Azria Health Rose Vista
1109 Normal Street, Woodbine, IA 51579 · For profit - Limited Liability company · 76 certified beds · (712) 647-2010 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.0% | 17.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.1% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.8% | 2.4% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.0% | 4.2% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 3.8% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.1% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.7% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.9% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.1% | 19.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 12.9% | 2.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.7% | 73.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.5% | 20.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.5% | 13.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.49 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.80 | 2.08 | 1.80 | worse |
‡ 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.
36.7% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.0% 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 35 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 36.7%CMS range 26.6–50.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.3–15.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 40.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 28.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 20.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 4.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.5–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 76 beds and averages 64.9 residents a day — about 85% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 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 3.11 hrs/resident/day on weekends vs 3.79 on weekdays — 18% thinner on weekends. RN hours go from 0.68 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-11-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, provider interview, staff interviews, record review and policy review, the facility failed to provide timely and adequate skin care to prevent worsening of pressure ulcers for 2 of 3 residents reviewed. Resident #6 developed a pressure injury on her heel and staff failed to call the doctor when there was a change in the wound. Resident #71 was admitted to the facility with an identified Moisture Associated Skin (MASD), and staff failed to get a doctor's order for treatments. The facility reported a census of 69 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or…
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.
- Potential for harm · E2025-11-20 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 facility document review, staff interviews and clinical record review the facility failed to establish and implement a restorative nursing program to help prevent residents from decline for residents discharged from Physical Therapy/Occupational Therapy (PT/OT) services. The facility reported a census of 69 residents.Findings include: According to the Beneficiary Notice-Residents discharged within the Last Six Months, the facility had 25 resident that were discharged from a Medicare covered Part A stay and remained in the facility. The Minimum Data Set (MDS) dated [DATE], showed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8 (severe cognitive deficit.) He required partial assistance with hygiene, dressing, sit to stand and transfers. The Care Plan for Resident #39, updated on 9/21/25, showed that Resident #39 had unwitnessed falls on 4/4/25, 6/24/25 and 9/21/25. Resident #39 was at risk for injury related to weakness, balance problems medications and neurodegenerative…
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.
- Potential for harm · E2025-11-20 · tag F0725 — failed to have enough nursing staff — patternProvide 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 Electronic Health Record (EHR) review, document review, resident interview, staff interview and policy review, the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #8, #12, #20 and #38). The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 11/17/25 at 3:48 PM Resident #12 stated the facility had added several residents to the census recently and the facility could use more staff. Resident #12 stated usually at least once a week it takes longer to answer the call light than 15 minutes. 2. The MDS dated [DATE] documented Resident #20 had a BIMS of 15 indicating no cognitive impairment. On 11/17/25 at 11:42 AM Resident #20 said it takes longer than 15 minutes to get help when she turns the call light on.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-20 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 4 of 4 residents with a pureed diet (Resident #6, #13, #26, and #52) reviewed and also all the residents that ate the lunch meal on 11/19/25. The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia oropharyngeal phase. Review of Resident #6's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 10/22/25.2. The MDS dated [DATE] documented Resident #13 had a BIMS of 1 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia following cerebrovascular disease. Review of Resident #13's EHR titled, Orders documented a physician's order for a general diet with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, and staff interviews the facility failed to notify the resident's representative / family / Power of Attorney (POA) and the resident's primary care physician of a stage 2 pressure ulcer for 1 of 3 residents (Residents #1) reviewed. The facility reported a census of 69 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of Resident #1's Electronic Health Record (EHR) titled, Orders documented a physician's order to cleanse pressure ulcer to coccyx with saline and 4x4, apply xeroform to wound bed only and cover with Opti foam started 11/4/25.Review of Resident #1's EHR titled, Progress Notes at 2:00 AM on 10/31/25 Staff H, Licensed Practical Nurse (LPN) titled, Progress Notes documented Resident #1 had complaints of sacral pain. The area was documented as red but blanching. Directly over Resident #1's tailbone was an open…
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.
- Potential for harm · D2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interviews, clinical record review and policy review, the facility failed to implement the established interventions to prevent falls for 2 of 3 residents reviewed. Residents #39 and #1 had frequent falls and interventions included gripper strips on the floor to prevent slipping. Observations revealed that the staff failed to apply the safety strips. The facility reported a census of 69 residents. Findings include:1) The Minimum Data Set (MDS) dated [DATE], showed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8 (severe cognitive deficit.) He required partial assistance with hygiene, dressing, sit to stand and transfers. The Care Plan for Resident #39, updated on 9/21/25, showed that Resident #39 had unwitnessed falls on 4/4/25, 6/24/25 and 9/21/25. The intervention for the fall 6/24/25, was to have nonskid strips applied on the floor near the bed. Resident #39 was at risk for injury related to weakness, balance problems medications 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.
