Correctionville Specialty Care
1116 East Highway 20, Correctionville, IA 51016 · Non profit - Corporation · 39 certified beds · (712) 372-4466 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has abuse, neglect, or exploitation citations (F0600, F0607, F0609, F0610) — most recent May 2026
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (42) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $60,316 in federal fines (most recent 2023-10-19)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.6% | 17.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.9% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.4% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.2% | 3.8% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.1% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 36.8% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 37.3% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.2% | 2.1% | 1.4% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
How full it usually is: this home is certified for 39 beds and averages 34.5 residents a day — about 88% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.97 hrs/resident/day on weekends vs 3.45 on weekdays — 14% thinner on weekends. RN hours go from 0.66 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 52% 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
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.
42 citations, most serious first. The 17 most serious are shown; the remaining 25 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-11-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, law enforcement incident review, facility policy review, resident and staff interviews, the facility failed to keep residents safe from sexual abuse and financial exploitation for 1 of 3 residents (Resident #1). Resident #1 reported a male Certified Nurse Aide (CNA) forced her to perform sexual acts on him. In addition, that male CNA and another CNA transferred money from her account using an electronic money transferring service. Despite the allegation of sexual abuse from the male CNA to Resident #1, the facility failed to prevent him from working with other vulnerable residents in the corporation. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and 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.
- Immediate jeopardy · Jcited before2023-11-20 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 clinical record review, facility policy review, staff, and resident interviews, the facility failed to report allegations of abuse within 2 hours for 1 of 3 residents reviewed (Resident #1). Resident #1 reported to staff on 10/23/23 that a staff member sexually abused her, in addition to transferring money from her account to staff. The facility did not report the incident to the appropriate authorities until the evening of 10/24/23. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing…
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.
- Immediate jeopardy · J2023-11-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 interviews with residents, staff and law enforcement, record review and policy review the facility failed to adequately investigate allegations of abuse for 1 of 3 residents reviewed (Resident #1). After Resident #1 reported allegations of sexual and financial abuse, the administration only addressed the exchange of money but minimized and failed to fully investigate the allegations of sexual abuse. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing personal items for residents on 11/10/23.…
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.
- Immediate jeopardy · J2023-11-20 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to adequately planned transfers for 1 of 3 residents reviewed (Resident #1). The facility discharged Resident #1 abruptly after allegations of abuse to a homeless shelter that did not know of her transfer. The homeless shelter did not have nurses on staff to meet her medical needs and they did not have any staff overnight. The homeless shelter transferred Resident #1 to the hospital as she could not safely remain in the homeless shelter. After arriving to the homeless shelter, Resident #1 began to stumble and fall. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs.…
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.
- Immediate jeopardy · Jcited before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, facility policy review, resident, and staff interview the facility failed to assure that the alarm system worked properly to alert the staff to residents leaving the facility unattended for 3 of 6 reviews (Residents #1, #2, and #3). On 8/11/23 in the night, an on-duty staff member discovered Resident #1 in his wheelchair near Highway 20. The facility staff did not know that he left the building, that the alarms did not go off, and they thought that he went to bed. The survey determined that the staff failed to respond to door alarms, while 2 of 6 Wander Guard (WG) alarms did not work at the time of survey. This failure resulted in an Immediate Jeopardy situation to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 11, 2023, on August 16, 2023 at 5:33 PM. The Facility Staff removed the Immediate Jeopardy on August 16, 2023 with the following actions: a. Staff were educated…
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.
- Actual harm · G2023-11-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 interviews, record review and policy review the facility failed to prevent retribution to a resident and a staff member for 1 of 3 residents (Resident #1). Resident #1 reported that a male Certified Nurse Aide (CNA) sexually abused her. After the facility learned of the allegations on 10/24/23, they discharged Resident #1 to a homeless shelter on 10/25/23 with only approximately 30 minutes to pack. In addition, Staff P reported that the facility suspended her after she confronted the Administrator regarding the need to report the abuse. The facility suspended Staff Q from work for not reporting abuse within 2 hours after she learned about the allegation. At the time she reported the allegation, the facility already knew from other staff. The facility asked her to share information related to the abuse to speed up their investigation so she could return to work sooner. Due to the facility's treatment of Resident #1 after the facility learned of the allegation of abuse, caused Resident #1 to become afraid…
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.
