Living Center West

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.

43.8% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 94 beds and averages 72.8 residents a day — about 77% occupied, or roughly 21 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 2.82 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below 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 2.46 hrs/resident/day on weekends vs 2.97 on weekdays — 17% thinner on weekends. RN hours go from 0.32 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above 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

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.

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.

34 citations, most serious first. The 18 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-07-29 · 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, policy review, and staff and resident interviews, the facility failed to prevent sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). After a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room, they left the room leaving the two of them alone in the room. No one reported the witnessed event to members of administration until several weeks later and the facility didn't terminate Staff A until 6/17/24. In addition, the facility learned on 2/29/24 that Resident #10 stated he and Staff A kissed and she locked the door of the activity room so they could be alone. The facility failed to have documentation of an investigation into the situation, nor did they separate Staff A from Resident #10 or the other residents after 2/29/24. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-07-29 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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, policy review, staff, and resident interviews, the facility failed to report an allegation of sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). On 5/7/24 a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until 6/10/24. The facility suspended Staff A on 6/10/24 and terminated her on 6/17/24. The deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/25/24 at 9:30 AM The IJ began on 2/29/24. The facility staff removed the immediacy on 6/10/24 through the following actions: a. Previous Administrator employment at Living Center [NAME] ended 3/18/24. b. The facility suspended Staff A on 6/10/24. c. The facility terminated Staff A's employment on…

  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
• Immediate jeopardy · J2024-07-29 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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, policy review, staff, and resident interviews, the facility failed to investigate an allegation of sexual exploitation and separate an alleged perpetrator of sexual exploitation from other residents for 1 of 1 resident reviewed for abuse (Resident #10). When a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until several weeks later. At that time, the facility suspended Staff A and then terminated her employment on 6/17/24. In addition, the facility learned Resident #10 reported on 2/29/24 he and Staff A kissed and she locked the door of the activity room so they could be alone. In addition, the facility learned on 2/29/24 that Resident #10 stated he and Staff A kissed and she locked the door of the activity room so they could be alone. After learning of either incident, the facility failed to report the incident to the Department of Inspections,…

  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
• Actual harm · Gcited before2026-06-08 · 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, record review, resident and staff interview, and facility policy review the facility failed to provide a call light within reach of a resident, which resulted in a fall with a bruise to the hip for 1 of 1 resident reviewed with a fall (Resident #1). The facility identified a census of 74 residents. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Diagnoses per the resident's MDS assessment included stroke, arthritis, hemiplegia or hemiparesis, and anxiety disorder. The MDS indicated Resident #1 required partial to moderate assistance with toilet transfer, sit to stand transfer, and ambulation. The MDS assessment further revealed the resident had impairment on one side to the resident's upper extremity. Review of Resident #1's Care Plan, date initiated 2/12/25, revealed the resident was at risk for falling related to weakness,…

  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 before2024-05-08 · 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 resident interviews, observations, and facility policy review, the facility failed to identify impaired skin for residents at high risk to develop pressure sores for 2 of 6 resident's reviewed (Residents #5 and #6). The facility reported a census of 85 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had diagnoses which included Non-traumatic brain dysfunction, heart failure, diabetes, and dementia. The MDS revealed the resident required extensive assistance for personal hygiene and had total dependence on staff for toileting, moving about the facility via wheelchair, did not ambulate, and had incontinence of bowel and bladder. The MDS indicted the resident had moisture related damage due to incontinence and required treatments of ointments and creams. The resident had a Brief Interview for Mental Status score of 3 which indicated severe cognitive impairment. Review of the Care Plan dated 5/9/2023, informed staff 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-18 · 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 clinical record review, staff, resident, family member and Medical Director interviews, and facility policy review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed for abuse, when a direct care worker indicated they intentionally pressed on a resident's knee to cause pain and to avoid providing the resident care (Resident #32). The facility reported a census of 73 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed Resident #32 with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicative of moderate cognitive impairment. Resident #32 dependent on staff for transfers, toileting, and toileting hygiene and required substantial/maximal assistance of staff for bed mobility. Resident #32 utilized antipsychotic, antidepressant, and opioid (pain) medications. Diagnoses included: Alzheimer's Disease, Schizophrenia, and adult failure to thrive. The Care Plan, initiated 8/25/23, revealed a Focus Area…

