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Cedar Ridge Village

8950 Coachlight Drive, West Des Moines, IA 50266 · For profit - Corporation · 40 certified beds · (515) 369-2100 Medicare & Medicaid certified

Call the home — (515) 369-2100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0606) — cited Dec 2023
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0606), cited Dec 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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
  • nursing-staff turnover (56%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
180 Jordan Creek Pkwy #120 · (515) 224-5868 · Call to confirm hours
Pharmacy
375 S Jordan Creek Pkwy · (515) 216-2796 · Call to confirm hours
Grocery
9080 Mills Civic Pkwy · (515) 564-4946 · Call to confirm hours
Park
101-301 S 88th St · (515) 222-3444 · Typically dawn to dusk
Place of worship
33365 335th St · (515) 987-6090

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 3 of 5
Short-stay residentsrehab / post-hospital 5 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 improved from 3 to 4 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 rating4★
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 increased17.8%17.1%15.4%worse
Long-stay residents who lose too much weight2.2%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.5%0.9%better
Long-stay residents with a urinary tract infection1.7%2.4%2.0%better
Long-stay residents with depressive symptoms2.6%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 injury4.0%3.8%3.3%worse
Long-stay residents whose ability to walk worsened17.2%16.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication9.8%20.8%18.9%better
Long-stay residents given the seasonal flu vaccine97.0%95.3%95.3%typical
Long-stay residents with pressure ulcers4.7%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control36.9%25.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.5%19.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.1%1.4%better
Short-stay residents given the seasonal flu vaccine76.9%73.3%79.4%typical
Short-stay residents rehospitalized after admission15.7%20.9%22.6%better
Short-stay residents with an outpatient ER visit17.8%13.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.911.491.67worse
Long-stay outpatient ER visits per 1,000 resident days1.732.081.80typical

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.

56.1% 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 164 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.1%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
65.4%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 65.4% 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 52 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF56.1%CMS range 49.9–64.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.4–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.4%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 discharge73.1%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 discharge65.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge83.8%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 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 worsened4.9%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 hospitalization5.3%CMS range 2.8–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 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

1.31
RN hours/ resident / day
0.28
LPN hours/ resident / day
2.53
Aide hours/ resident / day
4.13
Total nurse hours/ resident / day
0.90
RN hoursweekends
56.5%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 38.8 residents a day — about 97% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.31 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.50 hrs/resident/day on weekends vs 4.38 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.48 to 0.90 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is well above the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-08-12)
2
at the previous standard inspection (2024-08-01)

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 10 most serious are shown; the remaining 10 are one tap away and print in full.

  • Potential for harm · D2025-08-12 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview, and facility policy review, the facility failed to provide the required beneficiary notifications to residents upon discharge for 1 of 3 residents sampled (Resident #50). The facility reported a census of 38. Findings include: The discharge Minimum Data Set (MDS) for Resident #50, completed 06/05/2025, documented the resident entered the facility on 05/20/2025 and discharged from the facility on 06/05/2025. An email from the Social Services coordinator, received on 08/05/2025 at 03:36 PM, contained the Beneficiary Notifications for two residents as requested by the surveyor, but did not contain the Beneficiary Notifications for Resident #50. In an interview on 08/05/2025 at 03:37 PM with the Social Services Coordinator, she stated she had been hired by the facility in June of 2025. When she was hired she was asked to begin auditing the work of her predecessor and discovered that for some residents, the Advanced Beneficiary Notification (ABN) and Notice of Medicare Non-Coverage (NOMNC), had not been provided to residents discharging…

