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Cottage Grove Place

2115 First Avenue SE, Cedar Rapids, IA 52402 · Non profit - Other · 64 certified beds · (319) 363-2420 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1953 1st Ave SE · (319) 365-0059 · Call to confirm hours
Pharmacy
Walgreens0.6 mi
2821 1st Ave SE · (319) 365-6306 · Call to confirm hours
Grocery
1445 1st Ave SE · (319) 249-1111 · Call to confirm hours
Park
129 22nd St NE · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.7%17.1%15.4%worse
Long-stay residents who lose too much weight12.2%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder2.7%1.5%0.9%worse
Long-stay residents with a urinary tract infection0.6%2.4%2.0%better
Long-stay residents with depressive symptoms1.2%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.7%3.8%3.3%worse
Long-stay residents whose ability to walk worsened32.0%16.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.5%20.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers5.5%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control25.6%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table21.4%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%2.1%1.4%better
Short-stay residents given the seasonal flu vaccine95.7%73.3%79.4%better
Short-stay residents rehospitalized after admission17.0%20.9%22.6%better
Short-stay residents with an outpatient ER visit3.8%13.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.701.491.67typical
Long-stay outpatient ER visits per 1,000 resident days1.172.081.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.5%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
60.2%U.S. median 56.6%
Met the expected recovery
0.68U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 60.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 93 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.5%CMS range 40.5–57.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.7–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.9–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.56
RN hours/ resident / day
0.56
LPN hours/ resident / day
3.11
Aide hours/ resident / day
4.23
Total nurse hours/ resident / day
0.41
RN hoursweekends
38.6%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 54.2 residents a day — about 85% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.11 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.89 hrs/resident/day on weekends vs 4.36 on weekdays — 11% thinner on weekends. RN hours go from 0.62 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-05-01)
10
at the previous standard inspection (2024-07-09)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, observation, fire department and police reports, ambulance reports, employee file review, and facility record review, the facility failed to utilize a lap and shoulder seatbelt restraint prior to transporting a resident in a facility van for 1 of 3 residents reviewed (Resident #1). On [DATE], during transport from a doctor's appointment, the facility van driver failed to secure a lap and shoulder seatbelt restraint for Resident #1, who was seated in a secured wheelchair in the back of a transport van. As a result, Resident #1 flew forward out of the wheelchair over a folded middle row seat when the driver swerved and braked to avoid another vehicle. Resident #1 landed face down on the folded second row seat, with her head near the floor between the second-row seating and back side of the driver's seat. Blood was present from Resident #1's nose. Resident #1 was unresponsive, did not appear to be breathing, was pulseless, and cyanotic (bluish or purplish…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-01-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews the facility failed to provide appropriate supervision to prevent a fall that resulted in fracture of the resident's right scapula (shoulder blade) and pain for one of three residents reviewed (Resident #1). The facility reported a census of 55 residents. Findings include:Resident #1 admitted to the facility on [DATE] from Assisted Living after she had a fall that resulted in a fracture of the left humerus (upper arm). The MDS (Minimum Data Set) dated 10/28/2025 revealed the resident had severely impaired cognitive skills for daily decision making, required substantial/maximum assistance to transfer from one surface to another, required supervision while eating, and had a history of falls with fracture in the prior 6 months. The resident had diagnoses including fractures, hypertension, diabetes, and dementia. The Care Plan initiated 10/22/2025 identified the resident had a risk for wandering related to dementia. It directed staff to be aware of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-01 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and policy review the facility failed to provide sufficient dietary staff with the appropriate skills and competencies to safely and effectively provide food service to the facility residents. The facility reported a census of 59 residents. Findings Include: During observation of the facility puree process with Staff A, [NAME] on 04/29/25 at 10:30 am revealed the staff member lacked training and knowledge of the puree process. Staff A lacked instruction on how to complete the puree process and ensure puree diet residents get the same portions as regular diets. Staff A was uncertain how to measure out the puree content, did not know portion sizes and advised they serve pudding or ice cream instead of the dessert of the day. Staff served dessert and advised it was a bit runny and made no attempts to thicken before serving. On 04/29/25 at 12:05 pm the facility Registered Dietician, (RD) was