Cycle 1
Health 2025-03-11 · Fire 2025-03-11
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Hawarden, IA
Hillcrest Health Care Center
1-star overall rating with 1-star inspections with $25,450 in total fines with 11 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
2121 Avenue L, Hawarden, IA
(712) 551-1074
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,491
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.62
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.69
Baseline 73.08% · Performance 62.50% · Measure score 1.69 · Achievement 0 · Improvement 1.69
Adjusted total nurse staffing
1.63
Baseline 3.3 hours · Performance 3.54 hours · Measure score 1.63 · Achievement 1.63 · Improvement 0.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.1% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 16.28% · Lower 95% interval 7.42% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 21 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 6 · Denominator 20 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 8 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.46% |
8.2%
0.7 pts worse
|
Numerator 5 · Denominator 67 |
| Staff flu vaccination coverage | 39.08% |
42%
2.9 pts worse
|
Numerator 34 · Denominator 87 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 8 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 0.6 |
1.5
0.9 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
94.0%
7.7 pts worse
|
93.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 80.9% · Q3 82.9% · Q4 92.5% · 4Q avg 86.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.2%
0.7 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.3% |
3.7%
4.6 pts worse
|
3.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.5% · Q3 4.9% · Q4 7.5% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.9% |
4.0%
18.9 pts worse
|
11.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 28.6% · Q3 21.6% · Q4 18.4% · 4Q avg 22.9% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
4.9%
1.9 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 12.2% · Q3 5.4% · Q4 2.8% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
20.6%
0.6 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 19.0% · Q3 15.8% · Q4 18.9% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
19.8%
1.9 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 15.2% · Q3 17.2% · Q4 29.6% · 4Q avg 17.9% · 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 | 21.0% |
18.5%
2.5 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 18.2% · Q3 26.6% · Q4 11.1% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
18.3%
8.5 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 35.9% · Q3 23.5% · Q4 17.6% · 4Q avg 26.8% · 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 | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
26.0%
5.6 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 33.6% · Q3 33.0% · Q4 31.4% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.3%
0.3 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.7% · Q3 5.6% · Q4 3.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 48.2% |
84.3%
36.1 pts worse
|
81.7%
33.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.8% · Q2 59.1% · 4Q avg 48.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.5% |
73.3%
29.8 pts worse
|
79.7%
36.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-31 · Fire 2024-01-31
35 health deficiencies
Top issue: Nutrition and Dietary (11 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-11
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-03-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-03-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-03-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-03-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-13
F · Potential for more than minimal harm
2025-03-11
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 2025-03-05
F · Potential for more than minimal harm
2025-03-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-12
F · Potential for more than minimal harm
2024-01-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-29
F · Potential for more than minimal harm
2024-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-02
F · Potential for more than minimal harm
2024-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-31
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 2024-01-30
F · Potential for more than minimal harm
2022-11-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-11-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-11-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-11-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-11-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-11-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-03-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-11
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 2025-03-28
E · Potential for more than minimal harm
2025-03-11
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
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 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
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 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
J · Immediate jeopardy
2024-07-28
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 2024-08-07
E · Potential for more than minimal harm
2024-07-28
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 2024-08-13
E · Potential for more than minimal harm
2024-07-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-28
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-28
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 2024-08-13
D · Potential for more than minimal harm
2024-07-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-08-13
K · Immediate jeopardy
2024-01-31
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 2024-02-08
F · Potential for more than minimal harm
2024-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
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 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
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 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-31
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
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 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-08-17
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 2023-06-14
E · Potential for more than minimal harm
2022-11-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-10
E · Potential for more than minimal harm
2022-11-10
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 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-10
Penalties and ownership
What sits behind the stars
$8,649
2024-07-28
Fine
Fine · fine $8,649
Fine
$16,801
2024-01-31
Fine
Fine · fine $16,801
Fine
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Koenig, Debra
Corporate Officer · Individual
Wilkins, Melodee
Operational/Managerial Control · Individual
Wilkins, Melodee
W-2 Managing Employee · Individual
Nearby options
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Alcester Care And Rehab Center, Inc
Alcester, SD
5-star overall rating with 5-star inspections with $9,116 in total fines with 1 fire-safety deficiencies in the latest cycle
#2
Akron Care Center, INC
Akron, IA
3-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Bethesda Of Beresford
Beresford, SD
3-star overall rating with 2-star inspections with $16,088 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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