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Harmony Utica Ridge

3800 Commerce Blvd, Davenport, IA 52807 · For profit - Corporation · 115 certified beds · (563) 344-2000 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jun 20262 immediate-jeopardy citations$51,292 in federal fines
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $51,292 in federal fines (most recent 2024-06-13)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (63%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 4 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4626 Progress Dr · (563) 441-9100 · Call to confirm hours
Pharmacy
5225 Elmore Ave · (563) 344-9629 · Call to confirm hours
Grocery
Davenport0.4 mi
3805 E 53rd St
Park
3223 S Hampton Dr · (563) 344-4113 · Typically dawn to dusk
Place of worship
4601 Utica Ridge Rd · (563) 359-3765

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%17.1%15.4%typical
Long-stay residents who lose too much weight4.8%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.5%0.9%better
Long-stay residents with a urinary tract infection0.4%2.4%2.0%better
Long-stay residents with depressive symptoms3.1%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.8%3.8%3.3%better
Long-stay residents whose ability to walk worsened14.2%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.2%20.8%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%95.3%95.3%typical
Long-stay residents with pressure ulcers6.9%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control25.1%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table3.8%19.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%2.1%1.4%better
Short-stay residents given the seasonal flu vaccine86.9%73.3%79.4%typical
Short-stay residents rehospitalized after admission25.5%20.9%22.6%worse
Short-stay residents with an outpatient ER visit16.8%13.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.481.491.67better
Long-stay outpatient ER visits per 1,000 resident days1.192.081.80better

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

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

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

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

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

63.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 355 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.4%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
56.4%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 56.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 117 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.4%CMS range 57.3–67.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 10.3–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge91.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 4.8–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.37
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.34
RN hoursweekends
62.8%
Total nursing turnover
47.8%
RN turnover

How full it usually is: this home is certified for 115 beds and averages 93.9 residents a day — about 82% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 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 3.37 hrs/resident/day on weekends vs 3.87 on weekdays — 13% thinner on weekends. RN hours go from 0.81 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