    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 · Past Non-Compliance
  • Potential for harm · D2025-08-12 · 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 clinical record review, staff interviews, and policy review the facility failed to ensure staff documented non-pharmacological interventions attempted prior to the administration of anti-anxiety medication (AA) for one of five residents reviewed for unnecessary medications (Resident #35). The facility reported a census of 38 residents. Findings Include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 admitted to the facility on [DATE] and had diagnosis of anxiety disorder. The MDS revealed the resident took an antianxiety (AA) medication during the seven day look-back period. The MDS recorded the resident had no behaviors. The Care Plan revised 4/23/25 lacked information related to Resident #35 taking an AA medication and the non-pharmacological interventions used or attempted prior to administration of the AA medication. The Order Summary revealed clonazepam (an AA medication) 0.5 milligrams (mg) by mouth every 8 hours as needed (PRN) started on 6/27/25. The…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to ensure that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for 2 of 5 residents investigated for unnecessary medications (Resident #21 and #35). The facility reported a census of 38.Findings include:1. The Care Plan initiated on 7/15/24 lacked documentation indicating Resident #21 was on an antidepressant and directives for staff related to monitoring side effects of medication. The Physician’s Orders indicated that Resident #21 was started on Lexapro 10 milligram (mg) daily for depression on 7/9/25. During an interview on 8/7/25 at 12:18 PM, Minimum Data Set (MDS) coordinator stated she has worked at this facility in the MDS role since 1/27/25. States she updates care plans whenever any medication changes or assistive level of care changes, and with admission or discharges. Stated…

    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 · D2025-08-12 · 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, observations, resident interview, staff interviews, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention for one resident with Lower Extremity Edema ([NAME]) for 1 of 1 resident reviewed for edema (Resident #21) and 1 of 4 residents sampled for skin conditions (Resident #1). The facility reported a census of 38.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #21 had diagnoses of coronary artery disease, hypertension, heart failure, localized edema and acute respiratory failure with hypoxia. The Care Plan initiated on 7/15/24 lacked documentation of [NAME] hose use for [NAME]. The Electronic Health Record (EHR) indicated that Resident #21 is having significant weight gain and [NAME] despite elevation and compression hose. It further indicated that Resident #21 is wearing [NAME] hose daily from 6/30/25 through 7/28/25 despite being discontinued on 6/30/25. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-12 · 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 direct observation, clinical record review, staff interview, and facility policy review, the facility failed to follow care planned interventions to prevent and mitigate falls for 1 of 3 residents sampled (Resident #6). The facility reported a census of 38. Findings include: The Significant Change Minimum Data Set (MDS) for Resident #6, dated 07/21/2025, documented the residents Brief Interview for Mental Status score (BIMS) as 9, indicating moderately impaired cognition. It documented the following relevant diagnoses: Atrial Fibrillation (A fib), Cerebrovascular Accident (Stroke), displaced fracture of the neck of the right femur (broken femur), and senile degeneration of the brain (lost of cognitive ability due to age). It further documented her as dependent on staff for mobility and documented her as unable to walk. The significant change MDS, dated [DATE], documented the resident as ambulatory and only requiring supervision while ambulating. The Care Plan for Resident #6, last revised on 07/15/2025,…

    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 · D2025-08-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of two residents reviewed for respiratory care (Resident #21). The facility reported a census of 38 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #21 had diagnoses of coronary artery disease, hypertension, heart failure, localized edema and acute respiratory failure with hypoxia. The Care Plan initiated on 7/15/24 indicated that Resident #21 has altered cardiovascular status, difficulty breathing and altered respiratory status requiring oxygen at 2-3 liters via nasal cannula (NC) to keep oxygen saturation greater than 88%. The Physician's Orders included an order oxygen continuous at 2-3 liters via NC to keep oxygen saturation greater than 88%. Observations revealed the following:a. On 8/4/25 at 3:11 PM Resident #21 had her oxygen concentrator set at 1 1/2 liters via NC. b. On 8/5/25 at 9:09 AM…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-12 · 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 clinical record review, observations, staff interviews, and policy review, the facility failed to utilize enhanced barrier precautions (EBP's) and infection control practices for 1 of 4 residents sampled on EBP's (Resident #34). The facility also failed to ensure staff followed infection control practices to protect against cross-contamination and potential spread of infection for a resident on droplet precautions for 1 of 4 residents on droplet/contact precautions (Resident #4). The facility reported a census of 38 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had a diagnosis of obstructive uropathy. The MDS indicated the resident had an indwelling catheter. The Care Plan revised 6/30/25 revealed the resident had a catheter due to urinary retention. The Care Plan directed staff to use EBP’s per facility guidelines. During observation on 8/6/25 at 1:50 PM, Staff E, certified nursing assistant (CNA) stood in the bathroom as Resident #34 sat 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure potentially hazardous food items were stored separately; thawing meat was stored above other food items in the refrigerator. The facility reported a census of 40 residents. Findings include: Observation 7/29/24 at 11:10 AM in the main kitchen with the Dietary Manager (DM) present revealed the following: a. Open undated bag of approximately 25 pounds of planko crumbs b. Open undated bag of approximately 25 pounds of sugar c. Two opened undated boxes of approximately 24 ounces of pancake mix d. Open undated package of hard taco shells e. Open undated package of soft taco shells f. A tray of frozen meat on a middle shelf in the walk in refrigerator thawing, with pie placed under the shelf During an interview 7/29/24 at 11:20 AM, the DM stated an expectation that dry food be stored in sealed containers and open food sealed, labeled and dated. The DM further acknowledged thawing meat should have been placed separately…

