Ramsey Village
1611 27TH Street, Des Moines, IA 50310 · Non profit - Other · 78 certified beds · (515) 274-3612 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.0% | 17.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.8% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 24.4% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.9% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.7% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 25.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.2% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 9.6% | 73.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.2% | 20.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.0% | 13.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.54 | 1.49 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.71 | 2.08 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 31.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 64 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.5%CMS range 33.6–53.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.1–13.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 31.2% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 28.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 20.3% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 2.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.5–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 78 beds and averages 68.4 residents a day — about 88% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.59 hrs/resident/day on weekends vs 4.23 on weekdays — 15% thinner on weekends. RN hours go from 0.57 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2025-04-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and policy review, the facility failed to appropriately provide assessments and interventions for necessary care and services for 1 of 4 residents reviewed (Resident #1). Clinical record review revealed the Assistant Director of Nursing notified the nursing staff of a wound on Resident #1's left foot after admission. The nurse failed to conduct an assessment and failed to notify the provider to acquire an intervention for 48 days after admission. The facility reported a census of 61 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that Resident #1 admitted to on 9/23/25 from Home/Community (e.g., assisted living). This MDS documented that Resident #1's diagnoses included diabetes, Alzheimer's disease, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without damage to the spinal cord), bipolar disorder, and polyneuropathy (nerve damage that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, pharmacy record review and policy review, the facility failed to follow professional standards regarding following physician's orders by failing to remove previously applied fentanyl patches after 72 hours of use and before applying new patches, putting residents at risk of an overdose for 1 of 3 residents (Resident #1) reviewed for medication administration. The facility reported a census of 69 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed, Resident #1's Brief Interview for Mental Status (BIMS) of 14, indicating cognitively intact. Resident #1's diagnoses include coronary artery disease, respiratory failure with hypoxia, history of polio resulting in chronic pain, muscle wasting and atrophy, anxiety, depression, and PTSD with dependence of two for assistance with a mechanical lift for ambulation and use of wheelchair for mobility. Resident #1's MDS included antipsychotics, antidepressants, diuretic, opioid and anticonvulsant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, staff interview, and policy review, the facility failed to ensure mechanical lifts were used correctly during transfers for 3 of 5 residents (#1, #4, #5). The facility failed to lock wheelchairs during resident transfers for 2 of 5 residents (#2, #4), and failed to ensure foot pedals were attached while transporting a resident in a wheelchair for 1 of 5 residents (#3). The facility reported a census of 69 residents.Findings include:. 1. The Minimum Data Set (MDS) for Resident #1 dated 9/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of end-stage renal disease, Alzheimer's Disease, non-Alzheimer's dementia, lack of coordination, and abnormalities of gait and mobility. It indicated she was independent with eating, required setup assistance with oral hygiene, maximal assistance with toileting hygiene, bathing, upper body dressing, and all mobility except lying to sitting on the side of the bed, and was dependent with lower body dressing, footwear,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to provide repositioning and incontinence care for 1 of 3 residents (#6). The facility reported a census of 69 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of renal (kidney) disease, Alzheimer's Disease, non-Alzheimer's dementia, disorder of kidney and ureter, and need for assistance with personal care. The MDS documented that the resident required supervision with eating, maximal assistance with oral and personal hygiene, bathing, upper body dressing, and rolling left and right in bed, and was dependent with all other Activities of Daily Living (ADLs) and mobility. The MDS also indicated he was always incontinent of bowel and bladder.The Care Plan dated 12/15/22 and revised 8/28/24 documented the following; the resident had bladder incontinence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and policy review the facility failed to disinfect a mechanical lift after use between 2 of 2 residents, failed to perform hand hygiene during perineal care for 1 of 3 residents reviewed (#4), and failed to remove Personal Protective