Pleasant Acres Care Center
309 Railroad Street, Hull, IA 51239 · For profit - Limited Liability company · 46 certified beds · (712) 439-2758 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 17.1% | 17.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.4% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.9% | 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 | 3.4% | 3.8% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 22.0% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.1% | 20.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.9% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.2% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 29.4% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.2% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.9% | 2.1% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.50 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.77 | 2.08 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 6% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.7% | 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 | 9.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 46 beds and averages 35.7 residents a day — about 78% occupied, or roughly 10 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.61 hrs/resident/day on weekends vs 3.19 on weekdays — 18% thinner on weekends. RN hours go from 0.90 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Ecited before2026-02-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food. The facility identified a census of 37 residents.Findings included: During the initial kitchen walkthrough on 12/16/26 at 10:35 AM, the following observations were made:Refrigerator units contained various scattered food debrisFreezer units with ice build upThe following foods not labeled: ranch dressingfrozen meatfrozen pizza During the initial tour, the Dietary Manager (DM) reported the facility had recently lost two kitchen staff, which resulted in some duties not being consistently completed. The DM reported the bottoms of the refrigerator units required cleaning, freezers needed defrosting, and all food required proper labeling. On 12/18/26 at 12:42 PM tour of the ice machine room showed:Ice machine with lime build up on outside of the machineSnack cart with loose debride build up on top of the cart and within the drawersWater cart 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 · D2026-02-19 · 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, clinical record review, and interviews with residents and staff, the facility failed to maintain resident dignity and privacy during incontinence care and to communicate about residents in a respectful manner for 2 of 12 residents reviewed (Residents #8 and #30). The facility reported a census of 37 residents.The findings include: 1. The Minimum Data Set (MDS) for Resident #30 dated 1/24/26 documented diagnoses of muscle weakness, anxiety disorder and respiratory failure. The MDS showed short-term memory and long-term memory coded as OK. Observation on 2/18/26 at 10:25 AM during incontinence care showed Staff B, Certified Nursing Assistant (CNA), used a walkie-talkie to request additional wet wipes for Resident #30. Upon arrival of the requested supplies, Staff A, Registered Nurse (RN), placed a brief over the resident's perineal area. When staff opened the door to deliver the wipes, Resident #30 lay on the bed with pants at her ankles and a brief covering her perineal area. Staff failed 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 · D2026-02-19 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, facility policy review and staff interview the facility failed to ensure resident self administering medications was safe to do and failed to watch resident not assessed to self administer medications took their medications for 1 of 1 resident observed (Resident #26). The facility reported a census of 37. Findings include: Observation on 02/18/2026 at 8:31 a.m. of Resident #26 sitting at the table in the activity room with 2 medication cups in front of her. One was noted to be full of applesauce and have a spoon in and the other was noted to have a variety of tablets in the cup. Resident #26 dumped the tablets onto the table and lined them up and took them with the applesauce. Observation revealed there was no facility staff in or around the area while resident took the tablets. Review of Resident #26's medical chart lacked documentation of assessment to self administer medications and lacked orders for self administration of medications. Review of facility provided policy titled Medication Administration dated 2025 revealed under policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review the facility failed to complete neurological checks after a resident fell for 1 of 1 residents reviewed (Resident #11). The facility reported a census of 37 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented disorientation, delirium due to known psychosocial condition, muscle weakness and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed. Review of report titled Incidents by Incident Type dated 2/18/26 revealed falls on the following dates:1/21/261/25/261/27/262/13/26 Review of the clinical record revealed the following:1/21/26- neurological checks 6:35 p.m., refused sleeping in wheelchair6:50 p.m., refused sleeping in wheelchair7:30 p.m., sleeping7:50 p.m., refused sleeping in wheelchair9:50 p.m., sleeping in wheelchair, refused11:50 p.m., refused sleeping in wheelchair 1/22/26 at 3:50 a.m., refused sleeping in wheelchair7:50…
