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Red Oak Rehab and Care Center

1600 Summit Street, Red Oak, IA 51566 · For profit - Limited Liability company · 58 certified beds · (712) 623-5156 Medicare & Medicaid certified

Call the home — (712) 623-5156 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jun 20242 actual-harm citations1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1400 Senate Ave Ste 108 · (712) 623-7280 · Call to confirm hours
Pharmacy
600 Senate Ave · (712) 623-1900 · Call to confirm hours
Grocery
1701 N Broadway St · (712) 623-3186 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1510 Highland Ave · (712) 623-2744

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 increased18.0%17.1%15.4%worse
Long-stay residents who lose too much weight9.0%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%1.5%0.9%worse
Long-stay residents with a urinary tract infection5.7%2.4%2.0%worse
Long-stay residents with depressive symptoms1.0%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.9%3.8%3.3%better
Long-stay residents whose ability to walk worsened17.6%16.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication31.1%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine92.3%95.3%95.3%typical
Long-stay residents with pressure ulcers3.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control20.5%25.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.1%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication8.8%2.1%1.4%worse
Short-stay residents rehospitalized after admission24.6%20.9%22.6%typical
Short-stay residents with an outpatient ER visit17.9%13.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.211.491.67worse
Long-stay outpatient ER visits per 1,000 resident days3.872.081.80worse

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.

49.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.5%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.10U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.5%CMS range 32.2–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 6.7–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified85.7%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.8%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 worsened0.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.77
RN hours/ resident / day
0.14
LPN hours/ resident / day
2.63
Aide hours/ resident / day
3.54
Total nurse hours/ resident / day
0.86
RN hoursweekends
44.8%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 28.7 residents a day — about 49% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 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 3.41 hrs/resident/day on weekends vs 3.59 on weekdays — 5% thinner on weekends. RN hours go from 0.73 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

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

Inspection trend

2
deficiencies at the latest standard inspection (2025-09-25)
3
at the previous standard inspection (2024-10-24)

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.

