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Northcrest Specialty Care

2001Health Street, Waterloo, IA 50703 · Non profit - Corporation · 94 certified beds · (319) 234-4423 Medicare & Medicaid certified

Call the home — (319) 234-4423 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
419 E Donald St · (319) 236-1911 · Call to confirm hours
Pharmacy
1850 Logan Ave · (319) 296-7761 · Call to confirm hours
Grocery
319 Independence Ave · (319) 290-1170 · Call to confirm hours
Park
(319) 291-4370 · 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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 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 increased12.0%17.1%15.4%better
Long-stay residents who lose too much weight6.5%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder3.5%1.5%0.9%worse
Long-stay residents with a urinary tract infection1.1%2.4%2.0%better
Long-stay residents with depressive symptoms0.8%4.2%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.1%3.8%3.3%better
Long-stay residents whose ability to walk worsened14.2%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.1%20.8%18.9%typical
Long-stay residents given the seasonal flu vaccine85.7%95.3%95.3%worse
Long-stay residents with pressure ulcers4.1%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control33.5%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.8%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.8%2.1%1.4%worse
Short-stay residents given the seasonal flu vaccine76.6%73.3%79.4%typical
Short-stay residents rehospitalized after admission15.9%20.9%22.6%better
Short-stay residents with an outpatient ER visit11.0%13.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.481.491.67better
Long-stay outpatient ER visits per 1,000 resident days2.302.081.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

59.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.3%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
38.2%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 38.2% 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 34 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNF59.3%CMS range 50.8–67.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.4–15.410.7%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 discharge38.2%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 discharge32.4%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 discharge17.6%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 identified88.5%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%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 worsened1.9%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 hospitalization8.0%CMS range 5.5–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 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

0.68
RN hours/ resident / day
0.64
LPN hours/ resident / day
1.96
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.36
RN hoursweekends
46.7%
Total nursing turnover
61.9%
RN turnover

How full it usually is: this home is certified for 94 beds and averages 86.2 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 2.97 hrs/resident/day on weekends vs 3.42 on weekdays — 13% thinner on weekends. RN hours go from 0.81 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-02-12)
7
at the previous standard inspection (2025-01-30)

Deficiencies are unchanged from the previous inspection. 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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2024-10-01 · 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 clinical record review, staff interview, and observation the facility failed to provide appropriate assessment and intervention for one of three residents reviewed (Resident #1). The facility reported a census of 79 residents. Findings include: The admission MDS (Minimum Data Set) an assessment tool dated 2/26/2024 revealed Resident #1 had mild impaired cognitive abilities, required staff assistance to transfer from one surface to another, used a wheel chair for mobility, and had no identified skin concerns. The MDS revealed the resident had diagnoses including anemia, malnutrition, ESRD (End Stage Renal Disease), diabetes, heart failure and received dialysis. The quarterly MDS dated [DATE] revealed the resident had intact cognitive abilities, required staff assistance to transfer, and received ointment/medication application other than to feet. The Care Plan identified the resident had a skin integrity concern due to venous insufficiency dated 3/12/2024. It directed staff to monitor the resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-12 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, resident interviews and policy review, the facility failed to provide resident call light access for alerting staff of needs or in the event of an emergency for 3 of 24 residents reviewed for call light access (Residents #42, #69, and #73). The facility reported a census of 87.Findings include: 1. Resident #73's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview of Mental Status (BIMS) scored 14, indicating intact cognition. The MDS included diagnoses of heart failure, orthostatic hypotension, high blood pressure, and kidney failure. The Care Plan Focus initiated 1/24/26 identified Resident #73 had a risk for falls. The Interventions directed to encourage him to use the call light for assistance. On 2/9/26 at 2:44 PM Resident #73 relayed he came to the facility for therapy. He had low blood pressure and repeat falls. He reported the call light worked when he arrived, then it became unpredictable. It didn't work on Saturday 2/6/26 and he alerted staff…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, policy review, family, and staff interviews, the facility failed to maintain a homelike environment free of odors. The facility identified a census of 87 residents.Findings include:On 2/9/26 at 10:41 AM smelled a slight urine odor outside Resident #53's room door. The nurse entered Resident #53's room to administer medications and returned to the medication cart parked outside in the hallway just up from Resident #53's room. Another staff member stood at a treatment cart in hallway approximately 3 doors down from Resident #53's room door talking to another resident.On 2/9/26 at 10:46 AM observed Resident #53 lying in bed. Upon entrance to the room noted a strong, stale urine type odor throughout the room. Resident #53 sat up in bed and stated they didn't smell an odor in the room. She explained when she tried to stand up urine just runs out of her. Resident #53 admitted if she had wet linens or brief, she would throw them on the floor. She stated she really didn't use her call light and the staff eventually come clean it up. She just…

