Luther Manor at Hillcrest

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

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

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

43.7% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 63 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

Staffing

How full it usually is: this home is certified for 103 beds and averages 91.2 residents a day — about 89% occupied, or roughly 12 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 4.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.45 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 3.99 hrs/resident/day on weekends vs 4.70 on weekdays — 15% thinner on weekends. RN hours go from 0.68 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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.

24 citations, most serious first. The 13 most serious are shown; the remaining 11 are one tap away and print in full.

• Actual harm · G2026-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy review the facility failed to follow fall interventions to prevent falls for 3 out of 4 residents reviewed with falls resulting in injuries. (Resident #11, #13 and #80). Staff failed to properly transfer Resident #11, resulting in a fractured ankle. The facility failed to follow fall interventions to prevent a fall for Resident #80, resulting in a hematoma and abrasion to forehead and a skin tear to left elbow. The facility failed to have interventions in place to prevent an abrasion to Resident #80's knee while in bed. The facility reported a census of 94 residents. Findings include. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #80 revealed a diagnosis of coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular accident and non Alzheimer's Dementia. The MDS revealed the resident had short and long term memory problem, with severely impaired decision making. The MDS indicated Resident #80 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-10-23 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure 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, staff interviews and facility policy review the facility failed to remove a transdermal patch prior to administering a new patch on 1 of 1 resident (Resident #2) which caused increased confusion and required an admission to the hospital for treatment of acute encephalopathy. The facility reported a census of 90 residents.Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #2, dated 8/8/25, revealed a list of diagnoses which included coronary artery disease, hypertension, Parkinson's disease, and bipolar disease. The MDS indicated the resident experienced short term memory problems and difficulty with decision making. The MDS assessed the resident required extensive assist with toileting, bathing and dressing. Review of Resident #2 September 2025 Medication Administration Record (MAR) revealed an order for Rivastigmine Transdermal Patch (a medication in the neurotransmitter class that helps with memory and cognition that is delivered through a patch…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-09-18 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interview, along with policy and procedures, the facility failed to treat and manage pain, for 1 out of 3 resident reviewed (Resident #1) Resident #1 ran out of pain medication on 8/13/25-8/18/25, for which resulted in the resident being sent out to the local Emergency Department on 8/16/25 and 8/17/25 for pain medications. The facility reported a census of 99 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with a Brief Interview For Mental Status (BIMS) score of 15 for which indicated no cognitive impairment. The MDS documented the resident with diagnosis for which included Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Diabetes Mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), absence of left leg above the knee and back pain. The MDS documented a scheduled pain medication…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, interviews, and policy review the facility failed to prevent physical contamination of food in the kitchen during 4 observations. Hair nets were improperly worn, the cleaning schedule was not followed, and staff did not adequately sweep and mop floors to remove dead cockroaches. The facility reported a census of 94 residents. Findings include:During a kitchen observation on 2/04/26 starting at 10:20 AM noted the following:Staff I, Dietary Director, wore a brown hairnet that left about 2 inches of hair exposed over each ear and about 3 inches exposed in the backStaff P, Dietary Aide (DA), wore a white hairnet with about 2-3 inches of hair exposed in the back.Staff N, DA, wore a hairnet with about 1-2 inches of hair exposed in the back and about an inch over each earStaff Q, Cook, wore a hairnet with hair exposed on the right side, about 1-2 inches out of hairnet over her earsStaff O, Cook, wore a hairnet with about 2 inches exposed in back and wisps out over both earsFreezer - Whipped cream sprayed on the right freezer wall. Staff I stated someone…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-02-12 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, review of the facility Quality Assurance and Performance Improvement (QAPI) documentation, QAPI policy review, and staff interview the facility failed to carry out QAPI activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting the facility. The facility reported a census of 94 residents.Findings include:The CMS 2567 Statement of Deficiencies dated 10/17/24 included the following concern: F812 Food Procurement, Store/Prepare/Serve-Sanitary.The CMS 2567 Statement of Deficiencies dated 12/30/24 included the following concerns: F812 Food Procurement, Store/Prepare/Serve-Sanitary; F865 QAPI Program/Plan, Disclosure/Good Faith AttemptThe CMS 2567 Statement of Deficiencies dated 7/25/25 included the following concerns: F689 Free of Accident Hazards/Supervision/Devices; F880 Infection Prevention & ControlThe current survey, conducted 2/04/26 through 2/12/26 also…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor 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 observation, invoices, resident and staff interviews, and policy review the facility failed to maintain a safe and sanitary environment for residents when the facility failed to keep vents between the kitchen and the dining room and in the dining room clean, failed to ensure facility windows, screens, and refrigerators were kept clean, and dead cockroaches from a prior treatment were found two days in a row in the family rooms in addition to sightings of live roaches. The facility reported a census of 94 residents. Findings include: 1. On 2/04/26 at 12:42 PM observed a live cockroach travel from the base of a cabinet under the sink in the family room to the inside of the cabinet. The cabinet contained a towel with brown and yellow stains on it that was stiff to the touch near the opening and damp towards the back. Where the water pipe entered the wall there was an approximately 1/4 inch gap between the wall and the sheetrock. On 2/04/26 at 5:16 PM the middle family room cabinets contained a live roach…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and staff interviews, the facility failed to notify the physician when bilateral lower extremity reduction kit wraps (velcro cloth wraps for legs to help reduce swelling) were not applied as ordered by the physician for 1 of 1 residents reviewed (Resident #89). The facility reported a census of 94 