11
deficiencies at the latest standard inspection (2026-05-14)
12
at the previous standard inspection (2025-04-21)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-06-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident, family and staff interviews, the facility failed to provide a wound assessment and intervention for 1 of 3 residents reviewed (Resident #16). A bandage over a wound to the right buttocks on Resident #16 was identified by nursing staff on [DATE] without prior documentation and without provider notification for a treatment order. Resident #16 required hospitalization on [DATE] for sepsis, an infected wound, Methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli (E.coli) and a Urinary Tract Infection (UTI). Resident #16 expired on [DATE]. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility identified a census of 89 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 10:00 AM. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Nurse education…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family and staff interview and facility failed to supervise and ensure a compromised resident (left sided weakness/paralysis) was safe from accidents when turned in bed, and the result was the subdural hematoma and death. (Resident #14). The facility reported a census of 99 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 2/22/24 at 1:50 PM. The IJ began on 2/20/24. Facility staff removed the Immediate Jeopardy on 2/22/24 at 4:34 PM by completing the following; a. At the direction of the center Quality Assessment and Assurance (QA&A) Committee, an investigation was initiated which included interviewing employees and interviewing like residents residing in the center beginning 2/20/24. b. A QAA meeting was held to review the incident and gather information on 2/20/24 and an addition QAA meeting was held on 2/21/24 to review and determine immediate action necessary and performance improvement plan. Like Residents identified as those residing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-09 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 and staff interview, and facility policy review, the facility failed to use non-pharmacological interventions prior to the administration of a medication prescribed for anxiety which caused for 1 of 1 resident (Resident #8) reviewed for chemical restraints to experience hypersomnolence (excessive sleepiness). The facility reported a census of 91.Findings includeReview of Resident #8's Minimum Data Set (MDS) annual assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included depression, adjustment disorder with mixed anxiety and depression, and insomnia.Review of Resident #8's Care Plan dated 10/09/24, revealed a Focus area to address Resident is at risk for pain related to diagnosis neuropathy and history of bilateral BKA (below knee amputation). Interventions included, in part:a. Encourage/Assist to reposition frequently to position of comfort. Initiated: 10/09/24.b.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interview, and facility policy review, the facility failed to document the outcome of weekly skin assessments and implement a new wound care order in a timely manner for 1 of 7 residents (Resident #1) reviewed for pressure ulcer care. The facility reported a census of 91.Findings include:Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below).Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-14 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to serve the correct portion size of the protein entree for 8 of 9 (Resident #1, #31, #43, #54, #77, #79, #89 and #96) residents with a mechanical soft diet order. The facility identified a census of 89 residents.Findings include:Review of the Week 1 Wednesday Noon Menu, approved by the Dietician directed to provide a 3- ounce (oz) portion of pork loin for the mechanical altered diet. The Diet Roster listed Resident #1, #31, #43, #54, #77, #79, #89 and #96 as receiving a mechanically altered diet. The Center for Medicare and Medicaid (CMS) Matrix provided by the facility listed Resident's #43 and #96 as having significant weight loss. During an observation of the Crow Creek Dining Room on 5/13/26 from the start of meal at 11:38 AM until 12:29 PM, Staff O, [NAME] used a #16 (2 Oz.) scoop to serve the ground pork loin to eight residents on the mechanical soft diet. During an interview on 5/13/26 at 12:56 PM, Staff O, [NAME] stated she used a #16 scoop for the ground pork…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, kitchen record review, facility policy review, the US Food Code (2017) and staff interviews, the facility failed to maintain clean and sanitary equipment in the main kitchen and in a kitchenette. The facility identified a census of 89 residents.Findings include:During the initial tour of the kitchen on 5/11/26 at 10:09 AM the following observations were made:a. A dried on black/brown substance 1.5 - 2 inches from the front of the stove running approximately 2.5-3-foot down the length of the stove. A dried on black/brown substance approximately 8-10 inches high in three areas and to the top of the stove backsplash in one area; all areas ran the entire length of the stove black splash. b. The walk-in cooler had 1-1.5 inches of a black substance running where the door seal connects to the cooler door around the entire cooler door frame and a build-up of a thick, black substance, along the cooler door threshold approximately four foot in length. c. A build-up of a black/brown/orange substance running approximately 4 feet down the front of the