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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D35 | E34 | F26 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 26, 2026 | Health | Health Complaint | 14 | Actual harm | 14 | Open → |
| Jun 4, 2026 | Health | Health Complaint | 7 | Potential harm | — | Open → |
| Feb 12, 2026 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Feb 12, 2026 | Health | Health Complaint, Health Standard | 7 | Potential harm | — | Open → |
| Oct 14, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jun 19, 2025 | Health | Health Complaint | 6 | Actual harm | — | Open → |
| Feb 20, 2025 | Fire safety | Fire Safety Standard | 15 | Potential harm | — | Open → |
| Feb 20, 2025 | Health | Health Complaint, Health Standard | 17 | Potential harm | — | Open → |
| Nov 26, 2024 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Aug 2, 2024 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Jun 25, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 21, 2024 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Mar 21, 2024 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Aug 2, 2024 | Civil money penalty (fine) | $51,773 | — | 165217|Fine|79466 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D35 | E34 | F26 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 26, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Anew Holdings Iowa LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Nov 1, 2022 |
| Mark Hastings | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Nov 1, 2022 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Anew Holdings Iowa LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Nov 1, 2022 |
| Mark Hastings | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Nov 1, 2022 |
| Michael Flanagan | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Aug 12, 2024 |
| Cornerstone Services LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2026 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Exira Care Center 411 South Carthage, Exira, IA 50076 CCN 165412 | 19.1 km | 60 | May 6, 2026 | 271 IJ | $23k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 165217 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 165217 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Complaint |
| Aug 26, 2026 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Sep 8, 2026 | Complaint |
| Aug 26, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Aug 26, 2026 | F-0926 | Have policies on smoking. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Plan of correction, not yet verified Sep 22, 2026 | Complaint |
| Jun 4, 2026 | F-0567 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0803 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jun 28, 2026 | Complaint |
| Jun 4, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 28, 2026 | Complaint |
| Feb 12, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 9, 2026 |
| Feb 12, 2026 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 12, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 12, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 12, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 13, 2026 | Complaint |
| Feb 12, 2026 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 12, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 12, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Oct 14, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 4, 2025 | Complaint |
| Oct 14, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 4, 2025 | Complaint |
| Oct 14, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Dec 4, 2025 | Complaint |
| Jun 19, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jul 2, 2025 | Complaint |
| Jun 19, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 2, 2025 | Complaint |
| Jun 19, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 2, 2025 | Complaint |
| Jun 19, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Jun 19, 2025 | Complaint |
| Jun 19, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 2, 2025 | Complaint |
| Jun 19, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 2, 2025 | Complaint |
| Feb 20, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 18, 2025 |
| Feb 20, 2025 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 18, 2025 |
| Feb 20, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 19, 2025 |
| Feb 20, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 18, 2025 |
| Feb 20, 2025 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 13, 2025 |
| Feb 20, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 13, 2025 |
| Feb 20, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 17, 2025 |
| Feb 20, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Feb 20, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 28, 2025 |
| Feb 20, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 28, 2025 |
| Feb 20, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 4, 2025 |
| Feb 20, 2025 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Mar 24, 2025 |
| Feb 20, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 27, 2025 |
| Feb 20, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 4, 2025 | Complaint |
| Feb 20, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 4, 2025 | Complaint |
| Feb 20, 2025 | F-0606 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0836 | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Feb 20, 2025 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 4, 2025 |
| Nov 26, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 20, 2024 | Complaint |
| Nov 26, 2024 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 20, 2024 | Complaint |
| Nov 26, 2024 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 20, 2024 | Complaint |
| Nov 26, 2024 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 20, 2024 | Complaint |
| Aug 2, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Aug 23, 2024 | Complaint |
| Aug 2, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Aug 23, 2024 | Complaint |
| Aug 2, 2024 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 23, 2024 | Complaint |
| Jun 25, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 12, 2024 | Complaint |
| Jun 25, 2024 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jul 12, 2024 | Complaint |
| Mar 21, 2024 | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 1, 2024 |
| Mar 21, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 26, 2024 |
| Mar 21, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 10, 2024 |
| Mar 21, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 10, 2024 |
| Mar 21, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 10, 2024 |
| Mar 21, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 10, 2024 |
| Mar 21, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 26, 2024 |
| Mar 21, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 1, 2024 |
| Mar 21, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 10, 2024 |
| Mar 21, 2024 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 10, 2024 |
| Mar 21, 2024 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 10, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.73 (case-mix index 1.18).
| Michael Flanagan | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 12, 2024 |
| Daniel Miller | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2025 |
| Rebecca Peterson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 16, 2026 |
| Tracy Thoren | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 25, 2025 |
| Mark Hastings | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 1, 2022 |
| 1000 Hillcrest Drive Propco LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Nov 1, 2022 |
| Cornerstone Services LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2026 |
| Michael Flanagan | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 12, 2024 |
| Daniel Miller | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 1, 2025 |
| Rebecca Peterson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 16, 2026 |
| Tracy Thoren | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 25, 2025 |