Solon Nursing Care Center
523 E Fifth Street, Solon, IA 52333 · For profit - Corporation · 96 certified beds · (319) 624-3492 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has 1 actual-harm citation
- its facility-reported quality-measure 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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 3 to 5 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 | 17.6% | 17.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.2% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.5% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.4% | 3.8% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.0% | 16.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 13.9% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.4% | 25.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.4% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.0% | 73.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.3% | 20.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.5% | 13.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.65 | 1.49 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.57 | 2.08 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.1% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.2% 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 48 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% 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 | 47.1%CMS range 35.7–58.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.0–17.0 | 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 | 54.2% | 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 | 54.2% | 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 | 50.0% | 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 | 88.7% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 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 96 beds and averages 80.6 residents a day — about 84% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 3.98 on weekdays — 14% thinner on weekends. RN hours go from 0.67 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% 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
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.
9 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2024-04-01 · 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 observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise one of four residents reviewed in order to prevent a fall with major injury (Resident #2). The facility reported a census of 67 residents. Findings include: The MDS (Minimum Data Set) dated 10/19/2023 revealed Resident #2 had moderately impaired cognitive abilities, required moderate assistance to transfer from one surface to another, use the toilet, and dress. The resident required supervision with eating, had urinary and bowel incontinence, and a fall resulting in a fracture. The MDS reported the resident had diagnoses including stroke, coronary artery disease, hypertension, dementia, and repeated falls. The MDS dated [DATE] revealed Resident #2 had moderate cognitive impairment, required extensive assistance of one staff for transfers and ambulation, unsteady balance, and had two falls without injury. The Care Plan identified the resident had a risk for falls due to impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and manufacturer's user recommendations, the facility failed to ensure wander guards (a monitoring bracelet with activated alarm when exiting) were monitored for placement and functioning for resident safety for 4 of 4 resident's reviewed (Resident #58, #28, #59, and #14) for wandering and risk for elopement. The facility also failed to assess 1 out of 4 residents (Resident #14) with the removal of a wander guard. The facility reported a census of 62. Findings include: 1. The Minimum Data Set Assessment (MDS) dated [DATE] for Resident #58 identified a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severely impaired cognition. The MDS identified Resident #58 had signs and symptoms of delirium with inattention and disorganized thinking with behavior present and fluctuates. The MDS identified the resident was independent with transfers and ambulation with no assistive devices. The MDS documented diagnoses that included…
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 · D2023-05-25 · 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 observations, clinical record review, resident and staff interviews, the facility failed to maintain the residents' dignity for two of three residents reviewed. (Residents #11 and #17) The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview of Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. It also identified the resident to be totally dependent on staff for locomotion on and off the unit and for bathing. During an observation and interview on 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, she pointed to her bed (which did not have side rails) and reported she is not happy that side rails were removed from her bed as she used to use them to help her out of bed. She stated now she has to hold the window frame to help her get out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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, resident and staff interviews, the facility failed to ensure the resident's call light had been placed within the resident's reach for one of one residents reviewed (Resident #11). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required minimal assist of one person for bed mobility, transfers, dressing, toileting and hygiene. Observations revealed the resident lying in bed without her call light in reach on the following dates and times: On 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, the call light was on top of the other nightstand out of her reach. She stated she could scoot up to the call light, but…
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 · D2023-05-25 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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, staff interview, and the MDS 3.0 Resident Assessment Instrument Manual (RAI), the facility failed to complete and transmit a discharge assessment for 1 of 1 resident (Resident #42) reviewed. The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. The Resident Census for Resident #42 documented the resident admitted to the facility on [DATE] and discharged from the facility on 12/29/22. Review of the clinical record for the resident revealed the discharge MDS assessment was not completed and not transmitted. On 5/24/23 at 9:40 AM the Director of Nursing (DON), verified and acknowledged the discharge assessment was not completed. The DON reported the facility follows the MDS 3.0 RAI guidelines for completing and submitting MDS.