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

  • Actual harm · Gcited before2024-07-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interviews, equipment manual review, and policy review the facility failed to maintain patient care equipment in safe operating conditions by not completing safety and maintenance checks allowing the actuator mount to wear and break causing the resident to fall to the floor and sustain a compression fracture for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also reported use of a sit to stand mechanical lift for transfers. On 7/19/24 at 12:40 PM Resident #2 stated on 6/12/24 she was halfway to the standing position when the sit to stand lift broke. Resident #2 stated she fell to the ground onto her buttocks. Resident #2 stated her buttocks did not hurt at first but when she was moved a little bit later it hurt. Resident #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 · Gcited before2024-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to transfer 1 of 3 resident (Resident #1) safely to prevent her from falling. Staff failed to obtain a gait belt prior to assisting Resident #1 from the toilet to the sink to wash her hands. Instead staff held on to the resident's pants during the transfer. As Resident #1 turned away from the sink, she lost balance, staff lost grip and the resident fell on her right shoulder. The resident was sent to the emergency room (ER) to be evaluated and was found to have a right proximal humerus fracture. The resident returned to the facility the same day with her right arm in a sling and recommendations to follow up with orthopedics. The facility reported a census of 28 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 Resident #1 had a Brief Interview of Mental Score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS indicated Resident #1 utilized a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-17 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to provide sufficient notice of discharge for 1 of 3 residents (Resident #2) reviewed. The facility failed to ensure proper discharge planning was documented prior to discharge. The facility reported the census was 28. Findings include: Resident #2's Entrance Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted from a short term general hospital.The Discharge Return Not Anticipated MDS assessment dated [DATE] revealed the discharge was unplanned and occurred on 4/29/26 to a short term general hospital. The document disclosed the facility staff completed the cognitive patterns indicating the resident presented with memory problems, severe impairment for daily decision making, and fluctuating inattention and disorganized thinking. The document included the resident had delusions, physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, rejection 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-17 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to provide a bed hold and notify the Long-Term Care Ombudsman (LTCO) of transfer to a hospital for 2 of 3 residents (Residents #2, #5) reviewed. The facility reported a census of 28 residents. Findings include:1. Resident #2's Discharge Return Not Anticipated Minimal Data Set (MDS) assessment dated [DATE] revealed the discharge was unplanned and occurred on 4/29/26 to a short term general hospital. The clinical record's Census revealed Resident #2 discharged against medical advice (AMA) on 4/29/26 at 4:02 PM .2. Resident #5's Discharge Return Anticipated MDS assessment dated [DATE] revealed the resident had an unplanned discharge on [DATE]. The clinical record's Census revealed Resident #5 transferred to the hospital on 3/6/26 at 7:51 AM, and was discharged on 3/25/26. On 6/17/26 at 9:49 AM the Administrator stated a bed hold had not been completed on Resident #5. The Administrator stated at this time she had not located 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 · D2026-06-17 · 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, observations, staff interviews, and policy review the facility failed to represent an accurate assessment of residents' status during the observation period of the Minimum Data Set (MDS) Assessment for 1 of 6 residents (Resident #3) reviewed. The facility reported a census of 28 residents.Findings include: The MDS assessment dated [DATE] for Resident #3 identified a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. The document coded the resident required partial/moderate assistance for sitting to/from stand, transfers to/from a chair and ambulation up to 150'.Resident #3's Care Plan revised 4/16/26 revealed a focus with alteration in activities of daily living (ADLs) (revised 3/31/23) with staff interventions of independence with transfers and ambulation with a wheeled walker (revised 7/17/24). A focus area identified an ADL self care performance deficit (revised 7/24/24) with interventions of transfers independent with use of a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policy review the facility failed to revise Care Plans for 2 of 3 residents (Residents #1, #4) reviewed. The facility failed to update the Care Plans with the residents' change in status and fall interventions. The facility reported a census of 28 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document coded the resident was independent with toileting, dressing, grooming/hygiene, ambulation, transfers and bed mobility. The document provided the resident had a bed alarm that was used daily. The Care Plan revised 1/3/26 identified Resident #1 had functional performance deficits with staff interventions of dressing independent/1 person physical assistance (6/4/25), toilet use limited assist/no setup or physical help (6/4/25), walk in corridor independent/2 person physical 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · 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, resident interview, clinical record review, facility policy review, and staff interviews the facility failed to re-evaluate the use of the motorized wheelchair quarterly to protect residents from accidents and injuries for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 30 residents. Findings include:Review of the Minimum Data Set (MDS) for Resident #1 dated 8/15/25 documented an admission date of 3/2/23 and a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented diagnoses of hemiplegia (a medical condition that causes paralysis or weakness on one side of the body) following cerebral infarction affecting left non-domical side, heart failure, atrial fibrillation, anemia (a condition where the body does not have enough healthy red blood cells to carry oxygen throughout the body), diabetes mellitus, respiratory failure, visual hallucinations, and nausea without vomiting. The MDS revealed the resident required a total dependence on staff to complete transfers and used a wheelchair 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · 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 clinical record review, family interview, staff interviews, and policy review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 13 residents (Residents #4 and #6). The facility failed to completely fill out the Medication Administration Record (MAR) - Treatment Administration Record (TAR) for the residents. The facility had a census of 30. Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status of 14/15 indicating normal cognition. The document provided the resident had diagnoses of Non-Alzheimer's Dementia, anxiety, depression, and chronic obstructive pulmonary disease (COPD) and took medications that included antipsychotics and antidepressants. The resident required oxygen. The resident's Care Plan dated 9/23/25 contained a focus area of shortness of breath related to COPD. Interventions for staff included use…

