University Park Nursing And Rehabilitation Center
233 University Avenue, Des Moines, IA 50314 · For profit - Corporation · 91 certified beds · (515) 284-1280 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Jan 2025
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (98%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 3 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 | 14.5% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.9% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.3% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.4% | 4.2% | 6.5% | better |
| 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 | 2.3% | 3.8% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.1% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.8% | 20.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.1% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.1% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.5% | 19.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 73.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.9% | 20.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.4% | 13.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 1.49 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.22 | 2.08 | 1.80 | better |
‡ 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.
46.9% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.1% 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 21 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 46.9%CMS range 31.2–61.4 | 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 | 10.1%CMS range 6.8–14.6 | 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 | 38.1% | 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 | 33.3% | 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 | 28.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 6.9% | 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 | 8.9%CMS range 5.2–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 91 beds and averages 74.6 residents a day — about 82% occupied, or roughly 16 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.07 hrs/resident/day on weekends vs 3.55 on weekdays — 13% thinner on weekends. RN hours go from 0.72 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 98% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Ecited before2026-03-05 · 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 interview, and policy review the facility failed to disinfect a mechanical lift after use between 2 of 2 residents (#37, #55) and failed to use appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and enteric isolation precautions for 2 of 2 residents (#13, #75). The facility reported a census of 74 residents. Findings include:During a continuous observation that began on 3/03/2026 at 6:37 AM, Staff K, Certified Nurse Aide (CNA) transported a mechanical lift from a storage room to Resident #54's room.At 6:40 AM, Staff K transported the mechanical lift from Resident #54's room to Resident #55's room. The mechanical lift was not sanitized between resident use.At 6:50 AM, Staff J, CNA transported the mechanical lift from Resident #55's room and took it to Resident #37's room. The mechanical lift was not sanitized between resident use.At 6:56 AM, Staff J transported the mechanical lift from Resident #37's room and placed it in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · 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
Based on clinical record review, staff and resident interview, and facility policy review, the facility failed to provide showers for dependent residents in 1 of 18 resident's reviewed for activities of daily living (ADLs) (Resident #58). The facility reported a census of 74. Findings include: The Minimum Data Set (MDS) for Resident #58, completed on 02/25/2025, recorded the resident's Brief Interview for Mental Status (BIMS) score as 14, which indicated intact cognition. It documented the following relevant diagnoses: Diabetes Mellitus (diabetes), and arthritis. It documented the resident was a below-the-knee amputee and had reduced mobility and a need for assistance with personal cares. It documented the resident entered the facility on 11/28/2025. The Care Plan for Resident #58, last revised on 03/02/2026, documented the resident required two-person assistance for bathing and showering, and instructed staff members to encourage the resident to bathe or shower twice weekly. Review of bath and shower records from 12/01/2025 through 03/01/2026 revealed the following: Resident #58…
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 before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and policy review, the facility failed to correctly position a resident in a mechanical lift during transfer for 1 of 3 residents (#14), failed to lock the wheelchair during resident transfers for 2 of 3 residents (#44, #55), and failed to attach foot pedals on the wheelchair while transporting a resident for 1 of 1 resident (#69). The facility reported a census of 74 residents.Findings include:1.Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hemiplegia (one-sided body paralysis caused by brain or spinal cord damage), diabetes mellitus, and a stroke. It revealed he was independent with eating and oral hygiene, was dependent with toileting, and required maximal assistance with all other Activities of Daily Living (ADLs) and all forms of mobility.The Care Plan initiated 10/24/24 directed staff…
