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Shell Rock Senior Living

920 North Cherry Street, Shell Rock, IA 50670 · For profit - Corporation · 41 certified beds · (319) 885-4341 Medicare & Medicaid certified

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1 immediate-jeopardy citation$17,167 in federal fines
Insights

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

Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,167 in federal fines (most recent 2024-07-19)
  • 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.

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 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1001 Mason Way · (319) 885-6530 · Call to confirm hours
Pharmacy
110 10th St SW · (319) 352-3120 · Call to confirm hours
Grocery
1311 4th St SW · (319) 352-1365 · Call to confirm hours
Park
Shell Rock Co Park, 22562 Willow Ave · (319) 278-4237 · Typically dawn to dusk
Place of worship
422 N Prairie St · (319) 885-4547

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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.2%17.1%15.4%worse
Long-stay residents who lose too much weight4.7%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.5%0.9%better
Long-stay residents with a urinary tract infection3.3%2.4%2.0%worse
Long-stay residents with depressive symptoms9.7%4.2%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.4%3.8%3.3%better
Long-stay residents whose ability to walk worsened18.1%16.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.0%20.8%18.9%better
Long-stay residents given the seasonal flu vaccine91.4%95.3%95.3%typical
Long-stay residents with pressure ulcers4.2%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control34.8%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table32.9%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.3%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine82.6%73.3%79.4%typical

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.

53.8% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.8%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
0.18U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.8%CMS range 37.7–67.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 5.6–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 staynot 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 worsenednot 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 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 SNFs0.831.02Oct 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

0.40
RN hours/ resident / day
0.56
LPN hours/ resident / day
2.70
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.26
RN hoursweekends
43.6%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 41 beds and averages 39.2 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 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 3.20 hrs/resident/day on weekends vs 3.84 on weekdays — 17% thinner on weekends. RN hours go from 0.46 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

7
deficiencies at the latest standard inspection (2025-09-04)
4
at the previous standard inspection (2024-09-15)

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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, facility kitchen photos, and facility policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the kitchen had working equipment to clean the dishes, such as a dishwasher and garbage disposal. The dishwasher failed to release the required chemicals used to clean the dishes. The sink used for the garbage disposal had standing debris filled water. The tour of the kitchen revealed multiple items covered in dirt, dust, and debris. The kitchen had undated and open items. The meal planned for that evening's dinner had flies landing on the food. In addition, the kitchen had spiderwebs and mold in the kitchen. Due to the lack of working equipment used to disinfect and clean the dishes, the standing debris filled water, insects in the kitchen touching the food, the undated and opened food, this resulted in an immediate jeopardy…

