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Regency Park Nursing & Rehab Center of Jefferson

100 Ram Road, Jefferson, IA 50129 · For profit - Limited Liability company · 46 certified beds · (515) 386-4107 Medicare & Medicaid certified

Call the home — (515) 386-4107 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • nursing-staff turnover (98%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1002 W Lincoln Way · (515) 386-0500 · Call to confirm hours
Pharmacy
400 N Elm St · (515) 386-2164 · Call to confirm hours
Grocery
Hy-Vee1.1 mi
106 W Washington St · (515) 386-4153 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.9%17.1%15.4%better
Long-stay residents who lose too much weight3.9%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.5%0.9%better
Long-stay residents with a urinary tract infection1.3%2.4%2.0%better
Long-stay residents with depressive symptoms2.1%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%3.8%3.3%better
Long-stay residents whose ability to walk worsened19.5%16.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.3%20.8%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers1.0%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control25.0%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.4%19.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.1%1.4%better
Short-stay residents given the seasonal flu vaccine90.9%73.3%79.4%better
Long-stay hospitalizations per 1,000 resident days0.621.491.67better
Long-stay outpatient ER visits per 1,000 resident days1.252.081.80better

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

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

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

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

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

49.8% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.8%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
0.10U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.10 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 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.8%CMS range 37.6–62.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 5.9–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
0.40
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.04
Total nurse hours/ resident / day
0.32
RN hoursweekends
97.5%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 46 beds and averages 44.5 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.67 hrs/resident/day on weekends vs 3.18 on weekdays — 16% thinner on weekends. RN hours go from 0.81 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 98% is well above the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-12-31)
4
at the previous standard inspection (2025-01-15)

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.

ABCDEFGHIJKL

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

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

  • Actual harm · Gcited before2023-11-13 · 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 clinical record reviews, observations, resident, and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 2 of 2 residents reviewed (Residents #18 and #10) for falls. 1. Resident #18 fell two times and the facility failed to either put an intervention in place or put an inadequate intervention in place to prevent future falls. After Resident #18 fell on 7/8/23, the facility requested a urinalysis on 7/12/23. The facility collected and received the results on 7/14/23 that revealed a urinary tract infection. The provider ordered to wait for the culture and sensitivity (C&S) results then update them with the results. Resident #18 attempted to get up on her own multiple times, with the staff intervening to prevent her from falling. On 7/18/23 a staff member left Resident #18 unattended in the bathroom with the call light and instructions to pull it when she was ready. Without using the call light, Resident #18 attempted to get to bed by herself…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · 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 clinical record reviews, facility investigation review, staff interviews, and policy review, the facility failed to provide adequate nursing supervision to prevent a resident to resident altercation for 2 of 4 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 43 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #1 was independent with bed mobility and all transfers. The MDS included diagnoses of non-alzheimer's disease, bipolar disorder and schizophrenia. The Care Plan with a target date of 5/27/26 documented Resident #1 may have episodes of behaviors and potential for behaviors as evidenced by being combative, negative verbalizations, name calling, refusal of medications/care, resistance to care, attempts to leave building, crying episodes, screaming out, attention seeking behaviors,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-31 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and policy review, the facility failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and food borne illness. The facility identified a census of 43 residents. Findings include: On 12/30/25 at 10:52 AM, observed the Dietary Manager puree a grilled turkey [NAME] sandwich while wearing gloves. When finished with pureeing the sandwich, the Dietary Manager removed her gloves and then proceeded to wash out the dishes used to puree the sandwich in the sink, put the dirty dishes in the dishwasher and then continued to puree the next food items without washing her hands. On 12/30/25 at 11:30 AM, observation revealed the Dietary Manager wore gloves to get the room trays ready to be delivered to the unit. During the process, the Dietary Manager touched each grilled turkey [NAME] sandwich with her gloved hands, then served the potatoes and peas with a utensil, then with her gloved hands took a cookie out of the plastic container and put 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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

