Emmetsburg Care Center
2405 21st Street, Emmetsburg, IA 50536 · Palo Alto County · 46 certified beds · avg 41 residents/day · certified since Aug 1, 1997
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 28, 2025 · F-0805
The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 15, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 28, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 15, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 11, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| May 11, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 11, 2026 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 28, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jul 28, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 28, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 28, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 28, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 28, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 20, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 5 | 0 | D |
| 2025 | 7 | 2 | J ▲ |
| 2026 | 10 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $25,695.
| Date | Type | Amount / length |
|---|---|---|
| Jul 28, 2025 | Fine | $25,695 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.14 | 4.37 | 3.95 | bottom 45% in Iowa; top 34% in the U.S. |
| Registered Nurse hours | 0.73 | 0.85 | 0.69 | bottom 41% in Iowa; top 33% in the U.S. |
| Weekend total nurse staffing | 3.69 | 3.86 | 3.50 | bottom 46% in Iowa; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.58 | 0.51 | 0.48 | top 28% in Iowa; top 25% in the U.S. |
| Total nursing staff turnover (%) | 56.9 | 44.0 | 45.8 | bottom 16% in Iowa; bottom 21% in the U.S. |
| RN turnover (%) | 57.1 | 42.1 | 42.9 | bottom 30% in Iowa; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.66, RN 0.65, weekend 3.27. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cascade Capital Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 08/15/2024 |
| Beasley, Karla | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Beasley, Karla | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| CCG Gorgona LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Emmetsburg Ia Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Friedenberg, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Friedenberg, Laura | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Friedman, Brian | Individual | Trustee of the SNF | NOT APPLICABLE | 01/03/2012 |
| Gorgona Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Propco Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Sub Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lakeside Lutheran Home | 1.1 mi | Emmetsburg, IA | ★★★☆☆ | 3/5 | |
| Palo Alto County Hospital | 1.3 mi | Emmetsburg, IA | ★★★★☆ | 4/5 | |
| Ruthven Community Care Center | 11.2 mi | Ruthven, IA | ★★★★☆ | 4/5 | |
| West Bend Health and Rehabilitation | 15.5 mi | West Bend, IA | ★★★★☆ | 3/5 | |
| Laurens Care Center | 19.7 mi | Laurens, IA | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 165352.