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 · D2026-02-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility policy review, the facility failed to provide safe transfers of residents with transfers 1 of 3 residents reviewed (Resident #11). The facility reported a total census of 37 residents. Findings include: Staff D, Certified Nursing Assistant (CNA) applied gait belt around Resident #11. Staff B, Registered Nurse (RN) and Staff E, CNA with their arms under Resident #11's armpits assisted Resident #11 to a standing position. Staff B and Staff E did not use the gait belt when assisting resident to standing position. After Resident #11 was finished with the toilet, Staff B and Staff E and with their arms under Resident #11's armpits assisted Resident #11 to a standing position. Staff D performed perineal care while Staff B and Staff E continued to assisted Resident #11 with standing position. Staff B and Staff E did not use the gait belt and assisted the resident back into his wheelchair. Once Resident #11 was back in the wheelchair. Staff D removed the gait belt. Review of the facility provided policy titled Use of Gait Belt dated 2025…
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 · D2026-02-19 · 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, record review, interviews, and policy review, the facility failed to implement and practice appropriate infection control measures for use of a Bilevel Positive Airway Pressure (BiPAP) machine by not establishing or following a routine cleaning schedule for 1 of 12 residents reviewed (Resident #7). The facility reported a census of 37 residents. Findings include:The Minimum Data Set assessment dated [DATE] for Resident #7 documented diagnoses of obstructive sleep apnea, respiratory failure and obesity. The MDS indicated Resident #7 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.Observation on 2/17/26 at 9:25 AM revealed a BiPAP machine on Resident #7's bedside table. When asked whether staff regularly cleaned the BiPAP oxygen tubing or facemask, Resident #7 stated, They have never cleaned it. When asked how long he had the BiPAP, the resident reported, For about a year and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interviews, the facility failed to perform blood sugar testing and administer insulin in a manner that protected the resident from bloodborne pathogens for 1 of 1 residents reviewed (Resident #7). The facility reported a census of 37 residents.Findings included: Observation on 2/19/26 at 7:29 AM showed Staff C, Registered Nurse (RN), opened the medication cart, removed the storage container for Resident #7's glucometer and testing supplies, locked the cart, and entered the resident's room. The nurse placed a barrier on the bedside table, set the glucometer and supplies on the barrier, and donned gloves without performing hand hygiene. Staff C completed the glucose check and discarded the used disposable supplies. Staff C exited the room wearing soiled gloves while holding the glucometer, returned to the medication cart, removed one glove, failed to perform hand hygiene, reached into her scrub pocket to retrieve the medication cart keys, and unlocked the cart. Staff A then opened the cart drawer, retrieved the storage container, returned…
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 · E2024-12-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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, document review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs. The facility reported a census of 27 residents. Findings include: On 12/11/24 at 12:45 PM Staff D, [NAME] stated that she used one bag of diced chicken for the lunch meal. Staff D stated she followed the recipe for 36 servings of Chicken [NAME] Alfredo. Staff D acknowledged the menu required 9 lbs of chicken. Staff D acknowledged that she used 1 bag of diced chicken from the box that contained 2 bags of diced chicken. Staff D stated she did not know how many pounds of chicken were in the bag but she could look at the box to find out. On 12/11/24 at 1:00 PM an observation of the box of diced chicken used for lunch 12/11/24 revealed two 5lbs bags in each box. Review of a document titled, Chicken [NAME] Recipe #8723 documented the recipe required 9lbs of chicken for 36 servings. Review of document titled, Week 2 Wednesday documented Chicken [NAME] for noon meal.