- Potential for harm · D2025-11-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, Electronic Health Records (EHR), document review, staff interview and policy review the facility failed to maintain medical records on a resident that were complete and accurate by failing to document a pressure ulcer in the EHR appropriately for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 69 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of Resident #1's EHR at 2:00 AM on 10/31/25 Staff H, Licensed Practical Nurse (LPN) titled, Progress Notes documented Resident #1 had complaints of sacral pain. The area was documented as red but blanching. Directly over Resident #1's tailbone was an open area with white tissue. Review of Resident #1's EHR titled, Progress Notes documented an inaccurate description of wound on 10/28/25, 10/24/25, 10/23/25, 10/21/25 with description of stage 2 pressure that was found on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, observation, staff interview, and policy review the facility failed to properly use universal infection control measures (hand hygiene and proper glove use) while completing peri cares and catheter cares for 1 of 3 residents (Resident #32) reviewed. The facility further failed to properly wear personal protective equipment (PPE) while completing personal cares for a resident with Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #1). The facility reported a census of 69 residents.Findings include: 1. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of progressive neurological conditions, obstructive uropathy, paraplegia, and Multiple Sclerosis. Review of Resident #32's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for a 16 french (fr) 10cc foley catheter to be changed every 30 days on day shift dated 11/14/25. This page further revealed an order for catheter cares to be completed every…
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.
- Potential for harm · Ecited before2024-11-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portion of fried rice for 13 of 15 residents who received carbohydrate controlled or consistent carbohydrate diets. The facility reported a census of 49 residents. Findings include: On 11/05/24 at 11:57 AM, Staff A, cook, identified the following lunch menu items and corresponding serving size scoop size: a) Sweet & Sour chicken - 6-ounce (oz) scoop b) Oriental vegetables - 4 oz scoop c) Fried rice - 4 oz scoop A review of the Diet Type Report indicated 15 residents were ordered carbohydrate controlled/consistent carbohydrate diets. On 11/05/24 beginning at 12:09 pm, a continuous lunch service observation revealed 13 residents with Carbohydrate Controlled/Consistent Carbohydrate (CCHO) diets were served 4-ounce (oz) servings of fried rice instead of 2 2/3 oz servings as ordered. Four (4) of the residents with CCHO diets received full 3 x 2.5 servings of mandarin orange cake…
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.
- Potential for harm · E2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food. The facility reported a census of 49 residents. Findings include: On 11/04/24 at 9:45 AM, a kitchen observation identified the following findings: 1. Three (3) unlabeled plastic containers with cereal-like contents on a kitchen counter. Two (2) were not dated. 2. An unlabeled bowl of macaroni-like substance in an Arctic Air refrigerator. 3. An undated, unlabeled bag of hamburger bun-like items in the dry goods storage area. 4. An unlabeled bag of hot dog bun-like items. 5. A rack of trays with multiple undated & unlabeled plates of yellow, pie-like items in the Norlake walk-in refrigerator. 6. A tube of undated & unlabeled ground beef-like meat in the Norlake walk-in refrigerator. 7. Seven (7) trays of multiple bowls of undated, unlabeled, and uncovered salad-like substance. The bowls' contents were in direct contact with the bottom surface of the tray placed directly on them. 8. A bag of unlabeled and undated waffle-like items in 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.
- Potential for harm · Dcited before2024-11-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview and resident interview, the facility failed to follow physician's positioning orders for 1 of 1 resident's (#16) reviewed. The facility reported a census of 49 residents. Findings Include: On 11/04/24 at 10:51 AM, Resident #16 was observed lying supine (flat on the back) in bed. A sign was observed at the head of her bed that directed staff to keep the head of her bed elevated above a 30-degree angle at all times. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, Non-Alzheimer's dementia, dysphagia (difficulty swallowing), Gastro-Esophageal Reflux Disease (GERD), and Calculus of Gallbladder (gallstones). It indicated the resident was dependent with all aspects of Activities of Daily Living (ADL's). The Electronic Health Record (EHR) included a physician order dated 7/19/22 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.