    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 before2026-02-12 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed complete the Minimum Data Set (MDS) Assessment within 14 days of admission for 1 of 2 resident reviewed for new admission (Resident #39). The facility identified a census of 87 residents.Findings include:An Electronic Medical Record (EMR) Census documented Resident #39 admitted to the facility on [DATE].Resident #39's MDS 3.0 Summary Page showed the admission MDS signed off as completed late on 9/5/25. During an interview on 2/12/26 at 11:50 AM Staff L, MDS Coordinator, reported the facility completed Resident #39's MDS late. They look at the MDS list and spend time everyday working on them, looking to see where they are at. Staff L stated she has a calendar made up that she used to track when the MDS are due. Staff L voiced they have one week to get the MDS done and she utilized a Paper Document Titled Section GG…

    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 · D2026-02-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed encode and transmit Minimum Data Set (MDS) documents to the CMS system in the appropriate time frames for 3 of 4 records reviewed for MDS timing requirements (Residents #36, #39 and #61). The facility identified a census of 87 residents.Findings include:1. Resident #36's Electronic Healthcare Record (EMR) Census documented a discharge date of 8/7/25. Resident #36's MDS Discharge Return Anticipated Assessment documented a discharge date in A2000 of 8/7/25. Section Z0400 related to the signature of persons completing the assessment or entry/death reporting reflected a completion date of 8/24/25.The MDS 3.0 Summary Page documented a MDS Discharge Return Anticipated Assessment completed late on 8/24/25, 24 days after their discharge.During an interview on 2/12/26 at 11:50 AM Staff L, MDS Coordinator, reported they look at the MDS list and spend time everyday working on the MDS schedule. Staff…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed to accurately code the Preadmission Screening and Resident Review (PASRR, an assessment for serious mental illness or intellectual or developmental disability for appropriate services) on the Minimum Data Set (MDS) assessment for 2 of 2 residents sampled (Resident #6 and #10). The facility identified a census of 87 residents.Findings include: 1. Resident #6's Notice of PASRR Level 1 Screen Outcome dated 10/2/25 documented a Determination of Level 1 Positive, No Status Change. The PASRR Outcome Explanation documented Resident #6 had evidence of a serious mental illness. The previous PASRR Summary of Findings remains valid for your stay. The Explanation further detailed the facility should mark yes for question A1500 on the MDS, Is the resident currently considered by the state level II PASRR process to have serious…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-12 · 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, record review, facility records, policy review, and staff interviews, the facility failed to utilize infection control standards to prevent cross contamination when they placed gauze that dropped on a bed pad directly on a wound for 1 of 2 residents reviewed (Resident #65). The facility reported a census of 87 residents. Findings include:Resident #65's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #65 as frequently incontinent of urine and bowel during the lookback period. The MDS listed active diagnoses of wound infection, diabetes mellitus and chronic obstructive pulmonary disease (COPD - an ongoing lung condition caused by damage to the lungs). The MDS identified Resident #65 required surgical wound care and application of a nonsurgical dressing. A Progress Note dated 2/6/25 at 6:35 PM documented the surgical incision site measured 7.03 centimeters (cm) in length 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    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, facility records, record review, policy review, resident and staff interviews the facility failed to follow their smoking policies to ensure resident safety for 1 of 1 resident reviewed (Resident #70). The facility failed to complete a smoking assessment or safety assessment to ensure a resident could safely smoke alone in the designated smoking area off the facility's property. In addition, the facility failed to ensure the facility grounds remained smoke free as declared by the staff with 50 cigarette butts on the facility's ground near the area of a resident observed smoking. The facility reported a census of 87 residents.Findings include:Resident #70's Minimum Data Set (MDS) assessment dated [DATE], documented an admission date of 12/20/25. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #70 used a walker and a wheelchair during the 7-day lookback period. The MDS listed Resident #70 as independent 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-04 · 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 observations, interviews, and record review, the facility failed to provide adequate grooming for 1 of 4 residents reviewed (Resident #1). An observation revealed Resident #1 still wore his t-shirt from bedtime, the following day. In addition, Resident #1 had hairs remaining on his shirt after his visit to the barber, the day before. The facility reported a census of 82 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #1 as dependent on staff with upper and lower body dressing. The MDS included diagnoses hemiplegia (extreme weakness on half of the body) following a cerebral infarction (stroke) and depression. On 6/3/25 at 12:46 PM, Resident #1's Sister reported Resident #1 wore the same shirt as he did the day before (6/2/25). She reported Resident #1 received a haircut the day before (6/2/25) and his shirt still had hair from his haircut. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-30 · 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, interviews, and record review the facility failed to remove expired foods from storage, to maintain a sanitary environment, and to date opened food during 2 of 2 observations. The facility reported a census of 87 residents. Findings include: During the initial kitchen tour and observation on 1/27/25 at 9:36 AM the dry storage area contained an undated and nearly full clear bin of rice with a blue lid. The shelf below the rice contained two round snack bins without lids with prepackaged snacks. The bin on the left held 6 items, cheese puffs out of the wrapper, and crumbs. The bin on the right held 11 items, corn chips out of the wrapper, and chip crumbs. Another shelf contained an open, undated package of chicken and herb stuffing. The bottom shelf of the next unit contained 3 boxes of lemon bar mix. One of the boxes had two sides crumpled, and the tops of the other two had a film of dust and food particles. The boxes had expiration dates listed on the boxes as 8/1/23, 1/23/24, and 4/17/24. On the top shelf of that unit contained a box of gluten free chocolate…