Equipment (PPE) before leaving a resident's room who was on Enhanced Barrier Precautions (EBP). The facility reported a census of 69 residents. Findings include:1. On 10/22/25 at 2:56 PM, Staff A, Certified Nurse Aide (CNA) and Staff E, CNA used a mechanical lift in a resident's room to transfer him from his wheelchair to his bed. After they completed the transfer, Staff E pushed the mechanical lift into the hallway and returned to the resident's room. The mechanical lift was not sanitized.At 3:16 PM, Staff F, Certified Medication Aide (CMA), took the mechanical lift into Resident #4's room to transfer him from his bed to his wheelchair and did not sanitize it. Staff F positioned the lift near Resident #4's bed and Staff F and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0880 — failed to prevent and control infections — patternProvide 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, staff interviews, guidance from the Centers for Disease Control (CDC) and facility policy review the facility failed to implement enhanced barrier precautions for one of one resident reviwed (Resident #4), and failed to perform appropriate hand hygiene during personal cares for three of three residents observed for toileting hygiene (Res #3, Res #4 and Res #61). The facility additionally failed to properly sanitize a full body mechanical lift between the usage of the lift between two residents. The facility reported a census of 62 residents. Findings include: 1. The admission Minimum Data Set (MDS) of Resident #4 dated 6/14/25 recorded the resident to require substantial/maximal assistance for toileting hygiene. The Care Plan of Resident #4 documented the resident had an indwelling urinary catheter, dated 6/10/25. Observation of transfer, toileting, and catheter care began on 8/27/25 at 10:13 am with Staff E and Staff I, Certified Nurse Aides (CNA) present. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 electronic health record review, staff interview, and policy review, the facility failed to notify the physician of blood sugars <60 for 1 of 1 residents reviewed for insulin use (Resident #22). The facility reported a census of 62. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 5/24/25, revealed Resident #22 with a Brief Interview for Mental Status score of 2, indicated severe cognitive impairment. Diagnoses on the MDS include diabetes, stroke, seizure disorder, and non-Alzheimer's dementia. Medications listed include an anticonvulsant and hypoglycemic (to lower blood sugar). The Medication Administration Report (MAR) on Resident #22 for August 2025 listed the use of a long acting insulin, Lantus 32 units, administered one time a day in the morning, and the use of a short acting insulin, Humalog, administered at meals three times a day in amounts based on blood sugar readings. Blood sugars are checked three times a day to correlate with meal service.The MAR for August…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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
Based on record review, staff interview, and policy review, the facility failed to identify target behaviors for psychotropic medications (medications that affect a person's mental state, emotions, and behavior) for 2 of 5 resident (#28, #50). The facility reported a census of 62. Findings include: 1. 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #28 dated 8/10/25 revealed a Brief Interview for Mental Status (BIMS) score was not established because the resident was rarely or never understood. The MDS documented diagnoses of cerebral infarction (tissue damage caused by lack of blood flow to the brain), non-Alzheimer's dementia, anxiety, depression, sarcopenia (age-related loss of muscle mass, strength, and function), and quadriplegia. It indicated the resident required setup assistance with eating, maximum assistance with oral and personal hygiene, upper body dressing, and rolling left-to-right in bed, and was dependent with all other Activities of Daily Living (ADLs) and other mobility. It further revealed the resident took antianxiety and antidepressant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to fully develop a comprehensive care plan for 3 of 17 residents reviewed (Resident #4, #28, & #50). The faciltiy reported a census of 62 residents. Findings include: 1. The admission Minimum Data Set (MDS) of Resident #4 dated 6/14/25 recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless; having trouble concentrating on things, and moving or speaking slowly or being fidgety or restless during the previous 2-week look back period. The MDS recorded diagnoses that included Alzheimer's Disease, Anxiety and Depression. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications during the prior 7 days of the lookback period. Section V of the MDS, The Care Area Assessment Summary (CAA) documented communication, behavioral symptoms, and pressure ulcer/skin integrity would be included on the resident Care Plan. The MDS question V0200B2 was signed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on electronic health record review, staff interview, and policy review, the facility failed to update the Care Plan for 1 of 17 residents reviewed (Resident #9) for the discontinued use of a diuretic. The facility reported a census of 62. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 6/8/25 revealed Resident #9 with a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's dementia, hypertension, and seizure disorder/epilepsy. The MDS noted the use of an anticonvulsant and no other high-risk drug. The Care Plan, with a target date of 9/14/25, listed the use of diuretic therapy for edema. This was initiated on 9/20/24. The Progress Noted dated 9/19/24 at 9:43 a.m. documented the use of Lasix, a diuretic, for three days due to edema (swelling) and tenderness to Resident #9's lower legs. The medication order history noted an order for Lasix from 9/19/24 to 9/22/24. The Order Summary Report, obtained on 8/28/25, did not list a current order for a diuretic. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of three residents reviewed for respiratory care (Resident #71). The facility reported a census of 62 residents.Findings include:The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #71 had diagnoses of anemia, congestive heart failure, chronic respiratory failure with hypoxia and obstructive sleep apnea. The MDS documented that the resident had oxygen therapy. The MDS documented a Brief Interview for Mental Status score of 14 out of 15 for the resident, which is a score for cognitive status skills intact.The Care Plan documented a problem with initiated date 8/19/25 as follows; Resident #71 had altered respiratory status and difficulty breathing requiring oxygen. The Care Plan lacked documentation on oxygen flow rate or delivery method. It also indicated that Resident #71 could use Continuous Positive Airway Pressure (CPAP) on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Dcited before2025-08-28 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, family interviews and staff interviews, the facility staff failed to provide sufficient staff to safely feed residents who required feeding assistance during three of three meals observed. The facility staff also failed to complete incontinence care for 1 of 2 residents reviewed for incontinence care (#2) in a timely manner. The facility reported a census of 62 residents.Findings include:1.On 8/25/25 at 1:30 pm, a family member of Resident #61 stated she comes to feed her family member daily every day for lunch and again for supper. She stated she feels if she is not there to feed him, he would not get feeding assistance. She added that when she arrives, there are other residents at the next table who require feeding assistance and often no staff is present, or if they are present, they are often on their phones rather than assisting the residents.On 8/26/25 at 5:25 pm, observation began for the evening meal. Resident #61 was at one table, with his family member assisting him to eat. Residents #8, #17, #23 & #64 were sitting at Table #2, all had meals in front…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview and manufacturer's instructions, the facility failed to prime an insulin flexpen prior to administering the insulin dose to ensure the proper amount of insulin administered for one of one residents observed who received insulin during medication pass (Resident #72). The facility reported a census of 62 residents.Findings include:The electronic health record (EHR) Medical Diagnosis list revealed Resident #72 had a diagnosis of Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene. The Order Summary for Resident #72 dated 8/27/25 included a physician's order for insulin Aspart 10 units subcutaneously (SQ) two times daily for diabetes started on 8/25/25. It also included a physician's order for additional insulin Aspart on a sliding scale based on Resident #72's blood sugar results three times daily for diabetes started on 8/25/25.The Medication Administration Record (MAR) dated 8/1/25 - 8/31/25 revealed an order for insulin 10…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0641 — isolatedEnsure 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, staff interview, and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of sixteen residents reviewed (Resident #4). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment completed on 9/13/24 revealed Resident #4 readmitted to the facility on [DATE] from the hospital and had a diagnosis of coronary artery disease. The MDS documented the resident took an anticoagulant medication during the 7-day look-back period. The Care Plan initiated on 4/18/23 revealed the resident on anticoagulant therapy but the problem was resolved (removed) from the Care Plan on 4/30/23. The Order Summary revealed Eliquis (Apixaban) (an anticoagulant) 5 milligrams (mg) by mouth two times a day for DVT (deep vein thrombosis) (blood clot) for three months started on 3/22/24 and discontinued on 6/22/24. The Medication Administration Record (MAR) revealed Eliquis 5 mg by mouth…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review the facility failed to develop and implement a comprehensive person-centered Care Plan for one of sixteen residents sampled (Residents #54). The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 admitted to the facility on [DATE] and had diagnoses of cancer and a pleural effusion. The assessment documented the resident took an antibiotic during the 7-day assessment look-back period and received IV (intravenous) (into a vein) medications during the 14-day look-back period. The Care Plan initiated on 9/3/24 and revised on 9/30/24 revealed Resident #54 on IV antibiotic therapy. The Care Plan directed staff to administer antibiotic medications as ordered by the physician, and monitor for the effectiveness and side effects of the medication. The Care Plan lacked information about the resident's PICC (peripherally inserted central catheter) line…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and policy review the facility failed to check and verify placement of a gastrostomy tube (g-tube) before medications and enteral feeding administered through the gastrostomy tube for one of one residents reviewed with a gastrostomy tube (Resident #117). Facility staff also failed to flush the gastrostomy tube with water after each