTIS, TRAVISIndividualINDIRECT OWNERSHIP INTERESTsince 09/01/2018
RINARD, SANDRAIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODYsince 09/01/2018
SOULEK, WENDYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
MOORE, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2018
LANTIS ENTERPRISES, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2018
JENNINGS, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
MOERMAN, BILLIJEANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2023

CMS files one row per role, so the 23 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.0M
Net patient revenuemost recent cost report
-13.7%
Operating marginrevenue minus expenses
$635K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 3%Other / private 42%

This home reported $635K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$296per resident / day
operating cost
$9,004per month
≈ monthly operating cost
$261per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Iowa
$9,277/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,381/mo
Assisted living

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 165145. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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