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Good Shepherd Health Center

302 Second Street NE, Mason City, IA 50401 · Non profit - Corporation · 170 certified beds · (641) 424-1740 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Mar 20251 immediate-jeopardy citation$87,458 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $87,458 in federal fines (most recent 2024-08-30)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (69%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
321 14th St NW · (641) 512-8568 · Call to confirm hours
Pharmacy
101 S Monroe Ave · (641) 422-9333 · Call to confirm hours
Grocery
13 S Federal Ave · (641) 450-0893 · Call to confirm hours
Park
22 N Georgia Ave Ste 4 · (641) 421-3673 · Typically dawn to dusk
Place of worship
213 N Pennsylvania Ave · (641) 423-0536

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 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 rating2★
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 increased20.5%17.1%15.4%worse
Long-stay residents who lose too much weight3.3%4.6%5.4%better
Long-stay residents with a catheter left in their bladder2.6%1.5%0.9%worse
Long-stay residents with a urinary tract infection2.9%2.4%2.0%worse
Long-stay residents with depressive symptoms10.1%4.2%6.5%worse
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 injury7.4%3.8%3.3%worse
Long-stay residents whose ability to walk worsened21.6%16.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.7%20.8%18.9%typical
Long-stay residents given the seasonal flu vaccine98.8%95.3%95.3%typical
Long-stay residents with pressure ulcers3.1%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control29.9%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table26.7%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.3%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine52.2%73.3%79.4%worse
Short-stay residents rehospitalized after admission27.8%20.9%22.6%worse
Short-stay residents with an outpatient ER visit7.3%13.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.191.491.67better
Long-stay outpatient ER visits per 1,000 resident days2.182.081.80worse

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.

34.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.2%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 78 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.2%CMS range 26.2–42.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.9–13.610.7%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 discharge50.0%56.6%Oct 2024–Sep 2025CMS 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 discharge44.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.0%50.0%Oct 2024–Sep 2025CMS 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 identified91.7%98.7%Oct 2024–Sep 2025CMS 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 setting90.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.7–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.521.02Oct 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

0.36
RN hours/ resident / day
0.70
LPN hours/ resident / day
2.59
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.27
RN hoursweekends
68.7%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 170 beds and averages 147.0 residents a day — about 86% occupied, or roughly 23 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 3.72 on weekdays — 7% thinner on weekends. RN hours go from 0.39 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% 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 (2025-12-11)
7
at the previous standard inspection (2024-10-31)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-08-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, family, physician, emergency medical personnel, and staff interview, the facility failed to implement interventions in a timely manner for a resident following a fall for 1 of 3 residents reviewed (Resident #3). The facility failed to intervene after Resident #3 fell and complained instantly of new pain to his ribs. Despite, the family's frequent questioning about Resident #3's situation, the facility failed to send him to the hospital for 2 hours and 36 minutes following his fall. The facility's policy requires someone from nursing management to assess a resident following an incident. It took the nursing supervisor approximately 1 hours after Resident #3 fell for the nursing supervisor assessed Resident #3. Following the nursing supervisor's assessment requested by Resident #3's family, the nursing supervisor attempted to contact the physician for an order to send him to the hospital. Resident #3 transferred to the hospital approximately 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
  • Actual harm · G2025-03-13 · tag F0713 — isolated
    Provide or arrange emergency care by a doctor 24 hours a day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to intervene timely for a resident who needed had a change in condition following a fall on 2/3/25 for 1 of 4 residents reviewed (Resident #2). At Resident #2's admission in December 2024, he came to the facility with a repaired fractured right hip due to a fall at home. Due to his cognition, he frequently forgot he previously had a hip fracture and would frequently transfer by himself. On 2/3/25, he had an unwitnessed fall. When the nurse assessed him, he reported pain to his right hip. After the nurse's assessment, 2 Certified Nurse Aides (CNAs) assisted Resident #2 from the floor and back into bed. Despite Resident #2's recent surgical repair of his right hip, the nurse faxed the physician instead of sending him for evaluation. Resident #2 continued to report pain during the nurses' assessments to his right hip and needed assistance of 2 staff for transfers.…

