Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Rehab And Care Center during CMS and state inspections, most recent first.
Food was not stored, prepared, served, and distributed according to professional standards. A cook and another dietary staff member used gloves inconsistently, changed gloves without hand hygiene, and handled multiple foods and utensils in ways that created cross-contamination concerns during meal prep and service. Pureed and hot foods were served at temperatures below the facility’s stated standards, and the resident snack/supplement refrigerator had an incomplete temperature log with missing entries; the DON confirmed the log was not completed as required.
Failure to maintain hand hygiene during meal service. A dietary aide wore the same gloves throughout dining room service, handled dirty dishes, returned to the dining room without removing gloves or cleaning hands, touched residents' cups, and retrieved condiments while still gloved. A CNA touched a resident's hair, then handled coffee cups and served coffee without hand hygiene, and the DM handled residents' cups, touched residents and wheelchair handles, picked up trash, kept condiments in scrub pockets, and drank from a personal coffee cup.
Dignity and Privacy During Resident Care: A CNA called out a resident's name, whistled to get her attention, and loudly asked in the dining room whether she needed to use the bathroom. In a separate event, an RN administered PEG tube medications to a resident without closing the room door, despite the facility policy requiring privacy during medical treatment.
Failure to address dementia care in the care plan for a resident with a documented dementia diagnosis. Record review showed the resident had non-Alzheimer’s dementia and alcohol dependence with alcohol-induced persisting dementia, but the care plan lacked dementia-related information. The DON stated dementia should be addressed on the care plan if the resident has a diagnosis.
Inaccurate documentation of resident care tasks occurred when the ADON charted follow-up reports for CNAs without confirming the care was actually completed. Records showed the ADON documented toilet transfer, toileting hygiene, and upper body dressing tasks for multiple residents with cognitive impairment, including residents with dementia, severe cognitive impairment, arthritis, hip fracture, legal blindness, urinary incontinence, and intellectual disabilities. Interviews confirmed staff were expected to chart their own care, but the ADON often charted for them and did not know for certain the tasks had been done.
The facility failed to submit accurate staffing reports to CMS, with the PBJ Staffing Data Report indicating excessively low weekend staffing. Despite this, daily assignment sheets showed similar staffing levels for nurses and CNAs on weekdays and weekends. The facility reported a census of 38 residents.
The facility failed to follow the menu and use correct scoop sizes during meal service, impacting the nutritional needs of residents on regular diets. Staff used incorrect scoop sizes for beef stroganoff, noodles, and Brussels sprouts, contrary to the diet spreadsheet specifications. The Certified Dietary Manager and Administrator confirmed the expectation to use correct scoops as per the guidelines.
The facility failed to store food according to professional standards by not labeling and dating open food items. During a kitchen tour, open and undated items were found in the dry storage freezer, dry storage room, and refrigerator. A Certified Dietary Manager acknowledged the issue and disposed of the items. The facility lacked a policy for labeling and dating open food, despite expectations for compliance.
The facility failed to consistently provide snacks to residents who wanted to eat at non-traditional times. Several residents reported not receiving snacks as expected, with staff confirming that snack carts were not routinely delivered to rooms. The Administrator acknowledged the issue, noting it had been discussed in the resident council but not yet resolved.
The facility did not notify the LTC Ombudsman of hospital transfers for two residents, both with no cognitive impairment, as required by regulations. The administrator cited a misunderstanding of state-specific requirements, as most staff were familiar with South Dakota regulations, not Iowa's.
The facility did not provide bed hold notifications for two residents who were hospitalized, despite regulations requiring such notifications. Both residents had no cognitive impairment, and the facility lacked a policy for bed holds. The administrator acknowledged that bed holds were not completed for residents on Medicaid.
A resident was left exposed during incontinence care when CNAs failed to cover them before opening the door to retrieve a nurse. The door drifted open multiple times, leaving the resident exposed as staff entered the room. Staff interviews confirmed the resident should have been covered, violating the facility's policy on resident dignity.
The facility failed to follow infection prevention practices, including Enhanced Barrier Precautions and hand hygiene. A resident with a G-tube did not receive care with the required PPE, and another resident's incontinence care was handled without proper hand hygiene, violating facility policies.