  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 · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-12 · 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, staff and Physician interviews, observations, and facility policy review, the facility failed to assess 1 of 7 residents who had reports of pain (Resident #3). The facility reported a census of 81. Findings Include: According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had diagnoses which included dementia, vascular dementia, stroke, diabetes type 2, kidney disease, above the knee left leg amputation and osteoarthritis. The resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated the resident had moderate cognitive ability. The resident required extensive assistance of 2 staff for transfers, dressing, toileting and total dependence on staff for hygiene needs. The resident did not walk or bear weight. According to the Care Plan dated 7/1/2023, Resident #3 identified with a self-care deficit related to decreased mobility, diabetes, depression, anxiety, dementia and a left above the knee amputation. The Care Plan directed the staff 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
• Actual harm · Gcited before2023-10-12 · 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, observations, staff and resident interviews, and facility policy review, the facility failed to provide appropriate supervision to keep residents safe during a transfer for two of seven residents reviewed. (Residents #1 and #3). The facility reported a census of 81 residents. Findings Include: 1. According to the MDS (Minimum Data Set) dated 8/16/2023, Resident #1 had no cognitive impairment, transferred from one surface to another with extensive assistance of two staff, had a fall with a major injury since the prior assessment and diagnoses including end stage renal disease, diabetes, and heart failure. The Care Card dated 6/9/2023 revealed the resident required the assistance of two staff and a gait belt to stand pivot transfer. The Care Card dated 8/9/2023 revealed the resident required a full body lift with a large sling to transfer from one surface to another. The Emergency Department (ED) Note dated 8/7/2023 revealed resident #1 had a closed fracture of the left ankle. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 policy review the facility failed to provide written bed hold notices at the time of hospital transfer for 1 of 1 residents reviewed for hospitalization (Resident #68). The facility reported a census of 67 residents.Findings include:Resident #68's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 6/19/25. The MDS included diagnoses of heart failure, renal insufficiency (poor working kidneys), respiratory failure (lungs unable to work efficiently), and pneumonia (lung infection).The Clinical Census reviewed 8/27/25 listed a status of stop billing on 7/12/25.The Clinical - MDS list reviewed 8/28/25 listed a Discharge Return Anticipated (left the facility overnight but planned to return)/End of PPS Part A stay (end of Medicare Stay) MDS assessment dated [DATE].The Communication with Physician Note dated 7/12/25 at 9:49 AM indicated at 9:00 AM the facility notified Resident #68's provider of his change in condition of diminished lung…

  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 · Dcited before2025-08-28 · 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 observations, staff interviews, and facility policy review the facility failed to utilize Enhanced [NAME] Precaution (EBP) for high contact resident care for one of four residents reviewed (Resident #2). The facility reported a census of 67 residents. Findings includeResident #2's Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental States (BIMS) score of 5, indicating severe cognitive impairment. The MDS listed Resident #2 had an indwelling urinary catheter. The MDS identified Resident #2 had an unhealed pressure ulcer. Resident #2's Medical Diagnosis list reviewed 8/28/25 listed diagnoses dated 8/8/25 of retention of urine and a pressure ulcer of the right buttock.The Care Plan Focus dated 8/18/25 indicated Resident #2 dated needed EBP related to a pressure ulcer and catheter. The Goal listed precautions would reduce the spread of infectious agent and minimize the transmission of infection. The Interventions directed the following dated 8/18/25:a. Wear a gown 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-09 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, clinical record review, facility investigation, and facility policy review, the facility failed to protect resident's right to privacy for 1 of 3 residents reviewed for resident rights when staff took video of a resident and posted it to social media (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The Care Plan, initiated 7/09/24, revealed Resident #1 had impaired cognition related to moderate intellectual disability, Schizophrenia, and Major Depressive Disorder. The facility submitted a self-reported incident on 11/12/24 at 10:58 to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of 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 · Dcited before2025-01-09 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, facility investigation review, and facility policy review, the facility failed to report to the state agency within 2 hours of knowledge of an abuse allegation for 1 of 3 residents reviewed for resident's rights (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 10/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #1's diagnoses included Schizophrenia, moderate intellectual disability, and depression. The facility submitted a self-reported incident on 11/12/24 at 10:58 AM to the Department of Inspections, Appeals, and Licensing (DIAL) for video of Resident #1, taken by Staff A, Certified Nursing Assistant (CNA) on 11/11/24, and posted to a social media platform (Snapchat). Review of facility internal investigation revealed a statement of incident, signed and dated on 11/12/24 by Staff A. Staff A wrote that on 11/11/24, they were joking with a resident while eating an ice cream cone and had…