    Based on observation and staff interview, the facility failed to ensure resident's had a safe, clean, comfortable and homelike environment, with 2 recliners showing extensive wear. The facility reported a census of 43 residents. Findings include:On 12/29/25 at 12:40 p.m. observed Resident #50 in her room sitting in a recliner. The arms of the recliner had large areas of the top covering warn off. The area behind the head also warn off. On 12/29/25 at 1:30 p.m. the burgundy recliner in the common area (of the 300, 400 and 500 halls) showed the burgundy covering worn off at the the back of the head area. On 12/31/25 at 7:45 a.m. the Maintenance Staff (MS) brought another chair into Resident #50's room, and said another resident may be moving in. He stated the recliner already in the room would be a facility chair, and said it looked bad, and should be replaced. On 12/31/2025 at 9:16 AM the MS verified the burgundy chair in the common area belonged to the facility. The undated facility policy, Resident Environmental Quality, documented it was the policy of the facility to be designed,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · 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 observations, clinical record review, staff interviews, resident interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 13 residents reviewed (Resident #12 and #4). The facility failed to document a gastrointestinal assessment and notify the physician when indicated for Resident #12. The facility also failed to implement interventions for Resident #4 with new skin issues. The facility reported a census of 43 residents.Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #12 was dependent on staff for toileting hygiene and transfers to the toilet. The MDS documented Resident #12 was frequently incontinent of bowel and constipation was present. The MDS included diagnoses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, staff interviews, and policy review, the facility failed to change oxygen tubing and water humidifier for 1 of 1 residents reviewed (Resident #12) for respiratory services. The facility reported a census of 43 residents. Findings Include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD)(progressive lung condition) and congestive heart failure (heart inability to pump blood causing fluid build up). The MDS documented Resident #12 received oxygen while a resident within the last 14 days. A Physician order dated 11/7/25 directed Resident #12 to wear oxygen per nasal cannula to keep oxygen saturation above 90% as needed related to COPD. The order directed no more than 3 liters of oxygen for diagnosis of COPD.The Care Plan with a target date of 2/25/26 documented…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, the Centers for Disease Control and Prevention (CDC) and the facility policy review, the facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not wearing the required personal protective equipment for 1 of 2 residents (Resident #4) reviewed for catheter care. The facility also failed to keep dirty linens off the floor. The facility reported a census of 43 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #4's MDS included diagnoses of benign prostatic hyperplasia (enlargement of prostate gland), renal (kidney) disease and obstructive uropathy (blockage in urinary tract preventing normal urine flow). The MDS revealed Resident #4 had an indwelling catheter (thin tube used to drain urine). The Care Plan with a target date of 12/31/25 documented…

    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 · Ecited before2025-01-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 42. Findings include: A direct observation on 01/12/2025 at 10:23 AM of the kitchen revealed an open container of cottage cheese with a discard date of 01/11/2025. It also revealed an unmarked, undated meat product stored in the freezer in a single sheet of plastic cling wrap. The Dietary Manager identified the item as roast beef, and stated it had been prepared within a day or two of the observation. A direct observation on 01/14/2025 at 09:33 AM of the kitchen dining service Staff A, Cook, was observed wearing the same pair of disposable vinyl gloves while prepping three unique food items, touching different utensils, the walls, as well as other contaminated surfaces before returning to prepare ground meat for the lunch service. During the same observation, Staff A was witnessed coughing into the same pair of vinyl gloves without changing them. While preparing…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 verify the resident's advanced directive choice for 1 (Resident #46) of 12 residents reviewed. The facility reported a census of 42 residents. Findings include: The Clinical Census Sheet dated [DATE], documented Resident #46 admitted to the facility on [DATE] and Code Status, Advanced Directive of Do Not Resuscitate (DNR). Observation on [DATE] at 10:38 AM, resident's hard chart with sticker Full Code (initiate cardiopulmonary resuscitation (CPR) in the event resident is not breathing and has no pulse) on the outside of the chart and the inside of the chart lacked an IPOST (Iowa Physician's Order for Scope of Treatment) (document that allows a person to communicate their preferences for key life-sustaining treatments). The resident's electronic health record, revealed an Order Summary Report, dated [DATE], with a physician's order dated [DATE] for DNR. Interview on [DATE] at 10:39 AM, Staff B, Certified…

