Cycle 1
Health 2025-07-28 · Fire 2025-07-28
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Emmetsburg, IA
Emmetsburg Care Center
2-star overall rating with 2-star inspections with $25,695 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2405 21st Street, Emmetsburg, IA
(712) 852-4266
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1997-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
0.84
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.97
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,499
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.63
Baseline 6.79% · Performance 7.65% · Measure score 0.63 · Achievement 0.63 · Improvement 0
Total nurse turnover
0
Baseline 60.00% · Performance 65.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.35
Baseline 3.57 hours · Performance 4.31 hours · Measure score 4.35 · Achievement 4.35 · Improvement 2.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 5.66% · Lower 95% interval 6.68% |
| Discharge to community | 55.23% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 54.29% · Lower 95% interval 41.36% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 38 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | 30.3% |
53.69%
23.4 pts worse
|
Numerator 10 · Denominator 33 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 12 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 39.18% |
42%
2.8 pts worse
|
Numerator 38 · Denominator 97 |
| Discharge function score | 42.42% |
56.45%
14 pts worse
|
Numerator 14 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
94.0%
2.6 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 94.6% · Q4 92.5% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.7%
1.7 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.7% · Q4 2.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.9%
0.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.7% · Q3 0.0% · Q4 7.9% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
20.6%
16.7 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.7% · Q3 5.9% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
19.8%
2.7 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.7% · Q3 13.8% · Q4 17.1% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.1% |
18.5%
4.4 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 24.9% · Q4 3.5% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
18.3%
9.8 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 17.9% · Q3 5.9% · Q4 5.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.5%
1.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
26.0%
0.2 pts better
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 30.5% · Q3 19.0% · Q4 29.5% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.3%
3.4 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.9% |
84.3%
13.4 pts worse
|
81.7%
10.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 66.7% · Q3 62.5% · Q4 73.9% · 4Q avg 70.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
13.1%
4 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 18.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.2% |
1.9%
3.3 pts worse
|
1.6%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
73.3%
8.5 pts better
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.9% |
21.3%
9.4 pts better
|
23.9%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 13.6% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-28
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-07-22
F · Potential for more than minimal harm
2024-09-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-27
F · Potential for more than minimal harm
2023-06-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-06-26
F · Potential for more than minimal harm
2023-06-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-20
D · Potential for more than minimal harm
2026-01-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-20
J · Immediate jeopardy
2025-07-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-08-15
G · Actual harm
2025-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-09-12
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-04
Penalties and ownership
What sits behind the stars
$25,695
2025-07-28
Fine
Fine · fine $25,695
Fine
Ownership
Iowa Portfolio Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Beasley, Karla
Operational/Managerial Control · Individual
Behounek, Linsey
Operational/Managerial Control · Individual
Borcherding, Jenny
Operational/Managerial Control · Individual
Burken, Sheri
Operational/Managerial Control · Individual
Cascade Capital Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Indirect Ownership Interest · Organization
Friedenberg, Laura
Operational/Managerial Control · Individual
Hedberg, Jennifer
Operational/Managerial Control · Individual
Hennager, Christina
Operational/Managerial Control · Individual
Heying, Larina
Operational/Managerial Control · Individual
Houston, Mindy
Operational/Managerial Control · Individual
Jaeger, Krystle
Operational/Managerial Control · Individual
Kamstra, Lee
Operational/Managerial Control · Individual
Knutson, Michele
Operational/Managerial Control · Individual
Larson, Melissa
Operational/Managerial Control · Individual
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Mcclure, Dorothy
Operational/Managerial Control · Individual
Oakway Operations LLC
5% Or Greater Indirect Ownership Interest · Organization
Otterbeck, Patricia
Operational/Managerial Control · Individual
Rajchenbach, Chaim
Operational/Managerial Control · Individual
Runksmeier, Dawn
Operational/Managerial Control · Individual
Scott, Kathleen
Operational/Managerial Control · Individual
Seu, Joshua
Operational/Managerial Control · Individual
Shabat, Menachem
Operational/Managerial Control · Individual
Shabat, Menachem
Corporate Officer · Individual
Shear, Kiley
Operational/Managerial Control · Individual
Staudt, Sandra
Operational/Managerial Control · Individual
Thayer, Kay
Operational/Managerial Control · Individual
Van Veghel, Elizabeth
Operational/Managerial Control · Individual
Wierschem, Bobbie
Operational/Managerial Control · Individual
Wood, Rosemary
Operational/Managerial Control · Individual
Wright, Amy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lakeside Lutheran Home
Emmetsburg, IA
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#2
Palo Alto County Hospital
Emmetsburg, IA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Ruthven Community Care Center
Ruthven, IA
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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