- Potential for harm · D2023-05-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interviews and facility policy review the facility failed to ensure the accuracy of the Pre admission Screening and Resident Review (PASRR) for 1 out of 1 resident reviewed (Resident # 30). The facility reported a census of 62 resident. Findings include: The Minimum Data Set (MDS) Assessment for Resident # 30 dated 3/16/23, listed diagnoses of non-Alzheimer's dementia, and bipolar disorder. The MDS included a Brief Interview for Mental Status score of 13 out of 15 possible points indicating intact cognition. The MDS revealed Resident #30 rejected care 4-6 days in the 7 day look back period of the MDS. The Care Plan for Resident #30 dated 10/31/2022, listed he took psychotropic's (antidepressant, anti-psychotic) related to major depressive disorder and bipolar disorder. The Continuity of Care Document from the previous healthcare facility dated 10/20/22, included quetiapine 12.5 milligrams (mg) (anti-psychotic medication). The document revealed the Problem list included a diagnoses of bipolar disorder. The PASRR dated 03/16/21, included…
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 · D2023-05-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, staff interviews, and facility record review the facility failed to follow proper infection prevention techniques with indwelling catheters for two of two residents reviewed (Residents #17 and #23). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #17 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 7 out of 15 possible points. The MDS documented the resident had diagnoses to include renal insufficiency, neurogenic bladder and non-Alzheimer's dementia. It also identified the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. On 8/16/22, the Care Plan identified Resident #17 with the problem of requiring a suprapubic urinary catheter related to neurogenic bladder. The Care Plan directed staff to not allow tubing or any part of the drainage system to touch the floor, store collection bag inside…
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 · D2023-05-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observations, and staff interviews, the facility failed to provide oxygen according to the physician orders for 1 of 1 resident reviewed for respiratory services (Residents #4). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated 4/13/23 documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severely impaired cognition. The MDS identified Resident #4 required oxygen while a resident at the facility. The MDS documented diagnoses to include heart failure, hypertension, pulmonary fibrosis and dependence on supplemental oxygen (O2). The Care Plan revised on 4/19/23 documented Resident #4 to have oxygen as needed. The Care Plan directed staff to follow the doctor orders for liter flow and to provide assistance with the oxygen concentrator and portable oxygen tank. The Physician Order dated 3/2/2023 directed staff to administer oxygen at 2 liters per nasal cannula (NC) as needed for comfort. Review of resident vital sign records for oxygen…
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 · D2023-05-25 · tag F0725 — failed to have enough nursing staff — isolatedProvide 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 observations, clinical record review, resident and staff interviews, the facility failed to answer resident call lights in a timely manner for three of three residents reviewed (Residents #11, #25 and #55). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 cognitively intact with a BIMS (brief interview for mental status) of 12 out of 15 possible points. The MDS documented diagnoses to inclue heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required limited assitance of one person for transfers, dressing, toileting and hygiene and did not walk. The MDS documented the resident was occasionally incontinent of urine. The Care Plan dated 11/28/21 identified the resident with the problem of being at risk for falls due to impaired cognition, impaired mobility, and right rotator cuff injury and directed staff on 9/10/22, to place a sign in the room to remind…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CATTAIL BCG LLC | Organization | DIRECT OWNERSHIP INTEREST | since 10/01/2024 |
| CATTAIL INC | Organization | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST | since 10/01/2024 |
| ECSI INC | Organization | DIRECT OWNERSHIP INTEREST | since 10/01/2024 |
| FRAZIER, KAYLA | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | since 06/01/2025 |
| ATKINSON, LUCILLE | Individual | CORPORATE DIRECTOR | since 01/01/1999 |
| BROGHAMMER, TIMOTHY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2004 |
| HENDRICKS, MARITA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2007 |
| LEEFERS, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| NICOL, SCOTT | Individual | CORPORATE DIRECTOR | since 04/01/2013 |
| PROFFITT, JOSEPH | Individual | CORPORATE DIRECTOR | since 01/01/2005 |
| SCHMIDT, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2016 |
| CLARKE, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/06/2015 |
| EBERLY, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2013 |
| KLIMES, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/05/2010 |
| MILLER, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/21/2016 |
| REDLINGER, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/07/1995 |
| REED, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/29/2009 |
| STEMLER, KATHRYN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/22/2025 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CREATIVE PLANNING HOLD CO LLC | Organization | ADP OF THE SNF | since 08/01/2024 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | since 10/01/2024 |
| MILLENNIUM REHAB & CONSULTING INC | Organization | ADP OF THE SNF | since 06/30/2023 |
| WILLIAM BURKE LTD | Organization | ADP OF THE SNF | since 08/12/2015 |
| SCHIEL, BRIAN | Individual | ADP OF THE SNF | since 05/02/2023 |
CMS files one row per role, so the 31 rows in the source record cover these 24 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.
8 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.
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 165550. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-03, 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.