Food Handling, Temperature Monitoring, and Cross-Contamination Deficiencies
Penalty
Summary
Food was not stored, prepared, served, and distributed in accordance with professional standards. During meal modification, a cook completed hand hygiene and donned gloves before starting, but then showed inconsistency when removing gloves while handling parts of the food processor and placing them in the dish machine. The cook did not perform hand hygiene with glove changes. Modified portions of turkey, sweet potatoes, green bean casserole, and pumpkin pie were covered and left on the counter before later being placed in the microwave. During meal service, the cook used a single pair of gloves throughout the entire service and used tongs from the turkey to obtain pre-made sandwiches, then used a second set of tongs for multiple different items including deli meat sandwiches, peanut butter sandwiches, grilled cheese, hot dogs, and hamburgers. The cook also used a gloved hand to obtain cheese for a hamburger and then processed the hamburger to a ground consistency. The pureed meal was removed from the counter, warmed in the microwave, and served with temperatures of 128 degrees Fahrenheit for turkey, 125 degrees Fahrenheit for green bean casserole, and 135 degrees Fahrenheit for sweet potatoes. The Certified Dietary Manager stated the pureed food should be served above 135 degrees Fahrenheit and, when clarified that it had sat on the counter before microwaving, stated it should have been rewarmed to 160 degrees Fahrenheit. Staff B prepared peanut butter sandwiches and deli meat sandwiches while touching bread, knives, peanut butter containers, packaging, meat, cheese, the preparation surface, and the plate, and changed gloves without washing hands. The resident snack/supplement refrigerator in the nurses medication room had an incomplete temperature log. The May log required temperatures to be checked twice daily at 6:00 AM and 10:00 PM, but 11 of 35 opportunities were missing. The DON confirmed the log was not completed as required and stated she had not been monitoring it that month. The facility policies reviewed stated dietary staff should wash hands before and after wearing or changing gloves, use tongs/serving utensils to handle food, monitor food temperatures during meal service to maintain hot foods at or above 135 degrees Fahrenheit, and monitor refrigerated storage temperatures daily.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program and failed to provide specific policies related to hand hygiene for all employees during meal service. During observation on 5/19/26 at 12:24 PM, a Dietary Aide wore the same pair of gloves throughout dining room service, picked up food plates and cups from resident tables, placed the dishware into the dirty dish room, returned to the dining room without removing the soiled gloves or performing hand hygiene, touched residents' cups before asking if they were finished, and retrieved condiments while still wearing the same gloves. During observation on 5/20/26 at 7:43 AM, a CNA played with a resident's hair, did not perform hand hygiene, then obtained coffee cups, filled them from the coffee dispenser, and delivered coffee to two residents before exiting the dining room without hand hygiene. The Dietary Manager also failed to perform hand hygiene or wear gloves in the dining room during meal service while passing out breakfast plates and refilling cups from the coffee dispenser, milk jugs, and juice jugs; she handled residents' private drinking cups, touched residents and wheelchair handles, picked up trash from the floor, served condiments directly from her scrub pants pockets, and drank from her personal coffee cup. The facility's submitted Handwashing Guidelines for Dietary Employees addressed handwashing for dietary staff, including cleaning hands after touching garbage, soiled utensils or equipment, dirty dishes, and bare human body parts other than clean hands. The Administrator stated she expected all staff to perform appropriate hand hygiene during meal service, and the Infection Preventionist stated the CNA should have performed hand hygiene after touching the resident's hair or person and after collecting dirty dishes, and acknowledged staff should not keep condiments in their pants or scrubs.
Dignity and Privacy During Resident Care
Penalty
Summary
The facility failed to provide dignity during resident communication in the dining room. During an observation on 5/18/2026 at 1:11 p.m., a CNA was sitting at a table with a resident while she was eating and called out Resident #25's name from two tables away. When the resident did not respond, the CNA repeated the name and then whistled at the resident to get her attention. The CNA then asked loudly in the dining room whether the resident was going to need to go to the bathroom and told her that if she did, she should go back to her room and turn on the light for staff assistance. Resident #25 looked at the CNA but did not respond or move her wheelchair. During interview on 5/21/2026 at 9:02 a.m., the Administrator stated staff should not have been saying that in the dining room or whistling at residents to get their attention. The facility also failed to provide privacy during resident treatment. On 5/20/26 at 1:12 p.m., a RN positioned a medication cart in the doorway of Resident #29's room, prepared supplies and medications, donned PPE in accordance with EBP, and administered medications via the resident's PEG tube, but did not close the resident's door during the procedure. The Resident Right Policy revised April 2019 stated residents have the right to personal privacy during medical treatment and that staff must ensure privacy during care. During interview on 5/20/26 at 1:55 p.m., the RN stated she failed to close the door while administering medication and acknowledged she typically closes it but did not do so in this instance. The DON later stated she expects staff to shut residents' doors or at minimum pull the privacy curtain during care and that the staff member should have closed the door.