    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 · D2024-08-01 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility policy review, the facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for 3 of 3 residents requiring a pureed diet. The facility reported a census of 40 residents. Findings include: During an observation on 7/31/24 at 11:00 AM, Staff A, Cook, began the process to puree chicken fried steak by placing four pieces of chicken fried steak into the robot coupe, adding an unmeasured amount of beef broth three times during the pureeing. Staff A placed the pureed meat into a metal container, unmeasured. Staff A stated the green scoop would be used to serve residents for the amount. Staff A acknowledged uncertainty as to how it was determined the green scoop was used to measure the amount to serve residents. Staff A advised not being trained on the puree process. Staff A then began the process to puree corn, placing an unmeasured amount of corn into the robot coupe and added thickener to the robot…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-11 · 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 interview, the facility failed to serve food under sanitary conditions by touching the prepared food with their bare hands and the eating surface of the plates during meal service. The facility reported a census of 31 residents. Findings include: 1. Observation on 12/5/23 starting at 9:02 AM, Staff I, Certified Nurse Aide, assisted a resident to eat. She picked up the resident's strip of bacon with her bare hand and gave the resident a bite of the bacon. Then with the same bare hand touched her mask, the table surface, and then proceeded to touch another resident's strip of bacon to provide that resident a bite. 2. During continuous observation on 12/6/23, starting at 12:12 PM - 12:42 PM, Staff J, Dietary Aide, without completing hand hygiene, she started the service of the lunch meal. During the service, Staff J used her bare hands, repeatedly touching the eating surface of several residents' plates with her thumb, touched her face mask, and touched the eating service of the plates. In addition, as Staff J leaned over to scoop food,…

    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
Show the remaining 10 citations
  • Potential for harm · D2023-12-11 · tag F0606 — failed to not employ staff found guilty of abuse — isolated
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    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 personnel file review, facility record review, facility policy review, and staff interview the facility failed to complete the background record check evaluation process for a new employee, prior to employment, for 1 of 5 staff reviewed (Staff K, Certified Nurse Aide CNA). The facility reported a census of 31 residents. Findings: The untitled and undated facility form documented the facility hired Staff K on 5/16/23. Staff K's Single Contact License & Background Check, submitted on 5/17/23 at 2:32 PM, instructed to initiate record check evaluation process by completing form [PHONE NUMBER] (additional information required to determine eligibility to work in the nursing home) and submitting to Department of Human Services for Child Abuse Registry. The facility's payroll record for Staff K, listed the first day she worked at the facility as 5/18/23 at 10:04 AM. The Background Check Process policy, dated 10/7/22, directed the facility as required to complete state and federal background checks on all…

