23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Carroll, IA
1-star overall rating with 1-star inspections with 23 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2241 North West Street, Carroll, IA
(712) 792-9284
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
65
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Accura Healthcare
Operator or chain grouping
Approved since
2002-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
8,126
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.27
Baseline 18.87% · Performance 20.84% · Measure score 1.27 · Achievement 1.27 · Improvement 0
Healthcare-associated infections
2.58
Baseline 6.83% · Performance 7.06% · Measure score 2.58 · Achievement 2.58 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.89
Baseline 4.18 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.81% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 14.29% · Lower 95% interval 7.67% |
| Discharge to community | 42.33% |
50.57%
8.2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 37.25% · Lower 95% interval 31.44% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 39 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 48.39% |
53.69%
5.3 pts worse
|
Numerator 15 · Denominator 31 |
| Discharge mobility score | 61.29% |
50.94%
10.4 pts better
|
Numerator 19 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 39 |
| Staff flu vaccination coverage | 20.69% |
42%
21.3 pts worse
|
Numerator 18 · Denominator 87 |
| Discharge function score | 70.97% |
56.45%
14.5 pts better
|
Numerator 22 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.78% |
25.2%
9.6 pts better
|
Numerator 8 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
94.0%
3.7 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 92.2% · Q3 88.9% · Q4 92.7% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
95.2%
2.2 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.7%
1 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.2% · Q4 7.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
4.0%
About the same
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 6.8% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
4.9%
1.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.5% · Q3 2.6% · Q4 3.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
20.6%
6 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 6.8% · Q3 18.4% · Q4 17.6% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.1% |
19.8%
7.3 pts worse
|
16.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 25.8% · Q3 28.6% · Q4 28.0% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.8% |
18.5%
0.7 pts better
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.8% · Q3 31.1% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.3%
1.4 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 19.0% · Q3 17.1% · Q4 20.0% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.7%
0.4 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 3.2% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.5%
0.3 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 7.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
26.0%
0.1 pts better
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 21.3% · Q3 32.1% · Q4 22.5% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.3%
1.9 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.7% · Q3 5.2% · Q4 11.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
84.3%
15.9 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.1% · Q2 50.0% · Q3 73.9% · Q4 85.3% · 4Q avg 68.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
13.1%
0.4 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.1% |
1.9%
4.2 pts worse
|
1.6%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.0% |
73.3%
29.3 pts worse
|
79.7%
35.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.3% |
21.3%
8 pts better
|
23.9%
10.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 12.5% · Expected 22.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-10
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-05-14
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-14
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-10
Fire Safety
Have an externally vented heating system.
Corrected 2024-05-14
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-10
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-06
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-17
Inspection history
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Not marked corrected
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-16
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-25
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-25
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-25
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-11
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-25
Health
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.
Corrected 2025-03-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-17
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-03-18
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-03-14
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-25
Health
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.
Corrected 2025-03-18
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-24
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-24
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-01-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-23
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-23
Health
Implement 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.
Corrected 2024-05-23
Health
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.
Corrected 2024-05-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-15
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-15
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-15
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-15
Health
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.
Corrected 2023-09-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-05
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-05
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-05
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-04
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-04
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-03-04
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-04
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-04
Penalties and ownership
Payment Denial · denial start 2025-04-08 · 3 days
3 day denial
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
Carroll, IA
1-star overall rating with 2-star inspections with $12,038 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Carroll, IA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Lake City, IA
1-star overall rating with 1-star inspections with $38,610 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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