    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
  • Potential for harm · Dcited before2026-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, family, and staff interviews the facility failed to do a timely assessment on 1 of 3 residents reviewed (Resident #1). Resident #1 had a bruise on the right inner/outer thigh and hip area. The facility staff knew about the bruise on 2/13/26, and 2/14/26, which no staff assessed the area until 2/15/26 when the resident started to complain of pain. The facility reported a census of 150 residents.Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognitive decisions. Resident #1 could understand others and others understood them. They had adequate hearing, and vision. Resident #1 required total staff assistance with toileting and substantial to maximal assistance with hygiene and dressing. The MDS included diagnoses of hypertension (a condition where blood consistently pushes hard against artery walls), Alzheimer's Disease,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 and procedures, the facility failed to implement interventions to prevent weight loss and implement adequate hydration for 1 of 3 residents reviewed for weight loss and hydration (Resident #2). The facility identified a census of 150 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified short- and long-term memory problems with severely impaired decision-making abilities. Resident #2 required supervision for eating/drinking. The MDS listed Resident #2 at 230 pounds with no weight loss. The MDS included diagnoses of Alzheimer's Disease, Parkinson's and depression.The Care Plan Focus initiated dated 4/13/23, indicated Resident #2 had an activity of daily living (ADL) self-care performance deficit related to Alzheimer's/Parkinson's. The Interventions instructed the following:a. If you notice Resident #2 not eating or distracted at meal times, please sit with them and offer to assist…

    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 · E2025-12-11 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and staff interviews the facility failed to ensure the windows for 2 of 2 bird aviaries were maintained in between routine cleanings and kept free of excessive bird feces. The facility reported a census of 145 residents. Findings include: Observation on 12/11/25 at 10:45 AM the Memory Care bird aviary consisted of 8 windows. All windows had multiple areas with white bird feces on it. Observation on 12/11/25 at 10:40 AM the Dining Room bird aviary consisted of 8 windows. All windows had multiple areas with white bird feces on itReview of the Aviary Service Checklist dated 7/30/25 documented the Memory Care aviary and Dining Room aviary last cleaned on 7/30/25.In an interview on 12/11/25 at 11:53 AM with the Administrator revealed the facility has a contracted a company from another state that provides quarterly cleaning to the aviaries. She informed in-between quarterly cleanings no one cleans or goes inside the aviary unless something urgent need to be done.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-11 · tag F0868 — pattern
    Have 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 policy review the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) meetings quarterly. The facility reported a census of 145 residents. Findings include:The Quality Assurance (QA) Meeting Records provided by the facility revealed the Medical Director attended the QA meetings on 5/21/25 and 7/28/25 but not on the 1st quarterly meeting (3/20/25) or the 4th quarterly meeting (10/15/25). The facility failed to have the required members present at least quarterly for the facility's QA meetings.In an interview on 12/11/25 at 12:00 PM the Administrator reviewed the Quality Assurance Meeting Records and acknowledged that the Medical Director was not present at the 3/20/25 and 10/15/25 QA meetings. On 12/11/25 at 12:00 PM the Administrator stated that she is familiar with the QA committee meeting quarterly and the need for members to be present. In an interview on 12/11/25 at 12:00 PM the Director of Nursing (DON) reviewed the Quality Assurance Meeting Records and acknowledged the Medical Director…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to notify resident's representative in advance of the risks and benefits of a psychotropic medication, the treatment alternatives or other options and was able to choose the option the representative prefers for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 145 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of dementia, diabetes and respiratory failure. Physician order dated 11/17/25 for quetiapine (antipsychotic medicine that works in the brain) by mouth once daily as needed for aggression and agitation. Resident #1's Electronic Health Record (EHR) lacked documentation of notifying the resident's representative in advance of the risks and benefits of the medication, treatment alternatives or other options and let them choose 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interviews, and policy review the facility failed to ensure 1 of 2 residents personal belongings were retained in the facility and returned to the family after their death (Resident #159). The facility reported a census of 145 residents.Facility staff implemented immediate interventions on [DATE] and completed on [DATE] through the following actions:a. Discussion with facility staff on where the missing items went and identifying a miscommunication occurred with facility staff.b. Offered the family to replace the items at the facilities expense.The deficient practice was identified as past non-compliance singular event as of [DATE], the items were thrown away due to miscommunication prior to the survey, and financial compensation was offered to the family. Findings include:The Facility Death Record for Resident #159 documented she died on [DATE] at 1:50 PM.The Communication - with family/NOK/POA note dated [DATE] at 11:34 AM indicated the family hadn't finished with 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.