- Actual harm · G2023-10-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, interview and record review the facility failed to adequately monitor residents that had a high-risk for pressure ulcers for one of two residents reviewed (Resident #16). Resident #16 had a facility-acquired pressure on the bottom of his foot that was not discovered or documented until it measured over 7 centimeters in total area and was blackened. Despite Resident #16 receiving a bath the day before the discovery of the unstageable pressure wound, the staff denied knowledge of the wound. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also…
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.
- Potential for harm · Ecited before2026-05-07 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 4 out of 4 residents (Resident #3, #4, #6 & #8) reviewed from abuse. The facility reported a census of 35 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of depression, anxiety disorder and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the facility provided Incident Report dated 4/10/26 at 1:00 p.m., revealed Certified Nursing Assistant (CNA) reported that while giving the resident a bath the resident stated, I was eating in the living room but today I moved back to the dining room. She was asked why by the CNA. The resident responded I am afraid male resident is going to grope me. CNA verified the male resident. Resident continued to state last night…
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.
- Potential for harm · Dcited before2026-05-07 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 2 of 4 residents reviewed for abuse (Resident #3 & #6). The facility reported a census of 35 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of hypertension, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Interview on 5/5/26 at 10:44 a.m., with Resident #6 revealed she was sleeping in bed unclothed when that old man (Resident #7) came into her room. Resident #6 revealed he was sitting next to her bed and she asked him what he was doing and he leaned over and kissed her around her mouth area. Resident #6 again asked him what he was doing and he said come on and he kissed her again 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.
- Potential for harm · Dcited before2026-05-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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, policy review and staff interview the facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and resident to resident altercations for 2 out of 3 residents reviewed (Resident #1 and #4). The facility reported a census of 35 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During an interview on 5/5/26 at 11:16 AM, Staff E, Registered Nurse (RN) recalled a fall involving Resident #1 in April 2026. The RN remembered the resident attempted to walk from the bathroom to his wheelchair when he fell by the wheelchair. When asked about documenting the fall details, the nurse reported she hoped she performed them and thought she…
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.
- Potential for harm · Dcited before2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, clinical record review, and resident and staff interviews, the facility failed to ensure that a resident who experienced a fall received the necessary care and services to maintain their highest practicable physical well-being. For 1 of 3 residents reviewed (Resident #1), nursing staff failed to conduct a thorough assessment, implement immediate interventions, perform required neurological checks, or notify the resident's physician and family following an unwitnessed fall for 1 of 3 residents reviewed (Resident #1).Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During the interview on 5/4/26 at 3:40 PM, Staff A, Certified Nursing Assistant (CNA) stated she found Resident #1 on the floor near the wheelchair upon…
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.
- Potential for harm · Dcited before2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, family and staff interviews, the facility failed to provide appropriate supervision to ensure each resident's individual safety while using the commode for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 35 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of dementia, anxiety disorder, and repeated falls. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The Care Plan for Resident #2 indicated a risk for falls due to increased restlessness and anxiety. Resident #2 was documented as non-ambulatory and required assistance with a stand lift, though the resident expressed a preference for using the commode. During an interview on 5/5/26 at 11:05 AM, Resident #2's roommate recalled an incident on the night before Easter when Resident #2 waited on the commode around bedtime. The roommate noted that Resident #2 did not…
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.
- Potential for harm · Dcited before2026-05-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 and staff interviews, the facility failed to provide and maintain accurate resident records to reflect incidents that occurred in the facility for 2 of 3 residents (Residents #1 and #6). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During the interview on 5/4/26 at 3:40 PM, Staff A, Certified Nursing Assistant (CNA) stated she found Resident #1 on the floor near the wheelchair upon entering the room. Resident #1 reported losing his footing and falling while walking from the bathroom to his wheelchair. Staff A reported the incident occurred between 7:00 and 7:15 AM on the second or third Sunday of April 2025, before Resident #1 ate breakfast and attended…
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.