    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 before2025-01-15 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, resident and staff interview the facility failed to followed a physician's order for 1 resident (Resident #1) of 12 residents reviewed. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) for Resident # 1, dated 12/19/24, documented she scored 15 on the Brief Interview of Mental Status indicating intact cognition. The MDS included diagnoses of cerebral palsy, and documented received a scheduled pain medication regimen with frequent pain or hurting over the last 5 days. Interview on 1/14/25 at 10:22 AM, resident stated she is to receive a Lidocaine pain patch on her left shoulder every day and then removed at bedtime. The resident further stated the patch was not available today and there were also 2 weekends in December that the facility did not have the patch to apply to her. The resident stated the patch helps a lot with the shoulder pain. Review of the resident's Medication Administration Records documented the Lidocaine pain patch not available on the following dates in the past 3 months: a. 11/9, 11/10,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-15 · tag F0948 — isolated
    Ensure that paid feeding assistants have the training they need.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, staff interviews, and facility policy review the facility failed to ensure a person that assisted a resident to eat was a certified paid feeding assistant for 1 (Resident #36) of 15 residents reviewed. The facility reported a census of 42 residents. Findings include: The MDS for Resident #36, dated 12/23/24, indicated a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview, indicated severe cognitive impairment for decision-making. Observation on 1/13/25 at 12:00 PM, in the dining room with the Assistant Director of Nursing present, the resident was assisted to eat by another resident's wife. Facility policy Assistance with Meals revised March 2022, documented facility staff will serve resident trays and will help residents who require assistance with eating. Interview on 1/13/25 at 3:57 PM the Director of Nursing stated expectation for family/visitors to not assist non-family member residents to dine.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-09-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 pharmacy interview, staff interviews, policy review and clinical record review the facility failed to keep accurate account of narcotic medications for 2 of 3 residents. On 8/12/24, staff discovered that Resident #1 had 8 milliliters (ml) of morphine missing, and Resident #2 had 12 ml missing. Staff admitted that they did not always look at the bottles at shift change before documenting the amount of remaining liquid morphine. Documentation of narcotics administered was inconsistent between the paper chart and the electronic chart for Resident #1 and #2. The facility reported a census of 39 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits). She required substantial assistance with dressing and showering, and was totally dependent for transfers. The census tab showed that Resident #2 was admitted to Hospice services 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, policy review and clinical record review the facility failed to safely store liquid narcotic medications for 1 of 3 residents reviewed (Resident #3). Staff F left two liquid narcotic medications in the top drawer of the medication cart under a single lock. The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive deficit). She required substantial assistance with dressing, sit to stand and transfers. Her diagnosis included; diabetes mellitus, Alzheimer's disease, aphasia, cerebrovascular accident and fibromyalgia. The Care Plan for Resident #3, updated on 7/25/24, showed that she was at risk for elopement and was in the locked unit. She had elected for hospice care due to terminal condition and staff were to administer medications as ordered. On 9/10/24 at 8:06 AM a medication cart was sitting in the dining room…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and policy review, the facility failed to consistently count resident narcotics between shifts for 1 of 3 residents reviewed (Resident #7). Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety, and depression. Resident #7 received a scheduled pain medication. The Care Plan revised 10/25/23 reflected Resident #7 had a risk for alteration in comfort, had Alzheimer's and couldn't always effectively express her pain. The Care Plan included an Intervention for Resident #7 to take her medications as ordered. Resident #7's November 2023's Medication Administration Record (MAR) listed an order dated 8/13/23 for Hydrocodone-Acetaminophen 5-325 milligram (MG) 1 tablet by mouth 3 times a day for pain. The Incident Report dated 11/21/23 at 5:52 PM included a nursing description that the facility…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2024-01-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and policy review, the facility failed to ensure to resident narcotics were disposed of properly for 1 of 3 residents reviewed (Resident #7). Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety, and depression. Resident #7 received a scheduled pain medication. The Care Plan revised 10/25/23 reflected Resident #7 had a risk for alteration in comfort, had Alzheimer's and couldn't always effectively express her pain. The Care Plan included an Intervention for Resident #7 to take her medications as ordered. Resident #7's November 2023's Medication Administration Record (MAR) listed an order dated 8/13/23 for Hydrocodone-Acetaminophen 5-325 milligram (MG) 1 tablet by mouth 3 times a day for pain. The documentation indicated Resident #7 received all her hydrocodone. The facility's undated…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2023-11-13 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 4 out of 14 residents reviewed (Resident #29, #18, #30, #37). The facility reported a census of 38 residents. Findings includes: 1. Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMs) score of 7, indicating moderately impaired cognition. The MDS identified Resident #29 required substantial/maximal assistance with bed mobility, transfers, and toilet use. Resident #29's MDS included diagnoses of anemia, heart failure, hypertension, diabetes mellitus, non-alzheimer's dementia, anxiety disorder and post traumatic stress disorder. Resident #29 received insulin for 7 out of 7 days in the lookback period. Resident #29's November 2023 Medication Administration Record (MAR) included an order dated 4/1/23 for Levemir (long acting insulin) FlexPen Subcutaneous Solution Pen…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to label individualized insulin pens with a resident identifier, date open vial of tuberculin (TB) solution and had expired treatment supplies in the cupboard and medication cart. The facility reported a census of 38 residents. Findings include: On [DATE] at 7:19 AM observed Resident #29's Novolog and Lantus insulin pens stored in a clear plastic tube (toothbrush holder). The clear plastic tubes included the residents' name with a black marker. When the staff removed the insulin pens from the plastic tube, the insulin pen lacked resident identifiers. On [DATE] at 5:00 PM, the Director of Nursing (DON) and Staff E, RNC (Regional Nurse Consultant), reported the pharmacy sends 5 insulin pens in a box and the box is labeled with the resident identifier, not the individual pens. On [DATE] at 8:36 AM observed in the front nurses' station refrigerator an open vial of TB solution with no open date or a date to discard on vial or 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, and staff interview, staff failed to prepare and serve food under sanitary conditions and failed to properly thaw meat to reduce the risk of contamination and foodborne illness. The facility reported a census of 38 residents. Findings include: 1. On 11/8/23 at 10:00 AM and 11:16 AM observed 2 beef pot roasts in the sink submerged in standing water, without any water running into the sink. 2. On 11/8/23 at 10:00 AM observed Staff H, Cook, wash their hands, apply gloves, and then touch the pans, tongs, foil, and a scale. Staff H proceeded to use the tongs to place meat on the scale, the meat fell off the scale onto the counter. Staff H placed the meat back onto the scale with tongs and touched the meat with her gloved hands. Staff H removed their gloves and wiped the counter with a cloth from the sanitizer bucket and proceeded to place utensils on the wiped counter. Staff H tested the sanitizer bucket water, with the strip remaining orange, indicating 0 parts per million (ppm) of sanitizer. Staff H removed their gloves, washed the robot coupe…