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-12-11 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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, staff interview and policy review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents with new mental health diagnoses (Resident #22). The facility reported a census of 145 residents.Findings include:Resident #22's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anxiety, depression and psychotic disorder.The Electronic Health Record (EHR) listed a generalized anxiety disorder diagnosis added 5/14/19. In addition, an unspecified moderate dementia with other behavioral disturbance and unspecified psychosis diagnoses added 10/9/23.The Physician's Orders indicated that quetiapine (an antipsychotic medication) 25 milligrams two times daily started 2/7/23.Resident #22's Level I PASRR dated 10/21/18 lacked diagnoses of generalized anxiety disorder, unspecified moderate dementia with other behavioral disturbance and unspecified psychosis.Resident #24's clinical record lacked a PASRR after 10/21/18. In an interview…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · 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 clinical record review, policy/procedure review, and staff interview the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 resident reviewed. (Resident #2). The facility identified a census of 151 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition., documented diagnoses for which included Benign Prostatic Hyperplasia (BPH), diabetes mellitus, arthritis, recent hip fracture and mild cognitive impairment. The MDS revealed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 5 for which indicated severe memory impairments, is able to be understood and understand by others, and displayed verbal behavioral symptoms directed toward others, (threatening others, screaming at others, cursing at others) other behavioral symptoms not directed toward others…

    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 · D2025-03-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Resident [NAME] of Rights, facility investigation, staff interview, and review of policy and procedures, the facility failed to report an allegation of abuse to the Department of Inspection and Appeals and Licensing (DIAL) for 1 of 3 residents reviewed (Resident #2) within the required 2-hour timeframe. Staff A, Certified Nurse Aide (CNA), alleged the witnessed Staff B, CNA, hit Resident #2 on 3/7/25. Staff A failed to report the incident to the facility until 3/8/25, after the 2-hour window when they witnessed the alleged incident. The facility reported a census of 151 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition., documented diagnoses for which included Benign Prostatic Hyperplasia (BPH), diabetes mellitus, arthritis, recent hip fracture and mild cognitive impairment. The MDS revealed Resident #2 with a Brief Interview for Mental Status…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record view, staff interview, and the Resident Assessment Instrument (RAI) Manual, the facility failed to transmit 1 of 1 Minimum Data Set (MDS) assessments for the facility within the required timeframe (Resident #34). The facility reported a census of 159 residents. Findings include: The Discharge summary dated [DATE] at 1:00 PM reflected Resident #34 discharged to home. The Clinical - MDS reviewed on 10/29/24 at 12:37 PM listed the MDS' completed on 6/1/24 and 6/26/24 as completed, indicating they didn't get transmitted yet. The previous MDS' indicated accepted, indicating the facility transmitted them. During an interview on 10/29/24 at 1:16 PM, Staff H, Registered Nurse/Care Plan Nurse, reported she completed Resident #34's discharge MDS. She reported she didn't submit the MDS to the Centers of Medicare and Medicaid Services (CMS) and she should have. On 10/29.24 at 3:29 PM, the Administrator reported the facility didn't have a policy for MDS submissions. She reported the facility followed…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-10-31 · 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

