Strawberry Point Lutheran Home
313 Elkader Street, Strawberry Point, IA 52076 · Non profit - Corporation · 16 certified beds · (563) 933-6037 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 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 | 2.2% | 17.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 9.8% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 2.4% | 2.0% | better |
| 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 | 5.1% | 3.8% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.3% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.4% | 20.8% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 0.0% | 4.2% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 33.6% | 25.6% | 21.2% | worse |
* 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.
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.
Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | not 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 SNF | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 16 beds and averages 15.7 residents a day — about 98% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. 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 5.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.33 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.22 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 4.28 hrs/resident/day on weekends vs 5.47 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.52 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
10 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2026-06-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, guardian interview, and staff interview the facility failed to ensure a resident's legally appointed guardian received timely notification regarding medication changes and equipment management issues regarding hearing aids for 1 of 3 residents reviewed (Resident #17). The facility reported a census of 15 residents. Findings include: The Minimum Data Set, dated [DATE] documented that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The assessment noted Resident #17 had moderate difficulty with hearing, and used a hearing aid or other hearing appliance. Active diagnoses per the MDS included heart failure (weak heart muscle), non-Alzheimer's dementia, and chronic pain.A Progress Note titled Communication dated 6/15/26 at 11:02 AM revealed Resident #17's hearing aids were dropped off at the post office for repair and lacked notification to his legal representative. A Progress Note titled Order Note dated 6/15/26 at 12:15…
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.
- Potential for harm · D2026-06-17 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of electronic health records (EHR), the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interviews, the facility failed to complete and submit Minimum Data Set (MDS) assessments as required for 2 of 2 sampled residents (Resident #15 and Resident #3). The facility reported a census of 15 residents.Findings Include:1. Review of the facility Census List on 6/16/26 for Resident #15 revealed he was admitted to the facility on [DATE] and passed away on 3/17/26. Resident #15's Minimum Data Set (MDS) log in the Electronic Health Record (EHR) reviewed on 6/16/26 lacked a Death in Facility Tracking MDS. The review revealed the facility staff had not started or completed this tracking record. On 6/17/26 at 11:36 AM, an interview with the MDS Coordinator revealed she missed the discharge tracking record for Resident #15. She noted she should've completed a discharge MDS assessment for 3/17/26 and planned to create it immediately. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment to reflect Preadmission Screening and Resident Review (PASRR) status for 1 of 3 residents reviewed (Resident #16). The facility reported a census of 15 residents. Findings include: The MDS dated [DATE] for Resident #16 documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #16's current PASRR document dated October 2023 documented a notice of a PASRR Level II Outcome. The PASRR Determination was approved with specialized services.Review of Resident #16's current Care Plan on 6/16/26 documented PASRR goals and interventions.On 6/17/26 at 11:36 AM, the MDS Coordinator revealed during an interview that Resident #16 maintained a PASRR Level II status. The MDS Coordinator stated that she coded Resident #16's MDS inaccurately, as the assessment should show his Level II status. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents at risk for elopement from the facility remained in the facility (Resident #9). The facility reported a census of 15 residents. Findings include: The Minimum Data Set (MDS) for Resident #9 dated 2/10/25 documented a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed she is independent without staff assistance for dressing, bed mobility, transferring, and walking. The MDS also documented diagnoses of Wernicke's encephalopathy, cognitive communication deficit, and hypertension. Record review of the facilities undated, Final Report for Resident #9 elopement on 04/08/2025 documented the following timeline of events that occurred: a. At 2:15 PM Resident #9 was last seen by staff visiting another resident on the unit b. At 2:38 PM Staff B, [NAME] was driving by the facility and observed Resident #9 outside next to the facilities local church, Resident #9 walking down the sidewalk. Staff B immediately turned her vehicle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews,review of clinical records, and facility policy review, the facility failed to provide assessment and intervention in a timely manner when one of three residents reviewed had a change in condition. (Resident #1). The facility reported a census of 13 residents. Findings include: The MDS (Minimum Data Set), an assessment tool dated 12/24/2024 revealed Resident #1 had diagnoses including renal insufficiency, post traumatic stress disorder, cancer, medically complex condition, anemia, and heart failure. The resident had no cognitive impairment and required partial assistance to transfer and used a wheel chair for locomotion. The resident's Care Plan initiated 10/13/2024 indicated the resident had impaired physical mobility with an unavoidable end of life decline, and he required total staff assistance to transfer using a mechanical lift initiated 1/8/2025. It revealed the resident received St Croix Hospice Services due to terminal prognosis. It failed to address the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, Long Term Care Facility Resident Assessment Instrument (RAI) review, and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of determining a significant change for 2 of 2 residents reviewed for