    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 · D2023-12-11 · tag F0641 — isolated
    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 interview, and policy review the facility failed to complete an accurate assessment for a resident with a Preadmission Screening and Resident Review (PASRR) condition for one of one resident reviewed (Resident #12). Findings include: Resident #12's Minimum Data Set (MDS) assessment, dated 10/19/23, listed an admission date of 10/26/22. The MDS indicated that Resident #12 did not have a level II PASSR that indicated that she had a serious mental illness and/or intellectual disability or related condition. The MDS included diagnoses of schizophrenia and depression. The MDS reflected that Resident #12 did not take an antipsychotic medication. Resident #12's PASRR Level I Screen form dated 8/26/22, documented an exempted hospital discharge 30-day approval with diagnosis of schizoaffective. The form indicated Resident #12 had a serious mental health determined PASRR condition. Resident #12's November 2023 Medication Administration Records included an order with a start date of 3/16/23 for Invega (antipsychotic medication) 156 milligrams (mg) per…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview, and policy review the facility failed to refer a resident to the appropriate state-designated authority for a Level I Status Change Preadmission Screening and Resident Review (PASRR) evaluation and determination for a resident with a documented PASARR condition and an exempted hospital discharge 30-day approval for one of one resident reviewed (Resident #12). Findings include: Resident #12's Minimum Data Set (MDS) assessment, dated 10/19/23, listed an admission date of 10/26/22. The MDS indicated that Resident #12 did not have a level II PASRR that indicated that she had a serious mental illness and/or intellectual disability or related condition. The MDS included diagnoses of schizophrenia and depression. Resident #12's PASRR Level I Screen form dated 8/26/22, documented an exempted hospital discharge 30-day approval with diagnosis of schizoaffective. The form indicated Resident #12 had a serious mental health determined PASRR condition. The form directed that Resident #12 required a rescreening by or before the 30th day if expected…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and family interviews, clinical record review, policy review and staff interview, the facility failed to provide care plan conferences to enable resident/family participation in two (Resident ##17 and Resident #22) of two residents reviewed. Findings include: 1. Resident #17's Minimum data set (MDS) assessment dated [DATE] listed an admission date of 1/31/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment for decision-making. The MDS included diagnoses of Alzheimer's disease and depression. During an interview on 12/4/23 at 3:17 PM, Resident #17's wife stated she attended 1 care plan conference and spoke to management about another care conference. She still hadn't heard back from them about another care conference meeting. 2. Resident #22's MDS assessment dated [DATE] listed an admission date of 10/3/22. The MDS listed a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of anxiety disorder, hypertension…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-11 · 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 clinical record review, family interview, and staff interview, the facility failed to have a restorative program and provide restorative services for one (Resident ##17) of one resident reviewed. Findings include: 1. Resident #17's Minimum data set (MDS) assessment dated [DATE] listed an admission date of 1/31/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment for decision-making. Resident #17 required extensive assistance of two persons with bed mobility, transfers, and toilet use. In addition, he required limited assistance of one person with eating. The MDS included diagnoses of Alzheimer's disease and depression. Resident #17's Physical Therapy (PT) Discharge Summary signed 5/10/23, documented discharge reason of maximum potential achieved. The PT referred Resident #17 to the restorative nursing program (RNP). Resident #17's Restorative Recommendation, dated 5/10/23, listed a walking program 3-5 times a week, Sci Fit bike (a total…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-11 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance committee (QAA) was attended by the required members to include: 1) the Nursing Home Administer (NHA) or representative; 2) Director of Nursing (DON); 3) the Medical Director (MD) or representative; 4) the Infection Preventionist; and 5) two other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 31. Findings include: A facility document titled Quality Assurance Meeting Minutes, dated 7/27/23 lacked attendance signatures for the Executive Director (ED or NHA) and the DON. A facility document titled Quality Assurance Meeting Minutes, dated 8/17/23 lacked attendance signatures for the DON, the Infection Preventionist, and the MD. A facility document titled Quality Assurance Meeting Minutes, dated 9/28/23 lacked attendance signatures for the Infection Preventionist and the MD. On 12/4/23 at 10:55 AM, the Administrator and DON reported the DON as the facility's designated Infection Preventionist. On 12/7/23 at 12:15 PM,…