    Based on observations, interviews, and record review, the facility failed to reassess blood pressures for one of one resident reviewed (Resident #67). Resident #67 had high and low blood pressures that didn't get reassessed. The facility reported a census of 159. Findings include: Resident #67's September and October 2024 Treatment Administration Record (TAR) included an order dated 4/18/24, that directed staff to obtain blood pressure and temperature every shift. The Weights and Vitals Summary review on 10/30/24 at 10:29 AM related to blood pressures listed the following results: a. 9/29/24 at 2:08 PM: 62/41 mm/Hg (measurement of pressure) (Lying r/arm)(Resident was lying down and blood pressure was taken on the right arm) diastolic bottom number of the blood pressure reading)(measures the pressure in the artery walls between heart beat)(pressure in the arteries when the heart beats) low of 60 exceeded, systolic (top number of blood pressure reading) low of 90 exceeded. b. 9/29/24 at 8:28 PM: 53/49 mmHg (Lying l/arm)(Resident was lying down and blood pressure was taken on the right…

    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 · D2024-10-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, the facility failed to provide services to treat or prevent reduction in range of motion for 1 of 1 resident sampled (Resident #134). After finishing Occupational Therapy, Resident #134 received specially modified palm guards to protect her hand from her contractures. Multiple observations revealed Resident #134 didn't have palm guards. Interviews determined, she didn't have them for a while and no one contacted therapy about getting replacements. The facility identified a census of 159 residents. Findings include: Resident #134's Minimum Data Set (MDS) assessment dated [DATE] identified they have short/long term memory impairment and severely impaired decision-making ability. Resident #134 had a functional loss in range of motion (ROM) on one side of the upper (shoulder, elbow, wrist, hand) body. The MDS included diagnoses of cerebral palsy and dementia. The MDS lacked documentation Resident #134 received restorative nursing services. Resident…

    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 before2024-10-31 · 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 record review, observation, policy review, staff, and resident interviews, the facility failed to ensure a resident had their call light within reach at all times for 1 of 3 residents reviewed for recent falls (Resident #17). The facility reported a census of 159 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS listed Resident #17 as independent with bed mobility, walking, sitting, and toilet use. On 10/28/24 at 12:49 PM Resident #17 reported she had her call light sitting on the foot of her bed approximately eight (8) feet from her recliner she sat in. She had a sling to her right arm. She explained she recently fell in her bathroom and fractured her arm. On 10/30/24 at 2:34 PM the Director of Nursing (DON) reported she expected all residents have their call lights within reach when they are in their room including in bed, recliner, and toilet.…

    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 · D2024-10-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, and staff interviews the facility failed to catheterize residents only when they had an order for 1 of 1 resident reviewed (Resident #46). The facility reported a census of 159 residents. Findings include: Resident #46's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #46 needed substantial/maximal assistance from staff with toileting hygiene. Record review of an untitled disciplinary action for Staff I, Registered Nurse (RN), dated 6/20/24 documented she catheterized a resident without an order for a catheter (Resident #46). During an interview on 10/28/24 at 3:36 PM Resident #46 explained earlier that year a new nurse put a catheter in her when she was not supposed to and she didn't have an order. She said she yelled at the nurse to stop it. She then reported she made a big issue with upper management at the facility and the nurse ended up getting fired. She explained…

    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 · D2024-10-31 · tag F0838 — failed to assess facility resources and resident needs — isolated
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure the Facility Assessment evaluated each resident's need for activities of daily living (ADL's), bowel, bladder, mental ability, skin integrity, special care, treatment, and medications. In addition, the facility failed to evaluate their ability to meet their needs. The facility reported a census of 159. Findings include: Record review of the facility's current Facility assessment dated [DATE] lacked an assessment and evaluation of the facility's current residents that include but not limited to: a. ADL status for each resident and equipment that may be needed b. Bowel/bladder status and supply needs c. Mental abilities of residents and services to support cognitive function d. Skin integrity including type of treatments and supply needs e. Special care (such as palliative, hospice, therapy, oxygen) f. Treatments needed and suppliers g. Medications needed and suppliers. On 10/30/24 at 2:06 PM the Director of Nursing (DON) reported she…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · 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