    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 · F2024-10-24 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review, staff interview and facility policy review the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 11 of 90 days reviewed (April 1st through June 30th 2024). The facility reported a census of 25 residents. Findings include: Review of the Payroll Based Journal (PBJ) staffing data report for the fiscal year quarter three (April 1st through June 30th, 2024) revealed there was no Registered Nurse (RN) hours for 4/29, 5/4, 5/18, 5/23, 5/31, 6/1, 6/2, 6/11, 6/15, 6/16, and 6/25/2024. Interview 10/22/24 at 12:52 PM with the Administrator confirmed that the facility did not have RN coverage listed on the PBJ. The Administrator confirmed these dates, and revealed that the facility only had one RN at the facility during this time. The Administrator revealed that her expectation would be for 8 hours RN coverage per day. Review of a facility provided document titled, Facility Assessment with a completed date of 7/15/2024 revealed: a. Federal law requires nursing homes to have sufficient staff to meet the needs 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by improperly serving food and failing to ensure proper sanitizing solution concentration. The facility reported a census of 25 residents. Findings include: On 10/23/24 at 9:36 AM, Staff A, [NAME] and Staff B, Dietary Aide (DA) were unable to locate sanitizer test strips to perform a sanitizing solution concentration check. Staff B stated she used detergent to clean the dining room tables. On 10/23/24 observations in the kitchen revealed the following: At 11:45 AM, Staff A, Cook, grabbed potato chips from a bag and placed them on a resident's plate with gloved hands she previously used to touch other non-food items. At 11:55 AM, Staff A placed the mashed potato serving scoop in the mashed potatoes and the handle came in direct contact with the food. She picked it up and continued using it with the same gloves she had touched non-food items. At 12:00 PM, Staff A scooped meatloaf sauce into a bowl and used her right gloved hand to push the sauce off the rim and into the bowl…

    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 · D2024-10-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for anticoagulants for 1 of 5 residents (Residents #10) reviewed. The facility reported a census of 25 residents. Findings include: Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed anticoagulant medication usage for 7 of the 7 day look back period. Review of Resident #10's Electronic Healthcare Record page titled Physician's Orders revealed an order for Apixaban 5mg oral tablet take 1 tablet by mouth twice daily. Review of Resident #10's Care Plan with a review date of 8/23/24 revealed no documentation of anticoagulant medications. Interview on 10/22/24 at 2:48 PM with Staff D, MDS coordinator, confirmed Resident #10 is on an anticoagulant. Staff D further revealed that anticoagulants should be on care plans. Interview on 10/22/24 at 3:03 PM with the Director of Nursing (DON) revealed that her expectation…

    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 · D2024-06-13 · 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

    Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to ensure 2 of 3 (Resident #3 and #10) residents were treated with dignity and respect. The facility reported a census of 28 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment Resident #3 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS listed the following diagnoses: cancer, anemia, hypertension, neurogenic bladder, obstructive uropathy, septicemia, diabetes mellitus, depression, and insomnia. The Care Plan focus area with an initiation date of 2/20/24 documented Resident #3 exhibits the following behaviors: being non-compliant with the use of her call light, asking for assistance and walking without staff assistance. On 6/11/24 at 1:51 PM Resident #3 stated she could not recall staff telling another staff member to shove whipped cream in her face and if they did it was probably a joke. When asked how staff treat her, she stated they are great. Staff…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-06-13 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, employee timecard review, resident interview, staff interviews, and facility policy review the facility failed to ensure 2 of 3 resident (Resident #4 and #5) were free from exploitation. Staff signed out Resident #4's Tramadol on the medication count sheet at 12:00 AM but her timecard documented she clocked out at 11:09 PM. Staff had signed out Resident #5's Hydrocodone (narcotic pain medication) as being given. When staff spoke with Resident #5 during his comprehensive assessment he stated he had not received his Hydrocodone for 2-3 weeks. The facility reported a census of 28 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/3/24 documented Resident #4 had severely impaired cognitive skills for daily decision making. The MDS documented Resident #4 received scheduled pain medications and received an opioid while a resident in the facility. The MDS documented the following diagnoses: autistic disorder, anemia, dementia, seizure disorder, respiratory failure, COVID-19, and hypoxemia. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, hospital documents review, staff interviews and facility policy review the facility failed to update 1 of 10 resident (Resident #1) care plans after she sustained a fractured humerus. The facility reported a census of 28 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 documented Resident #1 had a Brief Interview of Mental Score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS documented she used a walker and wheelchair and dependent on staff for toilet transfers. The MDS listed the following diagnoses for Resident #1: fractures and other multiple trauma, coronary artery disease, thyroid disorder, hip fracture, anxiety, and depression. The facility provided a report titled Fall dated 2/25/24 at 1:05 PM. The report documented staff was called to Resident #1's room for a witnessed fall. An assessment was completed, resident complained of pain in her right shoulder. She was sent to the local emergency room (ER) to be evaluated. Review of a document…