    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 before2025-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, Center for Disease Control and Prevention (CDC) Guidelines, policy review and staff interview, the facility failed to implement Enhanced Barrier Precautions when providing high contact care for assessing a fistula (dialysis access site), working with a gastrostomy (G) tube (feeding tube) and emptying a Urinary catheter drainage bag for 3 of 3 resident sampled (Resident #10, #128 and #132). In addition, the facility failed to provide adequate infection control prevention and practices to prevent touching medication with bare hands or dirty gloves during medication administration for 3 of 4 resident observed (Resident #34, #43 and #63). The facility identified a census of 87 residents. Findings include: 1. Resident #132's Clinical Census listed an admission date of 1/14/25. A Brief Interview for Mental Status (BIMS) Evaluation dated 1/14/25 listed a score of 15, indicating intact cognition. Resident #132 Minimum Data Set (MDS) assessment dated [DATE] included 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-01-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to accurately reflect the medication status for 1 of 1 resident reviewed on anticoagulant (blood thinner) medications (Resident #10). The facility identified a census of 87 residents. Findings include: Resident #10's MDS assessment dated [DATE] included a diagnosis of cerebrovascular accident (CVA, stroke). The MDS reflected Resident #10 took an anticoagulant medication within the lookback period. An Order Review History Report signed by the Provider on 1/5/25 documented the following physician orders dated 1/11/24: a. Aspirin (nonsteroidal anti inflammatory and antiplatelet medication) enteric (thick coating to prevent the medicine from breaking down too soon) coated delayed release 81 milligrams (MG) give 1 tablet by mouth one time a day 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 observation, clinical record review, policy review and staff interview the facility failed to provide a timely assessment and physician notification for a resident with a history of bowel obstructions and peptic ulcer disease who exhibited nausea, vomiting, and loose stools for 1 of 1 resident's reviewed (Resident #45). The facility identified a census of 87 residents. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS listed Resident #45 as dependent upon staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after having a bowel movement). The MDS documented Resident #45 as incontinent of bowel. The MDS included diagnoses of unspecified intestinal obstruction versus complete obstruction and esophagitis (inflammation of the esophagus) with bleeding. The Patient Report dated 2/29/24 related to Resident #45's two view…