    Based on observation, clinical record review, policy review, and staff interview, the facility failed to implement adequate infection control prevention practices. While passing medication to a resident, the Certified Medication touched the resident's medication with their bare hands for 2 of 4 resident observed (Residents #213 and #26). The facility identified a census of 159 residents. Findings include: On 10/29/24 at 7:30 AM observed Staff E, CMA, compare the Electronic Medication Administration Record (EMAR) with the medication pack and punch 1 tablet of Resident #213's methylphenidate (attention deficit hyperactive disorder medication) 10 milligrams (MG) into her left hand, before placing it pill in a plastic med cup. At 7:32 AM Staff E shook two Vitamin D 1000 International Units (IU) tablets from the bottle into the lid, then with her left hand picked up one of the Vitamin D tablets, and placed it in the plastic medication cup. Staff E took the medication cup over to Resident #213, who took the medication. On 10/29/24 at 7:35 AM witnessed Staff E review Resident #26's EMAR…

    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 · Dcited before2024-09-06 · 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 record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents (Resident #1) did not fall when getting off of the facility van. The facility reported a census of 153 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating he intact cognition. The MDS listed Resident #1 as independent with transfers, walking, personal hygiene, and using the toilet. The MDS included diagnoses of cancer, hypertension (high blood pressure), and malnutrition (inadequate nutritional intake). Resident #1 received hospice services within the lookback period. The Fall with Injury Incident Report dated 9/2/24 at 12:32 PM reflected the receptionist called the staff to report a resident who fell in the driveway. Resident #1 complained of tenderness of his right wrist a few minutes after returning to his room. He could move it freely and had no deformity. Despite encouragement to go to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-30 · tag F0725 — failed to have enough nursing staff — pattern
    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 observation, resident, and family interview, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 3 of 5 residents reviewed (Resident #3, #4 and #5). The facility reported a census of 165 residents. Findings include: 1. On 8/23/24 at 11:53 AM observed Resident #4's call light on. According to the call light monitor at the nurse's station on the 1 [NAME] hallway the call light had been on for 16 minutes and counting. On 8/23/24 at 11:54 AM Staff G, Licensed Practical Nurse (LPN), entered the room. Staff G brought in a nutritional drink and Resident #4's pain patch. Staff G became defensive when she spoke with Resident #4 and his daughter. She spoke in a derogatory tone, rolled her eyes, and made negative facial expressions. Resident #4's family member (RR #4) asked if the surveyor saw that and reported Staff G always addressed her mother and/or herself that way. During observation, Staff G failed to address Resident #4's call light to see…

    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
  • Potential for harm · Dcited before2024-08-30 · 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

    Based on observation, family interview and review of the Resident Rights the facility staff failed to treat a resident with dignity and respect while providing cares and treatment while speaking with the resident and/or the family member present at bedside for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 165 residents. Findings include. On 8/23/24 at 11:53 AM observed the call light monitor and clock at the nurse's station. At that time, noted Resident #4's call light on for 16 minutes. At 11:54 AM Staff G, Licensed Practical Nurse (LPN), entered the room. Staff G brought in a nutritional drink and Resident #4's pain patch. Staff G became defensive when she spoke with Resident #4 and his daughter. She spoke in a derogatory tone, rolled her eyes, and made negative facial expressions. Resident #4's family member (RR #4) asked if the surveyor saw that and reported Staff G always addressed her mother and/or herself that way. The facility provided Resident Rights form dated October 2017 directed the facility to treat each resident with respect and dignity.…

    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 before2023-11-20 · 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