    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 before2024-02-14 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 reviews, facility record review, law enforcement file review, resident and staff interviews, and facility policy review the facility failed to ensure one of three residents reviewed (Resident #7) was free from financial exploitation. The facility reported a census of 28 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 11/17/23 documented Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented the resident had the following diagnoses: anxiety, asthma, thoracic spine pain, muscle weakness, and lymphedema. The Care Plan focus area with a revision date of 9/25/2023 documented Resident #7 was independent for meeting emotional, intellectual, physical, and social needs. The Care Plan focus area with a revision date of 11/6/23 documented she displayed signs of impulsivity to include: making plans without enough…

    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 · D2024-02-14 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff and family interviews and facility policy review the facility failed to obtain a bed hold within 24 hours of a hospitalization for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 28 residents. Findings include: Review of Resident #6's census tab in his Electronic Health Record (EHR) revealed he was hospitalized on the following dates: a. 12/12/23-12/15/23 b. 12/17/23-12/21/23 c. 1/4/24-1/14/24 Record review revealed Resident #6's record lacked bed hold forms for his hospitalizations. On 2/8/24 at 10:22 AM Resident #6's Power of Attorney (POA) stated the bed hold agreement was not signed when he was hospitalized three times during his time at the facility. The first hospitalization it was mentioned to her but never did sign it. On 2/13/24 at 12:20 PM when asked the Administrator if the facility had the bed hold forms for the three hospitalizations Resident #7 had while in the facility she indicated they only had the one for the resident's 12/12/23-12/15/23 hospitalization. On 2/14/24 at 9:15 AM the Administrator stated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and facility policy review, the facility failed to ensure proper sanitary conditions in the facility's two of three freezers, one flour container located in the facility's pantry, and two scoops hanging on the wall in the kitchen. This had the potential to contaminate food stored for the facility 25 of 25 residents who receive oral meals from the facility's kitchen. Finding include: During an initial kitchen observation on 07/17/23 at 9:59 AM, the freezer located in the pantry next to the door had a red substance on three shelves in the freezer on the left side. A second freezer located in the pantry had crumbs and debris on the bottom of the freezer. A large five-gallon container of flour had a white Styrofoam cup inside the container used as a scoop. A large five-gallon container of brown rice had a lid that was not secure or closed tightly. During an interview and observation on 07/17/23 at 10:09 AM, the Dietary Services Director (DSD) confirmed the red substance, crumbs, and debris in the freezers. The DSD also confirmed the Styrofoam cup…

    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 · F2023-07-19 · tag F0880 — failed to prevent and control infections — widespread
    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 facility record review, staff interviews and policy review, the facility failed to ensure a water management plan was in place to prevent a potential Legionella (a potentially dangerous water-borne bacterium capable of causing pneumonia) outbreak in the facility. The facility reported a census of 25. Findings include: Review of the facility's Water Management Program Policy dated 04/2020 read, in pertinent part, It is the policy of the facility to establish water management plans for reducing the risk of Legionella and/or other opportunistic pathogens in the facility's water system. Review of the facility's comprehensive Infection Control Program revealed the facility had a Legionella Program in place, and a risk assessment had been completed to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The facility was unable to provide any documentation to indicate routine water testing was being done per the plan to ensure no pathogens were growing in the identified high-risk areas. During an interview on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · 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, review of facility policy, and staff interview the facility failed to ensure timely reporting of potential abuse to facility Administration and the State Agency related to one of two residents reviewed for abuse (Resident #19). The resident was observed displaying sexually inappropriate behavior in facility common areas, potentially within view of other residents, and these behaviors were not reported to the Administrator or the Director of Nursing (DON). The facility reported a census of 25. Findings include: The admission Record dated 07/19/23 for Resident #19 indicated the resident was admitted to the facility on [DATE] with diagnoses including high-risk sexual behavior. The quarterly Minimum Data Set (MDS) for Resident #19 with an Assessment Reference Date (ARD) of 05/18/23 indicated a Brief Interview for Mental Status (BIMS) score of 99 (the assessment could not be conducted due to the resident's poor cognition.) The assessment indicated the resident was able to ambulate…

