Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Westbrook Acres during CMS and state inspections, most recent first.
Failure to Document Consent for Psychotropic Medication Changes: A resident with moderate cognitive impairment, Alzheimer’s disease, CVA, seizure disorder, anxiety, psychotic disorder, and a brain tumor received psychotropic meds including Buspirone, Quetiapine, and Citalopram. The record had consent for some initial orders, but lacked documentation of consent for a Buspirone dose increase, a Quetiapine restart, and the start and increase of Citalopram; the DON confirmed the missing documentation.
PRN Lorazepam was continued for a resident with moderate cognitive impairment, dementia, CVA, anxiety, and adult failure to thrive without documentation of a physician rationale to extend the order beyond 14 days. The resident’s chart showed the medication was used multiple times for agitation, anxiety, and restlessness, and an LPN reported it was minimally effective unless given early; the Facility Administrator confirmed the required rationale was not documented.
A resident with UTI, depression, and vascular dementia was admitted for skilled therapy and expected to transition to LTC, but staff documented confusion, refusal of care and meds, and escalating agitation in the dining room. The resident yelled that she did not belong there, tried to kick and swing at staff, pushed her chair toward others, and later was found with her wheelchair tipped backward. The facility sent the resident to the hospital for acute behavior changes and discharged her because it could not accommodate her in memory care, and the DON later acknowledged the resident was not reassessed after transfer.
The facility did not have an RN on duty for eight consecutive hours on five occasions, as required by Federal Regulations. The absence of RN coverage was confirmed through a review of nursing schedules and time card punches, as well as an interview with the administrator.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, triggering for excessively low weekend staffing. The Administrator acknowledged the report did not accurately reflect staffing for the quarter, despite using an outside accounting company and having a preliminary report for review. This led to a deficiency noted in the survey.
A facility failed to follow the CDC 2025 Adult Immunization Schedule for a resident who had received the PPSV23 vaccination but lacked documentation of a subsequent PCV vaccination. Despite a signed consent for a PCV20 vaccination, the facility did not administer it as recommended. Staff interviews revealed a lack of awareness of the updated CDC schedule, and conflicting information was provided regarding the resident's vaccination status. The facility's policy to offer pneumococcal vaccinations upon admission was not adhered to, resulting in the deficiency.
A resident reported a missing black hooded sweatshirt during Resident Council Meetings, but the facility failed to document the grievance using the appropriate form, as required by their grievance policy. Despite the resident's intact cognition and ability to communicate, the facility did not complete a grievance form or conduct further follow-up after the item could not be located. The resident expressed that the sweatshirt held sentimental value and could not be replaced.
The facility failed to notify the LTC Ombudsman of hospitalizations for two residents, one with moderate cognitive impairment and another with severe cognitive loss. The responsible staff did not complete the required notifications, and the facility lacked a policy for this process.
A facility failed to ensure an accurate MDS assessment for a resident's pneumococcal vaccination status. The resident had only received the PPSV23 vaccine, but the MDS inaccurately documented the vaccination status as up to date, contrary to CDC guidelines. The MDS Coordinator relied on the EHR and paper chart for verification but did not have complete records.
A facility failed to follow a physician's order for a resident with a PEG tube, resulting in the tube being flushed every hour instead of every 2 hours. The error was due to incorrect calibration of the pump after it was replaced. The resident had a history of Cerebral Palsy, seizure disorder, and gastrostomy status.
The facility failed to provide 8 consecutive hours of RN coverage on three specific days. On one day, the scheduled RN left early, resulting in only 5 hours of coverage. On another day, an agency RN provided only 6 hours of coverage, and on a third day, there was no RN coverage at all, with LPNs covering all shifts.
The facility failed to provide the bed hold policy to a resident's representative during a hospital transfer for seizures. The oversight was attributed to an agency nurse, and the facility's undated Bed Hold Policy required notification of the resident's power of attorney, guardian, or next of kin.
