No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Park View Rehabilitation Center

601 Park Avenue, Sac City, IA 50583 · For profit - Corporation · 77 certified beds · (712) 662-3818 Medicare & Medicaid certified

Call the home — (712) 662-3818 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jan 20262 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • 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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
301 Highland Ave · (712) 662-7119 · Call to confirm hours
Pharmacy
514 W Main St # 367 · (712) 662-7146 · Call to confirm hours
Grocery
401 N 13th St · (712) 662-4728 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 increased13.8%17.1%15.4%better
Long-stay residents who lose too much weight2.5%4.6%5.4%better
Long-stay residents with a catheter left in their bladder3.4%1.5%0.9%worse
Long-stay residents with a urinary tract infection2.1%2.4%2.0%typical
Long-stay residents with depressive symptoms0.0%4.2%6.5%check this — see note marked star below the table
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 injury3.5%3.8%3.3%typical
Long-stay residents whose ability to walk worsened12.0%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.7%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%95.3%95.3%typical
Long-stay residents with pressure ulcers9.3%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control27.1%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table28.4%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.3%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine56.2%73.3%79.4%worse
Short-stay residents rehospitalized after admission29.2%20.9%22.6%worse
Short-stay residents with an outpatient ER visit17.4%13.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.981.491.67better
Long-stay outpatient ER visits per 1,000 resident days2.022.081.80worse

* 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.

51.0% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.0%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
64.3%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 64.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF51.0%CMS range 39.8–65.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.0–15.310.7%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 discharge64.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge64.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.6%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 SNFs0.901.02Oct 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

0.69
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.64
RN hoursweekends
53.2%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 77 beds and averages 46.0 residents a day — about 60% occupied, or roughly 31 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below 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 3.17 hrs/resident/day on weekends vs 3.80 on weekdays — 16% thinner on weekends. RN hours go from 0.71 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2026-03-12)
3
at the previous standard inspection (2025-03-06)

