Rose Haven Nursing Home
1500 N Franklin Avenue, Marengo, IA 52301 · For profit - Corporation · 58 certified beds · (319) 642-5533 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,062 in federal fines (most recent 2023-11-07)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 improved from 2 to 4 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 | 11.7% | 17.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.4% | 3.8% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 12.3% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.3% | 20.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.9% | 19.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.2% | 73.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 14.6% | 20.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.3% | 13.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.49 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.79 | 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.
39.8% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 39.8%CMS range 26.4–56.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.8–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 62.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 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 | 7.7% | 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 | 10.5%CMS range 6.0–17.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.43 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 58 beds and averages 47.5 residents a day — about 82% 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.94 hrs/resident/day on weekends vs 3.44 on weekdays — 14% thinner on weekends. RN hours go from 0.55 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, State Climatologist Report, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision to prevent hazards during a temporary modification of a safety intervention. The Maintenance Supervisor turned off the alarm to the southeast outside door to allow workers access to resident areas for repairs and failed to notify nursing staff for 2 1/2 hours. A confused, independently mobile resident exited the door in his wheelchair and was found outside in 36-degree weather at the time of his exit from the building with wind gusts of 24 mph causing a Wind Chill of 27 degrees and no coat to protect him. Estimated time outside of the building was 10-15 minutes. The failure resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 44 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 30, 2023 on November 2, 2023 at…
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 · D2026-05-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement transmission based precaution procedures, monitor, and test residents with symptoms or exposure to COVID-19 virus for 2 of 4 residents reviewed for infection control. The facility failed to ensure that criteria was followed to reduce the risk of COVID-19 transmission when Resident #2 tested positive for COVID-19 on 2/19/26 at the hospital, then returned to the facility on 2/25/26 (7 days), the facility did not provide additional precautions for Resident #2 who continued to have respiratory symptoms. The facility further failed to prevent transmission of COVID-19 when 2 direct care staff reported symptoms while working of fever, body aches, cough, decreased smell/taste, and tested positive for COVID-19 at the facility on 2/24/26, both staff continued to provide direct cares and work 12 hour shifts on 3 of 3 hallways. The facility additionally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · 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, clinical record review, policy review, and staff interviews, the facility failed to determine that it was clinically appropriate and safe for a resident to self-administer medications for 1 of 1 residents reviewed for the self-administration of medications(Resident #13). The facility reported a census of 45 residents. Findings included: The Quarterly Minimum Data Set(MDS) assessment tool, dated 9/30/25, listed diagnoses for Resident #13 which included chronic obstructive pulmonary disease(COPD), a disease which caused symptoms such as shortness of breath), heart failure, and diabetes. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The 2022 facility policy Self-Administration of Medications stated residents had the right to self-administer medications if the interdisciplinary team determined that it was clinically appropriate and safe for the resident to do so. The December 2025 Medication Administration Record(MAR) listed a 7/21/25 order for Ipratropium-Albuterol Solution(a medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure residents were free from physical abuse for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated all residents had the right to be free from abuse and neglect. The policy stated assault of a dependent adult was the commission of any act which was generally intended to cause pain or injury or which was generally intended to result in physical contact considered by a reasonable person to be insulting or offensive or any act intended to place another in fear of immediate physical contact which would be painful, injurious, insulting, or offensive, coupled 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 · D2025-12-11 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to carry out a gradual dose reduction(GDR) or ensure the provider documented why the reduction would be clinically contraindicated for 1 of 5 residents reviewed for psychotropic medications(Resident #35). The facility reported a census of 45 residents. Findings included:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The December 2025 Medication Administration Record(MAR) listed the following:A 3/27/25 order for