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 2 of 2 residents reviewed who transferred to the hospital (Resident #4 and #15). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of heart failure, anemia and peripheral vascular disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #4's Progress Notes revealed the following information: On 2/5/24 at 11:06 p.m., Resident leaves facility via nonemergent transport. On 2/6/24 at 1:46 a.m., staff placed a phone call to the local hospital and the resident will be admitted to the local hospital. On 2/19/24 at 12:58 p.m., the local hospital called to give the facility report. Review of Resident #4's Census tab revealed the following: On 2/5/24- hospital paid leave. On 2/19/24- active. Review of MDS listing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record review, policy review, resident interviews, family interviews, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care to 2 of 12 residents reviewed (Resident #14 and #19). The facility reported a census of 27 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #14 was rarely / never understood and a Brief Interview for Mental Status (BIMS) was not completed indicating severe cognitive impairment. On 12/09/24 02:36 PM Resident #14's brother / POA stated there were no care conferences and would like them. Resident #14's brother / POA stated he was not ever told by the facility that he could be a part of the care conference. Review of EHR revealed no documentation of completion of care conference with family or…
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 13 citations
- Potential for harm · Dcited before2024-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered medications and failed to notify the physician of missed medications for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of heart failure, anemia and peripheral vascular disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the facility provided document titled Order Summary Report signed by the physician 11/20/24 revealed the following orders: Coumadin tablet, Bupropion tablet, and Calcitriol capsule. Review of Resident #4's Progress Notes revealed the following: On 11/14/24 at 5:16 p.m., Coumadin tablet, medication not available, attempted to remove medication from med bank-med bank states med bank unable to connect to drawers unable to take out medication. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · 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 interview, record review, and policy review, the facility failed to ensure call lights responded to in a timely manner for 2 out of 4 residents reviewed (Resident #4 and #23). The facility reported a census of 27 residents. Findings include: 1. Interview on 12/09/24 at 1:14 p.m., with Resident #4 revealed call lights can take awhile. Resident #4 revealed he has waited over 15 minutes several times. Review of facility provided document titled Alarm Event Report dated 12/4/24-12/11/24 revealed the following: On 12/4/24 the call light turned on at 8:12 a.m. and was on for 29 minutes. On 12/4/24 the call light turned on at 8:59 a.m. and was on for 28 minutes. On 12/4/24 the call light turned on at 12:19 p.m. and was on for 48 minutes. On 12/5/24 the call light turned on at 8:46 a.m. and was on for 16 minutes. On 12/6/24 the call light turned on at 12:15 p.m. and was on for 37 minutes. On 12/7/24 the call light turned on at 11:05 a.m. and was on for 20 minutes. On 12/8/24 the call light turned on at 12:02 p.m. and was on for 1 hour and 7 minutes. On 12/9/24 the call light turned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · 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, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a suprapubic catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #21). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #21 was rarely / never understood and a Brief Interview for Mental Status (BIMS) was not completed indicating severe cognitive impairment. On 12/11/24 at 9:11 AM an observation revealed Staff A, Certified Medication Assistant (CMA) knocked on Resident #21's door, entered the room, completed hand hygiene, applied gloves, applied mask, applied a gown, placed a barrier on the ground, sat a graduate on the barrier, emptied urine from the catheter bag, alcohol wipe utilized to clean the catheter tip, and catheter tip reapplied to bag, 450mL of urine removed from the catheter bag. Urine emptied from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy the facility failed to provide resident or resident representative quarterly statements for 3 out of 3 residents reviewed (Resident #9, #12 and #20) . The facility reported a census of 26. Findings include: 1. Interview on 10/16/23 at 1:10 p.m., with Resident #9 ' s financial power of attorney revealed he has never seen a statement for Resident #9 ' s trust account and does not know how much money he currently has. The facility revealed Resident #9 was given trust account statements and not provided to Resident #9 ' s financial power of attorney for Quarter Ending 3/2023, Quarter Ending 6/2023 and Quarter Ending 9/2023. Facility revealed Resident #9 was not provided with a trust account statement for Quarter Ending 9/2022 and for Quarter Ending 12/2022. 