    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 · Dcited before2023-12-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, clinical record review, and policy review the facility failed to implement appropriate infection control practices to prevent cross contamination. In addition, the facility failed to perform on-going infection control surveillance. The facility reported a census of 31 residents. Findings include: On 12/5/23 at 7:40 AM, Staff A, Licensed Practical Nurse (LPN), explained that Resident #35 tested positive for COVID-19. The Nurse's Note dated 12/5/23 at 4:34 AM indicated that Resident #35 returned to the facility at 4:00 AM by ambulance. Resident #35 tested positive for COVID-19 and started transmission-based precautions. On 12/5/23 at 8:18 AM, observed Staff B, Certified Nurse Aide (CNA), not wearing a face mask while transporting a resident to the dining area. On 12/5/23 at 9:34 AM observed Personal Protective Equipment (PPE) outside of Resident #35's room with no precautions sign posted. On 12/5/23 at 10:55 AM, witnessed Staff C, Housekeeper, wearing an ear loop face mask below her nose. On 12/6/23 at 5:55 AM, observed Staff D, CNA, without 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
  • Potential for harm · D2023-12-11 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, staff interviews, and policy review the facility failed to designate a qualified Infection Preventionist responsible for the facility's Infection Control and Prevention program. The facility reported a census of 31 residents. Findings include: On 12/4/23 at 10:55 AM, the Administrator and Director of Nursing (DON) reported the DON as the facility's designated Infection Preventionist. On 12/7/23 at 12:15 PM, the Administrator and DON stated they did not have and could not locate the Infection Preventionist qualification certificate. A policy titled Infection Preventionist revised September 2022 indicated the Infection Preventionist obtained specialized Infection Prevention and Control (IPC) training beyond initial professional training or education prior to assuming the role. It also indicated the certificate of completion or equivalent document as evidence of training.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility policy review the facility failed to thoroughly investigate bruises and skin issues of unknown origin for 2 of 3 residents reviewed (Residents #2 and #3). Both residents had bruising and/or skin issues that lacked an explanation of cause or an investigation. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. Resident #2 required extensive assistance of two persons for transfers, dressing, and toilet use. The MDS included diagnoses of non-Alzheimer's dementia, and Parkinson's disease. The N Adv - Long Term Care Evaluation Note dated 5/23/23 at 10:33 AM indicated that Resident #2 had the following new skin issues: a. Skin Issue: #001: New scab to the right shin that measures 0.8 centimeters (cm) in length and 0.2 cm in width. The wound had no order or tunneling. b. Skin Issue: #002: New scattered scratches to Resident…

    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
  • No harm found · Bcited before2023-08-07 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have the required members at their quarterly Quality Assessment and Assurance (QA) Committee. The facility did not have the Medical Director in attendance at the June quarterly meeting. Findings include: The Quality Assurance Meeting attendance sheet for the meeting on 6/22/23 reflected that the Medical Director did not attend. In an email sent on 8/7/23 at 1:17 p.m., the Administrator indicated that they attached the QA sheets with the Medical Director signatures. The note listed that they need to review the June meeting minutes with him the coming Thursday due to him being on vacation during the time of the Quality Assurance and Performance Improvement (QAPI) meeting. The note continued indicating that they planned to talk with him about the minutes that week. The Quality Assessment and Performance Improvement Manual reviewed 3/28/23 under Guidelines for Governance and Leadership instructed that the department managers, the Administrator, the Director of Nursing, Infection Control Preventionist, Medical Director,…

    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

“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 PIVOTAL HEALTH CARE — 9 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 3 of 53.9-0.9 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 8 homes this chain runs (chain average 3.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
CADET INVESTMENT LLCOrganizationDIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTERESTsince 04/01/2021
CENTRAL IOWA HOSPITAL CORPORATIONOrganizationDIRECT OWNERSHIP INTERESTsince 04/01/2021
POKY - 5R LLCOrganizationDIRECT OWNERSHIP INTERESTsince 04/01/2021
SCENIC DEVELOPMENT LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
WSG LLCOrganizationDIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTERESTsince 04/01/2021
ANDERSON, JORDANIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
ANDERSON, MARLENEIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2021
ANDERSON, WAYNEIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2021
GULLEDGE, SCOTTIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
GULLEDGE, TRAVISIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
HOWARD, STEVENIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2021
WOOD, GILBERTIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
PIVOTAL HEALTH CARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
DEHAVEN, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2024
OCONNER, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2021
HEALTHCARE ACCOUNTING SERVICES, LLCOrganizationADP OF THE SNFsince 04/01/2021
IOWA PHYSICIANS CLINIC MEDICAL FOUNDATIONOrganizationADP OF THE SNFsince 04/05/2021
SUMMIT CARE, LLCOrganizationADP OF THE SNFsince 04/01/2021

CMS files one row per role, so the 30 rows in the source record cover these 18 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.

$7.4M
Net patient revenuemost recent cost report
-28.1%
Operating marginrevenue minus expenses
$319K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 2%Medicare 17%Other / private 81%

This home reported $319K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$833per resident / day
operating cost
$25,324per month
≈ monthly operating cost
$650per 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 165790. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-12, 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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