- Potential for harm · E2025-12-31 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents (Residents #3, #9, and #12) reviewed. The facility reported a census of 35 residents.Findings include: 1. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview 12/29/2025 at 10:56 AM with Resident #9 revealed that the food is not always hot when it is delivered on the meal tray. 2. Review of Resident #12's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview 12/29/2025 at 1:00 PM with Resident #12 revealed that food is absolute garbage at the facility, and is always cold. Continuous observation 12/30/25 from 11:19 AM until 12:14 PM dining service was completed in the dining room. Pre-temp meal temperature on the food items in the steam table revealed gravy was 161 degrees, mashed potatoes were 170.9 degrees, spinach…
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.
- Potential for harm · Dcited before2025-12-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to oxygen use for 1 of 5 residents (Resident #9) reviewed. The facility reported a census of 35 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of hypertension (high blood pressure), renal insufficiency, and anxiety disorder. Review of a facility provided document titled, Order Summary Report with a date of 12/17/25 revealed a physician's order with a start date of 11/13/25 for oxygen continuously at 2 liters to keep oxygen saturation above 90% every shift for shortness of breath, and hypoxemia (a medical condition with abnormally low oxygen levels in the blood). Review of Resident #9's Care Plan with a revision date of 11/13/25 revealed no focus, goals, or interventions for oxygen utilization.Interview 12/30/25 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.
- Potential for harm · Dcited before2025-12-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, interview and record review the facility failed to provide thorough and timely assessment and intervention for 1 of 16 residents reviewed. Resident #24 was diagnosed with Covid-19 and was admitted to the hospital with pneumonia. The resident returned to the facility on 11/25 and the staff failed to assess the resident's Vital Signs (VS; heart rate, oxygen saturation, blood pressure and respirations) until 12/4/25 when she was found to have a change in condition, including low blood pressures. The resident was sent back to the hospital on [DATE]. The facility reported a census of 35 residents. Findings include:According to the Minimum Data Set (MDS), Resident #24 was admitted to the facility on [DATE]. She had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) Resident #24 required substantial assistance with sit to stand transfers, and was totally dependent on staff for dressing, toileting and showering. The resident was on oxygen therapy as needed. Her…
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.
- Potential for harm · Dcited before2025-12-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings include:Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document provided resident diagnoses of Post polio syndrome, neuromuscular dysfunction of bladder and Raynaud's Syndrome. The document disclosed the resident had an indwelling catheter and ostomy.Resident #3's Care Plan dated 12/18/25 revealed a focus of urinary catheter suprapubic 16fr with 10cc bulb initiated 12/16/24 and revised 6/9/25. Interventions dated 12/16/24 and 4/11/25 included monitoring kinks, encouraging fluids, enhanced barrier precautions (EBP) An additional focus area identified risk for urinary tract infection (UTI) related to suprapubic…
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.
Show the remaining 25 citations
- Potential for harm · D2025-12-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 4 residents reviewed (Residents #9) requiring the use of oxygen. The facility reported a census of 35 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of hypertension (high blood pressure), renal insufficiency, and anxiety disorder. Observation on 12/29/2025 10:58 AM Resident #9 was observed to be utilizing oxygen via a concentrator at 2 liters by nasal cannula at that time. It was also observed that the oxygen tubing was not dated. Interview on 12/29/25 at 10:58 AM with Resident #9 revealed that Resident #9 was unsure as to when the staff last changed the oxygen tubing. Review of Resident #9's Electronic Healthcare Record…
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.