2. The facility revealed Resident #12 was given trust account statements and not provided to Resident #12 ' s financial power of attorney for Quarter Ending 3/2023, Quarter Ending 6/2023 and Quarter Ending 9/2023. Facility revealed Resident #12 was not provided with a trust…
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 before2023-10-19 · 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 and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 4 of 4 residents reviewed who transferred to the hospital (Resident #9, #15, #19 and #25). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of hypertension, diabetes mellitus, and osteoporosis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of Resident #9 ' s Progress Notes revealed the following information: a. 3/2/23 at 2:00 p.m., revealed nurse received call to send resident back to local hospital to be admitted . b. 7/21/23 at 9:10 p.m., revealed Resident #9 was admitted to hospital at 3:00 p.m c. 7/27/23 at 10:13 a.m., revealed Resident #9 back at facility. Review of Resident #9 ' s Census tab revealed the following: a. 3/2/23 unpaid hospital leave b. 3/14/23 active c. 7/21/23 stop billing d. 7/27/23 active…
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 before2023-10-19 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy the facility failed to revise and update the care plan to include oral intake for 2 of 2 residents reviewed for oral intake (Resident # 1 and # 24) and failed to list high risk medications and side effects for 3 out of 5 residents reviewed for high risk medications (Resident #2, #12, #18). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnosis of dysphagia and nutritional deficiency. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of clinical record shows an order dated for 6/23/23 for pleasure feedings for pureed foods - moist, nectar thickened liquids, okay for patient to have small amounts of moist pureed (up to 2 teaspoon per session) and up to 2 ounces nectar thickened liquids 2 times per day. Review of clinical record shows an order dated for 8/18/23 to offer 1 meal per day,…
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 before2023-10-19 · tag F0725 — failed to have enough nursing staff — patternProvide 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 interview, record review, and policy review, the facility failed to ensure call lights responded to in a timely manner for 3 out of 3 residents reviewed (Resident #12, #18, #19). The facility reported a census of 26 residents. Findings include: 1. Interview on 10/16/23 at 1:24 p.m., with Resident #12 revealed the staff take a long time to answer the call lights and last month she had to sit on the commode for over an hour. Review of facility provided document titled Alarm Event Report dated 10/3/23- 10/17/23 revealed the following: On 10/3/23 the call light turned on at 2:36 a.m. and was on for 16 minutes. On 10/3/23 the call light turned on at 8:17 a.m. and was on for 20 minutes. On 10/3/23 the call light turned on at 4:17 p.m. and was on for 33 minutes. On 10/11/23 the call light turned on at 2:25 a.m. and was on for 25 minutes. On 10/11/23 the call light turned on at 12:32 p.m. and was on for 25 minutes. On 10/12/23 the call light turned on at 10:58 a.m. and was on for 27 minutes. On 10/13/23 the call light turned on at 11:49 p.m. and was on for 28 minutes. On 10/14/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility schedule reviews and staff interview, the facility failed to assure a Registered Nurse (RN) on duty for 8 hours daily, 7 days per week. The facility reported a census of 26 residents. Findings include: Review of the facility's nursing staff schedule dated 4/1/23 through 10/16/23 revealed there was no RN on duty for 8 hours on the following dates: 4/2/23, 4/8/23, 4/9/23, 4/16/23, 5/7/23, 5/29/23, 6/3/23, 6/17/23, 6/18/23, 6/24/23, 9/2/23, 9/3/23, 9/9/23, 9/10/23, 9/16/23, 9/17/23, 9/23/23, 9/24/23 and 10/1/23. The facility does not have a policy for RN coverage and follows the federal guidelines. Interview on 10/17/23 at 5:01 p.m., with the Director of Nursing (DON) revealed there should have been an RN for 8 hours everyday. Interview on 10/18/23 at 3:30 p.m., with the Administrator revealed there should have been RN coverage 8 hours everyday.
