Simpson Memorial Home
1000 North Miller Street, West Liberty, IA 52776 · Non profit - Corporation · 55 certified beds · (319) 627-4775 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 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 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 | 34.8% | 17.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.1% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 6.1% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.3% | 4.2% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 3.8% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 33.8% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 31.1% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 19.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 65.0% | 73.3% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.55 | 1.49 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.00 | 2.08 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
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 5% 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 | 49.2%CMS range 35.5–62.2 | 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 | 9.9%CMS range 6.2–14.9 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 0.79 | 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 55 beds and averages 33.4 residents a day — about 61% occupied, or roughly 22 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.08 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 3.65 hrs/resident/day on weekends vs 4.40 on weekdays — 17% thinner on weekends. RN hours go from 0.76 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
- Potential for harm · D2025-12-04 · 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
Based on clinical record review, facility policy review and staff interviews, the facility failed to notify the physician or their designee of significant weight loss for 1 of 1 residents reviewed for nutrition (Resident #17). The facility reported a census of 32. Findings include: The Minimum Data Set (MDS) Assessment completed 9/5/25 revealed Resident #17 with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Diagnoses include chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease, and heart failure. The Care Plan with a target date of 12/12/25 identified Resident #17 with an altered nutritional status related to poor appetite and progressive weight decline. Interventions initiated on 9/12/23 include referral to the medical doctor or Registered Dietitian (RD) as necessary. The Weight Change Progress Notes, completed by the RD revealed, in part: 1.On 1/7/25 at 3:50 PM .a significant weight loss was identified at 30 days .2.On 7/5/25 at 10:19 AM .a significant weight loss was identified at 90 days .3.On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · 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 clinical record review, the Resident Assessment Interview Manual, and staff interviews, the facility failed to accurately complete a Minimum Data Set assessment for 3 of 12resident's reviewed in the sample (Residents #6, #9 and #20). The facility reported a census of 32 residents.Findings include:1. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had diagnoses of Non-Alzheimer's Dementia, bipolar disorder and anxiety disorder. The MDS (under section A1500) documented the resident not currently considered by the state level II PASRR (Preadmission Screening and Record Review, a review to prevent inappropriate placement and ensure people with mental illness or an intellectual disability receive the most suitable care) process to have a serious mental illness and/or intellectual disability or a related condition. The Care Plan initiated 3/15/22 and revised 6/18/25 revealed the resident had diagnoses of bipolar disorder, depression, and anxiety disorder. The resident took…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review, the facility failed to ensure proper infection control practices to reduce the risk of contamination and food-borne illness during meal service. The facility reported a census of 32 residents. Findings include: Per the facility menu, the lunch on 10/16/24 for regular/NAS (no salt added) consisted of Sloppy [NAME] sliders, garden vegetable soup, American fries, seasonal vegetables blend, peas and mushrooms, spiced peach salad, and angel food cake During an observation of the lunch service on 10/16/24 starting at 11:39 AM, Staff B, Cook, wearing gloves reached into a bun bag to get a slider bun. Staff B, wearing the same gloves touched plates, utensils, ketchup bottles, resident menu orders and continued to obtain buns from the bag and plate meals. Staff B observed changing his gloves two times during the meal service. Each time after a glove change Staff B touched plates, condiment bottles, resident menu's and pull buns out of the bun bag and plate meals…
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 · D2024-10-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, interviews, and the facility policy, the facility failed to complete a significant change in status on Minimum Data Set (MDS) assessment after a resident discharged from hospice services for 1 of 2 residents reviewed (Resident #22). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 6 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed the diagnosis of senile degeneration of brain, not elsewhere classified. The MDS revealed the resident received hospice care while a resident. The Care Plan, dated 5/21/24, included a Focus area to address I have altered nutritional status related to malnutrition, worsening dementia, hospice services due to my end stage health status. A Physician Order, dated 5/17/24, revealed an order for [name redacted] Hospice Care. The Discharge Summary from [name redacted] Hospice Services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · 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 clinical record review, interviews, and the facility policy, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a resident receiving hospice services and a resident that did not take an anticoagulant for 2 of 14 residents reviewed for MDS assessments (Resident #15 and Resident #24). The facility reported a census of 32 residents. Findings include: 1. The MDS assessment dated [DATE] revealed Resident #24 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS listed diagnoses included: cerebral infarction (stroke) due to thrombus (blood clot) of unspecified precerebral artery, respiratory failure, and heart failure. The MDS High-Risk Drug Classes section indicated Resident #24 took an Anticoagulant during the seven days. A review of Physician Orders revealed an order, dated 4/22/23, for clopidogrel bisulfate oral tablet 75 mg (milligram)- give 75 mg by mouth one time a day. The Federal Drug and Food…
