Cycle 1
Health 2024-12-17 · Fire 2024-12-17
31 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
32 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Perry, IA
Aspire of Perry
2-star overall rating with 1-star inspections with Special Focus status with $116,271 in total fines with 31 recent health deficiencies with 32 fire-safety deficiencies in the latest cycle
2625 Iowa Street, Perry, IA
(515) 465-5349
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Beacon Health Management
Operator or chain grouping
Approved since
2000-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 1 overall / 2 health / 2 staffing / 2 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
Hours and turnover
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
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
1.24
Baseline 78.26% · Performance 68.97% · Measure score 1.24 · Achievement 0 · Improvement 1.24
Adjusted total nurse staffing
0
Baseline 3.18 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 12 · 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 2 · 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 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · 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 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 41 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 10 · Denominator 40 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
94.0%
11.5 pts worse
|
93.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.6% · Q2 75.0% · Q3 88.5% · Q4 100.0% · 4Q avg 82.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
95.2%
1.1 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| 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 | 1.7% |
4.0%
2.3 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.7% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
4.9%
0.7 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.2% · Q3 0.0% · Q4 4.3% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
20.6%
6.2 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 24.0% · Q3 26.1% · Q4 34.8% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 56.2% |
19.8%
36.4 pts worse
|
16.7%
39.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 56.2% · 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 | 15.5% |
18.5%
3 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
18.3%
3.2 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.0% · Q3 17.4% · Q4 30.4% · 4Q avg 15.1% · 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 | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 29.2% |
26.0%
3.2 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 17.7% · Q3 37.3% · Q4 27.1% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.3%
4.3 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
84.3%
2.5 pts worse
|
81.7%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 81.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
45 health deficiencies
Top issue: Resident Rights (9 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-23
F · Potential for more than minimal harm
2024-12-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-12-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-12-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-11
F · Potential for more than minimal harm
2024-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-17
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 2024-12-18
E · Potential for more than minimal harm
2024-12-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-09-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K321 · Smoke Deficiencies
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 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-09-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-09-07
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 2023-09-20
E · Potential for more than minimal harm
2023-09-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-20
F · Potential for more than minimal harm
2022-06-23
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-30
F · Potential for more than minimal harm
2022-06-23
K321 · Smoke Deficiencies
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 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-06-30
F · Potential for more than minimal harm
2022-06-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-08-23
F · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-20
F · Potential for more than minimal harm
2022-06-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-23
E · Potential for more than minimal harm
2022-06-23
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-08-23
E · Potential for more than minimal harm
2022-06-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-06-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-21
D · Potential for more than minimal harm
2022-06-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-06-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-10-15
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 2025-12-10
J · Immediate jeopardy
2025-06-03
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 2025-07-08
E · Potential for more than minimal harm
2025-06-03
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 2025-07-08
E · Potential for more than minimal harm
2025-06-03
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 2025-07-08
E · Potential for more than minimal harm
2025-02-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-12-17
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-17
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F584 · Resident Rights Deficiencies
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 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-17
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 2025-01-16
E · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
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 2025-01-16
D · Potential for more than minimal harm
2024-12-17
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 2025-01-16
D · Potential for more than minimal harm
2024-12-17
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 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F758 · Pharmacy Service Deficiencies
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 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F761 · Pharmacy Service Deficiencies
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 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-01-16
C · Minimal harm
2024-12-17
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-01-16
C · Minimal harm
2024-12-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-01-16
C · Minimal harm
2024-12-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-11-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-04
G · Actual harm
2024-10-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-10
F725 · Nursing and Physician Services Deficiencies
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 2024-11-08
F · Potential for more than minimal harm
2024-10-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-10
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
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 2024-11-08
D · Potential for more than minimal harm
2024-10-10
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 2024-11-08
D · Potential for more than minimal harm
2024-10-10
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 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-04
F725 · Nursing and Physician Services Deficiencies
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 2024-11-08
D · Potential for more than minimal harm
2024-09-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-05-09
F584 · Resident Rights Deficiencies
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 2024-06-10
E · Potential for more than minimal harm
2024-05-09
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-05-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-09
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 2024-06-10
J · Immediate jeopardy
2024-03-27
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 2024-04-09
D · Potential for more than minimal harm
2024-03-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-23
E · Potential for more than minimal harm
2023-09-07
F584 · Resident Rights Deficiencies
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 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F725 · Nursing and Physician Services Deficiencies
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 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F801 · Nutrition and Dietary Deficiencies
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 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-07
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F625 · Resident Rights Deficiencies
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 2023-10-18
D · Potential for more than minimal harm
2023-09-07
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 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
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 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
F947 · Nursing and Physician Services Deficiencies
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 2023-10-18
E · Potential for more than minimal harm
2022-06-23
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 2022-08-04
E · Potential for more than minimal harm
2022-06-23
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 2022-08-04
E · Potential for more than minimal harm
2022-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F625 · Resident Rights Deficiencies
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 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
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 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-06-23
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 2022-08-04
D · Potential for more than minimal harm
2022-06-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-08-04
Penalties and ownership
What sits behind the stars
$51,279
2025-06-03
Fine
Fine · fine $51,279
Fine
$0
2025-06-03
Payment Denial
Payment Denial · denial start 2025-06-26 · 12 days
12 day denial
$56,802
2024-10-10
Fine
Fine · fine $56,802
Fine
$0
2024-09-04
Payment Denial
Payment Denial · denial start 2024-11-07 · 1 days
1 day denial
$8,190
2024-03-27
Fine
Fine · fine $8,190
Fine
$0
2024-03-27
Payment Denial
Payment Denial · denial start 2024-04-24 · 47 days
47 day denial
Ownership
Black Hawk Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Wertheim, Bruce
5% Or Greater Indirect Ownership Interest · Individual
Beacon Health Management LLC
Operational/Managerial Control · Organization
Pulica, Patrice
W-2 Managing Employee · Individual
Wertheim, Bruce
Corporate Officer · Individual
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#3
Spurgeon Manor
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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