Trazodone(an antidepressant) 100 milligrams(mg) daily.A 3/28/25 order for Duloxetine(an antidepressant) 120 mg daily. As of 12/8/25, the facility lacked documentation of an attempted GDR for the above medications or provider documentation as to why the reduction would be clinically contraindicated.On 12/11/25, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated the facility would report all allegations of abuse to the State Agency within 2 hours.Care Plan entries, dated 4/4/25, stated the resident had impaired cognitive function, intellectual disability, and hearing loss impeding communications. The entries directed staff to orient the resident as needed, keep his routine consistent, and engage him in simple structured activities that avoided overly demanding tasks. An Unwitnessed Fall report, dated 10/28/25 at 1:46 p.m., stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interviews, the facility failed to separate an alleged perpetrator of abuse from residents for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated the facility would separate the employee accused of abuse from all residents.Care Plan entries, dated 4/4/25, stated the resident had impaired cognitive function, intellectual disability, and hearing loss impeding communications. The entries directed staff to orient the resident as needed, keep his routine consistent, and engage him in simple structured activities that avoided overly demanding tasks. An Unwitnessed Fall report, dated 10/28/25 at 1:46 p.m., stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interview, the facility failed to administer insulin in a timely manner with respect to the obtainment of the resident's blood sugar(BS) for 1 of 2 residents(Resident #2) reviewed for insulin(an injectable medication used to lower blood sugars). The facility reported a census of 45 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 11/2/25, listed diagnoses for Resident #2 which included diabetes(a disease which causes irregularities in blood sugars), arthritis, and anxiety, and listed his Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The resident's Blood Sugar Summary included the following blood sugar readings:11/23/25 5:20 a.m. 110 mg/dl(milligrams(mg)/deciliter(dl) and 8:11 a.m. 110 mg/dl11/24/25 5:25 a.m. 150 mg/dl and 9:18 a.m. 150 mg/dl11/25/25 5:30 a.m. 225 mg/dl and 6:50 a.m. 225 mg/dl11/26/25 6:23 a.m. 222 mg/dl and 8:58 a.m. 222 mg/dl11/29/25 5:37 a.m. 188 mg/dl and 8:28 a.m. 188 mg/dl11/30/25 5:19 a.m. 253 mg/dl and 826 a.m. 253 mg/dlThe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interview, the facility failed to assess and intervene in a timely manner after a resident complained of signs and symptoms of an infection for 1 of 2 residents reviewed for a change in condition(Resident #26). The facility reported a census of 45 residents. Findings included:The Minimum Data Set(MDS) assessment tool, dated 9/23/25, listed diagnoses for Resident #26 which included diabetes(a disease which caused irregularities in blood sugars), non-Alzheimer's dementia, and depression. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 12/8/25 at 1:42 p.m., Resident #26 stated it took the facility a week before they obtained medication for her yeast infection. She stated she had burning and itching and it was very, very uncomfortable.A 11/25/25 5:11 AM Nurses Note documented that the facility sent a fax to the resident's provider related to a possible yeast infection. The resident's vaginal area was red and she had discomfort when using the bathroom and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review, staff and resident interviews and facility policy review the facility failed to treat one out of four residents reviewed in a dignified manor (Resident#5). The facility reported a census of 49 residents. Finding include: The Significant Minimum Data Set (MDS) assessment for Resident #5 dated 2/18/25, included diagnoses of neurogenic bladder, pressure ulcer, diabetes mellitus (DM), anxiety, and depression. The MDS reflected Resident#5's Brief Interview for Mental Status score of 15 (intact cognition). The MDS listed Resident#5 dependent on staff for toilet transfers and toilet hygiene. The Care Plan for Resident#5 dated 2/18/25, directed Staff to assist her with toileting upon her request, Resident#5 often preferred to utilize the commode. Staff assist with peri cares (procedure to clean and maintain the genital and anal areas) every AM, PM and as needed with incontinence episodes. On 3/6/35 at 8:30 AM, Resident#5 sat in her room in her wheelchair and she confirmed Staff B, Certified Nurses Aid (CNA) told her to go to the bathroom in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident interviews, and facility policy review the facility failed to report an allegation of abuse in a timely manner for 1 out of 4 residents reviewed for abuse ( Resident#2). The facility reported a census of 49 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#2 dated 1/24/25, listed diagnoses of respiratory failure, heart failure, and diabetes mellitus. The BIMS reflected a score of 12 (moderate cognitive impairment). The MDS reflected Resident#2 required substantial/maximal assistance with toileting hygiene and partial/ moderate assistance to transfer off the toilet. The Care Plan for Resident#2 dated 8/8/24 directed assist of one staff for transfers, ambulation with walker and toileting. A facility document titled #408 Alleged Abuse dated 3/4/25, Resident#2 reported one of the CNA slammed her down on the toilet over the weekend. The document showed the facility asked eight residents about the care staff provided at the facility. During an interview on 3/4/25 at 12:52 PM, Resident#2 reported one CNA…
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 15 citations