- Potential for harm · Dcited before2025-02-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance as scheduled for 3 of 4 residents reviewed for bathing (Resident #2, #6 and #9). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented a new admission to the facility from the hospital. The Medical Diagnosis report for Resident #2 showed a diagnoses of Diabetes Mellitus, diabetic ulcer and pain in the lower leg. The Care Plan with an initiated date of 2/19/25 for Resident #2 showed the resident required assistance from one person for bathing. In an interview on 2/24/25 at 4:33 PM, Resident #2 reported he doesn't want to get anyone in trouble but hasn't been offered a bath since admission on [DATE]. When asked if he refused a bath Resident #2 stated, I was never offered one, so I couldn't refuse one. The Documentation Survey Report dated February 2025 showed the resident…
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.
- Potential for harm · Dcited before2025-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interviews, and policy review the facility failed to complete assessments for the necessary care and services to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff failed to perform neurological assessments for 1 out 3 residents reviewed for falls (Resident#1). The facility reported a census of 32 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of polyneuropathy, muscle weakness and repeated falls. The MDS showed the BIMS score of 9, which indicated moderate cognitive impairment. The Progress Notes for Resident #1 revealed the resident had unwitnessed falls on the following dates: a. 2/17/25 b. 2/18/25 c. 2/19/25 The neurological assessments for Resident #1 revealed the facility failed to complete and/or properly complete neurological assessments on the following dates: a. 2/17/25 b. 2/19/25 c. 2/20/25 The neurological assessment policy…
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.
- Potential for harm · Dcited before2025-02-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, clinical record review, resident, family and staff family interviews, the facility failed to provide an environment that is free from accidents and hazards for 2 of 2 residents reviewed (Resident #1 and #10). The facility reported a census of 32 residents. Findings include: In an interview on 2/20/25 at 2:38 PM, Staff C Certified Nursing Assistant (CNA) stated Resident #10 kept pulling on TV wires thinking it was the call light and almost pulled the TV off the wall, Resident #10 was directly below the TV. In an interview on 2/20/25 at 3:52 PM, Resident #1's family stated, the TV cords were close to the call lights. Mom kept pulling on the TV cords. She thought it was the call light. The TV is over the bed. We were afraid she was going to pull down the TV. Observations on 2/24/25 at 1:50 PM showed Resident #1's TV cords hanging down from the TV and inches from the call light string. The TV hung over the resident's bed. Observations on 2/24/25 at 1:55 PM showed Resident #10's TV cords hanging down from the TV and inches from the call light string. The TV hung…
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.
- Potential for harm · D2025-02-25 · tag F0725 — failed to have enough nursing staff — isolatedProvide 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 facility record review and resident and staff interviews, the facility staff did not consistently answer call lights within a reasonable amount of time. Residents reported having to wait over 15 minutes for call lights to be answered for 3 of 3 residents reviewed (Resident #6, #7 and #9). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool with the assessment reference date of 1/30/25 for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS indicated Resident #6 dependent for transfers, toileting and bathing. The MDS identified a diagnoses of difficult walking and muscle wasting. The Care Plan identified Resident #6 required a mechanical stand for transfers. In an interview on 2/25/25 at 9:28 AM, Resident #6 reported she waited over 15 minutes for call lights 1-4 times a day. Resident #6 reported she used a mechanical device for assistance with transfers 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.
- Potential for harm · Ecited before2025-01-15 · tag F0657 — failed to keep the care plan current — patternDevelop 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 observations, interview, and record review, the facility failed to review and revise care plans for four out of four residents reviewed (Residents #3, #11, #21 and #26). Specifically, the facility failed to identify the targeted behaviors for residents that received anti-psychotic, antidepressant and psychotic medications.The facility reported a census of 27 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #3 documented diagnoses of anxiety disorder, depression, dementia.The MDS showed a BIMS score of 15, which indicated no cognitive impairment. Review of the MDS dated [DATE] revealed Resident #3 is taking antipsychotic medications, and antidepressant medications in the review period. The Clinical Orders and Medication Administration Record for January 2024 for Resident #3 showed: a. Duloxatine started on 1/6/23 for anxiety b. Aripiprazole started on 7/19/23 for major depression. The care plan for Resident #3 failed to include the behaviors resident displayed,…
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.
