Hallmar Village

Location & what’s nearby

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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

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.

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.

Met the expected recovery: 51.4% 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 35 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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.

Staffing

How full it usually is: this home is certified for 55 beds and averages 53.3 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 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 4.12 hrs/resident/day on weekends vs 4.59 on weekdays — 10% thinner on weekends. RN hours go from 0.90 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Deficiencies are more than at the previous inspection — worsening. 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.

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.

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

• Actual harm · Gcited before2025-07-10 · 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, facility policy review, and staff interviews, the facility failed to use safe transfer techniques when using a mechanical lift to transfer 2 of 3 (Resident #101 and Resident #102) which resulted in one resident incurring bilateral femur fractures. The facility failed to safely transfer 2 of 2 residents (Resident #101 and Resident #102) from the floor after a fall. The facility reported a census of 52 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 6/04/25, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included type 1 diabetes, congestive heart failure, and neuromuscular dysfunction of the bladder (loss of control due to nerve damage). The MDS indicated Resident #101 dependent for all transfers, which included going from a seated to standing position. The MDS revealed the resident unable to walk and utilized a wheelchair. The MDS…

  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 before2025-01-23 · tag F0725 — failed to have enough nursing staff — isolated
  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 clinical record review, employee record review, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision for residents who occupied a 14 room shift assignment. This resulted in harm to Resident #3 due to her walker being left out of reach when she was put to bed, leading to a fall with injury. Staff failed to perform safety rounds and the resident was not found by staff for a significant amount of time after the fall. Additionally, other residents of the shift assignment were left without call lights in reach and others with call lights going unanswered. The facility reported a census of 50 residents. Findings include: The Minimum Data Set of Resident #3 dated 12/3/24 identified a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS indicated the resident had not had any falls since the prior assessment. The Care Plan documented that on 9/6/24 the resident was deemed to be independent in her room…

  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
• Actual harm · G2024-07-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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, staff interview, resident interview, and family interview the facility staff failed to properly insert a catheter for 1 of 3 residents reviewed which resulted in hospitalization (Resident #3). The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3.27.24 indicated Resident #3 had diagnoses that included Parkinson's Disease, End Stage Renal Disease (ESRD), Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, Bladder Neck Obstruction, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM). The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 (moderately impaired cognitive status), with the ability to understand others and make himself understood. The assessment indicated the Resident required maximum/substantial assistance to dependent on staff with activities of daily living (ADL's) and had a catheter. A Care Plan identified a Focus area of 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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, staff and resident interviews, the facility failed to supervise residents to ensure safety and freedom from abuse for one of 3 residents reviewed (Resident #1). On 4/15/26, staff found Resident #2 with Resident #1 in intimate situation. Resident #1 didn't have the ability to consent to the situation. The facility reported a census of 55 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) dated [DATE] identified they had severe cognitive impairment (decline in mental state). Resident #1 required total dependence on staff to transfer from one surface to another, and used a wheelchair for locomotion (moving around). The MDS included diagnoses of Alzheimer's disease (a progressive brain disorder causing memory loss) and anxiety (excessive worrying). The Care Plan dated 4/4/25 noted Resident #1 experienced non-verbal communication, a fall risk, and used a wheelchair for locomotion. The plan identified Resident #1 had a communication problem, remained…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-04-09 · tag F0725 — failed to have enough nursing staff — isolated
  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 clinical record review, staff and resident interviews, and policy review the facility failed to answer resident call lights within 15 minutes of activation for 2 of 4 residents reviewed (Resident #1 and #2). The facility reported a census of 54 residents.Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had diagnoses which included Dementia with agitation, heart failure, and diabetes mellitus. The resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The resident required partial assistance for toilet hygiene and transfers, and required substantial assistance with bathing and dressing. The MDS revealed the resident had occasional urinary incontinence. Review of the Care Plan revised 10/24/25 indicated the resident required assistance to perform activities of daily living due to weakness, impaired mobility. The Care Plan informed the staff the resident required assistance of 1 staff for dressing, grooming, 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-10-02 · 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 clinical record review, resident interviews, resident council minutes, call light device reports, staff interviews, and policy review the facility failed to provide sufficient nursing staff to ensure resident needs were met in a timely manner. During the survey residents reviewed for call lights reported waiting for 20 to 45 minutes for call lights to be answered and stated staff turned call lights off without completing cares. The facility reported a census of 44 residents. Findings include:A document titled Quality Concern Form dated 7/2/25 documented a resident waited 20 minutes for a second Certified Nurses Aide (CNA) to help with their transfer.A document titled Resident Council Meeting Minutes Template dated 7/14/25 documented 7 residents and 6 facility staff attended the meeting. The notes indicated call lights were 'still' not being answered in a timely manner and there was a new process for lights over 15 minutes. A resident reported to attendees that her call light was on for 30 minutes. Staff indicated they would access the call light report.A document titled…

  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 · Ecited before2025-10-02 · 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 observations, staff interviews, facility documents review, and facility policy review, the facility failed to discard undated and expired food found in 2 of 3 kitchens. The facility food items not contaminated when scoops were left in containers during 2 of 2 main kitchen observations. The facility failed to log food temperatures, refrigerator/freezer temperatures, or dishwasher temperatures to ensure safe food storage, thorough cooking, and sanitation for 3 of 3 kitchen logs observed. The facility additionally failed to check the temperature of mechanically altered diets before serving to residents to ensure safe food holding temperatures during 1 of 2 lunch services observed. The facility reported a census of 44 residents.Findings include: 1. During the initial walkthrough of serving kitchen #2, located on the second floor of the facility, on 9/29/25 at 9:30 AM, observed a container of cut fruit covered with plastic cling undated and an opened bag of whipped cream undated in the refrigerator located next to the serving area. During an interview on 9/29/25 at 9:30 AM, the…