    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 · D2025-01-30 · 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 observation, clinical record review, and staff interview, the facility failed to provide food to a resident while out of the facility while they received renal dialysis for 1 of 1 resident's sampled (Resident #128). The facility identified a census of 87 residents. Findings include: Resident #128's Clinical Census reflected they admitted to the facility on [DATE]. The Handoff Report dated 1/24/24 listed Resident #128 received hemodialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are no longer able to do so) at a local (renal/kidney) dialysis center. The Nursing Admission/readmission Evaluation - V 18 dated 1/24/25 documented Resident #128 as alert, oriented to person, place, time, situation and clear communication abilities. The Evaluation noted Resident #128 didn't have short term memory impairment, confusion, forgetfulness or impaired decision making ability. The Evaluation listed a Dietary Care Plan indicating the facility would provide with meals…

    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 · D2025-01-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review, staff interview, and policy review the facility failed to administer the flu vaccine for 1 of 6 residents reviewed (Resident #9). The resident requested the vaccine during her admission assessment. The facility reported a census of 87 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 9/4/24. The MDS included diagnoses of stroke and asthma. During an interview on 1/27/25 at 12:47 PM Resident #9 reported she didn't receive any vaccines at the facility, and she wanted the flu and COVID vaccines. When asked if she spoke to the staff about it, she replied she asked for the vaccines when she first arrived. On 1/30/25 at 10:19 AM the Director of Nursing (DON) provided documentation from Resident #10's clinical record dated 9/4/24 at 11:44 AM titled Admission/readmission Evaluation. It documented Resident #10 consented to the flu vaccine, directed staff to complete the consent form, and noted the consent…

    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 · D2025-01-30 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 interview, record review, staff interview, and policy review the facility failed to administer the flu vaccine for 1 of 6 residents reviewed (Resident #9). The resident requested the vaccine during her admission assessment. The facility reported a census of 87 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 9/4/24. The MDS included diagnoses of stroke and asthma. During an interview on 1/27/25 at 12:47 PM Resident #9 reported she didn't receive any vaccines at the facility, and she wanted the flu and COVID vaccines. When asked if she spoke to the staff about it, she replied she asked for the vaccines when she first arrived. On 1/30/25 at 10:19 AM the Director of Nursing (DON) provided documentation from Resident #10's clinical record dated 9/4/24 at 11:44 AM titled Admission/readmission Evaluation. It documented Resident #10 consented to the flu vaccine, directed staff to complete the consent form, and noted the consent…

    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 · D2024-04-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff, resident, physician, and pharmacist interview and policy review the facility failed to ensure 1 of 1 residents (Resident #4) pain medication patch was removed prior to applying a new pain medication patch. The facility reported a census of 84 residents. Findings include: Record review of Resident #4 March 2024, Individual Narcotic Record, documented on 3/3/2024 at 8:18 PM Staff A, Certified Medication Aide (CMA) removed one fentanyl patch from the narcotic lock box. Record review of Resident #4 March MAR documented on 3/3/24 during the hour before sleep (HS) medication pass a fentanyl (pain medication) patch was applied transdermally (a drug is placed on top of the skin, where it is absorbed into the bloodstream) on Resident #4. Record review of Resident #4 Progress Note dated 3/4/24 at 7:00 AM documented Resident #4 approached nursing staff reporting a new fentanyl patch had been applied last night (3/3/24) without the previous patch being removed. Upon assessment, one (1) fentanyl patch to the left chest was noted, as well as one (1) to the 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 · E2024-01-30 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, policy review, and record review the facility failed to respond or provide a rationale for the response to the Resident Council group concerns. The deficient practice had the potential to affect many residents in the facility. The facility reported a census of 87 residents. Findings include: Review of the facility policy revised 4/2017 Grievances/Complaints, Recording, and Investigating recorded that all grievances and complaints filed with the facility would be investigated and corrective action would be taken to resolve the grievance. The policy recorded the Administrator had assigned the responsibility of investigating grievances and complaints to the Grievance Officer. Upon receiving a grievance and complaint report, the Grievance Officer would begin an investigation into the allegations, and the person(s) investigating the grievance would inform the resident/interested party of the findings and disposition of the grievance. The Grievance/Concern Investigation Form would be filed with the Administrator within five (5) working days of the incident, and 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 · E2024-01-30 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and staff interview, the facility failed to take prompt action to address resident concerns, failed to ensure the residents/resident representatives had the ability to file grievances anonymously, failed to ensure the resident/resident representative were notified of the expected time frame for completing the review of the grievance, failed to provide the resident/resident representative a written decision regarding his or her grievance, and failed to ensure that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was provided to the resident/resident representative. The facility reported a census of 87. Findings include: Review of the facility…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 clinical record review, policy review, staff and resident interviews, the facility failed to ensure that residents that required assistance with their activities of daily living (ADL's) received bath assistance per their request and failed to ensure residents received appropriate peri-care for 5 of 7 residents sampled (Residents #17, #27, #48, #69, and #82). The facility reported a census of 87 residents. Findings include: 1. Review of Resident #48's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and diagnoses of cerebral vascular accident (CVA-stroke), hypertension (high blood pressure), hemiplegia (paralysis that affects one side of the body), and aphasia (loss of ability to express and/or understand speech). The Resident required staff assistance with bathing and personal hygiene and had urinary incontinence (leakage of urine from the bladder without urge to urinate). A review of Resident #48's 1/12/2024…