    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 · D2023-11-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, and facility policy review, the facility failed to provide care for 1 of 14 residents reviewed (Resident #37) in a manner to promote dignity and respect. The facility reported a census of 38 residents. Findings include: Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #37's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension (high blood pressure) and anemia (low blood iron). On 11/6/23 at 10:38 AM, Resident #37 described the facility as short staffed. Resident #37 stated she has waited 30-45 minutes for her call light to be answered. She has become incontinent of bowel due to having to wait so long. Resident #37 reported it happened in the morning before breakfast. Resident #37 reported being horrified and really upset as it is not normal for her. A facility policy titled Quality of Life-Dignity revised August…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to notify the Physician when a resident refused to take sliding scale insulin at bedtime and failed to report blood sugars below 70 mg/dl (milligrams per deciliter) for 1 of 1 resident reviewed (Resident #37) for insulin administration. The facility reported a census of 38. Findings include: Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #37's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension (high blood pressure) and anemia (low blood iron). The Care Plan revised 9/11/23 indicated that Resident #37 had a diagnosis of diabetes mellitus and had a risk for frequent infections, alteration of skin, visual impairment, hyper/hypoglycemia (low/high blood sugar), renal failure and cognitive/physical impairments. The Care Plan directed staff to monitor/check blood glucose levels as…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a significant change comprehensive assessment in a timely manner (14 days after facility identified a significant change from baseline had occurred) for 1 out of 14 resident reviewed (Resident #18). The facility reported a census of 38 residents. Findings include: Resident #18's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS identified Resident #18 had signs and symptoms of delirium (a temporary mental state characterize by confusion, anxiety, incoherent speech, and hallucinations) with inattention with behavior present, fluctuates. Resident #18 required extensive assistance of one person with bed mobility, transfers, ambulation and toilet use. The MDS indicated Resident #18 required a walker and wheelchair for mobility. A balance during transitions and walking identified Resident #18 as not steady, only able 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interviews, staff interviews and facility policy review the facility failed to provide oral hygiene per resident preference for 1 of 3 residents reviewed (Resident #26) for Activities of Daily Living. Findings include: Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS described Resident #26 as dependent on staff to complete oral hygiene. Resident #26's MDS included diagnoses of hypertension (high blood pressure), renal (kidney) disease, anxiety, depression and early onset of Alzheimer's disease. The Care Plan revised 11/5/23 revealed Resident #26 required one person to assist with oral care/hygiene. The Care Plan directed staff to encourage oral care in morning, afternoon, and at HS (hour of sleep). On 11/7/23 at 9:13 AM, Resident #26 reported that he did not have his teeth brushed. When asked when the last time he had oral hygiene, he stated he could not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interviews, the facility failed to provide oxygen as ordered by the physician for 1 of 1 resident (Resident #3) reviewed for respiratory services. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS indicated that Resident #3 required oxygen while a resident at the facility. Resident #3's MDS included diagnoses of cerebral palsy (neurological disorder that affects movement and muscle tone due to a brain injury or malformation before, during, or after birth), chronic lung disease, and respiratory failure. The Care Plan revised 7/20/23 listed that Resident #3 used oxygen as needed and had a risk for alterations in oxygen levels due to chronic lung issues. The care plan directed staff to administer oxygen via nasal cannula (N/C) as ordered. The Physician Order dated 2/27/23 directed staff to administer oxygen at 1-2…