- Potential for harm · E2025-01-15 · tag F0851 — patternElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 27 residents. Findings include: The PBJ Staffing Data Report with a run date 1/8/25 triggered for Excessively Low Weekend Staffing and One Star Staffing Rating. Review of Facility Daily Assignment Sheets revealed staffing for nurses and certified nursing assistants (CNAs) scheduled an extra CNA on weekdays to complete baths, and the Director of Nursing worked extra shifts on the nights and weekends. The Reporting Direct-Care Staffing Information (Payroll-Based Journal) policy October 2017 identifed staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Policy Interpretation and Implementation: 1. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016),…
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.
- Potential for harm · Dcited before2025-01-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, infection control policy, clinical record review and staff interview, the facility failed to conduct blood sugar tests in a manner that protected the resident from blood borne pathogens for 2 out of 2 residents reviewed (Resident #3 and #15). The facility reported a census of 27 residents. Findings included: 1. Observation on 1/14/25 at 11:32 AM Staff A, Licensed Practical Nurse (LPN), entered Resident #15 ' s room with a bag of supplies for a blood sugar test. Staff A placed testing supplies directly on Resident #15 ' s bedside table. Staff A failed to place a barrier between the surface of the bedside table and testing supplies. Staff A placed the blood testing strip into the glucometer. Staff A applied gloves, cleansed the resident's finger with an alcohol swab, allowed the solution to dry, then lanceted the resident ' s finger. Staff A collected a sample of blood using a testing strip. Staff A placed the glucometer back on the resident's table without a barrier. After the glucometer measured the blood sugar results Staff A removed the blood sugar strip from…
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.
- Potential for harm · D2024-01-04 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 clinical record, facility policy, resident, and staff interview, the facility failed to follow dentist referral to obtain specialty dental services for 1 of 3 residents reviewed (Resident #93). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #93 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS assessed the resident as having the following diagnoses: heart failure (may result in fluid buildup within the body creating difficulty in breathing) and asthma (COPD, chronic obstructive pulmonary disease) or chronic lung disease (may result in difficulty breathing). The resident required oxygen therapy and used a walker for assistance in walking. The resident's MDS dated [DATE] revealed she required the limited assistance of 1 person for personal hygiene which includes brushing her teeth. The MDS dated [DATE] revealed the resident obvious or likely cavity or broken natural teeth. 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.
- Potential for harm · E2023-11-20 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 interviews and record review the facility failed to ensure they provided adequate administration services. Upon allegations of abuse, the administrator failed to conduct a thorough investigation, failed to report the allegations to the proper authorities, and abruptly discharged the resident who made the allegation (Resident #1). The facility reported a census of 30 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), 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.
- Potential for harm · D2023-11-20 · tag F0660 — isolatedPlan 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 clinical record review, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to discharge planning for 1 of 3 residents reviewed. Resident #1 was discharged abruptly after allegations of abuse and was sent to a homeless shelter that was unaware that she was coming and could not meet her medical needs. The facility reported a census of 30 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic…
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.
- Potential for harm · E2023-10-19 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 observation, interview and record review the facility failed to ensure that staff accounted for narcotic medications upon shift change. The facility reported a census of 29 residents. Findings include: A review of the shift change Controlled Drugs Account Record revealed the following gaps in nurse signatures: 1. From 8/15/23 - 8/24/23; 11 signatures missing. 2. From 8/27/23 - 9/11/23; 7 missing signatures 3. From 9/27/23 - 10/11/23; 10 missing signatures On 10/17/23 at 6:58 AM Staff M, Registered Nurse (RN), explained the shift change process related to narcotics is that the nurses count all the narcotics with a second nurse, then sign the back of the narcotic count book. She acknowledged that this did not always get done and the nurse sometimes forget to sign the book. She reported that the facility did have one time that the count was off. On 10/19/23 at 12:01 PM the Administrator said she expected the nurses to count the narcotics and sign the narcotic book at shift change. The Controlled Substances policy dated April 2019 directed to reconcile controlled substances…
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.