    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 · D2023-07-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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, review of facility policy, and staff interview the facility failed to ensure a thorough investigation of potential abuse was completed related to one of two residents reviewed for abuse (Resident #19). The resident was observed displaying sexually inappropriate behavior in facility common areas, potentially within view of other residents, and these behaviors were not investigated to ensure resident safety. The facility reported a census of 25. Findings include: The admission Record dated 07/19/23 for Resident #19 indicated the resident was admitted to the facility on [DATE] with diagnoses including high-risk sexual behavior. The quarterly Minimum Data Set (MDS) for Resident #19 with an Assessment Reference Date (ARD) of 05/18/23 indicated a Brief Interview for Mental Status (BIMS) score of 99 (the assessment could not be conducted due to the resident's poor cognition.) The assessment indicated the resident was able to ambulate about the facility with supervision from staff. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · 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 clinical record review, staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were submitted within the 14-day time frame for one reviewed for resident assessments (Resident #9). The facility reported a census of 25. Findings include: The MDS for Resident #9 with an Assessment Reference Date (ARD) of 05/04/23 revealed the MDS was not transmitted no later than completion date plus 14 calendar days. The MDS was 120 days overdue. During an interview on 07/18/23 at 10:48 AM, the Corporate MDS Coordinator (CMDSC) stated that Resident #9's quarterly MDS was completed on time on 05/04/23, however, he did not batch the residents MDS due to an error, so it was not submitted timely. During an interview on 07/18/23 at 10:50 AM MDS Coordinator (MDSC) stated the facility did not have a policy or procedure for MDS submissions, the facility followed the RAI for any time frames. During an interview on 07/19/23 at 4:45 PM the facility Administrator stated she expected the MDSC to submit all MDS…

    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 · D2023-07-19 · 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, observations and staff interviews, the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II evaluation report into the assessment and care planning for one of one resident reviewed for PASARR (Resident #20). This failure had the potential to lead to decreased quality of life and dignity for Resident #20. The facility reported a census of 25. Findings include: The admission Record for Resident #20 indicated she was admitted to the facility on [DATE] with diagnoses including autistic disorder, profound intellectual disabilities, intermittent explosive disorder, mood disorder, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/04/23 for Resident #20, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and staff assessed her with memory problems and severely impaired cognition. The resident was rarely/never able to make herself…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to ensure an individualized program of activities designed to meet the needs of one of 15 residents reviewed for activities (Resident #20). This failure had the potential to lead to depression, boredom, feelings of worthlessness or hopelessness, and increased behaviors for Resident #20. The facility reported a census of 25. Findings include: The admission Record for Resident #20 indicated she was admitted to the facility on [DATE] with diagnoses including autistic disorder, profound intellectual disabilities, intermittent explosive disorder, mood disorder, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/04/23 for Resident #20, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and staff assessed her with memory problems and severely impaired cognition. The resident was rarely/never able to make herself understood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews and facility policy review, the facility failed to ensure one of three residents reviewed for accidents was secured in the facility vehicle to prevent a fall with minor injury (Resident #22). This failure had the potential to cause pain or serious injury. The facility reported a census of 25. Findings include: The admission Record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, pneumonia, type 2 diabetes, pressure ulcer of sacral region, and iron deficiency anemia. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 06/09/23 revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. The MDS documented the resident required extensive assistance by staff and used a wheelchair. Review of Resident #22's admission MDS assessment with an ARD of 03/09/23, indicated he had experienced a fall after admission. 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

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

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

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2024-07-09 for 23 days

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.

Part of a chain

This home belongs to LANTIS ENTERPRISES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 51.6+1.4 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 4 of 52.8+1.2 vs chain
Quality measures 2 of 51.6+0.4 vs chain
The other 4 homes this chain runs (chain average 1.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
KISMET HD LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2018
KISMET HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2018
LANTIS, CAMMYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2018
LANTIS, MARYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
LANTIS, TRAVISIndividualINDIRECT OWNERSHIP INTERESTsince 09/01/2018
RINARD, SANDRAIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODYsince 09/01/2018
SOULEK, WENDYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
MOORE, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2018
LANTIS ENTERPRISES, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2018
DONOSO PENA, DANIELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
RUNYAN, CHERYLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/08/2022

CMS files one row per role, so the 23 rows in the source record cover these 11 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.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.9M
Net patient revenuemost recent cost report
-26.0%
Operating marginrevenue minus expenses
$386K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 25%Other / private 40%

This home reported $386K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$275per resident / day
operating cost
$8,356per month
≈ monthly operating cost
$218per 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 165185. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, 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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