Cycle 1
Health 2025-05-29 · Fire 2025-05-29
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Le Mars, IA
Accura Healthcare of Le Mars
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
954 7th Avenue SE, Le Mars, IA
(712) 546-7831
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Accura Healthcare
Operator or chain grouping
Approved since
1996-12-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.79
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.80
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
19%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
56
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
91.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0274
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Performance 23.91% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.27
Baseline 3.86 hours · Performance 5.43 hours · Measure score 8.27 · Achievement 8.27 · Improvement 7.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 75 |
| Staff flu vaccination coverage | 19.48% |
42%
22.5 pts worse
|
Numerator 15 · Denominator 77 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.7%
3.7 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
4.0%
1.3 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.6% · Q3 0.0% · Q4 2.8% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.9%
2.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.1% · Q3 9.1% · Q4 2.9% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
20.6%
6.4 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 16.7% · Q3 14.3% · Q4 17.6% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
19.8%
3 pts better
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.1% · Q3 18.8% · Q4 18.2% · 4Q avg 16.8% · 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 | 15.6% |
18.5%
2.9 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 23.7% · Q3 22.0% · Q4 7.1% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
18.3%
0.7 pts better
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 23.5% · Q3 26.5% · Q4 9.1% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.5%
0.1 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.4% · Q3 2.6% · Q4 2.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
26.0%
5.8 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 20.9% · Q3 31.7% · Q4 21.7% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.3%
2.7 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-05
F · Potential for more than minimal harm
2024-05-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-05-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-29
F · Potential for more than minimal harm
2023-03-15
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-29
F803 · Nutrition and Dietary Deficiencies
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 2025-06-04
D · Potential for more than minimal harm
2025-05-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
G · Actual harm
2024-05-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-31
G · Actual harm
2024-05-30
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-12-25
E · Potential for more than minimal harm
2024-05-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F803 · Nutrition and Dietary Deficiencies
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 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-17
D · Potential for more than minimal harm
2023-03-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
American Healthcare Associates Inc
5% Or Greater Direct Ownership Interest · Organization
Accura Healthcare
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Management Services LLC
Operational/Managerial Control · Organization
Leneave, Ted
5% Or Greater Indirect Ownership Interest · Individual
Leneave, Ted
Corporate Director · Individual
Leneave, Ted
Corporate Officer · Individual
Leneave, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Leneave, Thomas
Corporate Director · Individual
Leneave, Thomas
Corporate Officer · Individual
Toti, Lisa
Corporate Director · Individual
Toti, Lisa
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Lemars
Le Mars, IA
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Happy Siesta Health Care Center
Remsen, IA
3-star overall rating with 3-star inspections with $9,835 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Kingsley Specialty Care
Kingsley, IA
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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