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Northgate Care Center

960 4th Street NW, Waukon, IA 52172 · For profit - Corporation · 50 certified beds · (563) 568-3493 Medicare & Medicaid certified

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Special Focus candidate (CMS is watching this home)Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Mar 20261 immediate-jeopardy citation$87,160 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $87,160 in federal fines (most recent 2026-03-04)
  • 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)
  • CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)

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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
120 2nd Ave SE · (563) 568-3000 · Call to confirm hours
Pharmacy
21 W Main St · (563) 568-6315 · Call to confirm hours
Grocery
9 9th St SW · (563) 568-3316 · Call to confirm hours
Park
1013 Rossville Rd · (563) 568-0081 · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 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 increased9.7%17.1%15.4%better
Long-stay residents who lose too much weight6.8%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.5%0.9%better
Long-stay residents with a urinary tract infection0.0%2.4%2.0%better
Long-stay residents with depressive symptoms0.0%4.2%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%3.8%3.3%better
Long-stay residents whose ability to walk worsened9.7%16.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.8%20.8%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers6.3%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control37.9%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.6%19.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.1%1.4%better
Long-stay hospitalizations per 1,000 resident days1.551.491.67typical
Long-stay outpatient ER visits per 1,000 resident days3.342.081.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

41.7% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.7%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
30.4%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy

Met the expected recovery: 30.4% 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 23 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.7%CMS range 29.8–57.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.2–14.410.7%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 discharge30.4%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 discharge17.4%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 discharge21.7%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 identified86.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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
0.54
LPN hours/ resident / day
2.04
Aide hours/ resident / day
2.97
Total nurse hours/ resident / day
0.31
RN hoursweekends
34.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 41.2 residents a day — about 82% occupied, or roughly 9 beds typically open. It usually has some room. 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 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 2.62 hrs/resident/day on weekends vs 3.11 on weekdays — 16% thinner on weekends. RN hours go from 0.43 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below 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

10
deficiencies at the latest standard inspection (2026-03-04)
0
at the previous standard inspection (2025-02-20)

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.

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2026-03-04 · tag F0760 — failed to prevent significant medication errors — widespread
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff, doctor, pharmacist interview, and policy review the facility failed to have 4 of 7 nurses administer medications following the 6 rights of medication administration. The 6 rights are a process of verifying the right resident, right drug, right dose, right route, right time, and right documentation performed to systematically minimize medication errors, ensure patient safety, and maintain the efficacy of treatment. By verifying these key factors, healthcare providers prevent adverse events, protect residents, and adhere to safety protocols. Staff A, Licensed Practical Nurse (LPN), Staff B, LPN, Staff F, Registered Nurse (RN), and Staff G, LPN administered medications for residents who resided in the facility on the morning of 2/22/26 and morning of 2/27/26 without following the proper medication administration procedures by administering medications which were pre-set (set up in advance of being administered). The residents' medications included insulin, blood…

    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
  • Actual harm · Gcited before2025-11-14 · 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, staff interview, facility video, and facility policy review the facility failed to properly assess and intervene for 2 of 3 residents reviewed, (Residents #3 and #8). The facility identified a census of 45 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 7/24/25 indicated Resident #3 had diagnosis that included Non-Traumatic Brain Dysfunction, Alzheimer's Disease, Non-Alzheimer's Dementia and a Retinal Vascular Occlusion. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (cognitively impaired), with delusions, ambulated with a walker, required supervision to touch assistance with transfers and ambulation and with two (2) falls since reentry to the facility on 2/25/25. A Care Plan included the following Focus and Interventions: a. I have impaired visual function related to (r/t) blindness in my right eye. b. The resident required assistance with activities of daily living (ADL's). 1. Ambulation - Supervision with assistance of one (1) staff member. c. At risk for falls.…