  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 · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-19 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 66 residents. Findings include: The CMS 2567, dated 1/18/24 listed, in part, the following concerns: F689, F698 The current survey, conducted 9/16/24-9/19/24 also identified the above concerns. In an interview on 9/19/24 at 12:27 PM the Administrator explained she did not know if the facility put plans in place to address the deficiencies from the previous survey. There was nothing handed off when the previous administrator left. A review of the facility QAPI Program Policies and Procedures, undated revealed the following: The QAA Committee functions under the facility's governing body and is responsible for developing and implementing appropriate plans of action to correct deficiencies…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-19 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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, policy review, and staff interview the facility failed to maintain accurate advance directive records based on resident preference for 1 of 8 residents reviewed (Resident #4). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated [DATE] documented the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. It further revealed diagnoses of coronary artery disease, chronic respiratory failure with hypoxia (not enough oxygen in the blood), and asthma. On [DATE] at 9:50 AM a document titled Policy for Resuscitative Services/Cardiopulmonary Resuscitation (CPR) dated [DATE] was located in front of the resident's chart. It documented that in the event respirations or pulse would cease for Resident #4, she requested CPR be performed. During the same chart review the resident's Iowa Physician's Orders for Scope of Treatment (IPOST), signed [DATE] and located in 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 · D2024-09-19 · tag F0660 — isolated
  Plan the resident's discharge to meet the resident's goals and needs.
  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 record review, resident and staff interviews, and policy review the facility failed to address the resident's goals for discharge for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 8/08/24 for Resident #52 indicated a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The MDS further indicated diagnoses including: alcohol cirrhosis of the liver with ascites (scar and fluid buildup), non-Alzheimer's dementia, and Diabetes Mellitus. The Care Plan for Resident #52 updated 7/11/22 noted the resident needed 24-hour care related to cognitive loss. It instructed staff to arrange for care conferences and review discharge plans quarterly and as needed. It further encouraged the resident/family/POA to share concerns. A review of the clinical record and Electronic Health Record revealed they lacked documentation pertaining to Durable Power of Attorney or mental…

  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 before2024-09-19 · 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

  Based on record review, staff and resident interviews, and policy review the facility failed to implement its policy to ensure the safety of both smoking and non-smoking residents (Resident #65). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) report dated 6/26/24 for Resident #65 indicated a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment. The MDS further indicated diagnoses including: Wernicke's Encephalopathy (difficulty waking, abnormal eye movements, confusion), bipolar disorder, and tremor. The Smoking Safety Screen dated 8/27/24 documented Resident #65 was able to smoke without supervision off campus. It indicated the need for the facility to store his lighter and cigarettes for safety. In an interview on 9/16/24 at 10:40 AM the resident reported he buys and keeps his own cigarettes and lighter in his room. He confirmed he smokes by himself whenever he wants. In an interview on 9/17/24 at 11:08 AM Staff A, Licensed Practical Nurse (LPN) explained most times residents keep their smoking…

  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 before2024-09-19 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, clinical record review, and facility policy review the facility failed to complete pre and post dialysis assessments that included site assessment for 1 of 1 dialysis residents reviewed (Resident #16). The facility reported a census of 66 residents. Findings include: The Medication Administration Record (MAR) for Resident #16 dated 7/2024, listed a diagnosis of chronic kidney disease, stage 4 (SEVERE) end stage renal disease. The MAR directed vital signs (VS) before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after return from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 8/2024, directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site after she returned from dialysis. The Medication Administration Record (MAR) for Resident #16 dated 9/2024, the MAR directed vital signs before and after dialysis every Monday, Wednesday, Friday. The MAR failed to direct staff to assess the dialysis site…

  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 before2024-07-29 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  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, policy review, and staff interviews, the facility failed to ensure privacy by leaving a resident exposed for several minutes during incontinence cares for 1 of 7 residents reviewed for dignity (Resident #6). The facility reported a census of 74 residents. Findings: Resident #6 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total assistance from staff for toileting hygiene. The MDS included diagnoses of anxiety disorder, depression, and weakness. The Care Plan Focus, dated 4/8/24, indicated Resident #6 experienced bladder incontinence related to impaired mobility, obesity, and overactive bladder. The Interventions directed the staff to use incontinence products to promote hygiene and dignity. On 7/23/24 at 1:25 PM, Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA, transferred Resident #6 to the bed with a mechanical lift, as the Director 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.

  Resident Rights 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

$72,070 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $54,081 — penalty dated 2024-05-08
• $17,989 — penalty dated 2024-01-18
• Medicare payment denial — starting 2024-05-28 for 65 days

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.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

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