griddle.A revisit to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, facility policy review, staff and resident interviews the facility failed to determine if 1 of 1 resident (Resident #4) with an inhaler at their bedside could safely self-administer the medication. The facility reported a census of 89 residents.Findings include:Review of Resident #4's Minimum Data Set (MDS) assessment, dated 4/16/26 revealed a Brief Interview for Mental Status (BIMS) with a result of 15 out of 15, which indicated intact cognition. The list of diagnoses in the MDS included stroke, atrial fibrillation (irregular heartbeat), and asthma.Review of Physician Orders revealed an order for ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT (Albuterol Sulfate) inhaler to provide 2 puffs inhaled orally every 4 hours as needed for wheezing/SOB. Start Date: 3/2/26. Review of Resident #4's Care Plan, dated 5/2/25, revealed a Focus area to address Resident is at risk for ineffective breathing pattern r/t (related to) asthma. Interventions included, in part: Medications as ordered. Date Initiated:…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, Centers for Medicare and Medicaid Services (CMS) Long-term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interviews, the facility failed to ensure he Minimum Data Set (MDS) assessments coded accurately to reflect resident use of an indwelling catheter and use of an antidepressant and hypnotic for 2 of 2 resident (Resident #32 and Resident #83) reviewed. The facility reported a census of 89 residents.Findings Include: 1. Review of Resident #32's MDS assessment, dated 5/4/26, revealed an admission date of 4/29/26. The list of diagnoses included: neurogenic bladder (lose of control due to nerve damage); multiple sclerosis and depression. The MDS identified Resident #32 with no appliance (such as a catheter or ostomy). Review of a Hospitalist Progress Note, dated 4/27/27 revealed an Assessment/Plan section which included, in part: Neurogenic bladder MS on chronic foley catheter (name of an urinary catheter). Review of the electronic health…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, facility policy review and staff interview the facility failed to provide complete shaving care for 2 out of 2 residents dependent residents (Resident#1 and Resident #67) reviewed for activities of daily living care. The facility reported a census of 89 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 3/4/26, listed diagnoses of coronary artery disease and non-Alzheimer's dementia. The MDS Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated a severe cognitive impairment. The MDS also reflected Resident#1 required partial/moderate assistance for personal hygiene, including shaving.The Care Plan for Resident#1 dated 02/20/2024, directed assistance of 1 staff for grooming.During an observation on 05/11/2026 at 12:16 PM, Resident#1 facial hair appeared unkempt with several days' growth. During an observation on 05/13/2026 at 7:50 AM, Resident #1 sat in his wheelchair at the nurse's station. His facial hair appeared long on both sides of his face and longer on his chin. During an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, the facility failed to complete physician ordered treatments for 1 of 4 residents (Resident #4) reviewed for wound care. The facility failed to reported a census of 89 residents.Findings include: 1.Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified Resident #4 with the skin problem of moisture associated skin damage (often referred to as MASD, skin damage caused by prolonged exposure to moisture such as for example urine, or perspiration), with the need for treatments such as non-surgical dressings and ointments/medications. Review of Resident #4 Care Plan dated 5/2/25, revealed a Focus area which addressed At Risk for alteration in skin integrity related to impaired mobility, incontinence and DM (diabetes).MASD to groin, buttocks, perineum and abd (abdomen) folds. Will frequently refuse treatments,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview the facility failed to implement pressure reducing interventions per the wound nurse practitioner's recommendations for 1 of 2 (Resident #11) reviewed for pressure injuries. The facility identified a census of 89 residents.The CMS RAI Manual defines the following pressure injury (PI) (a pressure ulcer/injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful) stages:Stage 1: Non-blanchable Erythema: Intact skin with persistent red/blue/purple discoloration; color does not blanch.Stage 2: Partial Thickness Loss: Shallow, open wound with red-pink bed (no slough) or a serum-filled blister.Stage 3: Full Thickness Skin Loss: Subcutaneous fat may be visible, but bone/muscle is not exposed; slough (moist, stringy, dead tissue) may be…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, manufacturer guidelines and staff interviews, the facility failed to use the correct size full-body mechanical lift sling based on resident weight during a transfer for 1 of 3 (Resident #67) reviewed for accidents. The facility reported a census of 89 residents.Findings include:Review of Resident #67's Minimum Data Set (MSD) assessment dated [DATE], revealed a list of diagnoses which included stroke, dementia, and aphasia (inability or impaired ability to understand or produce speech) The Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated a severe cognitive impairment. The MDS assessed Resident #67 dependent for chair to bed transfer. The MDS listed the resident's weight as 183 pounds.Review of Resident #67's