Estherville Community Care Center
2001 First Avenue North, Estherville, IA 51334 · Emmet County · 46 certified beds · avg 39 residents/day · certified since Feb 1, 2004
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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)
▲ Actual harm, one-off · Jun 10, 2026 · F-0689 · triggered by a complaint
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: Jun 30, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 6, 2024 · F-0689 · triggered by a complaint
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: Sep 18, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (23)
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 |
|---|---|---|
| Jun 10, 2026 | ▲ 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. · from a complaint |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint |
| Dec 12, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Dec 12, 2024 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Dec 12, 2024 | 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. |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Sep 6, 2024 | ▲ 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. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 6 | 1 | G ▲ |
| 2025 | 5 | 0 | D |
| 2026 | 3 | 1 | G ▲ |
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)
No fines or payment denials in the published 3-year window.
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) | 3.73 | 4.37 | 3.95 | bottom 20% in Iowa; bottom 48% in the U.S. |
| Registered Nurse hours | 1.00 | 0.85 | 0.69 | top 28% in Iowa; top 16% in the U.S. |
| Weekend total nurse staffing | 3.12 | 3.86 | 3.50 | bottom 11% in Iowa; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.57 | 0.51 | 0.48 | top 30% in Iowa; top 26% in the U.S. |
| Total nursing staff turnover (%) | 46.2 | 44.0 | 45.8 | bottom 40% in Iowa; bottom 47% in the U.S. |
| RN turnover (%) | 37.5 | 42.1 | 42.9 | top 45% in Iowa; top 42% 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 3.38, RN 0.91, weekend 2.82. Staffing rating: 4/5.
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: 2/5 · long-stay residents: 2/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation · changed ownership in the last 12 months
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Goldberger, Sheldon | Individual | Indirect Ownership Interest | NOT APPLICABLE | 11/01/2025 |
| GS Estherville Holdings LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 11/01/2025 |
| Kugler, Aaron | Individual | Indirect Ownership Interest | NOT APPLICABLE | 11/01/2025 |
| Estherville Propco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Genstar Healthcare Mgmt | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Genstar Healthcare Mgmt | Organization | ADP of the SNF | NOT APPLICABLE | 11/24/2025 |
| Goldberger, Sheldon | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Goldberger, Sheldon | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| GS Estherville Holdings LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| GS Estherville Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Kabrick, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Kabrick, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Kugler, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Kugler, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Prabhakaran, Madhan | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Prabhakaran, Madhan | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Yager, Sally | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Yager, Sally | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "How do you learn about each resident's background and history, and how does that shape their care?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "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 |
|---|---|---|---|---|---|
| Good Samaritan - Estherville | 0.5 mi | Estherville, IA | ★★☆☆☆ | 2/5 | |
| Accura Healthcare of Spirit Lake | 15.4 mi | Spirit Lake, IA | ★★☆☆☆ | 2/5 | |
| Valley Vue Care Center | 16.5 mi | Armstrong, IA | ★★★★★ | 4/5 | |
| Good Samaritan Society - Jackson | 17.9 mi | Jackson, MN | ★★★★☆ | 3/5 | |
| Accura Healthcare of Milford | 18.0 mi | Milford, IA | ★★★★☆ | 5/5 | |
| Ruthven Community Care Center | 19.2 mi | Ruthven, IA | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 165523.