    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
  • Actual harm · G2024-05-09 · 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, clinical record review, interviews, facility policy, and investigation review, the facility failed to ensure staff provided a safe transfer with a mechanical lift for 1 of 4 residents reviewed that required transfer assistance (Resident #1). Resident #1 sustained a fall on 2/19/24 from a mechanical lift transfer when the mechanical lift sling strap came undone resulting in Resident #1 falling to the floor feet first, striking their head, and receiving a left subtrochanteric femoral fracture (hip fracture). The facility reported a census of 34 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired decision-making abilities. Resident #1 required substantial to maximal assistance with transfers and bed mobility. The MDS included diagnoses of cerebrovascular accident (stroke), non-Alzheimer's dementia, hemiplegia/hemiparesis (weakness/paralysis to one side of 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 · Fcited before2025-09-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven and handwashing sink. In addition, the facility failed to ensure staff wore hairnets and didn't touch food with their contaminated gloved hands. The facility reported a census of 34 residents. Findings include: During an initial kitchen walk through on 9/2/25 at 9:18 AM observed the white hand washing sink had a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. In addition, the convection oven had a brown-like sticky discoloration on the inside and the outside of the doors, throughout the inside of the oven and on the metal racks. An observation of the Dietary Manager wearing a baseball cap without a hair net, and the hair appeared over one inch in length protruding out below the baseball cap. During a follow-up walk through observation on 9/3/25 at 11:56 AM the hand washing sink continued to have a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. The convection oven also continued to have 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-04 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interviews the facility failed to post daily staffing in a visible place for all visitors and residents to see. The facility reported a census of 34 residents.Findings include: During an observation on 9/2/25 at 10:42 AM the facility posted the Daily Staffing on a bulletin board behind the nurses' station out of view of residents, families, and visitors.During an observation on 9/3/25 at 1:55 PM the Daily Staffing remained at the same place out of site from residents, families, and visitors behind the nurses' station. During an interview on 9/4/25 at 10:37 AM the Administrator reported they kept the Daily Staffing behind the nurses' station. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) explained they used to keep the staff in the hallway in front of the nurses' station until the tack board broke. Now it's positioned behind the nurses' station.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-04 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, staff interview, and policy review the facility failed to provide the correct portion size of 8 ounce (oz.) of chicken and pasta alfredo for 32 of 34 residents during a meal observation on 9/3/25 at the noon meal service. The facility reported a census of 34 residents. Findings include:The facility's menu for the noon meal on 9/3/25 titled, Week 2 Wednesday, dated 5/14/25 instructed to provide 8 oz. of chicken and pasta alfredo. During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM, Staff D, Cook, used a 6 oz. scoop instead of an 8 oz. scoop as the menu directed for serving 32 servings of chicken and pasta alfredo. During an interview on 9/3/25 at 12:53 PM the Dietary Manager reported they provided a heaping 6 oz. scoop of the chicken and pasta alfredo to all residents instead of using an 8 oz. scoop as they didn't have 8 oz scoops in the facility and needed to order more. She explained she told Staff D he should use 2, four (4) oz. scoops, but he didn't. During an interview on 9/3/25 at 12:55 PM Staff D said he used…

    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 · E2025-09-04 · tag F0880 — failed to prevent and control infections — pattern
    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 clinical record review, observation, policy review, and staff interviews, the facility failed to have a separate entrance and exit for clean and dirty laundry into the laundry room. In addition, the facility failed to use proper infection control practices when staff touched resident medication with their bare hand prior to medication administration. The facility reported a census of 34 residents. Findings include:1. On 9/3/25 at 1:48 PM observed the laundry room, the staff used the same entrance and exit for clean and dirty laundry items. The room entrance/exit measured approximately 5 feet in width and couldn't keep workflow from cross-contamination. During an interview on 9/3/25 at 1:52 PM the Laundry Manager reported they used the same exit and entrance for clean and dirty laundry items. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist explained she hadn't completed audits on laundry. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) said having clean and dirty laundry going in and out the same door wouldn't prevent…

    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 · D2025-09-04 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to complete a significant change in condition assessment for 1 of 1 residents admitted to hospice care services (Resident #23). The facility identified a census of 34 residents.Findings include:/Resident #23's Minimum Data Set (MDS) assessment dated 6 /18/25 identified a Brief Interview for Mental Status (BIMS) score of 9, indicating a moderate cognitive loss. The MDS included diagnoses of stroke, atrial fibrillation (irregular heart rate), high blood pressure, diabetes mellitus, and pain unspecified.Resident #23's Clinical Census reviewed 9/3/25 identified Resident #23 admitted to hospice care on 6/19/25. The Hospice Visit Noted dated 6/19/25 at 6:41 PM reflected Resident #23's legal representative signed paperwork for her to start hospice care services with a primary diagnosis of stroke and a secondary diagnosis of failure to thrive with congestive heart failure. The Progress Note…