    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 · F2026-03-04 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff, and pharmacist interviews, and policy review the facility failed to store medications in the pharmacy labeled package for all residents on 2 of 8 days of the survey. The facility also failed to keep insulin pens in a locked container/cart/room and keep narcotic in a double locked container/cart/room. The facility reported a census of 44 residents. Findings include: An observation on 2/22/26 at 7:17 AM revealed the facility had two (2) medication carts (South cart and North cart) in the building that contained all residents oral daily medications. The South cart had 21 plastic cups with pill medications inside them and white paper cups with names written on them, in the top drawer of the cart. The North cart had 18 plastic plastic cups with medications inside them and white paper cups with names written on them, in the top drawer of the cart. There were also 6 insulin pens in an unlocked container sitting at the nurse's station pre-dialed up to dosages with insulin needles on. There were also 3 more insulin pens sitting in the same container not dialed up…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-04 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review the facility failed to make a good faith attempt and ensure effective quality assurance processes regarding significant medication errors when a deficient practice with F760, Residents are Free of Significant Medication Errors, was cited at the facility for 3 of 4 onsite surveys, which included the current survey, since 9/1/2024. The facility reported a census of 44 residents.Findings include: 1.Review of Form CMS-2567 (the official document produced after a state or federal inspection (survey) that included survey results) for the survey ending on 9/22/2024 documented the facility was cited for F760 relating to 1 of 3 residents received 6 medications that were not prescribed for him and was hospitalized overnight for observation. 2. Review of Form CMS-2567 for the survey ending on 11/14/2025 documented the facility was cited for F760 relating for 2 of 3 residents who had significant medication errors. One resident received 5 medications that were not prescribed to them and another resident continued to receive 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-04 · 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 observation, staff interviews, and policy review the facility failed to implement infection control measures when 6 of 6 morning insulins were stored together in a container (Resident #30, #14, #43, #19, #2, and #4). The facility also failed to provide Enhanced Barrier Precautions (EBP) as the Centers for Disease Control and Prevention (CDC) (an infection control strategy for nursing homes and long-term care facilities to reduce the spread of multidrug-resistant organisms, It involves using gowns and gloves during high-contact care for residents with wounds, indwelling devices, or known multi-drug resistant organism colonization) directs during wound care (Resident #37). The facility also failed complete routine glove change and hand hygiene during pressure ulcer care after cleaning the wound for 1 of 1 residents (Resident #37). The facility reported a census of 44 residents. Findings include: 1. An observation on 2/22/26 at 7:18 AM at the nurses station revealed 6 insulin pens were being stored with their lids off and touching in a plastic unlocked container with a blood…

    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 · D2026-03-04 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interviews and policy review the facility failed to provide informed consent regarding the risk and benefits for as needed psychotropic medications (medications that affect brain activity, influencing mood, thoughts, behavior, and perception to treat mental health conditions) for 1 of 3 residents reviewed for antipsychotic medications (Resident #7). The facility reported a census of 44 residents.Findings include: Review of Resident #7's Progress Notes written by his Doctor on 12/17/25 documented he continues to benefit from his medication ziprasidone (an antipsychotic given by a shot called an Intramuscular (IM) injection) and ABHR (ativan, benadryl, haldol, reglan) gel (a compounded gel medication that goes on the skin, containing Ativan/lorazepam (anti-anxiety medication), Benadryl/diphenhydramine (anti-histamine medication), Haldol/haloperidol (antipsychotic medication), and Reglan/metoclopramide (anti-dopaminergic) (a medication that blocks dopamine receptors, preventing dopamine from binding and reducing its activity)). Review of Resident #7…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review the facility failed to ensure non-pharmacological interventions were in place and anti-psychotics were used to treat relevant diagnoses and not a behavior (agitation) for 1 of 3 residents reviewed (Resident #38). The facility reported a census of 44 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #38 documented Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating no cognitive impairment. The MDS documented he admitted to the facility on [DATE] and had diagnoses of non-Alzheimer's dementia with other behavioral disturbances, anxiety, and unspecified depression. Per this assessment, the resident had no hallucinations, no delusions, no physical or verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed towards others, no rejection of care exhibited, and no wandering exhibited. Review of Resident #38's Medication Review Report signed by his Doctor on 1/28/26 indicated he had…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · 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 record review and staff interviews the facility failed to code 1 of 2 residents catheter (Resident #38), 1 of 1 resident pressure ulcer (Resident #37), and 1 of 2 residents Preadmission Screening and Resident Review (PASRR) outcome (Resident #8) on the Minimum Data Set (MDS) assessment to reflect their current status at the time of the MDS assessment. The facility reported a census of 44 residents. Findings include:1. Resident #38's Medication Review Report signed by his doctor on 1/28/26 revealed an active order to continue use a of his catheter that started on 8/15/25. The MDS assessment dated [DATE] for Resident #38 documented a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of obstructive uropathy (a blockage in the urinary tract that hinders urine flow, causing it to back up into the kidneys and leading to potential damage), and that he did not have a catheter. 2. Resident #37's Wound Evaluation, dated 12/2/25…

