Parkview Manor Care Center
1009 Third Street, Reinbeck, IA 50669 · For profit - Corporation · 28 certified beds · (319) 345-6811 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0609, F0610) — most recent Sep 2024
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,813 in federal fines (most recent 2024-09-30)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.3% | 17.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 4.8% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 4.2% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.8% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 11.4% | 16.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.0% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.5% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.4% | 19.5% | 17.1% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 28 beds and averages 25.3 residents a day — about 90% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.75 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 3.76 hrs/resident/day on weekends vs 4.31 on weekdays — 13% thinner on weekends. RN hours go from 0.93 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
31 citations, most serious first. The 14 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · L2024-09-30 · tag F0610 — failed to investigate and act on abuse reports — widespreadRespond 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 staff interview, facility investigation review, time card detail, and policy review, the facility failed to separate a staff member from dependent residents accused of alleged physical and verbal abuse that occurred on 8/30/24 around 11:30 PM in a timely manner for 1 of 13 residents reviewed for abuse (Resident #9). The staff member not only continued to work the rest of her shift on 8/30/24, they worked full shifts on 8/31/24, 9/1/24, and 9/2/24. Due to the facility failing to separate the alleged abuser from the alleged victim and/or other vulnerable residents, this resulted in an immediate jeopardy situation. The facility didn't initiate an investigation for the alleged abuse until 9/3/24. The Department notified the facility of the immediate jeopardy (IJ) on 9/24/24, that began on 8/30/24. The facility removed the immediacy on 9/24/24 after implementing the following: a. On 9/4/24 the facility began and completed education for all charge nurses to send the alleged abuser home immediately upon…
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.
- Immediate jeopardy · J2024-09-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility investigation review, clinical record review, and policy review, the facility failed to notify the Department of Inspections, Appeals and Licensing (DIAL) of alleged physical and verbal abuse that occurred on 8/30/24 around 11:30 PM in a timely manner. The Certified Nursing Aide (CNA) reported the alleged incident after first rounds on 8/30/24 to a Licensed Practical Nurse (LPN). The facility didn't start their investigation for the alleged abuse until 9/3/24 for 1 of 13 residents reviewed for abuse (Resident #9). The facility reported the incident to DIAL at approximately 1:00 PM on 9/3/24. The Department notified the facility of the immediate jeopardy (IJ) on 9/24/24, that began on 8/30/24. The facility removed the immediacy on 9/24/24 after completing the following: a. On 9/3/24 the facility disciplined and educated the nurse about their requirement to separate the employee from the resident and report to the Director of Nursing (DON) and/or Administrator immediately. b.…
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.
- Immediate jeopardy · J2024-09-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, observations, hospital record review, and policy review, the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed (Resident #21). On 9/17/24 Resident #21 attempted suicide by wrapping the bed remote cord around his neck twice which resulted in transfer to the hospital for a psychiatric evaluation and medication changes at the facility. Following his return, the facility gave him back his television, but failed to secure the television cords, cable cords, and a power cord under the bed to prevent access. Due to Resident #21's recent incident with wrapping a cord around his neck, this resulted in an immediate jeopardy situation. The State Agency informed the facility of the Immediate Jeopardy that began on 9/24/24 at 5:15 PM. The Facility Staff removed the Immediate Jeopardy on 9/24/24 through the following actions: - On 9/17/24, Resident #21 was seen at the Hospital Emergency Department. At that…
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.