medication administered. The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had diagnoses of sepsis due to e-coli (bacteria), gastroesophageal reflux disease (GERD), diabetes, and dysphagia. The MDS revealed the resident had coughing and choking during meals or when she swallowed medications, and had a tube feeding. The Care Plan initiated 9/19/24 revealed the resident required tube feedings. The Care Plan directed staff to check tube placement, check gastric contents/residual volume before each feeding started and hold the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide assessments and timely intervention regarding skin conditions and wounds for one of sixteen residents observed (Resident #15). The facility reported a census of 62 residents. Findings include: The quarterly Minimum Data Sample (MDS) for Resident #15, dated 09/06/2024, which documented relevant diagnoses of cancer, heart failure, diabetes mellitus (diabetes), cerebrovascular event, Non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, and depression. It documented her brief interview for mental status (BIMS) score as 12, indicating moderate cognitive impairment. The Care Plan, last revised 06/17/2024, revealed staff were to check all of the body for breaks in skin and treat promptly as ordered by doctor. It also revealed staff were to monitor and document any signs and symptoms of hyperglycemia, such as dry skin. A direct observation on 09/30/2024 at 03:09 PM revealed Resident #15 had a red lesion with a dark colored scab in the center on her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barrier precautions (EBP) practices for residents with indwelling medical devices for two of three residents reviewed for infection control (Resident #54 and Resident #117). The facility also failed to ensure infection control policy & procedure manual updated on an annual basis. The facility reported a census of 62 residents. Findings include: 1. Infection control manual review completed on 10/3/24 at 8:30 AM. The manual did not include a cover page to indicate the enclosed policies and procedures had been reviewed and approved annually. An interview on 10/3/24 at 8:45 AM, the Director of Nursing (DON) reported policies and procedures are approved annually during the facility's January Quality Assurance and Performance Improvement (QAPI) meeting. The DON provided a copy of January's QAPI sign-in sheet as well as a copy of a Record of Adoption form, which was not completely filled out. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility document review, and staff interview, the facility failed to treat a resident with respect and dignity when providing cares one of three residents reviewed for dignity (Resident # 9). The facility reported a census of 61 residents. Findings include: A Quarterly Minimum Data Set (MDS) Assessment documented Resident#9 had the diagnoses including non- traumatic brain dysfunction, dementia, high blood pressure, and stroke. The Brief Interview for Mental Status (BIMS) documented the resident scored a 3 out of 15, which indicated severe cognitive loss for daily decision making skills. The MDS revealed the resident required maximum assist of two staff members for transfers from surface to surface, and total dependence for cares including toileting, and showers. The MDS indicated that the resident used a manual wheelchair for moving about the facility with total dependence of staff. A facility Self Report dated 8/5/24 revealed Staff A, Certified Nurse Aide (CNA) reported an allegation that Staff B, Certified Medication Aide (CMA), while assisting a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, pharmacy & hospital record review, and staff interview, the facility failed to notify the physician when medication was unavailable and was not administered for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 61. Findings include: The Medical Diagnosis section of Resident #3 Electronic Health Record (EHR) reflected a diagnosis of Permanent Atrial Fibrillation (a condition where an irregular heartbeat can't be reset and no further treatments are attempted to restore a normal sinus rhythm). The admission Orders to the facility from the hospital, dated 3/20/24 reflected the resident had orders for: -Warfarin (a blood thinning medicine, used to treat and prevent blood clots, which can be caused by Atrial Fibrillation), 2.5 mg tablet, take 2 tablets each Monday. -Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday. The Coumadin Flow Sheet for Resident#3 documented as follows; The INR (international normalized ratio, a blood test to time how long it takes blood to clot) Result…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility document review, and staff interview, the facility failed to report suspected dependent adult abuse within the required two hour time frame for one resident (Resident # 9). The facility reported a census of 61 residents. Findings include: A Quarterly Minimum Data Set (MDS) Assessment documented Resident#9 had the diagnoses including non- traumatic brain dysfunction, dementia, high blood pressure, and stroke. The Brief Interview for Mental Status (BIMS) documented the resident scored a 3 out of 15, which indicated severe cognitive loss for daily decision making skills. The MDS revealed the resident required maximum assist of two staff members for transfers from surface to surface, and total dependence for cares including toileting, and showers. The MDS indicated that the resident used a manual wheelchair for moving about the facility with total dependence of staff. A facility Self Report dated 8/5/24 revealed Staff A, Certified Nurse Aide (CNA) reported an allegation that Staff