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 · D2026-03-05 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, electronic health record (EHR) review, staff interviews, and policy review, the facility failed to assure a medication error rate of less than 5%. A total of 27 ordered medications were reviewed with two errors, an error rate of 7.4%. The facility reported a census of 74. Findings include: During an observation on 3/4/26 at 7:55 AM, Staff B, Licensed Practical Nurse, prepared at total of 8 different medications for Resident #33. Staff B obtained one Omeprazole 20 milligrams (mg) pill from the resident's medication card as well as one Omeprazole 20mg pill from an over-the-counter floor stock bottle. Staff B also obtained two Vitamin D3 125 micrograms (mcg)/500 International Units (IU) pills from an over-the-counter floor stock bottle. These medications along with 6 others were administered to Resident #33. During reconciliation of the observed medication pass with current Physician Orders for Resident #33, the following was noted: 1.Omeprazole 20mg ordered for 1 capsule daily; 2.Vitamin D 1.25mg (50,000 IU) ordered for 1 capsule one time a week. In an interview…
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 · D2025-05-07 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 1 of 13 residents (Resident #6) reviewed. The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. MDS also indicated diagnosis of dysphagia, oropharyngeal phase. Review of EHR titled, Physician Orders for Resident #6 documented a regular diet of pureed texture. Review of EHR titled, Care Plan for Resident #6 documented a diet of puree consistency with thin liquids. Review of document titled, University Park FW 2024-2025, Week 3 Tuesday at noon documented a puree menu of 1 serving (8 oz) puree chili, 1 serving (1 each) puree cinnamon roll, 1 serving puree tossed salad, puree brownie/cinnamon buttercream frosting and 8 oz beverage. Review of untitled document…
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 before2025-05-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Heath Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a surgical wound, a pressure wound and a resident with a wound vacuum, that were on Enhanced Barrier Precautions (EBP) for 3 of 3 reviewed (Resident #3, #4, and #7). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. MDS also indicated Resident #3 had an unstageable pressure ulcer. Review of Resident #3's EHR dated 5/5/25 titled, Weekly Pressure Wound Assessment documented an unstageable pressure wound present on the left heel that measured 3/6 cm length x 1.1 cm width x 0.1 depth. Review of Resident #3's EHR titled, Care Plan documented Resident #3 required EBP related to the presence of a chronic wound - pressure ulcer. Observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-30 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel document review, staff interviews, and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 17 residents. Findings include: On 1/27/25 a request for documentation from the facility revealed the Dietary Director did not have the required certification. On 1/29/25 at 12:30 PM the Dietary Director confirmed he had been in the position for 3 weeks and had not completed the certification requirement yet. The Dietary Director stated he had previously held a Serve Safe Certification, but it had expired. The staff stated he was currently enrolled in the necessary coursework to complete the certification. On 1/29/25 at 1:20 PM the Administrator acknowledged the Dietary Manager was a new employee and had not completed his certification, but was currently taking the necessary coursework. The facility did not have a policy related to having a certified dietary manager. The Food and Drug Administration Food Code 2022 revealed the person in charge 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.
- Potential for harm · E2025-01-30 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documentation review, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to document temperatures of food in the kitchen prior to distribution. The facility reported a census of 76 residents. Findings include: Reviewed the kitchen meal temperature logs for 3 months. 4 meal temperatures out of 90 meals were not recorded in November. 8 meal temperatures out of 93 meals were not recorded in December. 25 meal temperatures out of 78 meals were not recorded in January On 1/29/25 at 12:30 PM the Dietary Director expected that all temperatures would be completed in the kitchen prior to distributing the food to the dining rooms, and completed in the dining rooms prior to serving. The Dietary Director stated he further expected that all temperatures were to be logged on the appropriate log forms whether the kitchen or dining rooms. The Dietary Director acknowledged with incomplete documentation it was unknown if the temperatures were taken prior to food distribution or serving,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility placed cooking utensils on countertops, and delivered drinks uncovered. The facility reported a census of 76 residents. Findings include: Observation on 1/27/25 at 9:45 AM revealed the ice machine had a light pink substance throughout. Continuous observation on 1/28/25 at 9:53 revealed Staff A placed a scraper on a countertop without a barrier during the preparation of pureed meat. During the preparation of mashed potatoes Staff A placed the whisk on the countertop without a barrier. Continuous observation on 1/28/25 at 12:07 PM revealed room tray service initiated. A room service tray left the dining room with 3 drinks uncovered. During