- Potential for harm · Dcited before2025-03-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident interviews, and facility policy review the facility failed to do a thorough investigation into an allegation of abuse for 1 out of 4 residents reviewed Resident#2). The facility reported a census of 49 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#2 dated 1/24/25, listed diagnoses of respiratory failure, heart failure, and diabetes mellitus. The BIMS reflected a score of 12 (moderate cognitive impairment). The MDS reflected Resident#2 required substantial/maximal assistance with toileting hygiene and partial/ moderate assistance to transfer off the toilet. The Care Plan for Resident#2 dated 8/8/24 directed assist of one staff for transfers, ambulation with walker and toileting. A facility document titled #408 Alleged Abuse dated 3/4/25, Resident#2 reported one of the CNA slammed her down on the toilet over the weekend. The document showed the facility asked eight residents about the care staff provided at the facility. During an interview on 3/4/25 at 12:52 PM, Resident#2 reported one CNA slammed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-10 · 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 observation, resident and staff interviews and facility policy review the facility failed to transfer 3 out of 4 residents safely Resident#1, #2, and #5). The facility reported a census of 49 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident#1 dated 12/10/24, listed diagnoses of pulmonary hypertension (blood pressure in the arteries of the lungs is abnormally high), hyperthyroidism and insomnia. The MDS reflected a Brief Interview for Mental Statues score of 15 (intact cognition). The MDS identified Resident#1 independent with sit to stand and ambulation up to 150 feet. The MDS reflected she needed partial/moderate assistance with toileting hygiene. The Care Plan for Resident#1 dated 9/30/24, identified Resident #1 independent in the facility with her walker, and independent with toileting. Staff assist her as needed upon her request. The Progress Notes for Resident#1 dated 1/4/25 at 9:43 AM, reflected Resident#1 went to the nurse's station and showed Staff I, Licensed Practical Nurse (LPN) a bruise on her left forearm, 3…
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 · E2024-10-24 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, clinical record review, staff interviews and facility policy review the facility failed to store medication in the packaging the medications came in, in the medication cart and stored held in a medication cup for one out of one resident s reviewed, the facility failed to keep one out of one refrigerators locked for 1 out of 3 days and failed to date one out of one insulin pens after staff opened it. The facility reported a census of 47 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated [DATE] listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated [DATE], identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain, diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interviews and facility policy review the facility failed to follow the facilities abuse policy and procedures after identifying a missing narcotic medication for 1 of 1 resident reviewed (Resident#24). The facility reported a census of 47 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated 12/7/23 listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated 7/13/22, identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain,diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please provide Resident#24 any pain management that my physician ordered and any as needed pain meds as he may need them. The Medication Administration Record (MAR) for Resident#24 dated 1/2024, directed the staff to administer PM medication that included: a.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff and resident interviews and facility policy review the facility failed to do a thorough investigation into medications found in a medication cup that failed to include a prescribed narcotic for 1 out of 1 resident reviewed Resident#24. The facility reported a census of 47 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated 12/7/23 listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated 7/13/22, identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain, diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please provide Resident#24 any pain management that my physician ordered and any as needed pain medication as he may need them. The Medication Administration Record (MAR) for Resident#24 dated 1/2024, directed the staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-30 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and Facility Assessment review, the facility failed to employ a Registered Nurse (RN) to serve as the Director of Nursing (DON) since March 9, 2023. The facility reported a census of 45 residents. Findings include: In an interview on 8/29/23 at 12:40 PM, the Administrator reported the facility did not currently employ a Director of Nursing (DON). She reported the previous DON and Infection Preventionist was staff I, Registered Nurse (RN). Staff I, RN went on leave and was to return on 6/12/23 into the Infection Preventionist role but did not plan to return to the DON role. She stated the facility had been without a DON since 3/9/23. The Administrator stated the facility had been actively trying to hire a new DON but had not been successful to this point and none of the current facility RN's were interested in taking the position. She stated the facility considered hiring an interim DON but the hourly cost was significant and she felt it was cost prohibitive and the facility 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.