    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 · E2024-01-30 · tag F0801 — pattern
    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 staff interview and job description review the facility failed to ensure the Dietary Manager was certified as required. The facility reported a census 87 residents. Findings include: During an interview on 1/22/24 at 10:05 AM the Dietary Manager explained she was not a Certified Dietary Manager. She further explained she had completed the class and taken the test but she failed the test. There is a 3 month wait to retake the test and she would be paying for the retake today. On 1/22/24 at 3:00 PM the Dietary Manager provided a receipt for taking the certification test. During an interview on 1/22/24 at 12:16 PM the Dietary Manager explained the Registered Dietician is only in the facility monthly. Review of the job description for the Dietary Manager last revised on 4/18 documented one of the qualifications for the Dietary Manager was to be a Certified Food Protection Manager.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-30 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review the facility failed to maintain a working call light system. The facility reported a census of 87 residents. Findings include: 1. During an interview on 1/22/24 at 1:34 PM Resident #73 reported needing a medication. He pressed his call light. The [NAME] sign at the end of the hall did not have his call light on. At 1:44 PM the resident pushed the call light a second time. He had to use quite a bit of pressure to push the light. Again the [NAME] sign did not have his light on. After the light was pressed a second time and did not come on, Staff U, (Registered Nurse) RN was alerted the resident's light was not working and he was requesting medication. Staff U alerted Staff V, Maintenance, the call light was not working. Staff U entered the resident's room and pressed the call light. Staff U reported to Staff L the call light was sticky. During an interview on 1/22/24 at 2:28 PM Staff V stated he fixed the call light and last he checked it was working. He…