Failure to Address Dementia Care in Care Plan
Penalty
Summary
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Clinical record review and staff interview revealed the facility failed to address dementia care for 1 of 4 residents reviewed, Resident #5. The resident’s MDS assessment documented diagnoses of non-Alzheimer’s dementia, and the MDS included a BIMS score of 15 indicating no cognitive impairment. Review of the resident’s active diagnosis list showed alcohol dependence with alcohol-induced persisting dementia. However, review of the care plan with a revision date of 5/8/26 lacked information regarding dementia care. During interview, the DON stated dementia should be addressed on the care plan if the resident has a diagnosis.
Inaccurate Documentation of Resident Care Tasks
Penalty
Summary
The facility failed to maintain accurate and verified documentation of task completion when staff signed off on assigned duties without actually performing the work or confirming completion with the staff assigned to provide care. Review of the facility’s documentation showed that Staff G, the ADON, completed follow-up question reports for toilet transfer, toileting hygiene, and upper body dressing on multiple occasions for residents when she was not the employee assigned to those tasks. The facility census was 42 residents. Resident #2 had diagnoses of non-Alzheimer’s dementia, arthritis, and heart failure, with a BIMS score of 10 indicating moderate cognitive impairment. For this resident, Staff G documented toilet transfer and toileting hygiene tasks not assigned to her on 15 and 16 separate occasions, respectively. Resident #6 had diagnoses of arthritis, hip fracture, and legal blindness, with a BIMS score of 6 indicating severe cognitive impairment; Staff G documented toilet transfer tasks not assigned to her on 8 occasions and upper body dressing on 24 occasions. Resident #39 had diagnoses of non-Alzheimer’s dementia, urinary incontinence, and intellectual disabilities, with a BIMS score of 1 indicating severe cognitive impairment; Staff G documented toilet transfer tasks not assigned to her on 8 occasions and toileting hygiene on 11 occasions. During interviews, Staff G stated CNAs were responsible for their own charting but also said she charted quite often for CNAs and did not know for a fact that each task she documented had been completed. A CNA stated the ADON had documented for staff when they did not have time to chart, and the Administrator stated Staff G should have talked to the staff providing the care before documenting.
Inaccurate Staffing Reports Submitted to CMS
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of January 1 to March 31. The report indicated excessively low weekend staffing, despite the facility's daily assignment sheets showing similar staffing levels for nurses and Certified Nursing Assistants (CNAs) on both weekdays and weekends. The facility reported a census of 38 residents. This discrepancy was identified during a review of the PBJ Staffing Data Report and through staff interviews.
Failure to Follow Menu and Use Correct Scoop Sizes
Penalty
Summary
The facility failed to follow the menu and prepare food to meet the nutritional needs of residents on regular diets. During a lunch service observation, it was noted that Staff A used incorrect scoop sizes for serving beef stroganoff, noodles, and Brussels sprouts. The diet spreadsheet specified that beef stroganoff should be served with a 2/3 cup scoop, noodles with a 1/2 cup scoop, and Brussels sprouts with a 1/2 cup scoop. However, Staff A used a 1/3 cup scoop for Brussels sprouts, a 3/8 cup scoop for noodles, and a 2/3 cup scoop for beef stroganoff. The facility's Food Preparation Guidelines required the cook or designee to prepare menu items according to the facility's written menus and standardized recipes. Staff B, the Certified Dietary Manager, confirmed that the expectation was to use the correct scoops as per the diet spreadsheet. The Administrator also stated that the facility expected appropriate scoop sizes to be used following the diet spreadsheet.
Failure to Label and Date Open Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards by not labeling and dating open items of food. During an initial kitchen tour, it was observed that the dry storage freezer chest contained cinnamon rolls in an open and undated bag. Additionally, the dry storage room had cornbread mix and baking powder that were open and undated. In the stand-up refrigerator, a 3.5-pound butter spread container, a 5-pound cottage cheese container, a 5-pound sour cream container, and a 16 oz. beef base container were also found open and undated. Staff B, a Certified Dietary Manager, acknowledged the presence of these open and undated food items and disposed of them. It was noted that the facility did not have a policy for labeling and dating open food items, although the facility's expectation was that all open food should be dated when opened. The Administrator confirmed that audits were conducted in the kitchen to ensure compliance with this expectation.
