Montrose Health Center
400 South 7th Street, Montrose, IA 52639 · Lee County · 44 certified beds · avg 40 residents/day · certified since Nov 1, 1996
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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 · Apr 25, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: May 10, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 19, 2024 · 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: Oct 8, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2024 · F-0686 · triggered by a complaint
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: May 10, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
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: May 10, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (15)
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 |
|---|---|---|
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 2, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Sep 19, 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. |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Sep 19, 2024 | 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. |
| Sep 19, 2024 | 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. |
| Apr 25, 2024 | ▲ J · Immediate jeopardy, 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 |
| Apr 25, 2024 | ▲ G · Actual 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. · from a complaint |
| Apr 25, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 25, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Apr 25, 2024 | 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. |
| Apr 25, 2024 | D · Potential for 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. |
| Apr 25, 2024 | 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. |
| Apr 25, 2024 | D · Potential for harm, one-off | 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 |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 13 | 4 | J ▲ |
| 2025 | 1 | 0 | D |
| 2026 | 1 | 0 | D |
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)
2 fines totaling $43,079.
| Date | Type | Amount / length |
|---|---|---|
| Sep 19, 2024 | Fine | $25,740 |
| Apr 25, 2024 | Fine | $17,339 |
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) | 4.36 | 4.37 | 3.95 | top 46% in Iowa; top 27% in the U.S. |
| Registered Nurse hours | 1.05 | 0.85 | 0.69 | top 23% in Iowa; top 14% in the U.S. |
| Weekend total nurse staffing | 3.55 | 3.86 | 3.50 | bottom 39% in Iowa; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.51 | 0.48 | bottom 23% in Iowa; bottom 38% in the U.S. |
| Total nursing staff turnover (%) | 43.6 | 44.0 | 45.8 | bottom 46% in Iowa; top 46% in the U.S. |
| RN turnover (%) | 50.0 | 42.1 | 42.9 | bottom 41% in Iowa; bottom 39% 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 3.32, RN 0.80, weekend 2.70. 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: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Holtkamp, Mark | Individual | 5% or Greater Direct Ownership Interest | 50% | 03/01/2020 |
| Kidwell, Kevin | Individual | 5% or Greater Direct Ownership Interest | 50% | 03/01/2020 |
| Healthcare of Iowa INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2020 |
| Holtkamp, Mark | Individual | Corporate Director | NOT APPLICABLE | 03/01/2020 |
| Holtkamp, Mark | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2020 |
| Kidwell, Kevin | Individual | Corporate Director | NOT APPLICABLE | 03/01/2020 |
| Lee County Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2020 |
| Payne, David M | Individual | W-2 Managing Employee | NOT APPLICABLE | 03/01/2020 |
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 make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "How do you make sure resident assessments are completed and submitted to the state on time?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "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 |
|---|---|---|---|---|---|
| River Hills Village in Keokuk | 6.4 mi | Keokuk, IA | ★★★☆☆ | 3/5 | |
| Southeast Iowa Healthcare Center | 7.3 mi | Keokuk, IA | ★★★★☆ | 2/5 | |
| Birkwood Village of Fort Madison | 7.3 mi | Fort Madison, IA | ★★★☆☆ | 3/5 | |
| Mississippi Valley | 7.3 mi | Keokuk, IA | ★★★☆☆ | 3/5 | |
| West Point Care Center INC | 13.6 mi | West Point, IA | ★★★★★ | 4/5 | |
| Clark County Nursing Home | 17.0 mi | Kahoka, MO | ★★☆☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165304.