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

Inspection deficiencies

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

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 · G2025-09-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 resident's reviewed (Resident #1). The facility reported a census of 43 residents. Resident #1 had wounds that were deteriorating. The resident was seen in the wound center. The facility sent the assessment of the wound in a fax to the PCP on 8/21/25 and wrote the resident would be seen in the wound center 8/22/25. The PCP replied okay. The PCP was not the wound center provider. The resident did not have an appointment on 8/22/25. The facility did not follow up until 8/27/25 with an assessment. The fax notified the wound center physician that the wound deteriorated and had a foul odor. The physician ordered a different treatment until seen on 8/29/25. The nurse who did the assessment had hoped he would want to see her sooner, but did not convey that in the fax. The resident admitted to the hospital 8/28/25 in respiratory distress, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-09-04 · 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 observation, record review, and staff interview, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Resident #1 fell on 7/10/25 fracturing his right elbow that would require surgical repair, and a laceration near his right eye requiring 7 sutures. The resident had a pressure alarm that did not sound to alert staff the resident was getting up without assistance. Staff failed to determine why the alarm did not sound. On 7/11/25 the resident fell again fracturing his left elbow, also requiring surgical repair. The resident's pressure alarm again failed to sound to alert staff the resident was getting up. The facility reported a census of 43 residents. Findings include:The Care Plan documented Resident #2 admitted to the facility on [DATE]. The Care Plan identified the resident had impaired cognitive function, and at risk for falls, on 7/10/25 at 10:30 a.m. fall with no injury, on 7/10/25 at 2:07 p.m. fall with right…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to ensure that only licensed staff administered medications. Additionally, the facility failed to ensure that narcotics were counted only by qualified personnel authorized to manage controlled substances, and that licensed nursing staff completed the shift-to-shift narcotic count together. These failures allowed an unlicensed staff member (CNA) to attempt medication administration and perform narcotic counts, both beyond their scope of practice. The facility reported a census of 42 residents. Findings include: 1. During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, stated that agency nurse Staff C, Licensed Practical Nurse (LPN), asked if she attended nursing school. Staff B confirmed she had and would graduate if she passed her final test in May. Later, Staff C informed Staff B that Resident #3 would not take her medications. Staff B reported that Staff C stood in the doorway and pressured her to help administer the medications to Resident #3. Staff B stated, I hate confrontation. Staff C handed me her med 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, the facility failed to ensure that medication cart keys were secured and handled exclusively by qualified personnel, allowing a Certified Nursing Assistant (CNA), who is unauthorized to manage controlled substances, to possess the keys and conduct narcotic counts. The facility reported a census of 42 residents. Findings Include: During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, admitted she performed narcotic counts with Staff C, Licensed Practical Nurse (LPN), and Staff D, LPN, separately, rather than together as directed by the Assistant Director of Nursing (ADON). Although Staff B stated she lacked the licensure to conduct counts, she claimed Staff C, LPN, insisted she participate and sign the documentation. Staff B noted she performed counts with each nurse individually, remarking that the CNAs were caught in the middle. During an interview on 6/10/26 at 2:03 PM, Staff D, LPN, reported that on 4/21/26, she witnessed Staff B, CNA, perform a narcotic medication count and receive a resident nurse report from Staff C, LPN. Staff D reported 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 record review and staff interviews, the facility failed to ensure that the resident's physician and responsible party were notified regarding the failure to administer prescribed, scheduled medications including a high-risk medications for 2 of 3 residents reviewed (Resident #1 and #2). The facility reported a census of 42 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline for depressionCefuroxine Axetil for abnormal findings in the lung fieldKlor-Con for low potassium 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 and resident interviews and record review, the facility failed to ensure residents remained free from significant medication errors. On 4/21/26, staff failed to administer scheduled evening medications for 2 of 3 resident reviewed (Resident #1 and #2). Instead, the medications were found in envelopes stapled to the residents' respective medication bubble packs. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-10 · 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 the record review and interviews with facility staff, the facility failed to maintain accurate documentation of medication administration as not administered on 4/21/26 for 2 of 3 residents reviewed (Residents #1 and #2). The facility reported a census of 42 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the following medications as administered. The Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were confirmed as not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline for depressionCefuroxine Axetil for abnormal findings in the lung fieldKlor-Con for low potassium 2. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-12 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident council meetings, Electronic Health Record (EHR)review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Resident #27, #53, #11 and #15). The facility reported a census of 45 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #27 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #27 was dependent on staff for toileting hygiene, lower body dressing, and taking off footwear. On 3/9/26 at 12:28 PM Resident #27 stated he has had to wait up to 45 minutes in the last week or two for his call light to be answered. Review of Resident #27's EHR documented Resident #27 resided in room [ROOM NUMBER]. Review of facility provided call light log for Resident #27 in room [ROOM NUMBER] from 3/4/26 - 3/11/26 revealed call lights that had…

    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 · E2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, not dating open food items and not disposing of expired food items. The facility reported a census of 45 residents.Findings include:Observation on 3/9/26 at 10:10 AM of a 2 door refrigerator revealed these food items open and undated 16 oz. container of parmesan cheese and a bag of diced chicken.Observation on 3/9/26 at 10:14 AM of a 2 door freezer revealed a large bag of bacon bits and a large bag of chicken cordon bleu both open and undated.Observation on 3/9/26 at 10:16 AM of a 3 door freezer revealed a plastic container containing about 10 biscuits and a large bag of cinnamon rolls open and undated. A box of pre-cooked hamburgers with bag open and box top cut away with food items on the shelf above and a box of pre-cooked omelets with the bag open and box top cut away with the hamburger box on the shelf above. Observation on 3/9/26 at 10:20 AM of dry…