- Potential for harm · D2023-10-19 · tag F0583 — failed to protect personal privacy — isolatedKeep 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, interview and record review the facility failed to protect a resident's right to privacy for one of one resident reviewed (Resident #1). Due to the resident's treatment of Staff H, Certified Nurse Aide (CNA), he recorded an interaction with Resident #1 without her permission. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed that she had moderate difficulty hearing, the speaker has to increase their volume and speak distinctly. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive ability. She required extensive assistance from one person for bed mobility, dressing and toilet use. The Care Plan included the following Focus Areas revised: a. 3/7/32: Resident #1 required assistance with some activities of daily living (ADLs) due to decreased range of motion (ROM) in bilateral shoulders and a balance problem. b. 3/29/22: Resident #1 had a behavior problem due to being impatient and short with staff 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.
- Potential for harm · Dcited before2023-10-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observations, electronic record review, policy review, and staff interviews the facility failed to provide a comprehensive care plan for 2 of five resident reviewed (Residents #3 and #33). Resident #3's Care Plan lacked her use an opioid (controlled pain medication) to manage her pain or that she had pain. Resident #33's Care Plan lacked that she used TED hose (stockings to prevent blood clots and swelling). Finding include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS identified a diagnosis of chronic migraine without aura (a headache that lasts for more than 72-hours and does not have the typical sensory or visual disturbances that happen before a migraine attack). The MDS indicated that Resident #3 used an opioid 7 out of 7 days in the lookback period. Resident #3's October 2023 Medication Administration Record (MAR) included an order dated 4/29/23 for Tramadol 50 mg. 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.
- Potential for harm · Dcited before2023-10-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observation, interview and record review the facility failed to include pertinent physician information in the Care Plan for 1 of 15 residents reviewed (Resident #33). On 7/25/23 Resident #33 admitted to the facility and the staff did not know that he had a penile implant. According to a hospital report on 10/17/23, Resident #33 went to the emergency room with penile pain and concerns with his urinary catheter. The hospital report indicated that Resident #33's implant malfunctioned. Findings include: Resident #33's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 7/25/23. The assessment identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #33 required extensive assistance from one person with dressing and hygiene. Resident #33 required total dependence from two staff for bathing. The MDS included diagnoses of adult failure to thrive, acute cystitis with hematuria (urinary tract infection with blood), type 2…
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.
- Potential for harm · D2023-10-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observations, interviews, record review, and policy review the facility failed to follow physician's orders for one of two residents' reviewed (Resident #33). In addition to not following the physician's orders, the facility documented that they completed Resident #33's order. Findings include: Resident #33's MDS assessment dated [DATE] identified a BIMS score of 8, indicating moderately impaired cognition. The MDS indicated that Resident #33 required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use. The Clinical Physician's Orders reviewed on 10/18/23 at 12:20 PM included an order dated 8/5/23 for Resident #33 have TED hose (stockings to prevent blood clots and swelling) put on in the morning and removed in the evening. On 10/16/23 at 12:16 PM observed Resident #33 sitting in her room in a chair with swollen feet and ankles. She said that she needed assistance with applying her TED hose. She pointed in the bathroom where they hanged on a towel rack. She said…
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.
- Potential for harm · Dcited before2023-10-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observations, interviews, clinical record reviews, and facility policies, the facility failed to change the urinary catheter for a resident for one of two residents reviewed for catheter care (Resident #16). Resident #16 had an order to change his catheter every thirty days. In August 2023, the facility failed to change Resident #16's urinary catheter, his clinical record lacked documentation until 10/15/23 that his catheter got changed. On 10/19/23, Resident #16 went to the hospital for groin pain, while there the Urologist discovered a kidney stone and cystitis (inflammation of the bladder). Due to the possibility of the bladder stone blocking the kidney's ureter that brings the urine to the bladder, Resident #16 received a stent. The Urologist indicated that the kidney stone developed due to no one changing his urinary catheter. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 7/25/23. The assessment identified a Brief Interview for 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.