  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 · Dcited before2025-10-02 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident, family, and staff interviews, and policy review the facility failed to ensure dignified care for 1 of 3 residents reviewed for dignity (Resident #31). The resident was left on a bed pan for over 3 hours with her call light out of reach. The facility reported a census of 44 residents.Findings include:Minimum Data Set for Resident #31 dated 7/9/25 revealed diagnoses of neurogenic bladder (disruption of nerve signals between the brain, spinal cord, and bladder that led to problems storing and emptying urine), non-Alzheimer's dementia, anxiety, and chronic pain. Section GG documented the resident was dependent on staff for hygiene and toileting hygiene, and transferring to the toilet was not attempted due to medical condition or safety.The Care Plan for Resident #31 dated 7/3/24 indicated the resident also had neurogenic bowel (loss of bowel control due to nerve damage) and a suprapubic catheter. As of 7/22/24, staff were directed to to treat the absence of bowel function per facility protocol or standing orders. As of 9/25/24, staff were directed 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review, interviews, and policy review the facility failed to ensure a resident with limited Range of Motion (ROM) received appropriate treatment and services for 1 of 3 residents reviewed (Resident # 7). The facility reported a census of 44 residents.Findings include:The Minimum Data Set (MDS) for Resident #7 dated 9/3/25 documented diagnoses of non-Alzheimer's dementia, malnutrition, idiopathic peripheral autonomic neuropathy (nerve damage affecting involuntary bodily functions). The MDS indicated the resident was dependent on staff assistance for transfers, hygiene, and bed mobility and required the use of a wheelchair.The Care Plan for Resident #7 dated 12/3/24 documented an ADL (Activities of Daily Living) self-care performance deficit and limited physical mobility related to impaired mobility, generalized weakness, and impaired cognition, and end of life stage. The Care Plan intervention dated 9/16/25 directed staff to assess functional ability with bed mobility, transfers, walking, and locomotion at admission, quarterly, annually, with…

  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 · D2025-10-02 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  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, interview, clinical record review, employee file review, and facility policy review, the facility failed to ensure insulins were stored in a locked treatment cart for 1 of 2 medication storage carts observed, and failed to label insulin with date opened to ensure medicine was not expired for 1 of 1 insulin administrations observed (Resident #4). The facility additionally failed to ensure medications were safely administered to 1 of 4 residents (Resident #5) reviewed for medication administration, when medications were given to a family member to administer to a resident. The facility reported a census of 44 residents.Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had the diagnoses of Type 2 Diabetes Mellitus and received insulin injections daily.Review of the Care Plan, initiated [DATE], identified Resident #4 being at risk for alteration in blood glucose levels related to diagnosis of Diabetes Mellitus and instructed staff to give medications as…

  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 · D2025-10-02 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  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, staff interview, facility document review, and facility policy review, the facility failed to ensure a resident's with a diet order for Nothing Per Oral (NPO) was followed when the resident recieved a meal tray for 1 of 1 residents (Resident #4) on an NPO diet. The facility additionally failed to ensure residents on pureed diet received food listed on the menu or had Dietitian approved alternatives to menu items for 1 of 1 meals observed. The facility reported a census of 44 residents. Findings include: Findings include:1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, malnutrition, dysphagia (difficulty swallowing), and gastrostomy (g-tube) status. The MDS revealed Resident #4 had a feeding tube and received 51% or more of total calories through tube feeding. Review of 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-29 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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 and resident interviews, the facility failed to ensure 3 of 6 residents reviewed were treated with respect and dignity (Residents #2, #3, #7). The facility reported a census of 51 residents. Findings include: 1. On 1/20/2025, Resident #2 had a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. On 3/4/2025 the resident had a score of 10, indicating moderate cognitive impairment. During an interview on 4/29/2025 at 1:00 PM, the resident revealed she reported to the former administrator a concern she had with staff G, C.N.A. The resident observed Staff G assist residents up from dining room chairs in a very harsh manner. Staff G assisted the resident in her room in a rough manner when she asked for bathroom assistance. Staff G told the resident she needed to be independent in her room when she asked for assistance. Staff G jerked the resident up from a seated position without warning or direction. The resident thought the…

  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 · D2025-04-29 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  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, observations, staff interviews, and facility policy review, the facility failed to follow standard and transmission-based precautions to prevent spread of infections for 3 of 6 residents reviewed (Residents #2,#3,#7). The facility reported a census of 51 residents. Findings include: 1. The MDS (Minimum Data Set) dated 3/26/2025 indicated Resident #2 had memory impairment, transferred and ambulated independently and had diagnoses including peripheral vascular disease, diabetes, and a right lower leg ulcer. The resident had a left iliofemoral endarterectomy with patch angioplasty (a surgical procedure to remove plaque buildup from narrowed or blocked iliac and femoral arteries) on 3/26/2025. The resident's Care Plan dated 8/30/2024 required staff to implement EBP (enhanced barrier precautions) related to wounds. It directed staff to follow EBP in addition to standard precautions: wear gown and gloves during high contact resident care activities. On 3/27/2025 the physician ordered…

  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.

  Infection Control 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.

Fines & penalties

$11,960 in federal fines across 1 penalty.

• $11,960 — penalty dated 2025-07-10

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PRESBYTERIAN HOMES & SERVICES — 21 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 →

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

CMS files one row per role, so the 30 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

What families pay in IA