- Potential for harm · Ecited before2023-10-19 · 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 facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 26 residents. Findings include: 1. An initial kitchen tour conducted on 10/16/23 at 11:10 AM, revealed the following observation, brown raised debris to the ceiling surrounding the air vents in the back corner. Observation on 10/18/23 at 11:30 AM Staff A, cook, applied gloves without performing hand hygiene. Staff A with gloved hands prepared and served the meal, touching the utensils, pans, and sprayer on the sink while washing out the robo coupe and while preparing a puree meal for Resident #1. Staff A then removed gloves and washed his hands and applied new gloves. Staff A with gloved hands picked up the plates, tongs, opened the cupboard and grabbed a bag of hotdog buns. With soiled gloves reached into the bag and removed a hotdog bun and with soiled gloves still on used the tongs to put the brat in the bun. Staff A with soiled gloves on placed the bag of hotdog buns on top of Resident #16…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0836 — patternEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Within 30 days of a resident's admission to a healthcare facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249 A, the facility shall ask the resident or the residents personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a veteran, the facility shall report the resident's name along with the names of the resident's spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veteran's affairs. Where appropriate, the facility first shall seek reimbursement from the identified payer source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. Based on facility record review and interviews the facility failed to verify veteran ' s eligibility for all residents admitted from 7/1/22 to 10/16/23 reviewed to the Iowa Department of Veteran Affairs (VA) Department. The facility reported a census of 26 residents. Review of the facility's provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy the facility failed to grant the resident or representative the right to rescind a signed Arbitration agreement within 30 calendar days of signing it.The facility reported a census of 26. Findings include: Review of the facility document titled Voluntary Arbitration Agreement Program Guide undated revealed if you sign the agreement and later change your mind, you will have ten (10) business days from the date of your admission to completely cancel and void the agreement. Review of the facility provided document titled Voluntary Arbitration Agreement undated revealed right to change your mind- the resident will receive from the facility a copy of this agreement upon it being fully executed. This agreement may be canceled via a written notice sent to the facility administrator by certified mail, return receipt requested, within ten (10) business days of the date it is executed by the resident. It is further documented in bold lettering and underlined- the resident is aware that he/she may rescind this agreement at anytime within…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy the facility failed to have the Medical Director at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings and hold QAA meetings every quarter. The facility reported a census of 26. Findings include: Review of the facility document titled Quality Assurance Process Improvement (QAPI) Committee meeting agenda and notes: a. Document dated 9/20/23 lacked the signature of the Medical Director The facility lacked documentation for an August 2022 QAPI meeting being held. Review of the facility provided policy titled Risk Management/Quality Assurance Performance Improvement Program with a revision date of 8/19 revealed The Risk Management/QAPI Committee, facilitated by the Quality Improvement Coordinator/Designee, will meet monthly. The Risk Management/QAPI committee will consist of no less than five members. Members are appointed by the Administrator and will include, but not be limited to: Administrator, Director of Nursing, Infection Preventionist, Medical Director or Physician designee, and at least…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete the comprehensive resident assessment accurately for 1 of 13 residents reviewed (Resident #5). The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #5 readmitted from an acute hospitalization 7/5/23. Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including atrial fibrillation, heart failure, renal failure, and diabetes. Special treatments did not include dialysis. According to the MDS assessment 7/12/23. Resident #5 scored 15 on the BIMS indicating no cognitive impairment. Special treatments did not include dialysis. readmission orders for a hospital stay dated 6/29/23 to 7/5/23 documented the resident had dialysis dependent chronic kidney failure. On 10/16/23 at 4:37 p.m. the resident stated he had dialysis 4 times a week. On 10/17/23 at 4:58 p.m. the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
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 | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.0 | +1.0 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 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 |
|---|---|---|---|
| CAMPBELL STREET SERVICES LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| 5V+ SENIORS HEALTHCARE FUND GP, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2025 |
| 5V+ SENIORS HEALTHCARE FUND, LP | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2025 |
| BEAR CREEK STRATEGIC REAL ASSETS FUND LP | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2025 |
| BIRCHWOOD HEALTHCARE PARTNERS LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2025 |
| DOLE, ISAAC | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2025 |
| CAMPBELL STREET IA 10 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| HOLDCO, IA, 10, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| LENNON, JODI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| RICKARD, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| ACD CONSOLIDATED LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
| BEAR CREEK SRAF GP HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
| DEFRANCO INVESTMENT CO LTD | Organization | ADP OF THE SNF | since 09/01/2024 |
| IAGA SNF HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
| IAGA SNF HULL LLC | Organization | ADP OF THE SNF | since 09/01/2025 |
| IAGA SNF PORTFOLIO LLC | Organization | ADP OF THE SNF | since 07/07/2025 |
| NAP HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/01/2024 |
CMS files one row per role, so the 26 rows in the source record cover these 17 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.
14 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 $123K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165248. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.