preparation of the second tray, Staff B, Certified Nursing Assistant (CNA), stated forgot to put lids on the drinks. Observed a tray with uncovered drinks leave the dining room and enter the hallway when the Registered Dietitian stopped the delivery, and directed the staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interviews, staff interviews and policy review, the facility failed to assure residents were treated with respect and dignity for 2 of 3 residents reviewed (Resident #84 and #54). The facility reported a census of 76 residents. Findings include: 1. According to the Minimum Data Set (MDS) for Resident #84, dated 1/21/25, Resident #84 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The resident was dependent on staff for toileting assistance and required substantial assistance for lower body dressing and chair to bed/chair transfer. The resident's diagnoses included a stroke. The Care Plan included Resident #84 had the potential for diversional activity due to cognitive impairment and/or physical assistance needed and the resident needed assistance to and from activities. Interventions included invite and encourage resident to attend activities and offer assistance for locomotion as indicated. The Care Plan further included…
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 12 citations
- Potential for harm · Dcited before2025-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews and policy review, the facility failed to maintain resident living areas in good repair and provide a homelike environment. The facility reported a census of 76 residents. Findings include: During an observation 1/27/25 at 12:00 PM, Resident #27 and #34's shared bathroom had wall damage on the floor board, a hole in the wall and the border coming off by the floor, with a large gap and hole in the wall. During an observation 1/27/25 at 12:58 PM, Resident #19 and #81's shared bathroom had a hole in the bathroom door in the middle, on the outside of the door. The bottom of the bathroom door was observed to be falling apart, with jagged edging and splintered wood. There was a hole along the floor board in the bathroom, by the sink. During an observation 1/29/25 at 12:30 PM, with the Administrator present, Resident #27 and #34's bathroom was observed, as well as Resident #19 and 81's bathroom. The Administrator advised she was not aware of the condition of the bathroom with damage to the walls in the bathrooms in more than one area and damage to 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 · D2025-01-30 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and policy review, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 resident's reviewed (Resident #35). The facility reported a census of 76 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) for Resident #35, dated 1/22/25, a Brief Interview for Mental Status (BIMS) was not conducted as the resident is rarely/never understood. The resident had diagnoses to include Debility, Cardiorespiratory Conditions, heart failure, renal insufficiency and Non-Alzheimer's Dementia. The Care Plan for Resident #35, with a revision date of 8/7/24, included the resident had the potential for diversional activity due to cognitive impairment and/or physical assistance needed. Interventions included to encourage ongoing family involvement and provide for social interaction opportunities. The Care Plan further included Resident #35 was the recipient of an allegation of abuse: theft of cellphone, with a revision date of 11/7/24. Interventions included encourage visits with Social…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family and staff interview, and policy review, the facility failed to ensure call light was within reach for 1 of 19 residents reviewed (Resident #68). The facility reported a census of 76. Findings include: The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #68 with a Brief Interview for Mental Status score of 13 indicating intact cognition. Diagnoses included anemia, heart failure, hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body), hip fracture with presence of an artificial hip joint, and osteoporosis. The MDS stated Resident #68 used either a walker or wheelchair and requires moderate assistance with transfers. The Admission/readmission Narrative Bundle, Section C-Falls, dated 12/19/24, assessed Resident #68 at risk for falls with a score of 14. The Care Plan revised on 1/15/25 revealed Resident #68 has self-care deficits. Interventions included staff assistance of one for transfers and walker mobility. The Care Plan also stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · 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 observation, resident and staff interviews, record review and policy review, the facility failed to have sufficient nursing staffing to respond to resident's needs in a timely manner after a call light was activated. The facility reported a census of 76 residents. Finding include: 1. According to the Minimum Data Set (MDS) for Resident #50, dated 11/15/24, Resident #50 scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident was dependent on staff for toileting hygiene and required substantial assistance for lower body dressing. The resident's diagnoses included muscle weakness and other orthopedic conditions. During an observation 1/27/25 at 2:00 PM, upon entering the hallway, Resident #50's call light was activated above the door to the bedroom. During an observation 1/27/25 at 2:10 PM, Resident #50 was sitting on the toilet in the bathroom located in his bedroom, the call light above his door was on and activated. Resident #50 stated he pushed his call light at least 20 minutes prior and was waiting for staff to assist with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-21 · tag F0623 — patternProvide 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 interviews, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 5 of 5 residents reviewed who were discharged or transferred from the facility (Residents #5, #14, #23 #42, and #59). The facility reported a census of 79 residents. Findings include: 1. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had an unplanned discharge to the hospital and reentered the facility on 10/16/23. The facility's Census List revealed Resident #5 hospitalized [DATE]-[DATE]. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #5's discharge to the hospital on [DATE] as required by federal regulation. 2. Review of the MDS assessment dated [DATE] and 1/3/24 revealed Resident #23 had unplanned discharges to the hospital and reentered the facility on 10/12/23 and 1/5/24. The facility's Census List revealed Resident #23 hospitalized…
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 before2024-03-21 · 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 and facility policy review, the facility failed to provide a sanitary environment to help prevent the spread of communicable disease and infections. The facility failed to perform hand hygiene, don gloves, change gloves and use a barrier under a graduate during catheter drainage for 3 of 3 residents reviewed (Resident #51, #11 and #61). The facility reported a census of 79 residents. 1.The Minimum Data Set (MDS) assessment for Resident #51 dated 1/3/2024, included diagnoses of non-Alzheimer's dementia and obstructive uropathy (condition that blocks the flow of urine). The MDS documented the resident had an indwelling catheter (tube to drain urine from the bladder). The MDS documented a Brief Interview for Mental Status (BIMS) score of 8 completed, indicating moderate cognitive impairment for decision-making. During an observation on 3/19/24 at 2:50 PM, Staff D, Certified Nurse Aide (CNA) entered Resident #51's room, did not perform hand hygiene 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 · D2024-03-21 · 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 observations, clinical record review, staff interview and facility policy review the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by providing oxygen (O2) without a physician's order and not changing oxygen tubing for 1 of 1 resident (Resident #73) reviewed. The facility reported a census of 79 residents. Findings include: A Minimum Data Set, dated [DATE] for Resident #73, included diagnoses of chronic obstructive pulmonary disease and received O2 therapy. A Brief Interview for Mental Status score of 12 indicated mild cognitive impairment. On 3/18/24 at 3:06 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 Liters (L) per nasal cannula (NC) and O2 tubing with no date marked on it. On 3/19/24 at 1:48 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 L per NC and tubing remained without a date. Resident's Order Summary Report with active orders as of 3/19/24 lacked 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 · Ecited before2023-11-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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, resident and staff interview, and policy review, the facility failed to ensure a safe, clean, and homelike environment for 2 of 2 nursing units. The facility reported a census of 80 residents. Finding include: Observations on 11/14/23 starting at 1:50 PM revealed the following: a. Missing paint from door frames on rooms 305, 306, 307, 308, 309, 312, 417, 419, 420, 422, 426, 427. b. A panel covering the lower part of the door on rooms [ROOM NUMBERS] was lifted up from the surface of the door, and had a sharp edge. c. The wall in room [ROOM NUMBER] was marred and had scuffed up paint. On 11/14/23 at 2:00 PM, the exit door on the 4th floor had a motorized wheelchair parked in front of it. The motorized wheelchair was plugged into an electrical outlet near the exit door. On 11/15/23 at 1:30 PM, the wall by the resident's bed and the recliner in room [ROOM NUMBER] had missing paint and dry wall showing. The ceiling tiles by the window were discolored and had shades of brown-colored water…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-21 · 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, staff interviews, and information from the Davis's Drug Guide, the facility failed to consistently report weight loss to the physician for 1 of 1 residents (Resident #4) reviewed who was prescribed a dosage of a weight based medication. The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) for Resident #4, dated 5/4/22 documented diagnoses that included heat failure, hypertension (high blood pressure), ischemic cardiomyopathy (damaged heart muscle) and coronary artery disease. The Care Plan revealed a focus area of anticoagulant medication dated 2/24/22. The Care Plan directed staff to perform daily skin inspection and to monitor and report signs of anticoagulant complications. The Care Plan failed to reveal to monitor resident weight related to the weight based ordered dosage. The Medication Administration Record (MAR) for August of 2022 for Resident #4 documented the resident received 10 mg of Prasugrel, (an anti-platelet medication) with an order start date of 2/24/22. The Weight Summary section 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.