    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 before2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and resident and staff interviews the facility failed to provide care routine skin monitoring to cancerous lesions on the scalp and resident requested assessment/treatment for 1 of 3 residents reviewed for skin conditions (Resident #36). The facility also failed to maintain documentation that Neurological assessments (often called neuro checks) were performed after unwitnessed falls for 3 of 7 falls that indicated a need for neuro assessment monitoring (to detect serious, hidden brain injuries that might not be obvious right away, because bleeding or swelling in the brain can develop slowly over hours or even days, these tests are repeated to monitor for changes in a person's condition) for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews and policy review the facility failed to provide restorative programs as directed for 2 of 2 residents reviewed for restorative and develop/implement a restorative treatment policy for the facility to follow (Resident #36 and #7). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating moderate cognitive impairment. The MDS also revealed she needed supervision/touching assistance to walk 10 feet but could not walk greater than 50 feet due to medical condition or safety concerns and needed partial to moderate assistance by staff when she used her manual wheelchair for distance greater than 50 feet. The resident had impairment on one side to her upper and lower extremity that interfered with daily function or placed her at risk for injury. The MDS documented diagnoses of cancer, hypertension and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to complete a root cause analysis after each fall to ensure an intervention to prevent future falls was put in place, and failed to ensure the intervention was related to the reason the fall occurred for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility also failed to update the Care Plan timely related to falls for Resident #7. The facility reported a census of 44 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 8 out of 15, indicating severe cognitive impairment. The MDS documented he was dependent on staff for walking and moving to desired locations in his wheelchair and was frequently incontinent of urine and bowel. The MDS also documented diagnoses of seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances. Review of Resident #7's current Care Plan on 2/25/26 revealed…

    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 before2025-11-14 · 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 observation, facility video review, resident interview, staff interview and facility policy review, the facility failed to follow appropriate infection control practices during direct resident cares for 3 of 3 residents reviewed. (Resident #1, #3 and #4) The facility identified a census of 45 residents.Findings includeAn observation of the facilities video coverage dated 10/17/25 revealed Staff J, Licensed Practical Nurse (LPN) as she washed and gloved her hands prior to the removal of a supportive boot and wound dressing on the left foot/leg of Resident #4. The staff member then performed the prescribed physician treatment to the resident's upper left heel and the tips of her toes with the same gloved hands. Following completion of the treatment Staff J placed the non-used and/or prescribed treatment supplies in a plastic bag and placed the plastic bag back into the resident's treatment supply basin without sanitization of the surface areas. During an interview on 10/28/25 at 4:20 p.m. the Director of Nursing (DON) confirmed the above documented observation. Review 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2025-11-14 · 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, video footage review, clinical record review, staff interview and review of the facilities Resident [NAME] of Rights, the facility failed to maintain the dignity and respect during cares for 2 of 3 residents reviews. (Resident #3 and Resident #4). The facilities identified a census of 45 residents. Findings include: 1. Review of the video footage revealed the following: a. 8:26:17 p.m. - As Resident #3 sat positioned in a recliner chair in the dining/lounge area, Staff A, Licensed Practical Nurse (LPN) approached the resident, pulled out her sweat pants at the waist band area, placed her hands inside the sweat pants and palpated the resident's left hip area following a fall as another resident sat approximately12 feet right across from Resident #3 in direct view. Review of the facilities timeline of events provided from the video footage included the following: a. 7:49:40 p.m. - Staff A pressed on the resident's left hip area. b. 7:50:34 p.m. The nurse looked under the resident's pajama bottoms as if she looked for any bruising or injury and pressed on 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 · D2025-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview, family interview, hospital staff interview and facility policy review the facility failed to notify 1 of 3 resident family members/representatives which pertained to a condition change and/or medication error. (Resident #3) The facility identified a census of 42 residents. Findings include: A Progress Note entry identified as a late entry for the following event dated 10/17/25 at 7 p.m. included the following information: Resident #3 had been administered the medications for Resident #6 which consisted of Melatonin (hormone that regulated sleep) 3 milligrams (mgs), Mirtazapine (antidepressant) 15 mg, Alprazolam (antianxiety) 0.375 mgs and Apixaban (anticoagulant) 2.5 mg. Staff A, Licensed Practical Nurse (LPN) asked the emergency room (ED) Physician Assistant to have notified the family. The facility notified the family on 10.20.25 at 4:30 p.m. During an interview on 10/21/25 at 1:50 p.m. the resident's family indicated just prior to her fall the resident received four (4) wrong medications, Mirtazapine, Alprazolam, Melatonin 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-14 · 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 email and a Skin Quick Reference form, the facility staff failed to maintain complete and accurate Care Plans for 1 of 3 residents reviewed. (Resident #8) The facility identified a census of 45 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 9/22/25, (follow up to his 9/15/25 readmission to the facility) indicated Resident #8 had diagnosis that included Heart Failure (HF), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, altered mental status, adult failure to thrive and abnormal weight loss. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required partial/moderate assistance with toileting, personal hygiene and non-ambulatory. The assessment identified the resident without any skin issues and as not on a repositioning program. A Nursing - Admission/readmission Assessment form dated 9/15/25 at 12:39 p.m. indicated the resident as readmitted to the facility with a right trochanter blister and a scabbed area on his coccyx and no further…