Show the remaining 11 citations
- Potential for harm · Dcited before2024-11-07 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 provide appropriate catheter and peri-care to prevent the development of communicable disease and infection for 2 of 2 residents (#16 & #27) reviewed. The facility reported a census of 49 residents. Findings include: 1. On 11/04/24 at 3:16 pm, Resident #16 was observed with an indwelling catheter. The Minimum Data Set (MDS) assessment for Resident #16 dated 9/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderately impaired cognition. It included diagnoses of heart failure, peripheral vascular disease, Non-Alzheimer's dementia, Stage 4 Chronic Kidney Disease, and neurogenic bladder (condition that affects bladder control due to damage to the brain, spinal cord, or nerve). The MDS indicated Resident #16 required setup assistance with eating, was dependent with toileting hygiene, required moderate assistance with personal hygiene. It indicated the resident had an indwelling catheter. The Care Plan revised 7/26/24 revealed the 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.
- Potential for harm · D2024-05-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, family interview, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not completing an x-ray ordered by a physician in a timely manner for 1 of 3 (Resident #1) residents reviewed. The facility reported a census of 45 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #1, dated 4/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS further revealed Resident #1 totally dependent on staff for assistance with sitting to lying, sitting to standing, the ability to transfer to or from bed to chair, and transferring to the toilet. Review of the Progress Notes for Resident #1 documented the following: On 5/1/24 at 10:30 PM Resident #1 found in the sitting position facing her bed on the floor. Range of motion per Resident #1's normal per progress notes. Neurological assessments initiated and hospice services, the Director of Nursing (DON), and primary care physician notified. On 5/2/24 at 12:18…
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.
- Potential for harm · Dcited before2024-03-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, family interview and policy review the facility failed to notify the Power of Attorney (POA) with resident medication changes for 1 of 3 residents (Residents #4) reviewed. The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The BIMS documented Resident #4 frequently incontinent of urine and always incontinent of bowel. The Progress Notes dated 3/21/24 at 10:14 PM documented new orders for a tapered dose of Quetiapine. The notes lacked documentation of family notification. Review of Resident #4's medication administration record (MAR) documented Quetiapine 100 mg give 1 tablet by mouth and Quetiapine 25 mg give 1.5 tablets by mouth. Both medications ordered 3/21/24 and started 3/22/24. On 3/26/24 at 9:50 AM Resident #4's family member, power of attorney (POA) stated the facility is supposed…
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.
- Potential for harm · D2024-03-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 facility policy review, the facility failed to obtain consent from the Power of Attorney (POA) to start a psychotropic medication for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The Progress Notes dated 1/3/24 at 11:56 AM documented the facility received a new order for Rexulti 0.5mg every day for one week and then increase the medication to 1 mg daily if family consents. Nurse called the family member and explained this. Family member stated she would speak with her family and get back to the facility. Order faxed, hold this if the pharmacy does deliver tonight until we receive the okay from the family member. Review of document titled, Fax Cover Sheet with date of 1/3/24 documented physicians response to fax to start Resident #1 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 observations, policy review, resident interview, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care for 2 of 3 residents reviewed (Resident #2 and #4). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS documented Resident #2 always incontinent of urine and bowel. On 3/25/24 at 1:45 PM observed Staff A, Certified Nurses Assistant (CNA) and Staff B, CNA complete hand hygiene and apply gloves. Staff B provided personal care to Resident #2 and then removed her gloves. She did not perform hand hygiene and no gloves applied. Staff B turned Resident #2 over to his left side and applied a clean brief. Staff B provided assistance to Resident #2 when turning to his right side. Staff B unrolled the brief, pulled the front of the brief up and completed 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.
- Potential for harm · E2023-09-28 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observations, staff interview, and policy review the facility failed to treat residents with dignity while providing assistance with meals. The facility reported a census of 49 residents. Findings include: During continuous observation of lunch service on 9/25/23 from 12:20 through 12:40 PM observed two staff standing over residents while feeding them. During continuous observation of lunch service on 9/26/23 from 12:20 PM through 1:00 PM observed Staff B Certified Nursing Assistant (CNA) standing and assisting a resident to eat. Staff B then moved and stood between two residents and assisted both residents to eat. During continuous observation on 9/26/23 of lunch service, at 12:37 PM observed Staff C CNA standing between two residents assisting to dine. During an interview on 9/26/23 at 3:27 PM with the Administrator revealed her expectations are for staff to sit while feeding residents. Review of the facility provided policy titled, Assistance with Meals with a revision date of 3/2022 documented: Residents who cannot feed themselves will be fed with attention to safety,…
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.