Care Plan dated 2/21/24, revealed a Focus area to address Resident requires assistance with ADL's (activities of daily living). Interventions included, in part: Transferring: assist 2;1 with hoyer (hoyer is a brand name of a mechanical lift…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · D2026-05-14 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to respond to a call light in a timely manner for 1 out of 4 residents (Resident 3#) reviewed for call lights. The facility reported a census of 89 residents.Findings include:Review of Resident #3's Minimum Data Set (MSD) assessment dated [DATE], revealed a list of diagnoses which included amputation, heart failure, and diabetes mellitus. The MDS listed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS assessed Resident#3 needed supervision or touching assistance for chair/bed to chair transfers. Review of Residents #3 Care Plan, dated 10/9/2024, revealed a Focus area to address Resident requires assistance with ADL's (activities of daily living - grooming, transfers, etc). Interventions included, in part: Transferring: 1:1 slide board to complete this ADL, and Call light within reach.Review of Resident Council Minutes, dated 2/2026…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review, and staff interviews, the facility staff failed to implement Enhanced Barrier Precautions when doing wound care for 1 of 4 residents (Resident #83) reviewed for infection control. The facility reported a census of 89 residents. Findings include:Review of Resident #83's Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive impairment. The MDS listed diagnoses of non-Alzheimer's dementia, urinary tract infection, and pressure ulcer, stage 3. Review of Resident 83's Care Plan revealed the following Focus area's:a. At risk for alteration in skin integrity related to impaired mobility and diabetes mellitus. admitted with a stage 3 pressure injury lt (left) buttock. Interventions included, in part: Administer Treatment per physician orders. Date Initiated: 3/25/26.b. EBP (enhanced barrier precautions - an infection control practice used to prevent 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-21 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on Payroll Based Journal (PBJ) review and staff interview, the facility failed to ensure accurate reporting of weekend staffing hours, resulting in a excessively low weekend staffing trigger for Quarter 1 2025 (October 1-December 31). The facility reported a census of 88 residents. Findings include: Review of the facility's PBJ report for Quarter 1 2025 (reported data from October 1-December 31 2024) revealed the facility triggered for excessively low weekend staffing for the time period. During an interview on 4/17/25 at 2:13 PM, the Administrator acknowledged they had not put agency hours in correctly. A facility policy to related to PBJ reporting requested. The facility reported they do not have such a policy.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility policy review, the facility failed to discard expired lettuce from refrigerator storage and failed to record evening meal temperatures for 3 of 7 days reviewed. The facility reported a census of 88 residents. Findings include: On 4/15/25 10:15 AM, the walk in refrigerator contained trays with multiple pre-filled side salads, covered with plastic wrap, dated 4/15/25. The walk-in refrigerator also contained a large plastic storage container, filled with shredded lettuce, dated 4/06/25, and labeled use by 4/13/25. On 4/15/25 at 1:00 PM, the Dietary Manager entered walk-in refrigerator and confirmed the container of lettuce had expired on 4/13/25. When queried if lettuce from expired container had been used for 4/15/25 lunch side salads, Dietary Manager stated, she did not know. Review of facility's meal temperature log, dated between 4/08/25 and 4/14/25, lacked record of temperatures for the food items served for evening meals on 4/11/25, 4/12/25, and 4/13/25. On 4/15/25 at 1:05 PM, Dietary Manager revealed expectation of all…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interviews, the facility failed to notify the provider of a weight change of 3 pounds or more in one day as ordered for 1 of 1 resident (Resident #67) in sample reviewed. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS listed diagnoses included: chronic systolic (congestive) heart failure; renal insufficiency, renal failure, ESRD (end stage renal disease), and non-Alzheimer's dementia. The MDS indicated the resident took a diuretic. Review of the Care Plan revealed a Focus area dated 5/6/24, for Resident #67 required the use of diuretic medication related to systolic CHF (congestive heart failure). The interventions dated 5/6/24 indicated to monitor for signs and symptoms of fluid defect and report to practitioner abnormal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 4 of 4 residents reviewed for quarterly MDS timeliness (Resident #1, Resident #10, Resident #34, Resident #61). The facility reported a census of 88 residents. Findings include: 1. Review of the quarterly MDS assessment for Resident #1, Assessment Reference Date (ARD) 3/5/25, revealed the assessment completed on 3/31/25. 2. Review of the quarterly MDS assessment for Resident #10, ARD 3/5/25, revealed the assessment completed on 3/27/25. 3. Review of the quarterly MDS assessment for Resident #34, ARD 1/22/25, revealed the assessment completed on 2/6/25. 