On With Life Long Term Care

Location & what’s nearby

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

Quality measures — how residents actually fare

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

Staffing

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection trend

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.

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.

• Potential for harm · D2025-08-05 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and facility policy review the facility failed to ensure accurate control, accountability, and disposition of scheduled controlled narcotic medication with narcotic medication not disposed of when the resident discharged from the facility for 1(Resident #1) of 1 resident reviewed and narcotic counts not being completed accurately. The facility reported a census of 38 residents. Findings include: The admission Minimum Data Set (MDS) for Resident #1, dated 5/15/25, documented diagnoses of stroke and hemiplegia (paralysis of one side of the body) with the resident dependent on staff for all activities of daily living. The MDS documented a Brief Interview of Mental Status was unable to be performed due to resident rarely/never understood. The Medication Administration Record (MAR), dated 3/1/25 - 3/31/25, for Resident #1 revealed a physician's order for Dronabinol (a Schedule 3 controlled medication that is a form of the main psychotic active component of…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Kitchen Based on observations, staff interview, and policy review the facility failed to serve food under sanitary conditions to prevent foodborne illness during one of two meals observed. Facility staff also failed to conceal hair completely in a hairnet to prevent foodborne illness. The facility reported a census of 40 residents. Findings include: Observations revealed the following: a. On 12/9/24 at 9:30 AM, the dietary supervisor wore a hairnet covering the hair pulled into a hair tie on the top of her head, but had the front, sides and back of the hair exposed (not in the hairnet). b. On 12/10/24 at 4:49 PM, Staff B, dietary aide, wore gloves while she served food to the residents. Staff B touched the handle of utensils used to serve entrees, and then used her gloved hand, picked up a piece of meat, and placed the meat onto the plates. c. During the lunch meal service on 12/11/24 starting at 11:55 AM, Staff A, dietary cook, wore gloves as he plated food for the residents. Staff A used a paring knife to cut up the chicken parmesan/ noodles and vegetables, then used tongs 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-12 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards due to a catheter bag not maintained in a bag cover and lying on the floor under the resident's wheelchair for 1 (Resident #26) of 1 resident reviewed for catheter care. The facility reported a census of 40 residents. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #26, dated 9/12/24, included diagnoses of anoxic (very low oxygen level) brain damage and seizure disorder. The Care Plan for Resident#26 with revision date 12/02/24 documented as focus area as follows; the resident had an indwelling urinary catheter due to urinary retention related to brain injury. The goal of the Care Plan documented the Foley cahteter was to be taken care of per protocol and discontinuation to be reassessed regularly. Interventions of the Care Plan included; monitor/record/ report to doctor for signs or symptoms of urinary tract infection which may include pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, foul…

  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 · D2023-09-28 · 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 clinical record review, staff interview, guidance from the Resident Assessment Instrument (RAI) and the Centers for Disease Control (CDC) guidelines, and facility policy review the facility failed to accurately reflect the pneumococcal vaccination status on the Minimum Data Set (MDS) Assessment for 1 of 5 residents reviewed (Res #8). The facility reported a census of 31 residents. Findings include: The MDS for Resident #8 dated 9/4/23 identified a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnoses that included traumatic brain dysfunction and diabetes mellitus. The MDS reflected an admission to the facility date as 7/2/07 and a birth year of 1952. The clinical record for Resident #8 revealed he had six MDS Assessments completed since last annual survey, dated 7/4/22, 10/4/22, 1/2/23, 4/4/23, 6/9/23 and 9/4/23. Five of the six of the MDS Assessments coded the resident's pneumococcal vaccination up to date. The immunization…

  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 · D2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on clinical record review, observation, staff interviews and family interviews, the facility failed to follow interventions on a comprehensive care plan for 1 of 12 residents reviewed (Resident #11). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) of Resident #11 dated 9/4/23 identified severely impaired cognitive skills for daily decision making. The MDS revealed the resident totally dependent upon staff assistance for bed mobility, transfers, wheelchair locomotion, dressing, eating, toilet use, personal hygiene and bathing. The MDS coded a functional limitation in range of motion (ROM) with impairments present on both sides of the resident's body in the upper and lower extremities. The Care Plan with a focus area of impaired skin integrity, dated 2/24/22 directed staff to: • Place pillows along side body and place arms to side, not across chest during nap during the day • Bilateral Upper Extremity Bivalves during nap during the day • Hard Wrist Splints during nap during the day • Bilateral PRAFO's when lying on back • Compression…

  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 · D2023-09-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed (Resident #10 and #15) requiring humidified air through tracheostomy. The facility reported a census of 31 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented the resident is in a persistent vegetative state/no discernible consciousness so was unable to complete a Brief Interview of Mental Status (BIMS). The MDS documented diagnoses to include traumatic brain dysfunction, quadriplegia, tracheostomy and chronic respiratory failure, unspecified with hypoxia or hypercapnia. An observation on 9/25/23 at 12:26 PM in Resident #10's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. An observation on 9/26/23 at 10:00 AM in Resident #10's bedroom revealed humidified air bubbler and connection tubing dated 9/1/23. Review of Resident #10's…

  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 · D2023-09-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and the Centers for Disease Control (CDC) guidelines, the facility failed to provide the pneumococcal vaccination as appropriate for 1 of 5 residents reviewed (Res #8). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 9/4/23 identified a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnoses that included traumatic brain dysfunction and diabetes mellitus. The MDS reflected an admission to the facility date as 7/2/07 and a birth year of 1952. The immunization portion of the Electronic Health Record reflected Resident #8 received a pneumococcal vaccination on 7/26/07 and had received no further pneumococcal vaccinations since that time. The guidelines from the CDC document the recommendation for adults age [AGE] older is to receive at least one further vaccination 1 year after the prior vaccination, based on the type of…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 9 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.

2 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.

What families pay in IA