- Actual harm · G2024-09-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interviews and facility policy the facility failed to complete and document treatment to a stage 2 pressure ulcer consistent with professional standards of practice for 1 of 2 residents reviewed (Resident #8). The facility reported a census of 26 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but didn't obscure the depth of tissue…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, policy review and observations the facility failed to respond timely (defined as 15 minutes of less) to a resident's request for assistance for 2 of 3 residents reviewed (Residents #3 and #4). The facility reported a census of 27 residents.Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #3 required substantial assistance of 1 staff for showers and hygiene tasks. Resident #3 used a positioning bar to assist with moving about in bed. They required the use of a standing mechanical lift for moving from bed to chair and couldn't stand on their own. She used a wheelchair to move about the facility. The MDS included diagnoses of heart failure and a history of falls with fractures.The Care Plan Focus revised 5/23/25 indicated Resident #3 had an activity of daily living (ADL) self-care performance deficit. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and policy review, the facility failed to maintain a sanitary kitchen and dining room. In addition, the facility failed to handle dishes in a sanitary manner to reduce the risk of cross contamination and food borne illness. The facility reported a census of 26.Findings include:On 8/18/25 at 9:45 AM observed during the initial walk through of the kitchen, limescale and rust on the dishwasher. In addition, the ice machine in kitchen had limescale build-up inside and outside. In the dining room saw the ice/water machine had limescale rust with rust on the waterspout. Observed dirty hand-washing stations in the dishwashing room and kitchen. The floor in the dishwashing room looked very dirty and had leaves under the shelves. On 8/19/25 at 11:40 AM during a follow-up observation of the kitchen witnessed the limescale remained on the dishwasher and ice machines. The hand washing stations remained dirty. During the observation Staff A, Dietary Aide, walked through the kitchen with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, family, and staff interview, the facility failed to provide a homelike environment by keeping register covers on the floor in 4 out of 4 resident rooms (Rooms #1, #6, #10 and #18). The facility reported a census of 26 residents.Findings include:During a walkthrough of the building on 8/18/25 at 12:28 PM, observed base board boiler system register covers detached and/or on the floor of the identified rooms #1, #6, #10 and #18.During a walkthrough of the building on 8/19/25 at 6:45 AM, observed base board boiler system register covers detached and/or on the floor of the identified rooms #1, #6, #10 and #18.During a walkthrough of the building on 8/20/25 at 1:20 PM, observed base board boiler system register covers detached and/or on the floor of the identified rooms #1, #6, #10 and #18.In an interview on 8/20/25 at 1:20 PM, an anonymous family member reported it is typical to see the base board boiler system register covers detached and/or on the floor. The family remember verbalized at times the floor had dust, candy wrappers and a toothbrush under the bed or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0628 — isolatedProvide 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, policy, and staff interview, the facility failed to notify the long-term care (LTC) Ombudsman for 2 of 2 residents who transferred to the hospital (Residents #6 and #24). The facility reported a census of 26 residents. Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] listed the most recent entry as 5/22/25, from a short-term general hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of heart failure, coronary artery disease, and depression.Resident #6's Clinical Census reviewed 8/19/25 listed the following changes in level of care:a. 5/19/25: Unpaid hospital leaveb. 5/22/25: Resident #6 returned to the facility.The Health Status Note dated 5/19/25 at 2:00 PM reflected Resident #6 transferred to the local hospital. The Health Status Note dated 5/20/25 at 3:06 AM indicated the facility received a call reporting Resident #6 transferred to another hospital.The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0644 — isolatedCoordinate 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, policy and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #24). The facility reported a census of 26 residents.Findings include:Resident #24's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS included a diagnosis of depression. In addition, Resident #63 received antidepressant medication during the lookback period.The Care Plan Focus initiated 11/8/22 reflected Resident #24 used an antidepressant due to his diagnosis of major depressive disorder, recurrent, moderate.Resident #24's Level 1 PASRR dated 10/22/22 lacked a diagnosis of major depression. Resident #24's clinical record lacked a PASRR after 10/22/22. On 8/19/25 at 2:02 PM the Administrator reported if a resident had a diagnosis change or medication change, the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility document review, and staff interviews, the facility failed to post the staff daily posting with the required staffing data. The facility reported a census of 26 residents. Findings include:On 8/18/25 at 11:17 AM observed the facility staff posting didn't include the total hours worked for each category nor identify if the type of nurse, Licensed Practical Nurse (LPN) or Registered Nurse (RN), for each shift.On 8/19/25 at 9:55 AM witnessed the facility staff posting didn't have the total hours worked for each category nor identify the type of nurse, LPN or RN, for each shift.An observation on 8/20/25 at 2:57 PM noted the facility staff posting didn't have total hours worked for each category nor identify the type of nurse, LPN or RN, each shift.In an interview on 8/20/25 at 2:58 PM, Staff C, LPN verbalized the overnight shift puts the daily posting out. Staff C had been unsure why the hours per shift weren't on the daily staff posting. In an interview on 8/20/25 at 3:10 PM, the Director of Nursing (DON) reported she puts the next day's posting behind…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-30 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interview, family interview, facility records and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility for 4 residents reviewed (Residents #23, #21, and #10). The facility reported a census of 26 residents. Findings include: 1. Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Clinical Census revealed Resident #23 resided in room [ROOM NUMBER] A 1. On 9/23/24 at 4:18 PM, Resident #23 reported call light times can be a problem at times especially on the weekends. She stated she had her call light on up to 30 minutes before. She reported the long call lights happen a couple times a month. She stated she knew the staff must answer the call lights within 15 minutes. She explained she times the call light response time with the clock on her wall. She reported she had bowel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-30 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 facility policy review, the facility failed to have an adequate clinical rationale for a gradual dose reduction (GDR) declination (decline) for 4 out of 5 residents reviewed for unnecessary medications (Residents #3, #8, #9, #11). The facility reported a census of 26 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS included diagnoses of non Alzheimer's dementia, anxiety and depression. The MDS documented Resident #3 received an antipsychotic, antianxiety, and antidepressant medication during the lookback period. A Physician order dated 5/18/23 directed staff to administer Aripiprazole (antipsychotic) 2 mg (milligrams) by mouth daily. A Physician order dated 10/20/21 directed staff to administer Bupropion (antidepressant) 150 mg by mouth twice daily. The Note to Attending Physician/Prescriber dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews, the facility failed to ensure resident's current code status was available for 1 out of 13 residents reviewed (Resident #130). The facility reported a census of 26 residents. Findings include: Resident #130's clinical record lacked a completed Minimum Data Set (MDS) assessment. The Clinical Census listed Resident #130 admitted to the facility on [DATE] to room [ROOM NUMBER] 1. The Clinical record lacked documentation regarding advance directives for Resident #130. On [DATE] at 3:26 PM unable to locate an Iowa Physician Orders for Scope of Treatment (IPOST) for Resident #130 in the IPOST binder on top of the crash cart inside the nurses' station. Staff D, Licensed Practical Nurse (LPN), reported the binder on the crash cart as only place the facility kept the residents' IPOST. Staff D reported the facility could only keep the IPOST in one place. When asked what she would do if she needed to know a resident's code status, she replied if the binder didn't have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to notify the Physician and family regarding the development of a new pressure ulcer for 1 of 2 residents reviewed (Residents #15). The facility reported a census of 26 residents. Findings include: Resident #15's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 3, indicating severely impaired cognition. The MDS identified Resident #15 required substantial/maximal assistance with bed mobility, transfers, and toileting. The MDS identified Resident #15 had an indwelling catheter. The MDS included diagnoses of anemia, hypertension (high blood pressure), heart failure (inability of the heart to pump blood well), atrial fibrillation, renal (kidney) disease, and benign prostatic hyperplasia. (BPH). The MDS identified Resident #15 was at risk for developing pressure ulcers/injuries. A Progress Note titled Skin/Wound note dated 8/7/24 documented an abrasion from the elastic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-09-30 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 review of Medicare guidelines, the facility failed to provide a notice of Medicare Non coverage 48 hours in advance of services ending. In addition, the facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) form for 1 of 3 residents reviewed (Resident #133) whose skilled stay ended and they continued to reside in the facility. The facility reported a census of 26 residents. Findings include: Resident #133's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. The Clinical Census listed Resident #133 admitted to the facility on [DATE] for a Medicare Part A Skilled stay. Resident #133 skilled stay ended on 5/8/24 and they remained in the facility. On 5/28/24 the facility discharged Resident #133 from the facility. They readmitted on [DATE] for a Medicare Part A stay. Resident #133 skilled stay ended on 6/28/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, personnel record review, staff interviews, and policy review, the facility failed to protect a resident from verbal abuse by a staff member for 1 of 13 residents reviewed for abuse (Resident #9). The facility reported a census of 28 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] indicated they had clear speech. The MDS reflected they had physical behavioral symptoms and rejected care for 1 to 3 days during the 7-day lookback period. The MDS identified a Brief Interview for Mental Status (BIMS) of 9, indicating moderately impaired cognition. Resident #9 required total assistance from staff with toileting. The MDS listed Resident #9 as always incontinent. The MDS included diagnoses of Alzheimer's disease and unspecified severity dementia with behavioral disturbances. The Care Plan Focuses revised 7/9/24 reflected Resident #9 had a. an activities of daily living (ADL) self-care performance deficit related to Alzheimer's disease. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 record review, staff interview and policy review the facility failed to develop a Care Plan to address risk factors and interventions for 1 out of 13 residents (Residents #21) reviewed for comprehensive Care Plans. The facility reported a census of 26 residents. Findings include: Resident #21's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS listed Resident #21 as independent with bed mobility and required partial/moderate assistance with transfers. The MDS identified Resident #21 used a manual wheelchair and required partial/moderate assistance with locomotion. Resident #21's MDS included diagnoses of atrial fibrillation (abnormal heart beat), hypertension (high blood pressure), heart failure (inability of the heart to pump blood well), renal disease (kidney), benign prostatic hyperplasia (BPH, enlarged prostate), stroke, and non Alzheimer's dementia. A Physician order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 3 of 13 residents reviewed (Residents #15, #21, #6). The facility reported a census of 26 residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 3, indicating severely impaired cognition. The MDS indicated Resident #15 required substantial/maximal assistance with bed mobility, transfers, and toileting. The MDS identified Resident #15 had an indwelling catheter. The MDS included diagnoses of anemia (low iron in the blood), hypertension (high blood pressure), heart failure (inability of the heart to pump blood well), atrial fibrillation (abnormal heart rate), renal (kidney) disease, and benign prostatic hyperplasia (BPH enlarged prostate). The MDS identified Resident #15 had a risk for developing pressure ulcers/injuries. A Progress Note dated 3/11/24 at 1:46 PM documented Resident #15 refused to lie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to follow physician orders regarding checking placement of a jejunostomy tube (J tube: a soft plastic tube that is surgically inserted into the small intestine to provide nutrition and medicine until a person can eat normally) for 1 of 1 resident reviewed (Resident #10). The facility reported a census of 26 residents. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of cancer, hypertension (high blood pressure), renal insufficiency (impaired kidney function), anxiety, and depression. The MDS reflected Resident #10 used a feeding tube while a resident. The Clinical Physician Orders reviewed on 9/24/24 included an order dated 5/17/24 to verify position of J tube each shift and evening shift by auscultating for a swooshing sound of an air bolus or measurement from the abdominal wall to the top edge 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.
- Potential for harm · D2024-09-30 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to have a Physician or a Non Physician Practitioner (NPP) provide a face to face visit, including a comprehensive assessment, once every 60 days for 1 of 5 residents (Residents #15) reviewed for Physician Services. The facility reported a census of 26 residents. Findings include: Resident #15's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 3, indicating severely impaired cognition. The MDS identified Resident #15 required substantial/maximal assistance with bed mobility, transfers, and toileting. The MDS indicated Resident #15 had an indwelling catheter. The MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), heart failure (inability of the heart to pump blood well), atrial fibrillation (abnormal heart rate), renal (kidney) disease, and benign prostatic hyperplasia (BPH - enlarged prostate). The Clinical record reflected a Physician saw…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinic record review, and policy review, the facility failed to administer medication appropriately for 1 out of 13 residents (Resident #1) which resulted in a significant medication error. Resident #1 received Xanax and morphine that wasn't prescribed to her, but to Resident #6; who had the same first name as Resident #1. The facility reported a census of 26 residents. Findings include: Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 9, indicating moderately impaired cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility, transfers, walking, and toileting. The MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), heart failure (inability of the heart to pump blood well), bradycardia (slow heart rate under 60 beats/minute), and renal (kidney) disease. The MDS indicated Resident #1 didn't receive opioid or antianxiety medications. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, document review and staff interview the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions and medication administration for 3 out of 3 residents reviewed (Residents #3, #10, and Resident #1). The facility reported a census of 26 residents. Finding include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS reflected Resident #3 used an indwelling catheter while a resident. The MDS included diagnoses of non Alzheimer's dementia, anxiety and depression. The MDS documented Resident #3 received an antipsychotic, antianxiety, and antidepressant medication during the lookback period. The Care Plan revised 11/23/21 indicated Resident #3 had an indwelling catheter. On 9/26/24 at 1:24 PM observed Staff O, certified nursing assistant, (CNA) assisted Resident #3 with catheter care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, the facility failed to ensure that 1 of 3 residents reviewed were treated with dignity and respect (Resident #1). On 3/23/24 Staff A, Certified Nursing Assistant (CNA) yelled at Resident #1 in a disrespectful and undignified manner using foul language The facility reported a census of 28 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. The MDS further documented the resident required set up or clean up, and totally dependent for chair/bed to chair transfer. The MDS further identified diagnoses that included: atrial fibrillation, non-Alzheimer ' s dementia, and anxiety. Review of an Alleged Abuse Facility Incident Report prepared on 3/23/24 at 5:30 p.m. by the Director of Nursing (DON) revealed: On 3/23/24 between 4:45 p.m. and 5:10 p.m. Staff B, CNA and Staff C, CNA were assisting Resident #1 up for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-04 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview the facility failed to answer call lights in a reasonable amount of time (15 minutes or less) for 12 of 55 documented call light alerts reviewed on Saturday 12/30/2023 from the hours of 12:25 AM to 3:57 PM. The facility reported a census of 25 residents Findings include: Record review of the facility's call light system logs provided by the Director of Nursing (DON) on 1/3/2024 at 3:53 PM for the following twelve (12) call light alerts documented wait times of greater than fifteen (15) minutes for a 15 hour 32 minute time period on Saturday 12/30/2023. 