4. Review of the quarterly MDS assessment for Resident #61, ARD 2/19/25, revealed the assessment completed on 3/6/25. On 4/17/25 at 3:31 PM, Staff J, MDS Coordinator explained infection control responsibilities had taken quite a bit of their time, and explained they should have asked for help. On 4/17/25 at 3:58 PM, the facility's Director of Nursing (DON) acknowledged timeliness of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 staff interview and clinical record review, the facility failed to ensure accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for unnecessary medications (Resident #26, Resident #34). The facility reported a census of 88 residents. Findings include: 1. Review of the MDS assessment dated [DATE], revealed Resident #34 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) which indicated intact cognition, and revealed the resident took antiplatelet medication. Review of the resident's January 2025 Medication Administration Record (MAR) lacked administration of antiplatelet medication. During an interview on 4/17/25 at 3:35 PM, Staff J, MDS Coordinator shown Resident #34's MAR, queried if resident on antiplatelets, and Staff J confirmed no. 2. The MDS assessment dated [DATE], revealed Resident #26 scored a 5 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS indicated the resident took a diuretic. Review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, the facility failed to include dialysis services and use of an anticoagulant in the Care Plan for 2 of 3 (Resident #3 and Resident # 83). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15. The MDS list of diagnoses included: fluid overload, coronary artery disease, and renal insufficiency requiring dialysis. Section O, Special Treatments, Procedures and Programs identified Resident #3 received dialysis services while a resident. Review of the admission Record revealed Resident #3 admitted to the facility on [DATE]. Review of Progress Notes revealed an Alert Note entered on 3/18/25 at 3:53 AM, which documented Resident #3 readmitted to the facility on [DATE] after a hospitalization. Review of the Order Summary Report dated 4/17/25, revealed an order for [Dialysis…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, clinical record review, and facility policy review, the facility failed to follow physician orders for treatment of left lower leg surgical site for 1 of 3 residents (Resident #87) reviewed for non-pressure injuries, when staff used an alternate treatment application to wound site during observation of wound care. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS identified surgical wounds and diagnosis of encounter for orthopedic aftercare. Resident #87 required surgical wound care, application of ointment or medication and application of non-sterile dressings. The Care Plan, dated 3/22/25, revealed Resident #87 had been at risk for alterations in skin integrity due to recent surgeries, resulting in open surgical wounds of left below the knee amputation with intervention to administer…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure foot pedals were utilized when residents transported in a wheelchair, and failed to ensure fall interventions were consistently implemented for 3 of 4 residents reviewed for accidents (Resident #16, Resident #66, Resident #310). The facility reported a census of 88 residents. Findings include: 1. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per the assessment, the resident utilized a wheelchair. Review of Resident #16's Care Plan dated 8/16/24, revealed Resident is at risk for falls related to right hemiparesis related to CVA (cerebrovascular accident) and decreased mobility. Interventions dated 8/16/24 included the following: Assist resident with ambulation and transfers as needed, bed is in a low position, and call light within reach. Additional 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews, the facility failed to ensure a indwelling catheter bag and tubing maintained in a position minimize the risk of a urinary tract infection for 1 of 1 residents (Resident #43) reviewed. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #43 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 out of 15. The MDS list of diagnoses included: neurogenic bladder (a condition where damage to the brain, spinal cord, or nerves affects bladder control), scoliosis (a condition where the spine curves abnormally, often appearing as an S or C shape), intestinal-genital tract fistulae (abnormal connections between the intestines and the genital tract). The MDS identified Resident #43 utilized an indwelling catheter. Review of the Care Plan, Date Initiated: 11/21/23 included a Focus area to address Suprapubic Catheter related to chronic urinary retention 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure availability of scheduled medications for a new administration and timely availability of an as needed pain medication for 1 of 3 residents (Resident #104) reviewed for pain management. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #104 admitted to the facility on [DATE]. The MDS list of diagnoses included: displaced tri-malleolar fracture (fracture involving 3 bones around the ankle) of right lower leg, malignant carcinoid tumors of other sites, and adjustment disorder with depressed mood. The MDS indicated Resident #104 prescribed an opioid (class of medications used to treat pain) during the last seven (7) days of the assessment. Review of hospital Discharge Summary Medications section, dated 1/24/25, revealed: a. New order for acetaminophen-hydrocodone (Norco 5-325 mg (milligrams) oral tablet. 