residents. Findings include: Review of Resident #89's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status exam (BIMS) score of 13 out of 15, which indicated intact cognition. The MDS included diagnoses of anemia (reduced quantity of red blood cells), high blood pressure (condition where the force of blood pushing against your artery walls is consistently too high) and lymphedema (swelling of arms or legs caused by build up of lymph fluid).Review of Resident #89's Treatment Administration Record (TAR) January 2026 revealed the resident to wear bilateral lower extremity reduction kit wraps (velcro cloth wraps for legs to help…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  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, therapy documentation, resident interview, and staff interviews the facility failed to provide required Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice forms (CMS 10055 and CMS 10123) at the completion of skilled services for 1 of 3 residents reviewed (Resident #61). The facility reported a census of 94 residents.Findings include:Review of Resident #61's Minimum Data Set (MDS) dated [DATE] for the end of Part A stay documented the resident's Brief Interview for Mental Status (BIMS) score was 15/15, which indicated intact cognition. A therapy note dated 11/21/25 revealed Staff H, Occupational Therapy advised the social worker of therapy recommendations for 24 hour care at the end of skilled services. During an interview on 2/11/26 at 10:13 AM, Staff H stated the resident's therapy ended 11/24/25. She confirmed the discussion with the social worker documented in the therapy note, and reported the social worker should have then…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review and staff interview the facility failed to provide complete perineal care after incontinence for 2 out of 5 resident reviewed (Resident #11 and Resident #84). The facility reported a census of 94 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #11 dated 1/14/26 revealed the following diagnoses: Hypertension, Diabetes, Anxiety Disorder and Depression. The MDS revealed a Brief Interview for Mental Status score of 6 out of 15, which indicated severe cognitive impairment, and revealed the resident was dependent on staff for toileting hygiene and toilet transfers. The MDS reflected Resident #11 was always incontinent of bowel and bladder. The Care Plan intervention for Resident #11 dated 5/7/25 revealed the resident was frequently incontinent of bowel and bladder, utilize incontinent products for dignity. Provide incontinent cares as needed and utilize stock barrier ointment for skin protection from breakdown due to incontinence. On 2/10/26 at 8:27 AM, Staff B, Certified Nursing Assistant (CNA) and Staff 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to provide adequate assessment and intervention after a fall for 1 of 3 residents reviewed with a fall (Resident #11). The facility reported a census of 94 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed a diagnosis of hypertension (high blood pressure), diabetes, and depression. The Brief interview for Mental Status (BIMS) revealed a score of 7 which indicated severe cognitive impairment. The MDS indicated the resident required maximal assistance from staff for transfers. An Incident Report dated 12/15/25 at 5:00 PM revealed Resident #11 told Certified Certified Nursing Assistant (CNA) she could walk and CNA pushed button on the recliner to raise it and when her partner saw this informed the CNA she was an EZ stand (mechanical lift). Resident #11 started to slide and CNA could not hold the resident up and CNA assisted Resident #11 to the floor. Resident did not hit head. No…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review, facility documentation, resident interview and staff interview the facility failed to ensure 2 of 3 residents observed for room trays received their meals in a timely manner (Residents #31 and Resident #104). The facility reported a census of 94 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident # 31 dated 11/19/25 documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment.During an observation on 2/5/26 beginning at 9:30 AM, Staff J, Restorative Aide, Staff K, Certified Nursing Assistant (CNA) and Staff L, CNA were heard at the nurses station on Bluff View discussing that Resident #31 just woke up and did not have a breakfast tray. During an interview on 2/5/26 at 10:30 AM, Resident #31 explained she did not get breakfast and no one woke her up for breakfast. She explained she does not get meals frequently and her son bought her a mini fridge for her room so she would always have food available. A mini fridge was observed between the bed and dresser. When asked if she…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and staff interview the facility failed to provide appropriate practices to prevent the spread of infection during wound care for 1 of 2 residents observed for wound care (Resident #80). The facility identified a census of 94 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for dated 1/14/26 revealed Resident #80 had severely impaired cognitive skills for daily decision making. Review of the Hospice order for wound care to Resident #80's left knee dated 2/4/26 revealed to cleanse left knee wounds with wound cleanser, apply triple antibiotic ointment, non adhesive dressing and wrap with cotton gauze twice a day and as needed. May discontinue when no longer draining and healed. On 2/05/26 at 11:02 AM, Staff E, Licensed Practical Nurse (LPN) provided wound care to abrasion on the left knee of Resident #80. Staff E removed the dressing from the left knee and cleansed the wounds. Staff E did not remove gloves or wash hands after she cleansed the wound Staff E used her index finger and applied triple antibiotic from the tube…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interview, and policy review the facility failed to offer and/or administer the influenza vaccine for 2 of 5 residents reviewed (Residents #19 and Resident #64). The facility reported a census of 94 residents. Findings include:1. The annual Minimum Data Set (MDS) for Resident #19 dated 9/03/25 included diagnoses of personal history of pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow) and localized edema. The Brief Interview for Mental Status (BIMS) assessment was blank and the staff assessment indicated the resident's cognitive skills for daily decision making was moderately impaired. An immunization consent form dated 10/29/25 documented the Infection Preventionist/Assistant Director of Nursing (IP/ADON) spoke to the resident's Power of Attorney (POA) who gave verbal consent for the COVID vaccine, influenza vaccine, and Respiratory Syncytial Virus (RSV) vaccines. A document titled Iowa Immunization Registry Information System (IRIS) revealed Resident #19 received the influenza (flu) vaccine in 2015, 2016,…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$42,406 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $34,125 — penalty dated 2026-02-12
• $8,281 — penalty dated 2025-07-25
• Medicare payment denial — starting 2025-09-20 for 34 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SHLOMO HOFFMAN — 10 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 →

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

CMS files one row per role, so the 24 rows in the source record cover these 12 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.

5 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