Failure to Provide Snacks at Non-Traditional Times
Penalty
Summary
The facility failed to provide snacks to residents who wanted to eat at non-traditional times or outside of scheduled meal service times. This deficiency was identified through resident interviews, policy reviews, and staff interviews. Resident #12, with no cognitive impairment, reported that snacks were not delivered during the day or evening, despite previously receiving them. Staff C, a CNA, confirmed that she had not taken the snack cart around and had not observed anyone else doing so during her shifts. Staff D, who worked the 2pm - 10pm shift, stated that the snack carts were parked at the nurses' desk and not delivered to residents' rooms, requiring residents to request snacks by turning on their lights. The Administrator acknowledged the issue, noting that it had been discussed in the resident council and that the procedure for delivering snacks had not been fully worked out. Other residents, including Resident #14 and Resident #5, reported inconsistent delivery of snacks, with Resident #14 stating snacks were brought less than half the time and Resident #5 indicating snacks were delivered about half the time. Resident #22, with no cognitive impairment, reported not being offered snacks anymore, despite previously receiving them.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of hospital transfers for two residents, as required by regulations. Resident #8, with a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment, was hospitalized multiple times without the ombudsman being notified. Similarly, Resident #10, with a BIMS score of 15 indicating no cognitive impairment, was also hospitalized without notification to the ombudsman. The facility's administrator acknowledged the lack of notifications, attributing it to a misunderstanding of state-specific requirements, as most staff were accustomed to South Dakota regulations, which differ from those in Iowa.
Failure to Provide Bed Hold Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed hold notifications for two residents who were hospitalized, as required by regulations. Resident #8, with a BIMS score of 13 indicating no cognitive impairment, was hospitalized on multiple occasions, including December 25, 2023, February 13, 2024, April 25, 2024, and June 4, 2024. Similarly, Resident #10, with a BIMS score of 15 indicating no cognitive impairment, was hospitalized on two occasions, including July 7, 2023. The facility did not have a policy in place for bed holds, and the administrator confirmed that bed holds were not being completed for residents on Medicaid.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during incontinence care and dressing change. During an observation, it was noted that after receiving incontinence care, the resident was left exposed from mid-abdomen to mid-thighs when a CNA opened the door to retrieve a nurse. The door drifted halfway open, leaving the resident exposed as staff entered the room. The door drifted partially open again before it was shut, and the resident remained exposed throughout these events. Interviews with staff confirmed that the resident should have been covered with a blanket before the door was opened. The facility's Residents Rights Policy, last revised in April 2019, states that residents have a right to respect and dignity.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention practices, specifically in the use of Enhanced Barrier Precautions (EBP) and hand hygiene. For Resident #39, who had a gastrostomy feeding tube and was diagnosed with Parkinson's disease and renal insufficiency, the facility's staff did not follow the required EBP. Despite the presence of a sign indicating the need for EBP and a bin for Personal Protective Equipment (PPE) outside the resident's room, a Licensed Practical Nurse (LPN) was observed administering medication and feeding through the G-tube without wearing the necessary gown. This was contrary to the facility's EBP policy, which mandates the use of gowns and gloves for residents with indwelling medical devices. In another instance, the facility failed to maintain proper hand hygiene during the care of Resident #4, who had paraplegia and Multiple Sclerosis and was dependent on staff for personal hygiene. During incontinence care, a Certified Nursing Assistant (CNA) dropped fecal matter on the bed pad and failed to retrieve it. Subsequently, an LPN removed a preventive dressing from the resident's coccyx area, cleansed the area, and changed gloves without performing hand hygiene. The staff also neglected to change the bed pad that had come into contact with fecal matter. These actions were in violation of the facility's handwashing policy, which requires hand hygiene after contact with body fluids and before and after handling invasive devices or treatments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Pioneer Valley Living And Rehab | 0.5 mi | ★★★★★ | 7 | 0 |
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| Adept Nursing & Rehab Of South Sioux City | 5.2 mi | ★★★★★ | 7 | 0 |
| Sunrise Retirement Community | 5.5 mi | ★★★★★ | 4 | 0 |
| St Luke's Regional Medical Center Snf | 7.2 mi | ★★★★★ | 0 | 0 |
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