Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 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.
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.
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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| St Luke's Regional Medical Center Snf | 7.2 mi | — | 0 | 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 August 2026) and official state health department websites.