1 tab Oral every 4 hours as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to implement Enhanced Barrier Precautions for one of one residents reviewed with an indwelling catheter (Resident #43). The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #43 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: neurogenic bladder (a condition where damage to the brain, spinal cord, or nerves affects bladder control), and intestinal-genital tract fistulae (abnormal connections between the intestines and the genital tract). The MDS identified Resident #43 utilized a suprapubic catheter. Review of the Care Plan, dated 4/1/24 identified Resident #43 with the problem of Enhanced Barrier Precautions and directed staff to wear a gown and gloves for high contact activities (such as emptying the catheter bag) During an observation on 4/15/25 at 7:23 AM, Resident #43 room equipped with a caddy hanging…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 the facility policy, the facility failed to provide documentation residents refused/accepted pneumococcal vaccine to 3 of 5 residents reviewed (Resident #16, #10, and #33). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The Review of the Immunization in the EMR (Electronic Medical Record) lacked documentation Resident #16 refused the pneumococcal vaccine. The Facility Unit Immunization Tracking Form revealed Resident #16 declined the pneumococcal vaccine. No date indicated when refused. The Facility lacked documentation of a declination/education provided to the resident/resident representative for the vaccine. 2. The MDS assessment dated [DATE] revealed Resident #10 scored a 4 out of 15 on the BIMS exam, which indicated cognition severely…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, the facility failed to implement infection control standards during wound care. After providing wound care, nursing staff did not remove an isolation gown prior to exiting a residents room to access a common medication cart drawer for supplies, and did not change gloves between wound care tasks for one of three residents observed (Resident #4). The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], diagnoses list included: obstructive uropathy (urine flow obstructed), septicemia (infection in blood), and non-Alzheimer's Dementia. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating a severe cognitive impairment. The MDS assessed Resident #4 dependent on staff for mobility, and transfers; and required substantial/maximal assistance with toileting, showers and repositioning. The MDS identified Resident #4 had one Stage II pressure ulcer, utilized an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, and staff interview the facility failed to submit a Change in Status Preadmission Screening and Resident Review (PASRR) assessment after two new mental health diagnoses were determined for 1 of 1 residents (Resident #38) reviewed. The facility reported a census of 89 residents. Findings include: The Minimum Data Set (MDS) for Resident #38, dated 6/28/2023, documented a Brief Interview of Mental Status (BIMS) of 12 indicating moderate cognitive impairment. A record review of Resident #38 PASRR, dated 1/11/2023, documented no diagnoses of Bipolar 2 disorder and schizophrenia. Record review of a untitled document of Resident #38 physician visit dated 9/21/2023 documented diagnoses of bipolar 2 disorder and schizophrenia. Record review of Resident #38 PASRR dated 6/10/2024, documented diagnoses bipolar 2 disorder and schizophrenia, the PASRR also documented Resident #38 will be evaluated for a Level II PASRR. The date on the PASRR revealed it was submitted to the PASRR agency during the survey During an interview on 6/13/2024 at 10:50 AM with the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, policy review, and resident and staff interview the facility failed to complete nursing assessments and monitoring of a resident before and after outpatient dialysis for 1 of 1 resident reviewed (Resident #72). The facility reported a census of 89 residents. Findings include: The Minimum Data Set (MDS) for Resident #72, dated 4/17/24, listed diagnoses of end stage renal disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. The MDS listed the Brief Interview for Mental Status (BIMS) with a score of 15 indicating no cognitive impairments. The MDS revealed Resident # 72 received dialysis. The Care Pan for Resident # 72 directed staff to check the fistula (a connection that's made between an artery and a vein for dialysis access) daily, identified the potential for bruising and hemorrhage due to anticoagulant (medication to keep blood from clotting) use. The Care Pan lacked direction for the nursing staff to provide an assessment for the resident before and after dialysis therapy. During an observation on 6/10/24 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-05 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, family and staff interviews and facility policy review, the facility failed to provide nail care to the feet of 3 of 3 residents reviewed (Residents #3, #12 and #13) and failed to provide showers twice weekly to 3 of 6 residents reviewed (Residents #14, #16, #17). The facility reported a census of 99 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 01 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (Kidney Failure). The MDS also identified Resident #3 required substantial/maximal assist from staff for toileting, personal hygiene and totally dependent on staff for lower body dressing, putting on and taking off footwear and transfers. On 3/7/23, the Care Plan identified Resident #3 with the problem of potential for skin impairment and directed