    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 · D2025-11-14 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview and facility policy review the facility failed to answer resident call lights in a timely manner, within 15 minutes and provide enough staff to meet the individual needs of the residents for 2 of 2 residents reviewed. (Resident #2 and #4) The facility identified a census of 45 residents. Findings include: During an interview on 10/28/25 at 11:03 a.m. Resident #2 offered she felt the facility failed to staff the appropriate amount of staff to meet the individual needs of the residents. The resident indicated she timed her call light as on for 2 1/2 hours as she used the clock on the wall which caused her anger. The resident also offered recently staff left her in bed in the morning because it took 2-3 staff for transfers and the facility failed to provide enough staff to get her up for the day that morning which she wanted to do. During an interview on 10/28/25 at 1:06 p.m. Resident #4 confirmed she waited for an extended period of time for staff to have responded 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the facilities video footage review, clinical record review and staff interview the facility failed to assure 2 of 3 residents remained free of significant medication errors. (Resident #3 and #5)Findings include: The facilities Investigative Report form included the following timeline of events per their review of the video footage: a. 7:10:25 p.m. (camera time) - Staff B, Certified Medication Aide (CMA) administered the physician prescribed medications for Resident #3. b. 7:30:06 p.m. - The CMA wrongfully administered medications prescribed for Resident #6 to Resident #3. According to a computer generated form the CMA administered the following medications prescribed to Resident #3 on 10/17/25 at 6:21 p.m. a. Buspirone Hydrochloride (anti-anxiety) 5 milligram (mg) tablet. b. Acetaminophen (pain) 325 mg tablet. c. Alprazolam/Xanax (anti-anxiety) 0.25 mg tablet. d. Melatonin (sedative/hypnotics) 5 mg tablet. e. Pepcid (H2-receptor (decreases acid in the stomach) 20 mg tablet.According to a Medication Event - Wrong Medication form dated 10/17/25 at 7 p.m. Staff A, Licensed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview, a Licensed Practical Nurse (LPN) Job Description form and facility policy review, the facility failed to maintain complete and accurate resident records for 2 of 3 residents reviewed. (Resident #3 and #5) The facility identified a census of 45 residents.Findings include: A Progress Note entry identified an Incident Report as a (late entry) dated 10/17/25 at 7 p.m. included the following information: The resident sat in a recliner in the day room, stood up and immediately fell to the floor next to the recliner. The nurse witnessed the fall from across the room and observed her as she landed on her left side on the floor while the pressure alarm sounded. Staff assisted the resident to her feet and helped her back into the recliner. The resident complained of pain to her left leg with no deformity noted and no pain as the nurse palpated the upper leg. Vital signs included a blood pressure (B/P) of 156/80, Pulse (P) 83, Respirations (R) 20, Temperature (T) 97.2 degrees Fahrenheit (F) and an oxygen saturation rate (O2) of 95%. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-22 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff and resident interviews the facility failed to give 1 of 3 residents the correct medications and inadvertently gave him another residents medications that included anti-psychotic medication resulting in over sedation and admission to the hospital for observation (Resident #1). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/15/24 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented he did NOT take anti-psychotic medication and had no neurological diagnoses. The MDS also documented his psychiatric/mood disorder was depression. Record review of an emergency room (ER) note dated 9/18/24 for Resident #1 documented he received the following wrong medications at the facility: Zonisamide 100 milligrams (mg) - anti-convulsant Zofran 4 mg - anti-emetic Sucralfate 1 gram (g) - ant-acid Seroquel 200 mg - anti-psychotic Propranolol 20 mg - beta blocker Tylenol 1000 mg - analgesic The ER note also documented he was minimally arousal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-25 · 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, policy review, and staff interviews the facility failed to keep bare hands off the drinking surfaces of glasses in order to serve meals under sanitary conditions for 1 of 1 meals observed. The facility reported a census of 39 residents. Findings include: An observation of the noon meal on 4/22/24 from 11:05 AM to 11:42 AM revealed Staff A, Cook, served 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Staff A picked up the glass with one hand, poured juice or milk with the other hand, and set the glass back on the table to serve the resident. Staff A also pushed the beverage cart throughout the dining room with her bare hands. The cart handle was not observed to be sanitized throughout meal service. Staff A was not observed to perform hand hygiene during the meal service. In an interview on 4/24/24 at 12:01 PM Staff B, Dietary Manager explained the facility provided training on appropriate serving techniques upon hire. She explained she expected staff to touch silverware only by the handles, never the tines of silverware.…