    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 · D2023-11-13 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility. The facility reported a census of 38 residents. Findings include: 1. Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #37's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension (high blood pressure) and anemia (low blood iron). On 11/6/23 at 10:38 AM, Resident #37 described the facility as short staffed. Resident #37 stated she has waited 30-45 minutes for her call light to be answered. She has become incontinent of bowel due to having to wait so long. Resident #37 reported it happened in the morning before breakfast. Resident #37 reported being horrified and really upset as it is not normal for her. Resident #37 stated she used the clock on the wall in her room to time the call…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

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 →

RatingThis homeChain avg
Overall 4 of 52.1+1.9 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 21 homes this chain runs (chain average 2.1★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
HOLDCO GOLDFINCH, LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
CHITAI INVESTMENT, LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
HOLDCO TABLETOP, LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
INVESTCO TABLETOP, LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
TECHCARE CORPOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
CURCIO, DOMINICIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2020
CAMPBELL STREET SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
MANAGERCO GOLDFINCH, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2020
CATES, JANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2022
CONNER, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
DOLE, ISAACIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
WESTPHAL, TASHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/16/2024
SATTERFIELD, BRENDAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 04/18/2025

CMS files one row per role, so the 25 rows in the source record cover these 13 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.

7 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.

$3.8M
Net patient revenuemost recent cost report
-4.9%
Operating marginrevenue minus expenses
$436K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 6%Other / private 42%

This home reported $436K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$257per resident / day
operating cost
$7,816per month
≈ monthly operating cost
$245per day
avg. revenue, all payers

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

What families pay in IA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165233. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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