B, Certified Medication Aide (CMA), while assisting a resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, pharmacy & hospital record review, staff interview, and facility policy review, the facility failed to transcribe and administer medication as ordered by the physician for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 61. Findings include: The Medical Diagnosis section of Resident #3 Electronic Health Record (EHR) reflected a diagnosis of Permanent Atrial Fibrillation (a condition where an irregular heartbeat can't be reset and no further treatments are attempted to restore a normal sinus rhythm). The Pharmacy Warfarin Consult, dated 3/19/24 documented the INR (international normalized ratio, a blood test to time how long it takes blood to clot) Goal to be 2-3. The admission Orders to the facility from the hospital, dated 3/20/24 reflected the resident had orders for: -Warfarin (a blood thinning medicine, used to treat and prevent blood clots, which can be caused by Atrial Fibrillation), 2.5 mg tablet, take 2 tablets each Monday. -Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Friday, Saturday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-20 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to notify the Long Term Care Ombudsman for 1 of 1 residents who transferred to the hospital (Resident #56). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #56 documented diagnoses of fractures and other multiple trauma, hip fracture, Alzheimer's disease, non-Alzheimer's disease and anxiety disorder. The MDS documented a Brief Interview for Mental Status (BIMS) should not be conducted as the resident was rarely/never understood. Review of MDS dated [DATE] documented Resident #56 was discharged to an acute hospital with return anticipated, unplanned. Review of MDS dated [DATE] documented Resident #56 had a re-entry to the facility 5/5/23. Review of Progress Notes for Resident #56 revealed the resident transferred to the hospital on 4/30/23 and returned to the facility 5/5/23. In an interview 7/20/23 at 8:30 AM, the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-20 · tag F0641 — isolatedEnsure 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, resident and staff interviews, direction from the Resident Assessment Instrument, and facility policy review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 17 residents reviewed for accuracy of assessment (Resident #16). Findings include: The Significant Change MDS dated [DATE] identified Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident had a psychotic disorder. The MDS failed to document the resident received any antipsychotic medication during the 7 day look back period. The Medicare 5 day MDS dated [DATE] failed to document the resident received any antipsychotic medication during the 7 day look back period. The Discharge MDS dated [DATE] failed to document the resident received any antipsychotic medication during the 7 day look back period. The Annual MDS dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-20 · tag F0644 — isolatedCoordinate 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 2 of 2 residents reviewed with a new mental health diagnosis (Residents #16 and #42). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #42 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severely impaired cognition. The MDS further documented the resident had diagnoses including depression, anxiety and psychotic disorder. The Care Plan for Resident #42 initiated 9/3/22 documented the resident had a diagnosis of depression. The Care Plan directed staff to administer antidepressant medications as ordered, monitor for side effects and monitor/document/report signs and symptoms of depression. Clinical record review revealed Resident #42 had diagnoses of major depressive disorder effective 12/8/22. The clinical record further revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to update the Comprehensive Care Plan care for 1 of 17 (Resident #16) residents reviewed for care plan completion and revision. Findings include The Significant Change MDS dated [DATE] identified Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated cognition intact. The MDS documented the resident had a psychotic disorder. The Comprehensive Care Plan, review date of 7/7/23 failed to reveal documentation the resident had a diagnosis of a psychotic disorder. The Care Plan also failed to reveal documentation of the resident taking an antipsychotic medication. The Care Plan documented the resident receives an anti anxiety medication. The Active Diagnosis List of Resident #16 documented the diagnosis of psychotic disorder with hallucinations due to known physiological condition was added to the Resident Record on 2/7/23. The Active Orders for Resident #16…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview and manufacturer's recommendation, the facility failed to administer insulin according to accepted standards of clinical practice for 1 of 2 residents reviewed for administration of insulin (Resident #37). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severely impaired cognition. The MDS documented the resident had diagnoses including diabetes mellitus (DM), non-Alzheimer's dementia and cerebrovascular accident (CVA) and received insulin injections 7 out of the past 7 days. The Care Plan revised 12/22/22 for Resident #37 revealed the resident had DM and was dependent on insulin and diabetes medication to manage it. The Care Plan directed staff to administer diabetes medication as ordered by the physician and to educate the resident and family the correct protocol for insulin injections. Review 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.