    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

“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

$87,160 in federal fines across 1 penalty.

  • $87,160 — penalty dated 2026-03-04

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 LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.9-1.9 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA 3 of 5Clark ManorChicago, IL

Showing 40 of 88; lowest-rated first.

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

Who owns this facility

Investor-owned

CMS ownership filings flag an owner of this facility as a real-estate investment trust (REIT). That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.

  • CHAIM RAJCHENBACH DESCENDANTS TR UA 04282008 — REIT · 45.50% share · 5% Or Greater Indirect Ownership Interest

Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →

Owner / managerTypeRoleSince
SHABAT, MENACHEMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/15/2024
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BEASLEY, KARLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BEHOUNEK, LINSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BORCHERDING, JENNYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
BURKEN, SHERIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
FRIEDENBERG, LAURAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HEDBERG, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HENNAGER, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HEYING, LARINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
HOUSTON, MINDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
JAEGER, KRYSTLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
LARSON, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
LOVE-STEIBER, ANDREAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
MCCLURE, DOROTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
OTTERBECK, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
RAJCHENBACH, CHAIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
SHEAR, KILEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
VAN VEGHEL, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WIERSCHEM, BOBBIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
WIKAN, LOU ANNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2024
FRIEDMAN, BRIANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/11/2025
RAJCHENBACH, AVRUMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/11/2025
RAJCHENBACH, RIVKAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/11/2025
SHABAT, AHUVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/11/2025
CASCADE CAPITAL HOLDINGS LLCOrganizationADP OF THE SNFsince 08/15/2024
CASCADE CAPITAL PARTNERS LLCOrganizationADP OF THE SNFsince 08/15/2024
CCG GORGONA LLCOrganizationADP OF THE SNFsince 08/15/2024
GORGONA HOLDCO LLCOrganizationADP OF THE SNFsince 08/15/2024
GORGONA PROPCO HOLDINGS LLCOrganizationADP OF THE SNFsince 08/15/2024
GORGONA SUB HOLDCO LLCOrganizationADP OF THE SNFsince 08/15/2024
MN8 RH HOLDCO LLCOrganizationADP OF THE SNFsince 08/15/2024
WAUKON IA PROPERTY HOLDINGS, LLCOrganizationADP OF THE SNFsince 08/15/2024
SCHWARTZ, DAVIDIndividualADP OF THE SNFsince 03/10/2025

CMS files one row per role, so the 55 rows in the source record cover these 34 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

9 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.

$4.3M
Net patient revenuemost recent cost report
+11.7%
Operating marginrevenue minus expenses
$594K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 4%Other / private 39%

This home reported $594K paid to related parties — landlords or management companies under common ownership — equal to about 16% 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 2024. 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

$260per resident / day
operating cost
$7,900per month
≈ monthly operating cost
$294per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 165338. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, 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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