    Based on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to prevent resident's with severe cognitive impairment from engaging in sexual contact for 2 of 4 residents reviewed. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 10/17/23 that documented Resident #2 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment. A score of 4 identified severely impaired cognition. The MDS identified no verbal or physical behavioral symptoms and independent for transfer and walking. The MDS documented the resident's diagnoses included: non-Alzheimer's dementia. Observation on 11/14/23 at 2:35 pm revealed resident in her private room on the memory care unit, resident was smiling and stated that she has never felt uncomfortable with another resident or staff person's actions. Review of electronic resident Progress Notes included the following: * On 11/1/23 at 8:45 a.m. Staff A, Registered Nurse (RN) documented Resident #2 found in her room with Resident…

    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 · F2023-07-06 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to post daily staffing in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility also failed to include the daily census on the posting. Findings include: Observation and interview on 7/5/23 at 2:52 PM revealed that the Scheduler (SCHR) had to show the surveyor where the Daily Staffing Report was located. The location was in the main lobby on a side hallway bulletin board that was completely filled. The SCHR stated, This could easily be missed depending on which hall you were going to, and it was not posted on the second floor. I am not informed of the daily census, and I have never put that on the report. The schedule could not be interpreted without an explanation by the SCHR. A resident or visitor would not be able to understand the report without an explanation. Interview on 7/6/23 at 2:45 PM with the Co-Director of Nursing Two (CDON)2, revealed, I did not know that the form had changed. It did not look like the form you are showing me. It should 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-06 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure garbage was properly disposed of and contained which would affect all the residents and staff in the facility. Findings include: A request was made to the facility for a policy regarding the disposal/storage of garbage/refuse. In an interview on 7/3/23 at 3:13 PM the Certified Dietary Manager (CDM) stated, we do not have a policy regarding trash. Observation on 7/3/23 at 10:10 AM, with the CDM of the area behind the kitchen where the trash dumpsters were located revealed one roll off style dumpster with partial lids, which were open and failed to cover the entire dumpster. There were bags of garbage visible and stacked above the rim of the dumpster. Flies were noted flying around and in the container and landing on the bags of garbage. There were four smaller dumpsters for recycling materials which were open and had boxes visible in all four containers. Observation on 7/6/23 at 3:15 PM revealed all the dumpsters to be open and uncovered. Multiple trash bags were visible with flies noted flying around the dumpster. In…

    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 · Dcited before2023-07-06 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure one of one resident (Resident (R) 149), reviewed for not having a Minimum Data Set (MDS) in over 120 days, had a discharge assessment transmitted to Centers for Medicaid and Medicare Services (CMS) in a timely manner. This failure has the potential to have Medicare or Medicaid services denied due to the payment system having the R149 as being a nursing facility resident. Findings include: Review of R149's admission Record, from the electronic medical record (EMR) Profile tab, showed a facility admission date of 12/8/22 with medical diagnoses that included chronic obstructive pulmonary disease (COPD) exacerbation, type II diabetes, obstructive sleep apnea, myocardial infarction/total occlusion of coronary artery, congestive heart failure (CHF), and hypoxia. Review of R149's EMR Progress Notes tab showed a note dated 1/14/23 Discharge Summary that stated R149 had discharged home with a family member at 9:50 AM. Review of R149's EMR MDS tab showed Assessment Reference Date (ARD) of 1/14/23 for a Discharge Return 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately assess two of four residents (Resident (R) 155 and R158) reviewed for hospice on the Minimum Data Set (MDS) assessment tool. This failure had the potential to affect the resident's Medicare hospice benefit and care planning coordination between the facility and hospice provider. Findings include: 1. Review of the CMS802 (Matrix) provided by the Co-Director of Nursing (CDON)1 on 7/3/23 revealed R155 was marked as receiving hospice services. Review of the Resident Dashboard in the electronic medical record (EMR) indicated R155 as having an advanced directive order, initiated on 3/24/23, of DNR - Comfort Measures - No artificial nutrition by tube. [name] Hospice. Review of R155's Diagnoses in the EMR indicated R155 was admitted on [DATE] with a primary diagnosis of senile degeneration of the brain, dementia, and malignant neoplasm (cancer) of the prostate. Review of a psychosocial Progress Note, dated 3/27/23, revealed R155 was signed up for…