- Potential for harm · D2023-07-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observations, staff interviews and policy review, the facility failed to provide 1 resident (Resident #8) with sufficient fluid intake. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #8 dated 5/26/23 reflected the resident had highly impaired vision. The MDS identified a Brief Interview of Mental Status (BIMS) score of 1 out of 15 which indicated severe cognitive impairment. The MDS coded the resident received hospice level of care services. The Care Plan revised on 7/7/23 revealed Resident #8 to be legally blind. It directed staff to provide set up assistance for meals and to tell the resident where the items were at. On 7/17/23 at 10:51 am observed Resident #8 resting in bed. No water observed anywhere in area of Resident #8's portion of the room. On 7/18/23 at 10:00 am, observed Resident #8 again resting in bed with no water present. On 7/19/23 at at 11:59, observed Resident #8 received her lunch tray with 3 drinks served to her on the tray. On 7/19/23 at 3:13 pm, observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-20 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record and policy review the facility failed to answer call lights timely (within 15 minutes) for 3 of 5 residents reviewed (Resident #2, #31, and #68). The facility reported a census of 67 residents. Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #2, dated 6/6/23, identified the resident needed extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating mild cognitive impairment. During an interview on 7/18/23 at 11:27 AM, Resident #2 stated it frequently takes more than 15 minutes for staff to answer her call light. Review of facility document titled Ciscor OneSource, (facility call light log report) documented the following call light response times longer than 15 minutes from the time period of 7/3/23 - 7/18/23 for Resident #2: a.7/4/23 5:16 AM - 36:18 minutes. b. 7/6/23 4:19 PM - 31:57 minutes. c.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, facility document review, staff interviews and facility policy review, the facility failed to maintain accurate and complete records for controlled medications for 2 of 2 residents (Resident #8 & #57) reviewed for controlled medication review. Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #8 dated 5/26/23 identified a Brief Interview of Mental Status (BIMS) score of 1 out of 15 which indicated severe cognitive impairment. The MDS documented the resident received opioid medication on 3 out of 7 days of the assessment reference period. The MDS coded the resident received hospice level of care services. The Care Plan revised on 7/7/23 revealed Resident #8 had pain with pain medication being managed by the hospice team. The controlled drug record for Resident #8 revealed the order for the morphine sulfate was to administer 0.25 mls every 6 hours as needed for pain, dated 2/6/23. The MAR for Resident #8…
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.
- No harm found · B2024-10-03 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of 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, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, and policy review, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required timeframe for one of sixteen residents reviewed (Resident #58). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 5/12/24 revealed the Director of Nursing (DON) signed the assessment as completed on 5/15/24. The MDS assessment dated [DATE], revealed Resident #58 admitted to the facility on [DATE], and discharged from the facility on 5/22/24. The MDS assessment revealed the DON signed the assessment as completed on 6/2/24. The Electronic Health Record (EHR) software program revealed the 5-day MDS assessment completed on 5/15/24 but not submitted to CMS (Center for Medicare Services). The EHR also revealed the discharge return not anticipated MDS assessment dated [DATE] 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CLAREMONT HOUSE INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/31/2010 |
| GILL, DOUGLAS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/15/2010 |
| WALGENBACH, BRIAN E | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/15/2010 |
| CLAREMONT RETIREMENT MANAGEMENT SERVICES CORP | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/15/2010 |
CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165514. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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.