12/30/23 6:09:21 AM- 6:28:11 AM, room [ROOM NUMBER], 18:50 minutes 12/30/23 6:19:51 AM- 6:44:14 AM, room [ROOM NUMBER], 24:23 minutes 12/30/23 6:25:31 AM- 6:44:14 AM, room [ROOM NUMBER], 18:46 minutes 12/30/23 7:58:09 AM- 8:27:40 AM, room [ROOM NUMBER], 29:31 minutes 12/30/23 8:32:45 AM- 8:55:18 AM, room [ROOM NUMBER], 22:33 minutes 12/30/23 8:53:56 AM- 9:19:39 AM, room [ROOM NUMBER], 26:33 minutes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident representative interview, staff interviews, and facility policy review the facility failed to provide notification of changes for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 25 Residents. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 10/25/23 documented diagnoses that included Traumatic brain dysfunction, non-Alzheimer's dementia, malnutrition, depression, macular degeneration, and muscle weakness. The Brief Interview of Mental Status (BIMS) was not scored, was coded resident is rarely/never understood. The MDS history revealed a significant change was completed on 8/2/23. The Electronic profile record updated for Resident #2 revealed the resident had an assigned guardian as responsible party, Power of Attorney for financial and care conferences. The Care Plan, focus revised 10/25/23 documented Resident #2 had nutritional problems related to dementia, history of compromised skin concerns, advanced age, a limited diet with significant weight loss noted 8/2023, 9/2023. Interventions included provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review the facility failed to provide privacy while a resident changed clothes for 1 of 1 resident reviewed (Resident #22). The facility reported a census of 25 residents. Findings include: On 01/02/24 at 11:05 AM the Physical Therapist (PT) was observed providing therapy to Resident #22 in his room with the door ajar. The resident stood upright, facing the door with no shirt on and was visible from the hallway. The resident's interior room curtain was not extended to provide the resident privacy. At 11:12 AM, the resident was observed standing in the same location wearing a shirt with no pants. The resident remained visible from the hallway. The room curtain was not used to provide privacy. The significant change Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 04; indicating severely impaired cognition. It also included a diagnosis of mild cognitive impairment of unknown origin. On 01/03/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and Resident Assessment Instrument (RAI) Manual the facility failed to complete the Minimum Data Set (MDS) within 14 days of starting Hospice services for 1 of 3 residents (Resident #7). The facility reported a census of 25 Residents. Findings include: The resident's quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 6 out of 15; indicating severely impaired cognition. It also included a diagnosis of Alzheimer's disease and indicated the resident was receiving hospice services. The Care Plan revised 7/24/23 did not address current hospice-related services. On 1/04/24 at 8:11 AM, the Director of Nursing (DON) stated the resident was no longer under hospice services due to a plateau in medical status. A significant change MDS dated [DATE] included the change removing the resident from hospice services. The resident's Electronic Health Record (EHR) clinical census changed from hospice to private pay on 10/05/23. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0641 — isolatedEnsure 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 interviews, direction from the Resident Assessment Instrument, and policy review, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 3 residents reviewed for Accuracy of Assessment (Resident #22). The facility reported a census of 25 residents. Findings include: On 1/03/24, the resident's Electronic Health Record (EHR) Physician Orders indicated the resident was ordered Haldol routinely 4 mg by mouth three times daily for behavioral disturbances. It also included diagnoses of Alzheimer's disease and dementia with agitation and unspecified severity. The annual Minimum Data Set (MDS) dated [DATE] indicated the resident did not exhibit verbal/vocal sounds such as screaming or disruptive sounds. The Progress Notes revealed the resident yelled out daily between 5/27/23 through 6/06/23 except on 6/03/23. The Medication Administration Record (MAR) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete a base line Care Plan within 48 hours of admission for 1 of 3 new residents sampled for review (Resident #78). The facility reported a census of 25 residents. Finding include: The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #78 admitted on [DATE]. The MDS was in progress for completion. The resident Brief Interview for Mental Status (BIMS) assessment was not completed. On 01/02/24 at 11:14 AM the responsible party was present with Resident #78 and relayed they could not recall a Care Plan copy received by them. The clinical record review lacked any documentation of a baseline Care Plan being completed. During an interview on 1/3/24 at 3:33 PM the Director of Nursing (DON) reported base line Care Plans