Failure to Document Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to obtain documented consent for psychotropic medication use for one resident with moderate cognitive impairment. The resident’s record showed diagnoses of Alzheimer’s disease, CVA, seizure disorder, anxiety disorder, psychotic disorder, and a frontal lobe meningioma, and the care plan identified psychotropic medication use related to anxiety, dementia, and psychotic disorder. The resident was receiving Buspirone, Quetiapine, and Citalopram, all listed as high-risk medications, with dose changes and restarts documented in the MAR between March 2025 and March 2026. The record contained a psychotropic medication informed consent form signed for Buspirone 5 mg three times daily and Quetiapine 25 mg at bedtime, but it lacked documentation of consent when Buspirone was increased to 10 mg three times daily, when Quetiapine was restarted at 12.5 mg daily, and when Citalopram 10 mg daily was started and later increased to 20 mg daily. The DON stated that the normal process was to obtain consent from the resident or representative upon admission and intermittently when medication doses changed or side effects were observed, and denied having documentation of consent for the Citalopram start and increase, the Buspirone increase, or the Quetiapine restart.
PRN Lorazepam Continued Without Required Rationale
Penalty
Summary
The facility failed to ensure an as-needed psychotropic medication was limited to 14 days unless the prescribing practitioner documented a rationale to extend the order for Resident #34. The resident had a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and diagnoses listed on the MDS included cancer, non-Alzheimer's dementia, CVA, anxiety disorder, and adult failure to thrive. The care plan identified use of Lorazepam 0.5 mg twice daily as needed for yelling out, insomnia, nonsensical speech, and fixation on health, with interventions to administer anti-anxiety medication as ordered and monitor for side effects and effectiveness. A nurse's note documented agitation and aggression and a new order for Lorazepam 0.5 mg twice daily as needed. Later, hospice increased the order to Lorazepam 0.5 mg every 4 hours as needed for increased unusual behaviors, and the March 2026 MAR showed the current order with multiple administrations for agitation, anxiety, and restlessness. The resident's EHR did not contain documentation of a physician rationale to continue the as-needed Lorazepam beyond 14 days. During interview, an LPN stated the medication had been started and later increased by hospice and was minimally effective unless given early, and the Facility Administrator denied documentation of a physician indication to continue the order past 14 days.
Failure to Reassess Resident Before Hospital Transfer and Discharge
Penalty
Summary
The facility failed to complete a comprehensive assessment and evaluation of a resident for readmission after hospitalization. Resident #48 had been admitted from the hospital with diagnoses including urinary tract infection, depression, and vascular dementia, and the baseline care plan and therapy documentation indicated the resident was expected to transition to LTC after skilled therapy. The resident was alert but confused, required assistance with transfers, bathing, grooming, and locomotion, and used a walker. During the stay, nursing notes documented increasing confusion, refusal of care and medications, and escalating agitation. The resident was noted to need reminders to use the call light and not transfer independently, later refused to get up at night, and then became loud and disruptive in the dining room, stating she did not belong at the facility and wanted to go home. Staff documented that the resident yelled, mimicked staff, tried to kick and swing at staff, pushed her chair toward other residents, refused breakfast, and was noncompliant with therapies. A urinalysis was ordered, and the resident later refused medications and spit them out. On the day of transfer, the resident was observed in her wheelchair tipped backward in her room, with the wheelchair handle bars preventing her head from reaching the floor. Staff documented that the resident wanted to leave, could not be calmed, and the nurse instructed staff to page 911. The facility notified the family that the resident was being sent to the hospital for acute behavior changes and documented that it would be discharging the resident that day because it was unable to accommodate a female admission in memory care at that time. The discharge summary stated the resident was discharged for inappropriate behaviors and lack of a female memory care bed, and the Administrator later acknowledged that the facility did not reassess the resident after she was sent to the hospital.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to comply with Federal Regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours each day. A review of nursing schedules and time card punches from July 1, 2024, through August 18, 2024, revealed that the facility did not have an RN on duty for the required hours on five specific dates: July 6, July 7, August 4, August 17, and August 18, 2024. The facility, which reported a census of 44 residents, utilized an accounting company to submit Payroll Based Journal staffing data. The administrator confirmed the absence of RN coverage on the identified dates during an interview on March 6, 2025.