queried regarding the puree process. The RD advised Staff A did not follow the menu and served larger portions than the menu called for. The RD advised Staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, facility documentation, and policy review, facility staff failed to ensure the internal temperature of food provided to the residents was cooked to the proper internal temperature and failed to document internal temperatures in the log book. The facility reported a census of 59 residents. Findings Include: After observation of the facility meal process with Staff A, [NAME] on 04/29/25 at approximately 11:50 am Staff A failed to log food temperatures into the log book. Staff A advised all food temperatures where taken prior to meal service and all temperatures met required internal temperatures and it was an oversight not to log the temperatures. On 04/29/25 at 12:05 pm the facility Registered Dietician, (RD) was queried regarding food temperatures and logging. The RD advised Staff A did not follow proper guidelines for appropriate food handling processes. The RD advised all hot foods should be checked for safe internal temperatures and logged into the facility food temperature log book. The RD advised additional training in the kitchen will be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, resident and staff interview the facility failed to make reasonable accommodations for a resident to reach her clothes hanging in the closet for 1 of 1 residents reviewed (Resident #16). The facility reported a census of 59 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment with a reference date of 3/18/25 documented admission to the facility on 3/12/25. The Brief Interview for Mental Status (BIMS) for Resident #16 had recorded a score of 14/15, which identified intact cognition. The MDS documented it is very important to Resident #16 to take care of her personal belongings or things. The MDS documented a mobility device of a wheelchair. The MDS documented Resident #16's functional abilities at admission included: * Substantial maximal (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) assistance for toileting, bathing and lower body dressing. * Partial/moderate (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-30 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, a posted notice, record review, staff interview, and family interview the facility failed to ensure sufficient staffing to respond to door alarms that sounded in the facility. Two door alarms sounded 4 times in 14 minutes without a staff response. 34 of 58 residents in the facility scored 12/15 or lower on the Brief Interview for Mental Status (BIMS) assessment, which indicated they had moderate to severely impaired cognition. The facility reported a census of 58 residents. Findings include: On 9/28/24 beginning at 11:00 AM facility residents could participate in an activity outside. Residents, staff, and family members had access to at least 2 exits near the main entrance of the building, one leading to the wheelchair ramp and the other leading to the lobby. A plastic sign mounted on the wall to the left of the door with the ramp indicated a code was needed for the door and could be obtained by contacting the nurse at the number provided. At 11:21 AM on 9/28/24 the ramp door alarm sounded which indicated the door had been open for more than 15 seconds. At…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interview, resident interview, and policy review the facility failed to ensure psychotropic medications administered to a resident for anxiety and depression had matching diagnoses in the resident's electronic health record for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) for Resident #6 documented an admission date of 9/20/24 and was in progress. Resident #6's Medication Administration Record (MAR) indicated the resident was taking the following: 1. Trazodone HCl oral tablet 50 MG, 25 mg by mouth at bedtime for depression/ insomnia (1/2 tab) 2. Duloxetine HCl oral capsule delayed release sprinkle 30 MG, 1 capsule by mouth two times a day for depression 3. Lorazepam Oral tablet 0.5 MG, 1 tablet by mouth three times a day for anxiety The resident's electronic health record diagnosis tab lacked diagnoses of depression and anxiety. The resident's Care Plan, with an admission date of 9/20/24, included focus areas for anxiety and depression monitoring and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, the facility failed to implement interventions to prevent weight loss for 1 of 3 resident reviewed for weight loss (Resident #2). The facility identified a census of 50 residents. Findings include: The Minimum Data Set (MDS), dated [DATE] for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating no cognitive decision making abilities or impairment. Resident #2 required set up assistance with eating. No weight loss, or unknown, at the time of the assessment. Diagnoses included: anemia, hypertension, chronic pain, and malaise. The Care Plan, Nutritional Status with an initiated dated 5/7/24, I am at risk and interventions included: *has an allergy to strawberries and mushrooms. Also reports that she can't eat fungus such as bleu cheese or cruciferous vegetables. *Provide alternative foods to avoid allergens and intolerance's. *likes to snack in her room. Family brings in snacks of preference…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and chart review the facility failed to offer toileting on a timely basis and failed perform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during incontinence cares for 2 of 3 residents reviewed (Residents #21, #27). In an observation it was discovered that Resident #21 was left in her chair for over 4 hours before offered toileting. Also, the facility failed to provide baths to residents per the resident's desired frequency for 1 of 4 residents reviewed (Resident #48). Facility further failed to put interventions in place to prevent voiding in inappropriate locations for 1 of 2 residents reviewed for wandering behavior (Resident #34). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #21 was always incontinent of bowel and bladder. The MDS documents the resident was dependent with toileting, personal hygiene, transfers,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-09 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, family, and staff interviews the facility failed to respond to call lights in a timely manner for 5 of 5 residents reviewed (Residents #42, #44, #251, #39, #203, #48 ). Facility reported a census of 53 residents. Findings include: 1. Resident #44's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS documented Resident #44 required substantial/maximal (the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) assistance for, toileting, bathing, and lower body dressing. The MDS listed diagnoses include hip fracture, hepatic encephalopathy, other cirrhosis of liver, and obesity. The Care Plan initiated on 5/30/2024 identified Resident #44 as alert and oriented. The Care Plan identified Resident #44 as needing assistance with transferring, toileting, bathing, and repositioning. On 07/01/24 at 1:27 PM, observed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, policy review, and staff and resident interviews, the facility failed to notify a resident's representative of a fall, medication refusals, and a significant weight loss for for 1 of 4 residents reviewed for a change in condition (Resident #48). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 11/22/24, listed diagnoses for Resident #48 which included skin changes, diabetes, and non-Alzheimer's dementia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impaired cognition. 12/18/23 eMAR Administration Notes stated the resident refused his Med Pass supplement. 12/28/23 eMAR Administration Notes stated the resident refused his donepezil (used to treat dementia), carbidopa-levodopa (used to treat Parkinson's disease, a neurological condition with affected movement), metformin (used to treat diabetes), and vinpocetine (used to treat degenerative diseases of the nervous system). The facility lacked documentation of family…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff and resident interviews, the facility failed to administer medications in accordance with professional standards for 3 of 6 residents reviewed for medications (Residents #33, #203, and #204). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 6/30/24 at 2:58 p.m., Resident #203 stated she received medications which were ordered twice daily 6 hours apart. The December Medication Administration Record (MAR) listed an order for sulfasalazine (used to treat ulcerative colitis, the inflammation of the colon) delayed release 500 milligrams, give 3 tablets by mouth two times per day. The hours for the MAR were listed as Day and Eve. The Medication Admin Audit Report listed an order for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-07-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff and resident interviews, the facility failed to obtain a treatment order for a new skin area in a timely manner for 1 of 3 residents observed with a non-pressure skin issue(Resident #203), failed to assess and carry out a treatment for a resident with moisture associated skin damage (MASD) for 1 of 3 residents observed with a non-pressure skin concern (Resident #48), failed to assess and intervene after a resident showed signs of altered mental status for 1 of 4 residents reviewed for a change in condition (Resident #48), and failed to assess and intervene when a surgical wound showed signs of infection for 1 of 3 residents revealed with a non-pressure skin concern (Resident #39). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS stated the resident required partial to moderate…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, clinical record review, and facility policy review, the facility failed to monitor and assess skin underneath a wander guard device which resulted in the development of a Stage 3, facility acquired, pressure injury of left inner foot for 1 of 4 residents reviewed for pressure injury (Resident #31). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of intact cognition. The MDS indicated Resident #31 had one unhealed stage 2 pressure injury and required pressure reducing device for chair, a turning/repositioning program, pressure ulcer care, and application of non-surgical dressing and ointments or medications. Diagnoses included: encounter for removal of internal fixation device, arthritis, osteoporosis, a mechanical complication of left knee prosthesis, and contracture of muscle in left lower leg. The Care Plan, revised 03/09/24,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and clinical record review, the facility failed to ensure adequate supervision of a resident known to wander, which resulted in unsafe actions and voiding in inappropriate locations for 1 of 2 residents reviewed for accidents and hazards (Resident #34). The facility reported a census of 53 residents. Finding include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS additionally indicated Resident #34 had continuous inattention and disorganized thinking, as well as frequent wandering behavior. Resident #34 able to transfer and ambulate independently but required staff supervision for toileting hygiene. Diagnoses included non-Alzheimer's dementia, hypothyroidism, and depression. Resident #34 required antianxiety and antidepressant medications. The Care Plan, initiated 03/13/24, revealed Resident #34 had potential for wandering and had been at risk for falls due to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, clinical record review, and facility policy review, the facility failed to prime tubing prior to administration of enteral tube feeding and further failed to ensure the head of bed had been elevated to an appropriate level throughout administration of enteral feeding for 1 of 1 residents reviewed for feeding tube treatment and services (Resident #248). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicative of moderate cognitive impairment. Diagnoses included cancer, malnutrition, and gastrostomy status. Resident #248 had documentation of coughing or choking during meals or when swallowing medications. Resident #248 required 51% or more proportion of total calories through tube feeding and 501 milliliters (mL) or more of average fluid intake per day by tube feeding. The Care Plan, initiated 06/27/24, revealed Resident #248 required tube…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of routine medications for 1 of 6 residents reviewed for medications (Resident #203). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The December 2023 Medication Administration Record (MAR) listed a 12/7/23 order for Rybelsus (a medication used to improve blood sugars) 7 milligrams daily. A Pharmacy Invoice, dated 12/31/23, listed a 12/6/23 order for Rybelsus. On 7/1/24 at 2:02 p.m., Resident #203 stated when she first arrived they had to use one of her own Rybelsus medications because they did not have it available. On 7/2/24 at 2:42 p.m., the pharmacy Director of Operations stated the pharmacy filled the resident's Rybelsus prescription on 12/6/23 but the facility did not sign for it until 12/8/23.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, policy review, and staff interviews, the facility failed to ensure the provision of Speech Therapy services for 1 of 1 residents reviewed for therapy services (Resident #48). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 11/22/23, listed diagnoses for Resident #48 which included skin changes, diabetes, and non-Alzheimer's dementia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impaired cognition. a. The Speech Therapy SLP Evaluation, dated 11/24/23, stated the resident's certification period was 11/24/23-12/21/23 for a duration of 6 weeks at a frequency of 12 times. A review of the Speech Therapy Treatment Encounter Notes revealed the resident received therapy on the following days: 11/24/23 11/28/23 12/5/23 12/12/23 12/20/23 12/26/23 The facility lacked documentation the resident received additional Speech Therapy treatments during the above certification period. b. The Speech Therapy SLP Evaluation, dated 2/13/24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and family interviews, the facility failed to appropriately assess and document skin alteration for one of three residents reviewed with pressure ulcers (Resident #4). The facility reported a census of 48 residents. Findings Include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #4, revealed the resident had severe cognitive impairment, required extensive assistance to transfer from one surface to another, failed to ambulate and had bowel and bladder incontinence. The MDS indicated the resident with a current Stage II pressure ulcer upon admission. The MDS dated [DATE] revealed Resident #4 with one unhealed Stage II pressure ulcer and diagnoses including diabetes, renal insufficiency, arthritis, anemia and muscle weakness. The Discharge MDS dated [DATE] indicated the resident without unhealed pressure ulcers. The Care Plan identified the resident at a risk for alteration in skin integrity and instructed staff to complete visual skin evaluations, provide…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review, the facility failed to follow Physician's Orders that resulted in a medication error for one of nine residents reviewed (Resident #3). The facility reported a census of 48. Findings Include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #3 required assistance with transfers, eating and dressing. The resident had severe cognitive impairment and diagnoses including Parkinson's Disease, dementia and chronic pain. The resident's Care Plan revealed the resident with a history of falls and anxiety. The Care Plan directed staff to administer medications including Ativan, Benadryl and Haldol (ABH) cream as directed. The Care Plan instructed staff to educate resident/family of risks, benefits, side effects and toxic symptoms. The Physician Orders dated 11/7/2023 included ABH cream - Ativan 1 milligram (mg)/ Benadryl 12.5 mg/ Haldol 2 mg Gel - apply 0.1 milliliters (ml) (2 clicks) topically to volar aspect of wrist, behind…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to address a medical diagnosis on the Care Plan for 1 of 12 residents reviewed for Care Plans (Resident #18). The facility reported a census of 45. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented the diagnosis of Type II DM (diabetes mellitus) with hyperglycemia and the resident received insulin 7 out of 7 days. The Care Plan dated 2/14/23 failed to reveal documentation of a focus problem and interventions for Type II DM. The Physician Orders are the following: a. Basaglar KwikPen U-100 Insulin 100 unit/ml (milliliter) (3 ml) subcutaneous every day- ordered on 2/28/23 b. Blood glucose checks two times weekly ordered on 2/6/23. During an interview on 5/3/23 at 3:57 PM, Staff A, MDS Coordinator queried on the expectations of diabetes being Care Planned and she stated yes,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, the facility failed to consistently provide Care Conferences on a quarterly basis for 2 of 3 residents reviewed for Care Conferences (Resident #10, Resident #37). The facility reported a census of 45. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The facility documentation lacked evidence a Care Conference occurred with the resident and the resident's family members with the Care Plan revision on 8/8/22. The facility documentation lacked evidence a Care Conference occurred with the resident and the resident's family members with the Care Plan revision on 3/27/23. During an interview on 5/1/23 at 12:09 PM, Resident #10 stated she hadn't discuss Care Conferences with the facility for a long time. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 scored 15 out of 15 on a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of Fall Incident and Investigation Reports, observations and staff interviews, the facility failed to ensure fall interventions were consistently implemented for one of one resident reviewed for falls (Resident #40). The facility reported a census of 45 residents. Findings Include: The admission Minimum Data Set (MDS) Assessment for Resident #40 dated 2/13/23 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had moderately impaired cognition. Per this assessment the resident had fallen in the last month prior to admit, entry, or reentry. The resident also had a fracture related to a fall in the six months prior to admit. entry, or reentry. The Care Plan dated 2/10/23 documented, in part, Resident #40 is at risk for Falls due to decreased mobility, new surgery, use of walker, and episodes of confusion. Has had falls at home prior to his fall sustaining the fracture. The Interventions per the Care Plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE SERVICES — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 54.1-3.1 vs chain
Health inspection 1 of 53.7-2.7 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 42 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Burcham Hills Retirement CenterEast Lansing, MI 2 of 5Casa De Las CampanasSan Diego, CA 2 of 5Linn Manor Care CenterMarion, IA 2 of 5Oakton Place Health And Rehabilitation At The ArliNaples, FL 2 of 5Pavilion At Brandon WildeEvans, GA 2 of 5Signature PointeDallas, TX 2 of 5The Stewart Health CenterCharlotte, NC 3 of 5Carillon INCLubbock, TX 3 of 5Friendship Village Of TempeTempe, AZ 3 of 5Westminster Village - West LafayetteWest Lafayette, IN 4 of 5Croasdaile VillageDurham, NC 4 of 5Dallas Retirement Village Health CenterDallas, OR 4 of 5Health Care Ctr At The Forum At Rancho San AntonioCupertino, CA 4 of 5Oaks Health Ctr At The Marshes Of Skidaway IslandSavannah, GA 4 of 5Parkwood VillageBedford, TX 4 of 5The Cedars of Chapel HillChapel Hill, NC 4 of 5Wesley Pines Retirement CommunityLumberton, NC 4 of 5Whitestone a Masonic and Eastern Star CommunityGreensboro, NC 5 of 5Acacia Health CenterPhoenix, AZ 5 of 5Avalon Health Care Center At StoneridgeMystic, CT 5 of 5Briarwood At Timber RidgeIssaquah, WA 5 of 5Chestnut Grn Hlth Ctr BlakehurTowson, MD 5 of 5Cypress Glen Retirement CommunityGreenville, NC 5 of 5Eastcastle Pl Bradford Ter Conv CtrMilwaukee, WI 5 of 5Essex Meadows Health CenterEssex, CT 5 of 5Friendship VillageKalamazoo, MI 5 of 5Green Hills Health Care CenterAmes, IA 5 of 5Greenwood Village SouthGreenwood, IN 5 of 5Hearthwood SNF Senior LivingBartlett, IL 5 of 5MarquetteIndianapolis, IN 5 of 5Premier Place At The GlenviewNaples, FL 5 of 5Radford GreenLincolnshire, IL 5 of 5Residences At Vantage PointColumbia, MD 5 of 5Rolling Green VillageGreenville, SC 5 of 5Somerfield At The HeritageBrentwood, TN 5 of 5Springs At Monarch Landing, TheNaperville, IL 5 of 5Terraces At The ClareChicago, IL 5 of 5The Arbour At Westminster ManorAustin, TX 5 of 5The Birches At Trillium WoodsPlymouth, MN 5 of 5The Preston Health CenterHilton Head Island, SC

Showing 40 of 42; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
COTTAGE GROVE PLACEOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 09/14/1992
FIRST INTERSTATE BANKOrganization5% OR GREATER SECURITY INTERESTsince 08/01/2012
COOPER, TADIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/19/2019
HATTERY, MICHAELIndividualCORPORATE DIRECTORsince 06/30/2021
LANDIS, CLINTIndividualCORPORATE DIRECTORsince 09/01/2022
LANDIS, RICHARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2025
LENZEN, PHILIPIndividualCORPORATE DIRECTORsince 09/18/2019
MCCARTAN, WILLIAMIndividualCORPORATE DIRECTORsince 09/01/2024
MEIBORG, TORYIndividualCORPORATE DIRECTORsince 09/21/2018
NASSIF, JANAIndividualCORPORATE DIRECTORsince 09/22/2023
SHERMAN, EDWARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/20/2022
SMITHSON, LELANDIndividualCORPORATE DIRECTORsince 09/18/2019
LIFE CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2025
SNOOK, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/07/2025
TAEGER, VINCENTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/27/2015

CMS files one row per role, so the 22 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.6M
Net patient revenuemost recent cost report
-39.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 13%Other / private 87%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$1,102per resident / day
operating cost
$33,501per month
≈ monthly operating cost
$788per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.

Typical monthly cost in Iowa
$9,277/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,381/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165322. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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