    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 · D2025-09-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to identify a weight loss and notify the primary care provider (PCP), dietitian, and/or family for 1 or 2 residents (Resident #3) reviewed for weight loss. The facility identified a census of 34 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 8/14/25. The MDS indicated Resident #3 weighed 191 pounds (#) at admission.The Order Summary Report (physician orders) included an order dated 8/18/25 to complete daily weights. In addition, call the PCP if Resident #3 had a difference in weight as 3# or more in a day, or 5# or more in a week. The Weights and Vitals Summary viewed 9/3/25 listed only the following weights. The dates not listed, lacked a weight:a. 8/14/25 191.4# b. 8/20/25 197.5# (difference of 6.1#). c. 8/23/25 191.4 (difference of 6.1#)d. 8/24/25 191.4#e. 8/25/25 188# (difference of 3.4#)f. 8/26/25 191.2# (difference of 3.2#)g. 8/28/25 186# (difference…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-04 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and policy review the facility failed to keep flies off the food prior to serving. The facility reported a census of 34 residents. Findings include: During an observation on 9/3/25 at 12:08 PM a fly landed on two (2) bowls of crushed pineapple, then flew over, and landed on pureed peas. The kitchen had (4) flies present during the observation in the kitchen and one (1) dead fly noted on a cupboard door from 11:55 AM to 12:55 AM. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist reported she hadn't completed audits on practices in the kitchen.During an interview on 9/4/25 at 10:37 AM with the Administrator explained the facility had bug traps but didn't know when pest control last came to the facility. She reported flies shouldn't land on the food during food service. Review of the facility's undated General Food Preparation and Handling policy instructed to prepare food items to conserve maximum nutritive value, develop, enhance flavor, and keep free of harmful organisms and substances. Review of the facility's undated…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-15 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews the facility failed to have a full time (40 hours a week) Director of Nursing (DON) at the facility. In addition, the facility failed to have eight (8) hours of consecutive Registered Nurse (RN) coverage a day for 4 of 30 days reviewed. The facility reported a census of 34 residents. Findings include: Record review of nursing schedules from 8/12/24 to 9/12/24 lacked RN coverage for 4 days: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/13/24 at 11:16 AM the Administrator confirmed the facility didn't have 8 consecutive hours of RN coverage from 8/12/24 to 9/12/24. The days that the facility didn't have RN coverage: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/15/24 at 11:46 AM the DON reported being the current DON as of 9/12/24. She informed she came to the facility for a routine rounding visit, as she is Regional Clinical Quality Specialist for the facilities corporation. She let she let the DON at the time know the state entered the building for the annual recertification survey and the DON said she…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-15 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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, policy review, staff, and resident interview, the facility failed to find or replace 1 of 1 resident (Resident #25) hearing aides when they identified them missing. The facility reported a census of 34 residents. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] reflected he wore a hearing aid. The MDS identified a Brief Interview of Mental Status (BIMS) of 9, indicating moderately impaired cognition. The MDS included diagnoses of dementia, depression, and need for assistance with personal care. The Progress Note dated 6/13/24 at 9:36 AM reflected he saw his Doctor at the facility. The facilities Social Worker (SW) must review with him regarding lost hearing aids. On 9/13/24 at 11:21 AM Resident #25 reported he lost his hearing aids a few months ago and is hard of hearing. He explained it bothered him and he didn't want to talk because he couldn't hear. On 9/15/24 at 11:52 AM the Director of Nursing (DON) reported she believed the SW had the responsibility 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-15 · 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

    Based on observation, record review, resident and staff interviews the facility failed to provide routine repositioning for 1 of 3 residents (Resident #19). The facility reported a census of 34 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment date 8/14/24 identified a Brief Interview of Mental Status (BIMS) score of 8, indicating severely impaired cognition. Resident #19 required total assistance from staff for transfers and bed mobility. The MDS reflected he didn't walk. The MDS included diagnoses of hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hip fracture, and a need for assistance with personal care. On 9/14/24 at 1:15 PM Staff A, Certified Nurse Aide (CNA), reported Resident #19 will get up in the morning and staff didn't assist him to lay down or reposition him until after lunch on most days of the week. She added the staff never reposition him when in bed. The Care Plan Focus dated 6/18/21 reflected Resident #19 had limited physical mobility with a high…