    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 · E2026-03-12 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review the facility failed to have the necessary required members attend quarterly quality assurance meetings. The facility reported a census of 45 residents.Findings include:Review of facility provided documents titled, Quality Assurance and Performance Improvement Committee Attendance Record for the months of August 2025 through February 2026 revealed there was no Infection Preventionist (IP) that attended the Quality Assurance (QA) meetings. Interview on 3/12/26 at 8:51 AM with the Administrator revealed that the facility did not have an IP until the new Director of Nursing (DON) came to the facility to work. Follow up interview on 3/12/26 11:13 AM with the Administrator confirmed the IP was not present at the meetings from August of last year to February of this year. The Administrator then revealed her expectation would be to have an IP at the meetings per expectations.Review of a facility provided document titled, QAPI Policy with a revision date 10/2023 revealed:a. The members of the QAPI committee must meet at least…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 Electronic Health Records (EHR) review, Medication Administration Records - Treatment Administration Records (MAR-TAR), resident interviews, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and failed to apply edema wear as ordered by the physician to 3 of 3 residents reviewed (Resident #4, #27 and #11). The facility reported a census of 45 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #4 required partial / moderate assistance to shower/bathe self with staff doing less than half the effort. On 3/10/26 at 9:28 AM Resident #4 said she was supposed to receive baths on Tuesdays and Thursdays. Resident #4 explained she would like a shower twice a week. Resident #4 said she was supposed to wear edema socks but has not had them in a couple of months. On 3/10/26 at 9:44 AM an observation in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Electronic Health Record (EHR) review, resident interview, staff interview, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 2 of 3 residents reviewed (Resident #4 and #9). The facility reported a census of 45.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #4 required partial / moderate assistance to shower/bathe self with staff doing less than half the effort.On 3/10/26 at 9:39 AM Resident #4 stated when she came in she had therapy and then it stopped. Resident #4 stated she could walk down the hall with a walker and did not need a wheelchair when she was in therapy. Resident #4 explained she used a walker now. Resident #4 stated she would like to have some therapy and had spoken to someone about therapy.…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2026-03-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, the facility failed to implement appropriate infection prevention and control practices to prevent the spread of infection. Specifically, the facility failed to clean equipment between resident use for 1 of 5 residents reviewed (Resident #15). The facility also failed to follow Transmission-Based Precautions (TBP) when delivering a meal tray to a resident with COVID-19 for 1 of 2 residents reviewed (Resident #37). Additionally, the facility failed to follow current Centers for Disease Control and Prevention (CDC) guidelines by not implementing Enhanced Barrier Precautions (EBP) during a wound care dressing change to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 45 residents.Findings Include: 1. Observation on 3/9/26 at 12:12 PM showed Staff A, Dietary Aide, failed to don personal protective equipment (PPE) prior to entering Resident #37's room while 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's 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 record review, staff and family interview, the facility failed to allow a resident representative/Power of Attorney (POA) assist a cognitively impaired resident with decision making for 1 resident reviewed (Resident #4). The facility reported a census of 47 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls.The Progress Noes dated 9/14/25 at 12:29 p.m. documented Resident #4 was alert to person, and to place. The resident was confused.The Progress Notes dated 9/15/25 at 10:32 a.m. documented the resident was alert to person. The resident was confused and forgetful.The Progress Notes dated 9/16/25 at 1:10 p.m. documented the resident was alert to person. The resident was confused and forgetful.The Progress Notes dated 9/17/25 at 1:48 p.m. documented the resident was alert to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed ensure an As Needed (PRN) psychotropic medication was only continued after 14 days with a provider written rationale and end date for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 47 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls. A New Prescription Summary dated 9/25/25 documented an order for Lorazepam/Ativan 0.25 mg by mouth every 4 hours PRN for anxiety.An order dated 10/2/25 changed the Lorazepam 0.25 mg, from every 4 hours PRN, to every 2 hours PRN with no rationale for continuing and no end date.The Medication Administration Record for October showed the PRN Lorazepam 0.25 mg administered 19 times through the 28th, and 11 of those times were ineffective.On 1/7/25 at 8:46 a.m. 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 before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure interventions were in place to prevent falls, and failed to ensure the completion of neuro assessments after falls for 1 of 3 resident's reviewed (Resident #4). The facility reported a census of 47 residents.Findings include:1.According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required partial/moderate assist with oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, sit to stand, and chair/bed-to-chair transfer. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls. The Care Plan with a goal target date of 1/4/26 identified the resident at risk for falls related to impaired cognition and recent falls. The resident's goal to minimize the risk for falls. Interventions included the resident to wear gripper socks in bed.The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-04 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 record review and staff interview, the facility failed to notify the resident's representative of a change in condition for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 43 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The resident had diagnoses including a stroke with hemiplegia of the right dominant side.The Care Plan identified the resident at risk for alteration in skin integrity related to immobility, right sided weakness Status Post (S/P) stroke, anticoagulant and antiplatelet usage. On 7/30/25 pressure ulcer right buttock, and 8/15/25 pressure ulcer left buttock. A Concern Form dated 8/29/25 documented Resident #1's family member gave a verbal in person report. She felt the facility had not notified her of the resident's wound worsening.The Progress Notes dated 8/21/25 at 3:54 p.m. documented 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 · E2025-03-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 4 of 12 residents reviewed (Resident #4, #15, #16, #22). The Care Plans failed to identify target behaviors related to the use of psychotropic, antianxiety, and antidepressant medications, and non-pharmalogical interventions. The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 12/13/24 identified a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The MDS included diagnoses of anxiety, depression, and Non-Alzheimer's Dementia. The document identified little interest or pleasure in doing things 2-6 days in the reporting period, rarely lonely or isolated from those around. The MDS identified Resident #4 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #4's Electronic Medical Record (EMR) Physician Orders dated 3/6/25 identified 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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 observations, staff interviews, clinical record reviews, and policy reviews the facility failed to review and revise the Care Plan interventions for 2 of 12 residents reviewed (#4, #17). The facility failed to revise Care Plan interventions for a resident who had a change in oxygen use and changed from weight gain to weight loss, and a resident who had a new intervention for fall prevention. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 12/13/24 identified a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The MDS included diagnoses of anxiety, depression, Non-Alzheimer's Dementia, and congestive heart failure (CHF). The MDS identified Resident #4 took antipsychotic and antidepressant medications. The document revealed the resident did not have a weight loss or gain of 5% or more in the past month or loss or gain of 10% or more in the last 6 months. The document revealed the resident did utilize oxygen (O2). a.) The Electronic Medical Record (EMR) Progress Notes 5/1/24 to 3/5/25 revealed on 2/19/25 the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, the facility failed to have an emergency tracheostomy kit with obturator at bedside for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 38. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of coronary artery disease, acute respiratory distress, depression, and pneumonia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #24 had a tracheostomy (surgical opening in neck to provide for obstruction of breathing) and required oxygen. Review of the Care Plan with a target date of 5/15/25 revealed Resident #24 has a tracheostomy in place related to malignant neoplasm of the larynx. The Care Plan revealed that the facility would maintain a spare trach at the bedside. The Care Plan failed to have documentation that Resident #24 would fiddle with the emergency trach kit while it was in the room. Review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and infection control policy review, the facility failed to complete hand hygiene when assisting residents to eat, at the same time, in an effort to reduce the risk of spreading infection for 3 out of 3 residents during meal service (Residents #6, #28, # 32). The facility reported a census of 39 residents. Findings include: Observed noon meal service on 4/24/24 at 11:30 AM: Staff A Certified Nursing Assistant (CNA) assisted two residents to eat at the same time (Resident #28 & #32). Staff A sat between the residents and used same hand to feed both residents. No hand hygiene observed when alternating between residents. Staff A wiped Resident #32's mouth with his napkin; no hand hygiene observed afterwards. Staff A wiped Resident #28's mouth with her napkin; no hand hygiene observed afterwards. Staff A walked over to 3rd resident at table (Resident #6) and helped with drink and straw; no hand hygiene observed before or after task. Staff A returned to her seat and continued to assist Resident #28 and #32. During lunch service, Staff A held…