- Potential for harm · D2023-10-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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, policy review, resident interview and staff interview, the facility failed to prevent a significant medication error for one of 3 residents reiviewed (Resident #87). Resident #87 admitted to the facility with orders for insulin gargaline (slow acting insulin) to receive once a day with breakfast the day after her admission. That morning on 2/21/23, the nurse gave Resident #87 her 16 units of insulin gargline. That afternoon, another nurse added the same order for insulin gargaline but for the hour of sleep (HS). At bedtime, Resident #87 received her second dose of 16 units of insulin gargaline that day, bringing the total insulin to 32 units for the day (double her dose). Findings include: Resident #87's Minimum Data Set (MDS) assessment dated [DATE] listed an lacked a Brief Interview for Mental Status (BIMS) score. She required extensive assistance from two persons for bed mobility, dressing, and toilet use. In addition, she required total assistance with eating and hygiene.…
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.
- Potential for harm · D2023-10-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observations, interviews, facility policy review, and clinical record reviews the facility failed to secure medications in a locked compartment for 2 of 3 residents reviewed (Residents #3 and #1). Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS identified a diagnosis of COPD (chronic lung disease that affects breathing). On 10/16/23 at 11:25 AM observed medications left on Resident #3's tray table of a red hand held inhaler. On 10/16/23 at 11:37 AM watched Staff B, Registered Nurse (RN)/Assisted Living Program Coordinator, enter the room to remove the medication. Resident #3's October 2023's Medication Administration Record listed an order dated 6/7/23 for Budesonide-Formoterol Fumarate inhalation aerosol 2 puffs to be inhaled orally twice a day related to the COPD. On 10/18/23 at 12:36 PM Staff B explained that Resident #3's Budesonide should be stored 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.
- Potential for harm · D2023-10-19 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual 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 document review, observation, record review, and staff interview the facility failed to prepare food in a form designed to meet the resident's individual needs by sending the incorrect consistency for a modified diet ordered for 2 of 2 residents reviewed (Resident #4, and #26). Findings include: 1. Resident #4 Minimum Data Set (MDS) assessment dated [DATE] initiated a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment. The MDS listed a diagnosis of dysphagia. The Clinical Physician Orders reviewed on 10/19/23 listed an order dated 12/30/22 of a regular, no added salt, mechanical soft texture level 0 thin consistency diet. Resident #4's Lunch Menu dated 10/18/23 reflected a shredded lettuce salad and dressing. 2. Resident #26's MDS assessment dated [DATE] identified a BIMS score of 00, indicating severe cognitive impairment. The Clinical Physician Orders reviewed on 10/19/23 listed an order dated 6/6/23 of a regular, no added salt, mechanical soft texture level 0 thin…
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.
- Potential for harm · Ecited before2023-08-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 observation, interviews and record review the facility failed to provide timely incontinence care for 4 of 4 residents reviewed (Residents #3, #4, #5, #6). Staff reported that on several occasions when they arrived on the morning shift many of the residents required a complete bed change because they were soaked with urine. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] indicated that she required extensive assistance from two persons for transfers, toilet use, and dressing. The MDS listed her as frequently incontinent of bowel and bladder. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified a score of 13, indicating intact cognition. On 8/23/23 at 10:32, Resident #4 said that sometimes she woke up in the morning and be very wet. She said that she slept through the night most of the time, but there are times when the bed was soaked by morning. When asked how that made her feel and she said wet. The Care Plan Focus revised 12/14/20 indicated…
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.
- Potential for harm · Dcited before2023-08-24 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews, record and policy review the facility failed to report an unusual occurrence as required by state and federal law. Resident #1 left the facility in his wheelchair, at night, unattended, and was found by an off-duty staff member near a busy highway. The facility failed to report this elopement. The facility reported a census of 38 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use. He used a manual wheelchair most of the time. The MDS included diagnoses of multiple sclerosis (MS), anxiety disorder, and depression. The Care Plan Focus revised 3/26/23 indicated that Resident #1 used antianxiety medication related to an anxiety disorder. Due to his diagnoses and personality, he is very stubborn and does not ask for help at all. The Interventions…
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.