significant change (Residents #4 and #15). The facility reported a census of 15 residents. Findings include: The Physician Orders for Resident #4 included an order dated 12/4/23 to admit to hospice. Resident #4's Progress Note written on 12/4/23 at 12:06 PM documented the resident was being admitted to hospice. The clinical record lacked documentation of a decline or condition change prior to this date. The Significant Change Minimum Data Set (MDS) for Resident #4 documented an Assessment Reference date (ARD) of 12/11/23. The MDS was signed off as complete on 12/25/23 (21 days after the noted need for hospice services). Resident #15's Progress Note written on 2/23/24 at 8:49 AM documented an order from the Primary Care Provider (PCP) for a hospice consult and may admit. The Significant Change MDS for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to document the implementation of non-pharmacological interventions (any type of health care intervention which is not primarily based on medication. Some examples include toileting, exercise, diversion activity, snacks, naps, music, etcetera) prior to medication administration for 1 of 2 residents sampled for as needed anti-anxiety medication (psychoactive medications are substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions) (Resident #10). The facility identified a census of 15 residents. Findings include: Resident #10 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS listed diagnoses of unspecified dementia and depression, and noted the use of antidepressant medication. A Order Summary Report signed by the Provider on 3/29/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, document review, and staff interview, the facility failed to utilize a clean barrier under a blood glucose meter and failed to sanitize the blood glucose meter according to the facility policy/manufacturer's directions for 2 of 2 residents observed (Resident #6 and #9). The facility reported a census of 15 residents. Findings include: 1. Resident #6 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented Resident #6 utilized insulin medication for a diagnosis of diabetes mellitus. A Physician Order Summary Report signed by the Provider on 6/7/24 listed an order to check the blood sugar twice a day at alternating times, two times a day on odd days. Resident #6 Care Plan revised 4/26/24 documented a Focus Problem of a diagnosis of diabetes mellitus type two and received insulin and oral hypoglycemic medications. The Care Plan intervention directed the staff to provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2025-04-24 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 1 of 2 residents reviewed for falls with major injury (Resident #7). The facility reported a census of 15 residents. Findings include: Resident #7 MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating a moderate cognitive loss. The MDS documented Resident #7 with a bilateral lower body (hips, knees, ankle, foot) functional impairment and required the use of a walker and wheelchair for mobility. Resident #7 required supervision to touch assistance for sit to stand transfers from bed/chair and partial/moderate assistance to walk 10 feet or less. The MDS listed active diagnoses of type two diabetes mellitus with neuropathy (nerve damage), anemia, arthritis, thyroid disorder, and Non-Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-06-13 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, document review, and staff interview, the facility failed to provide the Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or their legal representative within 48 hours of the ending of Medicare Skilled Part A therapy services for 1 of 2 residents sampled (Resident #69). The facility reported a census of 15 residents. Findings include: The Electronic Census Record showed Resident #69 admitted to Medicare Part A Skilled services on 2/23/24 and discharged from services on 3/14/24 remaining in the nursing facility. A 3/12/2024, 12:30 Communication with the Therapy Department Late Entry Progress Note documented Physical Therapy (PT) reported the resident was not progressing and would discharge from PT, Occupational Therapy (OT), and Speech Therapy (ST) on Thursday 3/14/24. The Power of Attorney was notified via phone and a discussion took place in the resident's room at 2 PM when the legal representative was present. Resident #69 wanted to return to independent living. Therapy recommended 24/7 caregiver, assistance of one staff with a…
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 |
|---|---|---|---|
| GOULD, DAVID | Individual | CORPORATE DIRECTOR | since 03/27/2025 |
| GOULD, TERRI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/01/2021 |
| HAPPEL, DENNIS | Individual | CORPORATE DIRECTOR | since 03/26/2015 |
| MORAREND, KRISTINE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/18/2023 |
| OLSON, GAIL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/27/2025 |
| OTDOERFER, DAVID | Individual | CORPORATE DIRECTOR | since 06/26/2025 |
| SCHLEE, CHRIS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 06/23/2022 |
| SCHNEIDER, ARLETTE | Individual | CORPORATE DIRECTOR | since 05/01/2021 |
| SWALES, ROGER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/01/2021 |
| GREEN, WILLIAM | Individual | CORPORATE OFFICER | since 03/27/2025 |
| ALTHOFF, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/02/2014 |
| CONDUFF, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/22/2022 |
| KRUSE, JOLENE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 08/05/2022 |
| MAY, NIKOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/29/2014 |
| PANTHIER, LENNARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/12/2024 |
| STUDEBACKER, ADARA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/12/2024 |
| BCG HOLDINGS INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CASCADE LUMBER COMPANY | Organization | ADP OF THE SNF | since 04/01/2023 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CATTAIL INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CLAYTON PHARMACY CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | since 05/01/2018 |
| ECSI INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | since 10/01/2024 |
| MILLENNIUM REHAB & CONSULTING INC | Organization | ADP OF THE SNF | since 01/01/2020 |
| RYUN, GIVENS & COMPANY, P.C. | Organization | ADP OF THE SNF | since 10/01/2024 |
| WARNKE, MEGAN | Individual | ADP OF THE SNF | since 07/18/2022 |
CMS files one row per role, so the 34 rows in the source record cover these 27 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.
10 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-17, 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.