    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 10 citations
  • Potential for harm · D2024-07-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff, and resident interview the facility failed to maintain and promote resident's dignity while serving meals for 3 of 3 residents reviewed (Residents #1, #2 and #3). The facility identified a census of 33 residents. Findings include: During an interview on 7/18/24 at 1:07 PM the Dietary Manager (DM) confirmed the facility had their garbage disposal broken for 2 weeks with the parts on back order. Prior to that their dishwasher had broken down but now functional. The DM also confirmed the dietary staff served all meals with paper products because of the dishwasher not functioning and then the disposal broken, but the residents didn't like it. On 7/18/24 at 12:03 PM observed the dietary staff serve the meal on ceramic plates. During an interview on 7/18/24 at 4:30 PM the DM confirmed the staff only served the noon meal on ceramic plates because of the presence of a Surveyor. On 7/18/24 at 5:30 PM saw the resident's meal served on paper plates with Styrofoam glasses and plastic silverware. On 7/19/24 at 12:10 PM observed the resident's meal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, staff interviews, and policy review the facility failed to keep kitchen equipment clean and sanitary for 32 of 32 residents that receive meals from the kitchen. The facility reported a census of 32 residents. Findings include: During an interview on 10/3/23 at 12:47 PM the Dietary Manager revealed she had cleaning schedules in place and there are no issues with them getting completed. During an observation of meal service on 10/4/23 from 11:53 AM to 12:25 PM revealed the following: a. Convection oven with brown substance baked on the wire racks, crumbs and debris throughout the bottom and unable to see through the window due to brown discoloration. b. Top of the convection oven with visible debris, dust, and a sticky substance. c. Four (4) slice toaster with black, brown, and yellow discoloration throughout the top. d. Steam table with brown and yellow spill marks by all knobs, the bottom with dust, debris, and yellow spills. e. Oven griddle with brown discoloration throughout the top and sides and brown substance down the front. f. Oven burners…

    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 · Ecited before2023-10-05 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code Minimum Data Set (MDS) Assessments when they inaccurately coded 1 of 1 residents Preadmission Screening and Resident Review (PASRR) (Resident #1), 1 of 1 residents use of anti-coagulant (blood thinner) medication (Resident #20), and 1 of 2 residents Hospice status on two different MDS assessments (Resident #8). The facility reported a census of 32 residents. Findings include: 1. Record review of Resident #1 PASRR dated 6/27/2023 documented she was a Level II PASRR and needed specialized services. Record Review of Resident #1 MDS dated [DATE] documented her as a Level I PASRR. During an interview on 10/4/23 at 3:12 PM with the facilities MDS Nurse revealed Resident #1 is a PASRR Level II and her 9/28/23 MDS assessment was coded incorrectly. 2. Record review of Resident #20 MDS dated [DATE] documented he received anti-coagulation medication for the 7 days of the look-back period. Record review of Resident #20 Medication…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview the facility failed to provide an assessment and implement interventions based on that assessment for 1 of 1 resident reviewed for falls (Resident #13). The facility reported a census of 32 residents. Findings include: The Progress Note for Resident #13 written by Staff B, Licensed Practical Nurse (LPN), on 9/5/23 at 10:49 AM documented she heard a noise in the hall and found the resident had fallen to the floor to his left side. Staff assisted the resident into a wheelchair so the ambulance could get through with another resident. Upon assessment the resident was able to move his left leg a small amount independently and voiced discomfort in his hip area. The resident was unable to rate his pain on a 0/10 scale but reported his left leg felt twisted. The Progress Note written by Staff B, LPN, on 9/5/23 at 1:42 PM documented the fall occurred at 8:00 AM. The Progress Note written by Staff B, LPN, on 9/5/23 at 11:02 AM documented the resident had a left femoral neck fracture. The Progress Note written by Staff B, LPN, on 9/5/23 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to complete assessments for 1 of 1 residents before and after dialysis treatments received at a certified dialysis facility (Resident #34). The facility reported a census of 32 Residents. Findings include: Record review of Resident #34 Dialysis Assessment log revealed assessments were completed, in progress, or incomplete on the following dates: 10/2/2023 Dialysis Pre and Post Assessment In Progress 9/29/2023 Dialysis Pre and Post Assessment In Progress 9/25/2023 Dialysis Pre and Post Assessment Complete 9/20/2023 Dialysis Pre and Post Assessment In Progress 9/11/2023 Dialysis Pre and Post Assessment Complete 9/1/2023 Dialysis Pre and Post Assessment Complete 8/30/2023 Dialysis Pre and Post Assessment Complete 8/25/2023 Dialysis Pre and Post Assessment Incomplete 8/21/2023 Dialysis Pre and Post Assessment Complete 8/18/2023 Dialysis Pre and Post Assessment Complete 8/16/2023 Dialysis Pre and Post Assessment Complete 8/14/2023…