- Potential for harm · D2023-08-24 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 interview, clinical record review, and policy review the facility failed to ensure that a resident on Medicare A services (skilled nursing services) saw an attending physician, not a non-physician practitioner (NPP, Nurse Practitioner, Physician's Assistant, or a clinical nurse specialist), within the first 30 days of admission for 1 of 3 residents reviewed (Resident #1). Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 2/24/23 from an acute hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use. He used a manual wheelchair most of the time. The MDS included diagnoses of multiple sclerosis, anxiety disorder, and depression. Resident #1's Census listed an admission date of 2/24/23 under Medicare A services (skilled services). The Occupational Therapy (OT) OT Evaluation 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.
- Potential for harm · Dcited before2023-08-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 and interviews that facility failed to include physician progress notes in the resident's records for 2 of 3 residents reviewed (Residents #1 and #3). Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 2/24/23 from an acute hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use. He used a manual wheelchair most of the time. The MDS included diagnoses of multiple sclerosis, anxiety disorder, and depression. Resident #1's clinical record review lacked documentation of physician visits. 2. Resident #3's MDS assessment dated [DATE] listed an admission date of 6/4/23. The MDS identified a BIMS score of 1, indicating severely impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, toilet use, and walking. Resident #3's…
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.
- Potential for harm · Dcited before2023-08-24 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 observation, interview and chart review the facility failed to implement infection control measures to mitigate the spread of pathogens for 1 of 3 residents. The facility reported a census of 38 residents. Findings include: Resident #5's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, toilet use, and locomotion. The MDS listed him as always incontinent of bowel and bladder. The Care Plan Focus dated 9/23/21 indicated that Resident #5 required staff assistance for all activities of daily living (ADL's). The Intervention related to toilet use indicated that Resident #5 used a standing mechanical lift to use the toilet. On 8/23/23 at 9:18 AM watched Staff L and Staff K provide incontinence care for Resident #5 due to his incontinence of bowel and bladder. Staff L used disposable wipes to clean the feces (poop) off the backside 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.
“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.
- 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.
Fines & penalties
$60,316 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $28,677 — penalty dated 2023-10-19
- $31,639 — penalty dated 2023-08-24
- Medicare payment denial — starting 2023-11-17 for 55 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.
Part of a chain
This home belongs to CARE INITIATIVES — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.9 | -1.9 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 3.7 | -0.7 vs chain |
The other 42 homes this chain runs (chain average 2.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CARE INITIATIVES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/12/2010 |
| COMPUTERSHARE CORPORATE TRUST COMPANY, NA | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 02/01/2025 |
| BEAL, MICHAEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 06/01/2020 |
| BOWEN, LANE | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| CAROTHERS, MARY JANE | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| CHILDS, KEVIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| CORLESS, PETER | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| KREIN, KEITH | Individual | CORPORATE DIRECTOR | — | since 06/29/2022 |
| RUST, ELIZABETH | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| STURM, DENISE | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| UPMEYER, LINDA | Individual | CORPORATE DIRECTOR | — | since 06/29/2022 |
| DIXON, DAVID | Individual | CORPORATE OFFICER | — | since 06/01/2016 |
| DRAKE, EMILY | Individual | CORPORATE OFFICER | — | since 01/04/2023 |
| GILYARD, TANYA | Individual | CORPORATE OFFICER | — | since 05/23/2025 |
| KUHN, JERAMY | Individual | CORPORATE OFFICER | — | since 06/25/2008 |
| MCDYER, JESSICA | Individual | CORPORATE OFFICER | — | since 02/01/2024 |
| BOEVE, DESTINY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| GIJIMA, DESIRE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| LANGE, BARBARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/28/2025 |
CMS files one row per role, so the 23 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $309K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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
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.
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 165323. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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.