- Potential for harm · Dcited before2023-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews, and staff competency checklist, the facility failed to ensure a mechanical (Hoyer) lift in a safe and functional condition to safely transfer a resident for 1 of 4 residents observed during a transfer (Resident #10). The facility staff also failed to ensure a proper sized sling used for transfer of a resident in a mechanical lift for 1 of 4 residents observed for transfers (Resident #13). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of dementia, sepsis, and schizophrenia. The resident had a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating severely impaired cognition. The MDS documented the resident had total dependence for transfers. The Care Plan revised 7/18/23 revealed the resident had a self-care deficit and required assistance with ADLs (activities of daily living). The staff directives included use 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 · D2023-11-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and facility peri-care competency checklist, the facility failed to provide incontinence care to minimize the risk and occurrence of urinary tract infections for two of four residents observed for incontinence care (Resident #10 and Resident #6). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of sepsis, UTI (urinary tract infection) in the past 30 days, and dementia. The resident had a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating severely impaired cognition. The MDS documented the resident had dependence for toileting hygiene, dressing, and transfers. The Care Plan revised 7/18/23 revealed the resident had a self-care deficit and required assistance with activities of daily living (ADLs). The resident also had a potential for infection related to a history of UTI, and had incontinence. The care plan staff directives…
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 before2023-11-21 · 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 observations, staff interviews, resident council meeting, and facility policy review, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes and met residents needs in a timely manner for one of two nursing units observed. The facility reported a census of 80 residents. Findings include: Observations on 11/15/23 on the 4th floor revealed: a. At 7:10 AM, 3 call lights on (which included room [ROOM NUMBER]). Staff I, Licensed Practical Nurse (LPN) stood by a medication cart in the hallway. b. At 7:12 AM, Staff J, certified nursing assistant (CNA) entered room [ROOM NUMBER], told the resident she had to help another aide get someone up and then she would be back to help her. Staff J shut the resident's call light off, then left the room and entered room [ROOM NUMBER]. c. At 7:22 AM, Staff J and Staff K, CNA, came out of room [ROOM NUMBER], wheeled a hoyer to the storage room, then went into another resident's room. d. At 7:36 AM, the resident in room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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.
Part of a chain
This home belongs to CAMPBELL STREET SERVICES — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.1 | +1.9 vs chain |
| Health inspection | 3 of 5 | 2.0 | +1.0 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 3.4 | +1.6 vs chain |
The other 21 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HOLDCO GOLDFINCH, LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| CHITAI INVESTMENT, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| HOLDCO TABLETOP, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| INVESTCO TABLETOP, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| TECHCARE CORP | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| CURCIO, DOMINIC | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/01/2020 |
| REALCO UNIVERSITY PARK, IA, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 03/01/2020 |
| CAMPBELL STREET SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2020 |
| MANAGERCO GOLDFINCH, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2020 |
| MANAGERCO TABLETOP, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2020 |
| DOLE, ISAAC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2020 |
| MILLER, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2024 |
| SODERSTRUM, STACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/25/2021 |
| WOODRUFF, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/07/2023 |
CMS files one row per role, so the 28 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $837K 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
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 165272. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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.