    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 · D2023-10-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews the facility failed to provide 3 of 37 medications as ordered by the provider. The facility reported a census of 32 residents. Findings include: During an observation on 10/3/23 at 11:57 AM Staff A, Certified Medication Aid (CMA), set up Resident #10's medications revealed she took out the following medications and put them into a medication cup. a. Iron b. Thiamine (Vitamin) c. Creon Delayed Release (enzyme for digestion) Staff A then proceeded to take the Iron and Thiamine and crush them together. She then opened the Creon capsule and mixed all three (3) medications together with applesauce. Staff A then on 10/3/23 at 12:01 PM gave the crushed medications in applesauce to Resident #10 and he swallowed them. Record review of Resident #10 Orders dated 10/4/23 lacked an order for him to have crushed medications. In an e-mail correspondence 10/4/23 at 11:36 AM the Director of Nursing (DON) revealed Resident #10 should receive his medications whole (in applesauce per his preference). He does not have an order to crush his…

    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
  • No harm found · Bcited before2024-09-15 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to code the Minimum Data Set (MDS) to reflect 1 of 2 residents (Resident #1) reviewed for hospice was receiving hospice services. The facility reported a census of 34 residents. Findings include: Resident #1's Census documented she started hospice services on 9/28/23. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] lacked documentation that she received hospice services. On 9/15/24 at 11:53 AM the Director of Nursing expected the facility to code the MDS correctly if a resident received hospice services. The facility used the Resident Assessment Instrument (RAI) for guidance on accurate coding.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-10-05 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interviews and policy review the facility failed to have a qualified professional serve as the Dietary Manager. The facility reported a census of 32 residents. Findings include: During an interview on 10/2/23 at 3:32 PM the facility Administrator revealed their Dietary Manager is not a Certified Dietary Manager. During an interview on 10/3/23 at 12:47 PM the facility Dietary Manager revealed she started in August of this year (2023) and got enrolled in a Certified Dietary Manager course a couple of weeks ago but has not started it. Record review of the facilities policy, Director of Food and Nutrition Services from 2021, revealed the facilities current Dietary Manager does not meet the criteria of the facilities policy to serve as the Dietary Manager. During an interview on 10/4/23 at 10:49 AM the facility Dietician revealed the Dietary Manager should be certified in the future.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-10-05 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to cover 6 of 6 garbage cans in the kitchen. The facility reported a census of 32 residents. Findings include: During an initial observation of the kitchen on 10/2/23 at 10:32 AM revealed six (6) garbage cans without lids and uncovered. During an observation of meal service on 10/4/23 from 11:53 AM to 12:25 PM revealed six (6) garbage cans were not covered during the meal service in the kitchen. During an interview on 10/4/23 at 10:47 AM the facility Dietician revealed she would expect all garbage cans to be covered in the kitchen.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-10-05 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, e-mail correspondence, and policy review the facility failed to have documentation for 1 of 3 quarterly Quality Assurance (QA) meetings for the calendar year of 2023. The facility reported a census of 32 residents. Findings include: Record review of the facilities QA meeting attendance logs for 2023 revealed the first meeting of the year occurred on 5/23/23. During an e-mail correspondence with the facility Administrator on 10/4/23 at 10:34 AM revealed she thought there was a meeting before 5/23/23 and the sign in sheet was misplaced. Review of the facility Policy, Quality Assurance and Performance Improvement Plan (QAPI)/ Quality Assessment and Assurance (QAA), dated 5/23/23 instructed the following: a. The QAPI Committee will meet monthly. b. The QAA Committee shall meet at least quarterly and shall include Director of Nursing, Medical Director, IP Nurse, and three other staff members which one must be the Executive Directors or another individual on your leadership team.