staff to monitor/document location, size 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews and facility policy review, the facility failed to ensure staff treated residents with dignity and respect for two of four residents reviewed (Residents #4 and #7). The facility reported a census of 99 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] (prior to the incident) identified Resident #4 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: Heart Failure, Peripheral Vascular Disease and Renal Insufficiency. The MDS also identified Resident #4 required extensive staff assistance with bed mobility, dressing, toileting, personal hygiene and dependent on staff for transfers and showers. The MDS also identified Resident #4 as occasionally incontinent of urine and always incontinent of bowel. On 7/6/18, the Care Plan identified Resident #4 with the problem of urinary incontinence and directed staff to provide incontinent care as needed. It did not identify the need to use…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, family and staff interview, the facility failed to update the Care Plan for one of three residents reviewed (Resident #15). The facility reported a census of 99 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #15 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of two. The MDS documented the resident had the following diagnoses including Non-Traumatic Brain Dysfunction, Heart Failure and Diabetes Mellitus. The MDS also identified Resident #15 required substantial/maximal assist with repositioning, totally dependent on staff for transfers and showers. A review of the Facility Incident Report dated 8/21/23 documented of the following by Staff AA Registered Nurse (RN): This RN was asked to come to resident's room and assessed the area to left leg which was covered with a towel which had a moderate amount of blood on it. Skin tear is large half moon shape on inner surface of left calf. There was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and hospital record review, the facility failed to document a complete assessment of two of four residents reviewed (Residents #5 and #13). The facility reported a census of 99 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #5 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 and had the following diagnoses: Stroke, Coronary Artery Disease and Diabetes Mellitus. The MDS also identified Resident #5 required substantial/maximal staff assistance with oral hygiene, toileting, showers, upper body dressing, transfers and totally dependent on staff for lower body dressing, putting on and taking off footwear and walking. The MDS also identified Resident #5 did not have an indwelling urinary catheter. On 10/18/23, the Care Plan identified Resident #5 with the potential for bruising, hemorrhage due to antiplatelet use related to history of cardiac stent placement and directed staff to monitor 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-05-14 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the Certification and Survey Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), facility policy review, and staff interviews, the facility failed to ensure an effective QAPI program to address previously cited deficiencies which resulted in five deficiencies being re-cited during the current Health Recertification survey. The facility reported a census of 89 residents.Findings include:A review of the facilities 4/21/25 Statement of Deficiencies and Plan of Correction revealed the following citations: F641 (Accuracy of Assessments); F684 (Quality of Care); F689 (Free of Accident Hazards/Supervision/Devices); F812 (Food Procurement, Store/Prepare/Serve-Sanitary); F880 (Infection Prevention and Control)The Health Recertification survey completed on 5/14/26 resulted in the following citations: F641, F684, F689, F812, and F880.During an interview on 5/14/26 at 10:55 AM, the Administrator reported the facility worked on all previously cited deficiencies in the Quality Assurance Performance Improvement (QAPI) and all deficiencies continued…

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

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$51,292 in federal fines across 2 penalties.

  • $37,665 — penalty dated 2024-06-13
  • $13,627 — penalty dated 2024-03-05

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 LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA 3 of 5Clark ManorChicago, IL

Showing 40 of 88; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST26%since 04/01/2023
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST60%since 04/01/2023
OAKWAY OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 04/01/2023
BURKEN, SHERIIndividualW-2 MANAGING EMPLOYEEsince 04/01/2023
SHABAT, MENACHEMIndividualCORPORATE OFFICERsince 04/01/2023
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2023

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

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.

$9.6M
Net patient revenuemost recent cost report
+1.9%
Operating marginrevenue minus expenses
$514K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 19%Other / private 24%

This home reported $514K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$382per resident / day
operating cost
$11,608per month
≈ monthly operating cost
$389per day
avg. revenue, all payers

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

What families pay in IA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165575. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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