Inaccurate Staffing Report Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024 - September 30, 2024. The report triggered for excessively low weekend staffing, indicating that the submitted weekend staffing data was excessively low. Upon review of the schedules for the months of July, August, and September 2024, it was found that nursing shifts were covered by both facility employees and outside staffing agencies. The Administrator revealed that an outside accounting company was used to submit the PBJ staffing data, and the data provided to the accounting company came from the Administrator and a corporate administrative assistant. A preliminary report was provided to the facility for review before submission, allowing the Administrator the opportunity to identify and correct any discrepancies. During an interview, the Administrator acknowledged that the submitted report did not accurately reflect the facility staffing for the fourth quarter. The CMS Staffing Data Submission website outlines the process for data collection and submission, including deadlines and recommended steps to ensure successful submission. Despite these guidelines, the facility's report was inaccurate, leading to the deficiency noted in the survey. The failure to accurately report staffing data is a significant issue, as it impacts the facility's compliance with CMS requirements.
Failure to Follow CDC Pneumococcal Vaccination Schedule
Penalty
Summary
The facility failed to adhere to the CDC 2025 Adult Immunization Schedule for pneumococcal vaccination for one resident. Resident #31, who was admitted to the facility, had previously received the PPSV23 vaccination but lacked documentation of receiving a PCV15, PCV20, or PCV21 vaccination. Despite a signed consent form for a PCV20 vaccination, the facility did not administer the vaccine as recommended by the CDC schedule, which advises offering a PCV dose at least one year after the last PPSV23 dose. Interviews with facility staff revealed a lack of awareness and adherence to the updated CDC pneumococcal vaccination schedule. The MDS Coordinator and the pharmacy provided conflicting information regarding the resident's vaccination schedule, and the Director of Nursing and Assistant Director of Nursing were unaware of the resident's complete vaccination history. The facility's policy, which directed offering pneumococcal vaccinations upon admission, was not followed, leading to the deficiency in ensuring the resident received the appropriate vaccination as per CDC guidelines.
Failure to Address Resident Grievance for Missing Item
Penalty
Summary
The facility failed to utilize a grievance form to address a missing item for a resident, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The resident, who had intact cognition and was able to communicate effectively, reported a missing black hooded sweatshirt with 'Iowa Select Farms' written on it during Resident Council Meetings. Despite the resident's repeated reports of the missing item, the facility did not document the grievance using the appropriate form, as required by their grievance policy. The facility's Administrator acknowledged that they had not completed a grievance form or conducted further follow-up after the item could not be located. The facility's grievance policy specified that all complaints, whether written or verbal, should be addressed, and a completed grievance form should be filed and kept for no less than one year. However, the facility did not adhere to this policy, as evidenced by the lack of a grievance form for the missing sweatshirt. The resident expressed that the sweatshirt held sentimental value and could not be replaced, highlighting the importance of addressing such grievances promptly and effectively.
Failure to Notify LTC Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Long-Term Care (LTC) Ombudsman of hospitalizations for two residents, leading to a deficiency in compliance with notification requirements. Resident #4, who had moderate cognitive impairment and diagnoses including non-traumatic brain dysfunction and Non-Alzheimer's Dementia, was hospitalized twice within the review period. The facility's records showed that notifications to the LTC Ombudsman were not completed for these hospitalizations, as confirmed by the Administrator and the Assistant Director of Nursing (ADON)/Admission Nurse, who was responsible for sending these notifications. Similarly, Resident #46, with severe cognitive loss and diagnoses including cancer and Non-Alzheimer's Dementia, was transferred to a hospital and later returned to the facility. The facility's documentation also lacked evidence of notification to the LTC Ombudsman for this resident's transfer. The facility did not provide a policy for the required notification process, indicating a systemic issue in ensuring compliance with notification requirements for resident transfers and discharges.