should be completed at admission and a copy printed and put behind the resident's name plate so all staff will know about the resident needs. The DON reviewed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned 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, interview, and policy review the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 1 discharged residents reviewed in the closed record sample (Resident #26). The facility reported a census of 25 residents. Findings include: The MDS (Minimum Data Set) assessment dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 and listed diagnoses for Resident #26 that included scoliosis and fracture of left hand. The Clinical Census report identified the resident discharged from the facility on 11/1/23. The facility lacked documentation of a discharge summary including a recapitulation of the resident's stay as required by regulations. In an interview on 1/4/24 at 1:57 PM, the Director of Nursing (DON) stated it was the expectation a discharge summary and recapitulation of stay be completed upon discharge. It was expected the staff complete an assessment including vital signs and the discharge summary and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-04 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, resident interviews and policy review, the facility failed to provide proper functioning call system to resident (Resident #14) and proper functioning response systems to staff (indicated wrong times on response and call pendant did not work). The facility reported a census of 25. The Minimum Data Set (MDS) for Resident #14 dated 10/18/23 listed diagnoses including complex conditions, hypertension, anxiety, history of falling, osteoarthritis, weakness, pain, and unsteady on feet. The MDS section for Brief Interview for Mental Status (BIMS) scored 15 indicated the resident cognition was intact. The Care Plan revised 9/3/22 documented self-care performance deficit, impaired visual function related to macular degeneration, bladder incontinence, weakness, and hyponatremia, required assistance of one person with bathing. On 1/2/24 at 11:28 AM Resident #14 voiced she had long waits and is not sure the call pendant always works, also relayed she will not wear the pendant when she leaves for the dining room because it sets off door alarms. On 1/3/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$23,813 in federal fines across 1 penalty.
- $23,813 — penalty dated 2024-09-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to WESTERN HOME COMMUNITIES — 6 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.7 | -2.7 vs chain |
| Health inspection | 1 of 5 | 3.5 | -2.5 vs chain |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 5 homes this chain runs (chain average 3.7★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MILLER, CONNIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 27% | since 01/01/1981 |
| MILLER, WALTER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 27% | since 01/01/1981 |
| LINCOLN SAVINGS BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 01/01/2025 |
| BACHMAN, DON | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
| OLESON, DEBRA | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| SCHILDROTH, DIXIE | Individual | CORPORATE DIRECTOR | — | since 05/08/2010 |
| THESING, JEFFREY | Individual | CORPORATE DIRECTOR | — | since 05/05/2010 |
| FOGT, MICHAEL | Individual | CORPORATE OFFICER | — | since 05/03/2016 |
| PETERSEN, RON | Individual | CORPORATE OFFICER | — | since 01/01/2021 |
| WESTERN HOME SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| AGER, WENDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| BRUBAKER, SHARAE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/14/2022 |
| ELLIS, MISTI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/11/2011 |
| EVANS, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| HANSEN, KRIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 01/01/2002 |
| HARRIS, JERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| HOEPPNER, CONNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2018 |
| KELLY, HUNTER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/06/2023 |
| KREMENAK, BRETT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/12/2013 |
| MCCORMICK, DARRELL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| O'LEARY, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| QUACKENBUSH, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/12/2013 |
| SELENKE, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2010 |
| BCG HOLDINGS INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | — | since 08/25/2021 |
| ECSI INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| HEALTH CARE RESOLUTIONS, LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| HELPING HANDS HEALTHCARE SOLUTIONS | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| HELPING HANDS NURSING SOLUTION INC | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| LOTUS ABOVE & BEYOND HEALTHCARE STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| MILLENNIUM REHAB & CONSULTING INC | Organization | ADP OF THE SNF | — | since 10/01/2012 |
| PRIME TIME HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| RELIANT CARE PHARMACY SERVICES LLC | Organization | ADP OF THE SNF | — | since 02/28/2023 |
| SUGAR CREEK HEALTH MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 09/30/2022 |
| TECH OF AGES LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| TOTALITY STAFFING & CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| TWOMAGNETS LLC | Organization | ADP OF THE SNF | — | since 04/01/2023 |
| MOONY-GEELS, AMY | Individual | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 54 rows in the source record cover these 42 parties — each is shown once here with every role it holds. Nothing is omitted.
20 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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165522. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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.