    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 · D2023-11-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, resident interviews, facility documentation, and review of facility policy, the facility failed to provide care for 2 of 6 residents reviewed (Resident #5 and #6) in a manner to promote dignity and respect. Interviews determined that Resident #5 sat visibly incontinent of urine in a common area for visitors and other residents to witness his incontinence for over 2 hours. In addition, Resident #6 felt that the staff ignored her husband when they turned off his call light and she did not hear the staff member state she would be back. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified no completed Brief Interview for Mental Status (BIMS) score. The Staff Assessment for Mental Status listed Resident #5 as severely impaired for decision making. Resident #5's MDS included diagnoses of moderate intellectual disabilities, depression, altered mental status and unspecified symptoms and signs with cognitive functions and awareness. The MDS listed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-01 · 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, clinical record review, and staff interviews, the facility failed to provide adequate transfers for 2 or 6 residents reviewed (Resident #2 and #1) to ensure a safe transfer according to plan of care. The facility did not provide the number of staff needed for each transfer according to the care plan. The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 9/14/23 identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified that Resident #2 required extensive assistance from two persons with bed mobility and toilet use. The MDS identified Resident #2 required extensive assistance of one person with transfers. Resident #2's MDS included diagnoses of hypertension (high blood pressure), hyperlipidemia, Alzheimer's disease, and history of falling. The Care Plan with target date of 1/10/24 revealed Resident #2 had mixed bladder incontinence and required assistance with activity of daily living (ADLs) related to Alzheimer's disease 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review the facility failed to provide adequate incontinence care in a timely manner for 1 of 5 resident reviewed (Resident #5). Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified no completed Brief Interview for Mental Status (BIMS) score. The Staff Assessment for Mental Status listed Resident #5 as severely impaired for decision making. Resident #5's MDS included diagnoses of moderate intellectual disabilities, depression, altered mental status and unspecified symptoms and signs with cognitive functions and awareness. The MDS identified Resident #5 required extensive assistance of two persons with bed mobility, transfers, and toilet use. The MDS listed Resident #5 as always incontinent of urine. The Care Plan with a target date of 11/9/23 revealed Resident #5 had mixed bladder incontinence related to physical limitations and required assistance with activities of daily living related to impaired…