- Potential for harm · Ecited before2023-08-30 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 2. The MDS Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. The MDS documented the resident's BIMS score as 15 out of 15, indicating intact cognition. A clinical record review revealed a Physician Order for colostomy care, with colostomy bag changes twice weekly on shower days. The Care Plan directed staff to assist with emptying the colostomy bag every shift and as needed. During an interview on 8/28/23 at 9:34 AM, the resident stated there are times the colostomy bag will pop off due to a gas build up. The resident stated that when this happens Staff D, CNA has yelled at him to stop playing with the bag. He stated the staff asks why he does this and he has to stop. Resident #11 stated he feels bad when this happens and finds it upsetting. During an interview on 8/29/23 at 8:45 AM,…
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 · D2023-08-30 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interviews, and facility document review the facility failed to promote resident choice in their morning schedule for 1 of 1 residents in the sample (Resident #11). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. Total dependence is required for transfers. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an observation on 8/27/23 at 11:00 AM, Resident #11 found to be in his bed resting. During an interview on 8/28/23 at 9:29 AM, Resident #11 stated that several staff will not get him up in the morning for breakfast. He stated this often happens on his scheduled shower days. The resident stated he could be left in bed as long as 11:15 AM.…
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 · D2023-08-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident and staff interviews, and facility document review, the facility failed to provide follow up on a discovery of missing personal items for 1 of 2 residents in the sample (Resident #18). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #18 included: essential tremor, anxiety disorder, and polymyalgia rheumatica (muscle pain and stiffness around shoulders and hips). The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an interview on 8/28/23 at 11:02 AM, Resident #18 stated several months ago a bracelet went missing from her over the bedside table. The resident stated she had put the bracelet on top of her cell phone. The resident stated she reported this to the Business Office Manager (BOM). A review of 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.
- Potential for harm · D2023-08-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, Consultant Pharmacist and staff interviews the facility failed to revise care plans, after a hospitalization and resident falls for 2 of 3 residents in the sample (Residents #21, and #26). The facility reported a census of 46 residents Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #21 included: depression, and anxiety disorder. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. During an interview on 8/27/23 at 2:50 PM, Resident #21 stated in June 2023 she had been hospitalized for a problem with her medications. A 6/10/23 Nurse's Note revealed a Certified Nursing Assistant (CNA) reported the resident seemed off. The Nurse Assessment indicated the resident experienced increased confusion, difficulty staying awake, shakiness and crying out in pain. A Physician Order given to transfer the resident to the emergency room (ER) for evaluation and treatment. A 6/16/23 Hospital Discharge Summary revealed an admitting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to implement interventions in a timely manner after a resident made suicide threats for 1 of 1 residents (Resident #18). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #18 included: essential tremor, anxiety disorder, and polymyalgia rheumatica (muscle pain and stiffness around shoulders and hips). The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan included a focus area on Mood/Behavior, with the following interventions: A. I do have a major depression diagnosis,and I do get easily anxious. Initiated on 1/5/22. B. I report moods of feeling down, depressed, hopeless, trouble falling asleep,and feeling bad about myself. I need to be told…
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 · D2023-08-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility policy review, the facility failed to ensure catheter tubing and bag are situated in a manner to provide possible infection for 1 of 2 residents in the sample (Resident #23). The facility reported a census of 46 residents Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #23 included: Type 2 diabetes mellitus, and amputation of left lesser toe (not the big toe). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan revealed Resident #23 admitted to the facility with an indwelling Foley catheter During an observation on 8/29/23 at 10:40 AM, noted the resident's catheter bag hooked on to the side of her garbage can, with tubing resting on the floor. During an interview on 8/29/23 at 11:21 AM Staff F, Registered Nurse (RN) stated all catheter bags should be placed below the bladder, and usually placed under a wheelchair seat, or hooked on to the recliner. Staff F stated the bag should not be…
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 · D2023-08-30 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and the Infection Control Policy review, the facility failed to employ an Infection Preventionist at least part time as required. The facility reported a census of 45 residents Findings Include: In an email dated 8/28/23 at 5:18 PM, the Administrator stated Staff I, Registered Nurse (RN) went on leave on 3/9/23. Staff I, RN was the Infection Preventionist at that time and she planned to return to the position on 6/9/23, but was unable to return due to health concerns. Staff J, RN was the previous Infection Preventionist and had been assisting with Infection Control. The facility hired Staff K, RN as the facility's Assistant Director of Nursing (ADON) and Infection Preventionist on 8/21/23. In an interview in 8/29/23 at 12:40 PM, the Administrator reported the previous Director of Nursing (DON) and Infection Preventionist was staff I, RN. She left work on leave on 3/9/23 and was to return to work on 6/12/23 in the Infection Preventionist role but not the DON role. Staff I remained off work due to health concerns and did not return to either position. 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.