    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 · D2024-01-30 · 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 observation, clinical record review, and staff interview the facility failed to promote resident dignity when dirty linens were passed over the top of a resident while laying in bed awake during cares and failed to allow a resident to eat in the main dining room per the resident's request for 2 of 5 residents observed (Resident #48 and #69). The facility reported a census of 87 residents. Findings include: 1. An observation on 1/23/2024 at 12:47 PM showed Resident 48 seated in her wheelchair in the hallway outside her room. Staff B, Licensed Practical Nurse (LPN) retrieved Resident #48's lunch tray from the cart and took the tray to a table located in a common area at the end of the hall and informed Resident #48 that because her lunch tray had left the dining room, she could not eat in the dining room but had to eat at the table at the end of the hall. During an interview on 1/23/2024 at 12:49 PM Resident #48 indicated that she preferred to take her meals in the dining room and did not want to eat 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to document an accurate code status for 2 of 2 residents reviewed for advanced directives (Resident #42 and #141). The facility reported a census of 87 residents. Findings include: The significant change Minimum Data Set (MDS) assessment tool dated [DATE], documented Resident #42 had a Brief Interview for Mental Status (BIMS) of 4 indicating severely impaired cognition. The resident had diagnoses of Type II diabetes mellitus, vascular dementia, chronic pain, neoplasm of the bladder, and ileus. The MDS documented [DATE] as the resident's admission date. The Care Plan updated on [DATE] had a focus area for Advanced Directives with a goal for the Advanced Directives to be followed per the resident/family request and interventions that included: honor the resident's wishes, review the resident's choices quarterly and as needed and to see the code status declaration form in the code status book. The Iowa Physician Orders 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews the facility failed to promote a homelike environment by allowing a resident to eat meals from a dirty bedside table for 1 of 9 residents observed (Resident #80). The facility identified a census of 87 residents. Findings include: Resident #80's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Resident #80 could eat independently after a meal was set up on a tray for her. Observation on 1/22/24 at 2:29 PM revealed Resident #80's bedside table with over 1/3 of the table with stuck down cup rings and a crusty, brown, gritty film over the table. The dirty 1/3 of the bedside table did not contain resident personal items. Resident #80 reported no one had cleaned the bedside table and she had eaten her lunch tray from the table. On 1/23/24 at 11:16 AM Resident #80's bedside table observed with dirty cup rings and a crusty, brown, film on over 1/3 of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to complete the Minimum Data Set (MDS) admission Assessment, Care Area Assessments (CAA) and Care Plan within the required time frame for 1 of 4 residents sampled on hospice care (Resident #69). The facility reported a census of 87 residents. Finding include: Resident #69's MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive loss. The MDS documented Resident #69 received hospice care services for a diagnosis of colon cancer and admitted to the facility on [DATE]. A Physician Order dated 4/14/23 documented admission to hospice care with a life expectancy of less than six months. Resident #69's Electronic Health Record (EHR) Point Click Care MDS 3.0 Summary page documented MDS completion, Care Area Assessment, and Care Plan decision date of 5/05/23.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interviews, and policy review, the facility failed to accurately complete a comprehensive Care Plan for 1 of 3 residents reviewed for positioning (Resident #45). The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) for Resident #45 dated 11/02/23 revealed diagnoses of hemiplegia (paralysis to left side), muscle wasting and atrophy to left side, blindness, and history of Transient Ischemic Attack (TIA/mini stroke). Review of Resident #45 Electronic Health Record (EHR) documented resident had hemiplegia with affected left non-dominant side, muscle wasting and atrophy, and contractures to right hip, right knee, left hip and left knee. Review of Care Plan for Resident #45 lacked of documentation of Resident #45 hemiplegia and contractures. During an interview on 1/24/24 at 3:37 PM Staff P, MDS Coordinator reported the Care Plan should address contractures and hemiplegia. She reported it must have been missed. On 1/24/24 at 3:49 PM, the Cooperate Consultant reported she expects staff to address contractures…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-30 · 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, policy review, and staff interviews, the facility failed to have a safe smoking area for 1 of 1 residents reviewed (Resident #74). The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #74 with a Brief Interview for Mental Status (BIMS) Score of 15 indicating cognitively intact. The MDS further documented the resident had diagnoses of diabetes, muscle weakness, and fibromyalgia. At the time of admission the MDS documented resident used tobacco. Resident #74's Care Plan revised on 1/22/24 directed the resident had been instructed on the facility smoking policy and could smoke unsupervised. The Care Plan further directed the staff to notify the nursing supervisor immediately when he had been suspected to have violated the facility smoking policy. Review of Resident #74 Smoking assessment dated [DATE] documented the resident was not permitted to keep cigarettes or lighter. A 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-01-30 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessments for 2 of 15 residents reviewed (Resident #9 and #45). The facility reported a census of 87 residents. Findings include: 1. The MDS for Resident #9 dated 11/16/23 revealed diagnoses of congestive heart failure, hypertension, and coronary artery disease. The MDS documented the resident received an anticoagulant during the 7 day look back period. Review of the November 2023 Medication Administration Record lacked documentation of a anticoagulant given. 2. The MDS for Resident #45 dated 11/02/23 revealed diagnoses of hemiplegia (paralysis to left side), muscle wasting and atrophy to left side, blindness, and history of Transient ischemic attack (TIA/mini stroke). The MDS lacked documentation of impairment to upper or lower extremities for functional limitation in range of motion. Review of Resident #45 Electronic Health Record (EHR) documented resident with hemiplegia 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.