    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.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 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 1 of 52.9-1.9 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 2 of 53.3-1.3 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA 3 of 5Clark ManorChicago, IL

Showing 40 of 88; lowest-rated first.

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 / managerTypeRoleShareSince
SHABAT, MENACHEMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/15/2024
CASCADE CAPITAL PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/15/2024
CCG GORGONA LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/15/2024
GORGONA HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/15/2024
GORGONA PROPCO HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/15/2024
GORGONA SUB HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 08/15/2024
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BEASLEY, KARLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BEHOUNEK, LINSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BORCHERDING, JENNYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BURKEN, SHERIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
FRIEDENBERG, LAURAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HEDBERG, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HENNAGER, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HEYING, LARINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HOUSTON, MINDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
JAEGER, KRYSTLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
KNUTSON, MICHELEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
LARSON, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
MARCZEWSKI, LESZEKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
MCCLURE, DOROTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
OTTERBECK, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
RAJCHENBACH, CHAIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
SCOTT, KATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
SEU, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
SHEAR, KILEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
SHULL, KAYLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
STAUDT, SANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
VAN VEGHEL, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WIBBEN, KAYLEAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WIERSCHEM, BOBBIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WOOD, ROSEMARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WRIGHT, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
FRIEDMAN, BRIANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/05/2025
RAJCHENBACH, AVRUMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/05/2025
RAJCHENBACH, RIVKAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/05/2025
SHABAT, AHUVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/05/2025
DOROS GENERATION TRUST U/A/D 1/3/12OrganizationTRUSTEE OF THE SNF; ADP OF THE SNFsince 03/05/2025
CASCADE CAPITAL HOLDINGS LLCOrganizationADP OF THE SNFsince 08/15/2024
GPN FAMILY TRUST U/A/D 4/28/08OrganizationADP OF THE SNFsince 03/05/2025
MN8 RH HOLDCO LLCOrganizationADP OF THE SNFsince 08/15/2024
OAKWAY OPERATIONS LLCOrganizationADP OF THE SNFsince 03/05/2025
SAC CITY IA PROPERTY HOLDINGS, LLCOrganizationADP OF THE SNFsince 08/15/2024

CMS files one row per role, so the 79 rows in the source record cover these 43 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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
-8.8%
Operating marginrevenue minus expenses
$645K
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 9%Other / private 41%

This home reported $645K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$315per resident / day
operating cost
$9,583per month
≈ monthly operating cost
$290per 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 165343. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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.

What to do next