- No harm found · C2025-03-10 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, facility record review and facility policy review the facility failed to address previously cited deficiencies in the Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 49 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) Statements of Deficiencies 2567 dated 10/24/24, included violation at F609 and F610. The current survey dated 3/4/25 through 3/10/25 identified the same violation at F609 and F610. Form CMS-2567 dated of 11/13/24, reflected acceptance of your credible allegation of substantial compliance and Plan of Correction. On 3/10/25 at 3:44 PM, the Administrator reported the facility followed up on other previous deficiencies cited. The facility Quality Assessment and Performance Improvement (QAPI) policy undated, that identified: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included developing and implementing corrective action or performance improvement activities; and monitoring or evaluating 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.
- No harm found · C2023-08-30 · tag F0868 — widespreadHave 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, staff interview, and facility policy review the facility failed to have the required members present at their Quarterly Quality Assurance (QA) Meetings. The facility reported a census of 45 residents. Findings Include: QA Committee Meetings were conducted on the following dates; 7/21/22, 10/20/22, 1/19/23, 4/20/23, and 7/20/23. Review of the Attendance Sheets for the QA meetings revealed the required members attended the QA meetings on 7/21/22, 10/20/22 and 1/19/23. The Attendance Sheets for the QA Meetings held on 4/20/23 and 7/20/23 revealed the Director of Nursing (DON) and Infection Preventionist (IP) were not in attendance. In an interview on 8/29/23 at 12:55 PM, the Administrator stated it was the expectation that required members attend the meetings when they have active staff in the roles to attend. She stated they currently did not have a DON or part time IP. Per the Quality Assurance/QAPI (Quality Assurance and Performance Improvement), Safety and Disaster Planning, Infection Control policy, all interested individuals are invited to attend these…
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
$10,062 in federal fines across 1 penalty.
- $10,062 — penalty dated 2023-11-07
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SISSEL, SHANE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 01/01/2012 |
| SISSEL, SUSAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 01/01/2012 |
| KEYSTONE SAVINGS BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 01/01/2016 |
| DOSE, RONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2018 |
| GERARD, DALE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/18/2022 |
| GULICK, KENSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/29/2015 |
| KEPLER, TERENI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/08/2025 |
| MCMANN, MACY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/22/2022 |
| RADEKE, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/05/2024 |
| SCHAFFNER, TRISTA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/08/2025 |
| ACCESS TECHNOLOGIES INC | Organization | ADP OF THE SNF | — | since 10/24/2017 |
| BAKERSTARRETT LLP | Organization | ADP OF THE SNF | — | since 07/17/2020 |
| BCG HOLDINGS INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| ECSI INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| J EVANS NUTRITION CONSULTING LLC | Organization | ADP OF THE SNF | — | since 11/30/2022 |
| KEY REHABILITATION INC | Organization | ADP OF THE SNF | — | since 10/31/2012 |
| PM ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 07/01/2017 |
| VIRTUOUS LTC CONSULTING | Organization | ADP OF THE SNF | — | since 02/29/2020 |
CMS files one row per role, so the 31 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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 $102K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165614. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.