Cycle 1
Health 2025-05-01 · Fire 2025-05-01
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
West Bend, IA
West Bend Health and Rehabilitation
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
203 Fourth Street NW, West Bend, IA
(515) 887-4071
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
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
2001-11-14
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
0.76
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.23
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.09
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,572
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
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
5.18
Baseline 5.92% · Performance 6.29% · Measure score 5.18 · Achievement 5.18 · Improvement 0
Total nurse turnover
3.35
Baseline 45.45% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
3.3
Baseline 3.38 hours · Performance 4.02 hours · Measure score 3.3 · Achievement 3.3 · Improvement 2.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 5% · Lower 95% interval 7.18% |
| Discharge to community | 54.52% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 58.82% · Lower 95% interval 43.49% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 1 · Denominator 35 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 14 · Denominator 30 |
| Discharge mobility score | 70% |
50.94%
19.1 pts better
|
Numerator 21 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 10.68% |
42%
31.3 pts worse
|
Numerator 11 · Denominator 103 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 20 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.0%
4.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 97.2% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
95.2%
0.3 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.7%
0.9 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.3% |
4.0%
30.3 pts worse
|
11.4%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 13.9% · Q3 51.4% · Q4 60.0% · 4Q avg 34.3% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.9%
2.2 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.4% · Q3 8.8% · Q4 0.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
20.6%
2.3 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.6% · Q3 20.6% · Q4 16.7% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
19.8%
3.4 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 14.8% · Q3 17.9% · Q4 14.3% · 4Q avg 16.4% · 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 | 24.7% |
18.5%
6.2 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.9% · Q2 27.6% · Q3 24.8% · Q4 4.2% · 4Q avg 24.7% · 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 43.3% · Q2 35.5% · Q3 24.2% · Q4 3.4% · 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 | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
26.0%
4.1 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 30.5% · Q3 28.1% · Q4 28.4% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.3%
2.7 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
84.3%
9.6 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 96.4% · Q3 95.8% · Q4 100.0% · 4Q avg 93.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.9%
0.5 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
73.3%
1.7 pts better
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
9 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-12-29 · Fire 2022-12-29
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-05-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-16
F · Potential for more than minimal harm
2024-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-27
F · Potential for more than minimal harm
2022-12-29
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-29
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 2023-01-20
E · Potential for more than minimal harm
2022-12-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-12-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-12-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
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 2025-05-16
D · Potential for more than minimal harm
2025-05-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
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 2025-05-16
D · Potential for more than minimal harm
2025-05-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
D · Potential for more than minimal harm
2024-12-16
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 2025-01-22
D · Potential for more than minimal harm
2024-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-16
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 2025-01-22
D · Potential for more than minimal harm
2024-03-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-03
E · Potential for more than minimal harm
2024-01-12
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 2024-01-30
D · Potential for more than minimal harm
2023-07-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-31
E · Potential for more than minimal harm
2022-12-29
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 2023-01-27
E · Potential for more than minimal harm
2022-12-29
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 2023-01-27
E · Potential for more than minimal harm
2022-12-29
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 2023-01-27
D · Potential for more than minimal harm
2022-12-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-29
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 2023-01-27
D · Potential for more than minimal harm
2022-12-29
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 2023-01-27
D · Potential for more than minimal harm
2022-12-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-27
Penalties and ownership
What sits behind the stars
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
Kleinstreuber, Peter
Operational/Managerial Control · Individual
Kleinstreuber, Peter
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Algona
Algona, IA
3-star overall rating with 3-star inspections with $6,962 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Algona Manor Care Center
Algona, IA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Emmetsburg Care Center
Emmetsburg, IA
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
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