    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 · Dcited before2023-07-06 · 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 observations, interviews, and record review, the facility failed to ensure that one resident (Resident (R) 20) received treatments for dandruff with a prescribed shampoo regimen out of a total sample of 33 residents. This failed practice hindered this resident's dandruff from getting better. Findings include: Observation and interview on 7/3/23 at 5:07 PM with R20's Family (F)20 revealed dry, flaky skin on R20's scalp. F20 stated the staff should be using shampoo to treat his dry scalp, but it does not seem to be getting better and it was started months ago. Observation on 7/6/23 at 3:08 PM with Certified Nursing Assistant (CNA) 1, revealed R20's scalp and hair were noted to be dry and flaky. The flakiness was also noted on resident's shirt collar. CNA1 agreed that resident's scalp was dry and flaky when she separated his hair with gloved hands. CNA1 stated she was not aware that R20 required a medicated shampoo. Record review revealed an admission date of 12/20/20, with a Brief Interview for Mental Status…

    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 · D2023-07-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 observation, interview, and record review, the facility failed to properly document the need and removal of a wander guard for one resident (Resident (R) 83) out of four residents reviewed for unsafe wandering and elopement out of a total of 33 sampled residents. Findings include: Review of R83's electronic medical record (EMR) titled admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of heart failure, dementia, and history of falling. Review of R83's EMR quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 6/10/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed R83 was severely cognitively impaired. Review of R83's Progress Notes, located in the EMR under the Progress Notes tab and dated 4/21/23, indicated that R83 was wandering around the front entrance and was brought back to the nurses' station. R83 had been confused throughout the day due…

    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

“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

$87,458 in federal fines across 1 penalty.

  • $87,458 — penalty dated 2024-08-30

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 / managerTypeRoleSince
DEMARIS, ANNEIndividualW-2 MANAGING EMPLOYEEsince 11/19/2008
STOCKBEGER, IANIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2013
ALDEN, KATHRYNIndividualCORPORATE DIRECTORsince 01/01/2021
BOEDEKER, JOHNIndividualCORPORATE DIRECTORsince 01/01/2021
DOUGLAS, TOMIndividualCORPORATE DIRECTORsince 01/01/2021
EVERIST, BURTONIndividualCORPORATE DIRECTORsince 01/01/2021
FLYNN, ANNEIndividualCORPORATE DIRECTORsince 01/01/2021
GERRIETTS, DANIndividualCORPORATE DIRECTORsince 01/01/2021
HUNT, SAMUELIndividualCORPORATE DIRECTORsince 01/01/2021
MADDEN, THELMAIndividualCORPORATE DIRECTORsince 01/01/2021
PAULSON, KIRKIndividualCORPORATE DIRECTORsince 01/01/2021
SCHUMAKER, TERRYIndividualCORPORATE DIRECTORsince 01/01/2021
SHIPMAN, SCOTTIndividualCORPORATE DIRECTORsince 01/01/2021
SMED, SCOTTIndividualCORPORATE DIRECTORsince 01/01/2021
WHITE, JERROLDIndividualCORPORATE DIRECTORsince 01/01/2021
ZOOK, ANNEIndividualCORPORATE DIRECTORsince 01/01/2021
GOOD SHEPHERD GERIATRIC CENTER INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/19/2008

CMS files one row per role, so the 18 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$20.2M
Net patient revenuemost recent cost report
+1.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 52%Medicare 2%Other / private 46%

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

$343per resident / day
operating cost
$10,436per month
≈ monthly operating cost
$349per 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 165072. 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.

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