    Administration 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

$17,167 in federal fines across 1 penalty.

  • $17,167 — penalty dated 2024-07-19

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 ACCURA HEALTHCARE — 41 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 52.5-1.5 vs chain
Health inspection 1 of 52.6-1.6 vs chain
Staffing 3 of 53.1-0.1 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 40 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Aberdeen Health And RehabAberdeen, SD 1 of 5Accura HealthCare of TekamahTekamah, NE 1 of 5Accura Healthcare of CarrollCarroll, IA 1 of 5Accura Healthcare of MarshalltownMarshalltown, IA 1 of 5Accura Healthcare of Newton East, LLCNewton, IA 1 of 5Accura Healthcare of O'NeillO' Neill, NE 1 of 5Accura Healthcare of Pleasantville, LLCPleasantville, IA 1 of 5Accura Healthcare of ShenandoahShenandoah, IA 1 of 5Green Lea Senior LivingMabel, MN 1 of 5Lake Andes Senior LivingLake Andes, SD 2 of 5Accura Healthcare of Cascade LLCCascade, IA 2 of 5Accura Healthcare of CrestonCreston, IA 2 of 5Accura Healthcare of FranklinFranklin, NE 2 of 5Accura Healthcare of Knoxville, LLCKnoxville, IA 2 of 5Accura Healthcare of Lake City, LLCLake City, IA 2 of 5Accura Healthcare of MuscatineMuscatine, IA 2 of 5Accura Healthcare of OnawaOnawa, IA 2 of 5Accura Healthcare of Spirit LakeSpirit Lake, IA 2 of 5Sterling Park Health Care CenterWaite Park, MN 2 of 5Woodlyn Heights Healthcare CenterInver Grove Heights, MN 3 of 5Accura Healthcare of Ames, LLCAmes, IA 3 of 5Accura Healthcare of Aurelia, LLCAurelia, IA 3 of 5Accura Healthcare of Cherokee, LLCCherokee, IA 3 of 5Accura Healthcare of FullertonFullerton, NE 3 of 5Accura Healthcare of Pomeroy, LLCPomeroy, IA 3 of 5Accura Healthcare of StantonStanton, IA 3 of 5Accura Healthcare of ToledoToledo, IA 3 of 5Meadow ManorGrand Meadow, MN 3 of 5Prairie View Senior LivingTracy, MN 3 of 5Traditions Memory Care of NewtonNewton, IA 4 of 5Accura HealthCare of North PlatteNorth Platte, NE 4 of 5Accura Healthcare of Le MarsLe Mars, IA 4 of 5Accura Healthcare of MilfordMilford, IA 4 of 5Accura Healthcare of New HamptonNew Hampton, IA 4 of 5Accura Healthcare of Ogden, LLCOgden, IA 4 of 5Accura Healthcare of Sioux City, LLCSioux City, IA 4 of 5Faulkton Senior LivingFaulkton, SD 5 of 5Accura HealthCare of HartingtonHartington, NE 5 of 5Accura Healthcare of BancroftBancroft, IA 5 of 5Karlstad Healthcare Center INCKarlstad, MN

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
TEALWOOD ENTERPRISE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2012
GROFF, HOWARDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 09/03/2008
SHERIDAN, GAILIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 09/03/2008
SPURGIN, KASSIDYIndividualW-2 MANAGING EMPLOYEEsince 01/01/2023
LENEAVE, TEDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019
AMERICAN HEALTHCARE MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019

CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

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.

$4.2M
Net patient revenuemost recent cost report
+0.2%
Operating marginrevenue minus expenses
$219K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 26%Medicare 5%Other / private 69%

This home reported $219K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$228per resident / day
operating cost
$6,918per month
≈ monthly operating cost
$228per 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 165309. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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