Inaccurate MDS Assessment of Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the health status of a resident regarding pneumococcal immunizations. The resident, who was admitted to the facility, had received the pneumococcal polysaccharide (PPSV)23 vaccination at the age of 53. However, the resident's immunization record lacked documentation of any other pneumococcal vaccination, which was not in accordance with the CDC 2025 Adult Immunization Schedule. This schedule recommends that if PPSV23 is the only pneumococcal vaccination received, a dose of PCV15, PCV20, or PCV21 should be offered at least one year after the last PPSV23 dose. Despite this, the MDS assessment documented the resident's pneumococcal vaccination status as up to date. The MDS Coordinator explained that she checks the residents' electronic health record (EHR) immunization record and reviews documentation in the resident's paper chart to determine if the resident is up to date on vaccinations before coding the MDS. She also mentioned that she had reached out to the resident's prior nursing home to verify vaccination records. The facility's failure to accurately document the resident's vaccination status on the MDS assessment was not in compliance with the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, which requires that assessments accurately reflect the resident's status in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations.
Failure to Follow Physician's Order for PEG Tube Flush
Penalty
Summary
The facility failed to follow a physician's order for a resident with a PEG tube. The resident was ordered to have their PEG tube flushed with 30 cc of water every 2 hours. However, observations revealed that the machine was set to flush the tube every hour instead of every 2 hours. This discrepancy was confirmed by a Registered Nurse (RN) and the Director of Nursing (DON), who acknowledged that the pump had been incorrectly calibrated after it was replaced and sent for recalibration. The Licensed Nursing Home Administrator (LNHA) also confirmed that the pump had been set up incorrectly, leading to the resident receiving water more frequently than ordered by the physician. The resident involved had a history of Cerebral Palsy, seizure disorder, and gastrostomy status, and relied on the PEG tube for nutritional support. The error was discovered during a review of the Routine Medication record and through staff interviews. The RN and DON both acknowledged the mistake, and it was noted that the new pump may have been set up incorrectly when it was calibrated. The facility's Physician Order Policy and Procedure mandates that all physician's orders must be accurately transcribed, which was not adhered to in this case.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage daily, as required. The deficiency was identified through interview and record review, revealing that on three specific days, the facility did not meet the RN coverage requirement. On 4/6/24, the scheduled RN had to leave early, resulting in only 5 hours of coverage, with the remaining hours covered by a Licensed Practical Nurse (LPN). On 4/13/24, an agency RN worked from midnight to 6:00 a.m., providing only 6 hours of coverage. On 4/14/24, there was no RN coverage at all, with LPNs covering all shifts. The facility's RN Staffing Policy mandates 8 consecutive hours of RN coverage per 24-hour period, starting at midnight each day, which was not adhered to on these dates.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide the bed hold policy for one of the two residents reviewed. On December 8, 2023, the resident was sent to the hospital for seizures, and the bed hold policy was not discussed or given to the resident's representative. The facility had a census of 51 residents at the time. Documentation showed that billing for the resident stopped on December 8, 2023, and the resident returned to the facility on December 11, 2023, after an acute hospital stay. The Licensed Nursing Home Administrator stated that the bed hold was not documented for the hospital stay, attributing the oversight to an agency nurse who was working at the time. The facility's undated Bed Hold Policy directed staff to notify the resident's power of attorney, guardian, or next of kin of the transfer and provide the Bed Hold form.
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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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Nursing homes near Gladbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing Home | 8 mi | ★★★★★ | 1 | 0 |
| Parkview Manor Care Center | 11.3 mi | ★★★★★ | 8 | 0 |
| Creekside | 12.2 mi | ★★★★★ | 6 | 0 |
| Grundy Care Center | 12.3 mi | ★★★★★ | 15 | 0 |
| Sunrise Hill Care Center | 13.3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.