Iowa ›West Bend

West Bend Health and Rehabilitation

203 Fourth Street NW, West Bend, IA 50597 · Palo Alto County · 45 certified beds · avg 43 residents/day · certified since Nov 14, 2001

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.52
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

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.

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.

DateSeverityWhat the facility was cited for
May 1, 2025D · Potential for harm, one-offThe 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).
May 1, 2025D · Potential for harm, one-offThe 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.
May 1, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 1, 2025D · Potential for harm, one-offThe 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.
May 1, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 1, 2025D · Potential for harm, one-offThe 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.
Dec 16, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Dec 16, 2024D · Potential for harm, one-offThe 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
Dec 16, 2024D · Potential for harm, one-offThe 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
Mar 7, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 7, 2024D · Potential for harm, one-offThe 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.
Mar 7, 2024D · Potential for harm, one-offThe 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.
Mar 7, 2024D · Potential for harm, one-offThe 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
Mar 7, 2024D · Potential for harm, one-offWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Mar 7, 2024D · Potential for harm, one-offThe 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.
Jan 12, 2024E · Potential for harm, repeatedThe 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
Dec 29, 2022E · Potential for harm, repeatedThe 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.
Dec 29, 2022E · Potential for harm, repeatedThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Dec 29, 2022E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 29, 2022D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Dec 29, 2022D · Potential for harm, one-offThe 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.
Dec 29, 2022D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 29, 2022D · Potential for harm, one-offThe 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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 6).

YearCitationsSerious (G–L)Worst severity that year
202270E
2024100E
202560D

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)

MeasureThis facilityIowa avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.524.373.95bottom 8% in Iowa; bottom 37% in the U.S.
Registered Nurse hours0.700.850.69bottom 36% in Iowa; top 36% in the U.S.
Weekend total nurse staffing3.183.863.50bottom 15% in Iowa; bottom 41% in the U.S.
Weekend RN hours (not acuity-adjusted)0.430.510.48bottom 43% in Iowa; top 43% in the U.S.
Total nursing staff turnover (%)0.044.045.8—
RN turnover (%)0.042.142.9—

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 2.94, RN 0.59, weekend 2.66. 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: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / managerTypeRoleStakeSince
4th Street Holdings LLCOrganizationADP of the SNFNOT APPLICABLE07/18/2011
Burnam, SoonIndividualCorporate OfficerNOT APPLICABLE07/18/2011
Burnam, SoonIndividualADP of the SNFNOT APPLICABLE07/09/2025
Caretrust GP LLCOrganizationADP of the SNFNOT APPLICABLE07/18/2011
Caretrust Reit INCOrganizationADP of the SNFNOT APPLICABLE07/18/2011
Ctr Partnership LPOrganizationADP of the SNFNOT APPLICABLE07/18/2011
Ensign Services INCOrganizationADP of the SNFNOT APPLICABLE06/01/2011
Jorgensen, DavidIndividualCorporate DirectorNOT APPLICABLE01/01/2024
Keetch, ChadIndividualCorporate OfficerNOT APPLICABLE03/01/2011
Kleinstreuber, PeterIndividualManaging Control - Governing BodyNOT APPLICABLE11/19/2019
Kleinstreuber, PeterIndividualOperational/Managerial ControlNOT APPLICABLE11/19/2019
Kleinstreuber, PeterIndividualADP of the SNFNOT APPLICABLE07/09/2025
Koenig, DebraIndividualCorporate OfficerNOT APPLICABLE01/01/2020
Owen, BrentIndividualManaging Control - Governing BodyNOT APPLICABLE05/01/2014
Owen, BrentIndividualOperational/Managerial ControlNOT APPLICABLE05/01/2014
Owen, BrentIndividualADP of the SNFNOT APPLICABLE07/09/2025
Port, BarryIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE07/09/2025
Sato, AmiIndividualCorporate OfficerNOT APPLICABLE09/09/2024
Ventura Medstaff, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE07/18/2011

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Good Samaritan - Algona12.9 miAlgona, IA★★★☆☆3/5
Algona Manor Care Center14.3 miAlgona, IA★★★★★4/5
Emmetsburg Care Center15.5 miEmmetsburg, IA★☆☆☆☆1/5
Lakeside Lutheran Home16.2 miEmmetsburg, IA★★★☆☆3/5
Palo Alto County Hospital16.6 miEmmetsburg, IA★★★★☆4/5
Humboldt County Memorial Hospital19.0 miHumboldt, IA★★★★★4/5

Compare this facility with the 3 closest →

All facilities in West Bend →

Facility data as of CMS processing date 2026-08-01. CCN 165444.