    Resident Assessment and Care Planning 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 CARE INITIATIVES — 43 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 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 53.7+0.3 vs chain
The other 42 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avoca Specialty CareAvoca, IA 1 of 5Correctionville Specialty CareCorrectionville, IA 1 of 5Crestview Specialty CareWest Branch, IA 1 of 5Heritage Specialty CareCedar Rapids, IA 1 of 5Kingsley Specialty CareKingsley, IA 1 of 5Parkridge Specialty CarePleasant Hill, IA 1 of 5Ravenwood Specialty CareWaterloo, IA 1 of 5Westwood Specialty CareSioux City, IA 2 of 5Chariton Specialty CareChariton, IA 2 of 5Creston Specialty CareCreston, IA 2 of 5Dubuque Specialty CareDubuque, IA 2 of 5Lantern Park Specialty CareCoralville, IA 2 of 5New London Specialty CareNew London, IA 2 of 5Northern Mahaska Specialty CareOskaloosa, IA 2 of 5Pinnacle Specialty CareCedar Falls, IA 2 of 5Southridge Specialty CareMarshalltown, IA 2 of 5Stratford Specialty CareStratford, IA 3 of 5Atlantic Specialty CareAtlantic, IA 3 of 5Centerville Specialty CareCenterville, IA 3 of 5Cherokee Specialty CareCherokee, IA 3 of 5Eldora Specialty CareEldora, IA 3 of 5Manly Specialty CareManly, IA 3 of 5Montezuma Specialty CareMontezuma, IA 3 of 5Odebolt Specialty CareOdebolt, IA 3 of 5Panora Specialty CarePanora, IA 3 of 5Ridgewood Specialty CareOttumwa, IA 3 of 5Southern Hills Specialty CareOsceola, IA 3 of 5West Ridge Specialty CareKnoxville, IA 4 of 5Bedford Specialty CareBedford, IA 4 of 5Belle Plaine Specialty CareBelle Plaine, IA 4 of 5Corning Specialty CareCorning, IA 4 of 5Corydon Specialty CareCorydon, IA 4 of 5Dunlap Specialty CareDunlap, IA 4 of 5Laporte City Specialty CareLa Porte City, IA 4 of 5Lyon Specialty CareRock Rapids, IA 4 of 5Oakwood Specialty CareAlbia, IA 5 of 5Fonda Specialty CareFonda, IA 5 of 5Lamoni Specialty CareLamoni, IA 5 of 5Mechanicsville Specialty CareMechanicsville, IA 5 of 5Sibley Specialty CareSibley, IA

Showing 40 of 42; 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
CARE INITIATIVESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2012
COMPUTERSHARE CORPORATE TRUST COMPANY, NAOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2025
BEAL, MICHAELIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/01/2020
BOWEN, LANEIndividualCORPORATE DIRECTORsince 01/01/2021
CAROTHERS, MARY JANEIndividualCORPORATE DIRECTORsince 01/01/2023
CHILDS, KEVINIndividualCORPORATE DIRECTORsince 04/01/2023
CORLESS, PETERIndividualCORPORATE DIRECTORsince 01/01/2025
KREIN, KEITHIndividualCORPORATE DIRECTORsince 01/01/2022
RUST, ELIZABETHIndividualCORPORATE DIRECTORsince 01/01/2023
STURM, DENISEIndividualCORPORATE DIRECTORsince 01/01/2021
UPMEYER, LINDAIndividualCORPORATE DIRECTORsince 01/01/2022
DIXON, DAVIDIndividualCORPORATE OFFICERsince 06/01/2016
DRAKE, EMILYIndividualCORPORATE OFFICERsince 01/04/2023
GILYARD, TANYAIndividualCORPORATE OFFICERsince 05/23/2025
KUHN, JERAMYIndividualCORPORATE OFFICERsince 06/25/2008
MCDYER, JESSICAIndividualCORPORATE OFFICERsince 02/22/2023
VOLM, JOHANNAIndividualCORPORATE OFFICERsince 01/01/2021
ADAMS, RUSSELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
BAEDKE, CHARISSAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
BODE, JESSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/05/2025

CMS files one row per role, so the 25 rows in the source record cover these 20 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.

$10.0M
Net patient revenuemost recent cost report
+7.3%
Operating marginrevenue minus expenses
$991K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 9%Other / private 31%

This home reported $991K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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.

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

$312per resident / day
operating cost
$9,473per month
≈ monthly operating cost
$336per 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 165165. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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.

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