- Potential for harm · D2023-09-28 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, facility record review, facility policy review, and staff interview the facility failed to complete a back-ground check for a new employee, prior to employment, for 1 of 5 staff reviewed. The facility reported a census of 49 residents. Findings Include: Facility New Employee Data form documented the facility hired Staff D, Registered Nurse on 4/28/23. Single Contact License & Background Check for Staff D, documented completion on 5/1/23 at 8:17 AM. Facility payroll record for Staff D, revealed Staff D worked 4/29/23 at 1:45 PM - 6:30 PM and 4/30/23 at 11:45 AM - 6:30 PM. Facility policy Background Check Investigations, revised 3/2019, documented background and criminal checks are initiated with offer of employment or contract agreement, and completed prior to employment. Interview on 9/27/23 at 3:16 PM, the Business Office Manager confirmed Staff D worked 2 days prior to Staff D's background check being completed and stated the background check should have been completed prior to Staff D being allowed to work. Interview on 9/27/23 at 3:20 PM, 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.
- Potential for harm · D2023-09-28 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of three residents reviewed (Resident #20). The facility reported a census of 49 residents. Findings include: The Minimum Data Set assessment for Resident #20, dated 7/12/23, included diagnoses of anxiety disorder, depression, and psychotic disorder. Review of Resident #20's PASARR Level I Screen form dated 12/17/20, documented anxiety disorder and dementia only. Review of Resident #20's Medication Administration Records dated 9/1/23 - 9/30/23, documented the resident received Sertraline (antidepressant medication) 37.5 milligrams daily related to major depressive disorder. Review of Resident #20's medical diagnosis sheet revealed diagnoses of unspecified psychosis not due to a substance or known physiological condition starting 7/9/21,during facility stay, and major depressive disorder,…
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.
- Potential for harm · D2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interviews, and policy review the facility failed to provide a comprehensive care plan related to edema for a resident with an order for a diuretic with a diagnosis of localized edema for 1 of 1 residents reviewed (Resident #47). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #47 dated 7/1/23 revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. The MDS further revealed Resident #47 re-entered the facility 6/26/23. Review of the Electronic Health Record (EHR) page titled Clinical Physician Orders revealed an order for Furosemide 40 mg tab take one tablet by mouth daily for a related diagnosis of localized edema (swelling). Review of the Care Plan dated 7/7/23 for Resident #47 revealed no comprehensive care plan for diuretic use or edema. During an interview 9/26/23 at 3:08 PM with the MDS Coordinator revealed her expectations are to update the care plans when there are changes with the residents status. During an…
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.
- Potential for harm · Dcited before2023-09-28 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 follow a physician order for 1 of 8 residents reviewed (Resident #44). The resident was found to have audible wheezes in her breathing and the doctor prescribed a steroid medication. The order did not get entered into the electronic chart or get administered. The facility reported a census of 49 residents. Findings include According to the Minimum Data Set (MDS) dated [DATE], Resident #44 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating moderate cognitive deficits. The MDS documented the resident required extensive assistance with the help of 2 staff for bed mobility, dressing and hygiene. The Care Plan updated on 6/12/23 documented Resident #44 had cognitive impairment, and dementia and was admitted to Hospice services for end of life care on 1/16/23. The resident was on a house supplement for wound healing, staff were directed to monitor for signs and symptoms of respiratory distress and 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.
- Potential for harm · D2023-09-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview the facility failed to ensure that residents were offered nutritional supplements when meal consumption had decreased for Resident #1. The resident had a decline in health that included significant weight loss and the dietician recommended a supplement as needed. The supplement was not used. The facility reported a census of 49 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicating severe cognitive deficit. The MDS documented the resident required extensive assistance with help of 2 staff for dressing, toileting and hygiene, and extensive assistance with the help of 1 staff for eating. The Care Plan updated on 8/31/23, showed that Resident #1 had cognitive impairment related to dementia due to head trauma and staff were to encourage fluids. On 1/17/23, the resident was started on hospice services. The following was discovered in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AZRIA HEALTH — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.9 | +1.1 vs chain |
| Quality measures | 1 of 5 | 1.8 | -0.8 vs chain |
The other 8 homes this chain runs (chain average 1.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOVETAIL OPCO HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2021 |
| AZRIA VENTURES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2021 |
| HORNUNG, STEVEN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 04/01/2021 |
| KAMINER, AARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 04/01/2021 |
| BEHRENDT, KARA | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2021 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $218K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 165357. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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.