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 · D2024-10-17 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff and resident interview, and policy review, the facility failed to revise the care plan to include the use of warfarin for 1 of 14 residents (Resident #19), and personalized interventions to prevent falls for 1 of 14 residents (Resident #21 reviewed. The facility reported a census of 32 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment, dated 7/7/24, indicated Resident #19 admitted the facility on 7/1/24. The MDS listed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses included: atrial fibrillation, pneumonia, chronic obstructive pulmonary disease (COPD), and presence of a cardiac pacemaker. A review of the clinical record revealed the following Physician Orders: a. Warfarin ((blood thinner, brand name Coumadin) 5 mg by mouth in the afternoon every Thursday. Start date 9/16/24, with hold date of 10/14/24, and start of 10/17/24. b. Warfarin 2.5 mg by mouth in 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 · E2023-08-17 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interview, and facility policy review the facility failed to ensure adequate series of pneumococcal vaccinations were offered and administered or declined for four of five residents reviewed for immunizations (Resident #1, Resident #9, Resident #10, Resident #12). The facility reported a census of 30 residents. Findings include: Review of the Immunization tab in the electronic health record (EHR) revealed the following pertaining to dates pneumovax dose 1 was given, without documentation of administration of additional pneumococcal vaccination: a. The clinical record for Resident #1 lacked documentation of administration of pneumococcal vaccinations. b. The clinical record for Resident #9 revealed pneumovax dose 1 was administered 6/25/12, with no additional pneumococcal vaccination documented. c. The clinical record for Resident #10 revealed pneumovax dose 1 was administered 5/22/15. d. The clinical record for Resident #12 revealed pneumovax dose 1 was administered 12/30/15. On 8/17/23 at 12:26 PM, additional information for pneumococcal…
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 · D2023-08-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review the facility failed to follow physician's order for hold parameters set on the cardiac medication Digoxin, as pulse rates had not been monitored or recorded for 1 of 6 residents (Resident #11) medication administrations observed. The facility reported a census of 30 residents. Findings include: The current Care Plan indicated Resident #11 on Digoxin therapy related to atrial fibrillation with a goal to be free from discomfort or adverse reactions related to Digoxin use. Interventions include: Record baseline peripheral pulses and report to physician if pulse falls below 60 or rises above 110, or if changes in heart rhythm are detected. Order Summary report, active as of 7/1/23, revealed physician order for Digoxin 125mcg by mouth one time a day related to Heart Failure; Hold if pulse less than 60 beats per minute. On 8/17/23 at 8:21 AM, Observed Staff A, LPN, administer one tablet of Digoxin 0.125mcg to Resident #11 without first performing pulse check to determine whether the pulse rate allows for medication administration in…
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 · C2023-08-17 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility record review, and staff interviews the facility failed to submit accurate payroll data 5 of 90 days during the second quarter of 2023. Findings include: During an interview on 8/15/23 at 12:44 PM, the Business Office Manager (BOM) stated the facility contracted a payroll service, and the service submitted all required Payroll Based Journal (PBJ) information to the Center for Medicare and Medicaid Services (CMS) quarterly. The BOM stated she and the Administrator receive a copy of the PBJ information submitted, and it has always seemed to be correct. The BOM states she is unsure if the report is received before or after the payroll service submits the data to CMS. The BOM received a list of the days triggered on the PBJ report due to a lack of 24 hour nursing data. On 8/16/23, the Administrator provided an undated document titled Registered Nurse Hours Analysis by Day for the quarter 1/1/23 to 3/31/23 received from the payroll service. The report revealed the facility reported the following nursing hours: a. 1/2/23 - 12 hours reported b. 1/3/23 - 17.25 hours…
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 |
|---|---|---|---|
| HILLS BANK AND TRUST COMPANY | Organization | 5% OR GREATER MORTGAGE INTEREST | since 08/29/2013 |
| ANDERSON, ETHAN | Individual | CORPORATE DIRECTOR | since 07/01/2025 |
| GEERTZ, EMILY | Individual | CORPORATE DIRECTOR | since 07/01/2024 |
| LEGGINS, LORI | Individual | CORPORATE DIRECTOR | since 05/01/2019 |
| MAROLF, TED | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| MOELLER, GARY | Individual | CORPORATE DIRECTOR | since 03/01/2021 |
| OWEN, ROBERT | Individual | CORPORATE DIRECTOR | since 08/01/2023 |
| THOMAS, CHAD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2022 |
| GRUNDER, FREDRICK | Individual | CORPORATE OFFICER | since 07/01/2025 |
| MILLER, ROBERT | Individual | CORPORATE OFFICER | since 07/01/2025 |
| SMITH, DAWN | Individual | CORPORATE OFFICER | since 07/01/2025 |
| BARNHART, MIRANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/31/2025 |
| HAZELWOOD, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/17/2022 |
| HUTCHINGS, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/26/2024 |
| MCCASLIN, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/24/2023 |
| ORVIS, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| WHEELER, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/27/2015 |
| WHITE, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/25/2012 |
| BCG HOLDINGS INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| BLUE STONE THERAPY INC | Organization | ADP OF THE SNF | since 01/01/2024 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | since 10/01/2024 |
| CATTAIL INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| ECSI INC | Organization | ADP OF THE SNF | since 10/01/2024 |
| FORGE FINANCIAL & MANAGEMENT CONSULTING, INC | Organization | ADP OF THE SNF | since 10/31/2015 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | since 10/01/2024 |
| OFFICE MACHINE CONSULTANTS | Organization | ADP OF THE SNF | since 02/09/2012 |
| WILLIAM BURKE LTD | Organization | ADP OF THE SNF | since 01/31/2012 |
| WILSON, JULIE | Individual | ADP OF THE SNF | since 01/31/2012 |
CMS files one row per role, so the 31 rows in the source record cover these 29 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.
11 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 2024. 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, FY2024). 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 165418. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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 →
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