Winterset, IA

Azria Health Winterset

2-star overall rating with 2-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1015 West Summit, Winterset, IA

(515) 462-1711

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Azria Health

Operator or chain grouping

Approved since

1993-08-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 1 overall / 2 health / 3 staffing / 2 quality stars

Changed ownership

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

0.47

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.68

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.39

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

3.54

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.15

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

3.18

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.56

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,173

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9846

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

3.60

Baseline 67.44% · Performance 50.00% · Measure score 3.60 · Achievement 3.35 · Improvement 3.60

Adjusted total nurse staffing

1.92

Baseline 3.72 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.47%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 6.62%
Discharge to community	53.99%	50.57% 3.4 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 55.17% · Lower 95% interval 40.5%
Medicare spending per beneficiary	1.04	1.02 About the same
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 9 · 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 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	12.15%	8.2% 4 pts better	Numerator 13 · Denominator 107
Staff flu vaccination coverage	46.72%	42% 4.7 pts better	Numerator 57 · Denominator 122
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · 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 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 3 · 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	1.6	1.5 0.1 pts worse	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 0.8 · Expected 0.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.7	2.1 1.6 pts worse	1.8 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 2.3 · Expected 1.0 · Used in QM five-star
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	94.0%	95.2% 1.2 pts worse	95.5% 1.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.1%	3.7% 2.6 pts better	3.3% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	4.0% 2.4 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 4.3% · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	3.1%	4.9% 1.8 pts better	5.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.5% · Q3 2.7% · Q4 2.6% · 4Q avg 3.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.4%	20.6% 3.2 pts better	19.6% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 20.0% · Q3 20.5% · Q4 15.4% · 4Q avg 17.4%
Percentage of long-stay residents who received an antipsychotic medication	14.3%	19.8% 5.5 pts better	16.7% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.9% · Q3 14.8% · Q4 17.2% · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.1%	0.2% 1.9 pts worse	0.1% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 2.1% · Q4 2.0% · 4Q avg 2.1%
Percentage of long-stay residents whose ability to walk independently worsened	29.6%	18.5% 11.1 pts worse	16.3% 13.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 32.5% · Q3 28.8% · Q4 19.0% · 4Q avg 29.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	33.3%	18.3% 15 pts worse	14.9% 18.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 44.1% · Q3 29.4% · Q4 28.6% · 4Q avg 33.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.6%	1.7% 0.9 pts worse	1.0% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.7% · Q3 5.1% · Q4 1.6% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.1%	2.5% 1.4 pts better	1.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.1%	26.0% 5.9 pts better	19.8% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 19.4% · Q3 29.8% · Q4 10.6% · 4Q avg 20.1%
Percentage of long-stay residents with pressure ulcers	7.7%	4.3% 3.4 pts worse	5.1% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 10.0% · Q3 5.4% · Q4 4.6% · 4Q avg 7.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.5%	84.3% 10.2 pts better	81.7% 12.8 pts better	Short Stay · 2024Q4-2025Q3 · Q3 90.0% · Q4 91.3% · 4Q avg 94.5%
Percentage of short-stay residents who newly received an antipsychotic medication	5.9%	1.9% 4 pts worse	1.6% 4.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-10 · Fire 2025-03-10

13 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-05-09 · Fire 2024-05-09

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-01-19 · Fire 2023-01-19

4 health deficiencies

Top issue: Resident Rights (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-10

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-04-04

F · Potential for more than minimal harm 2025-03-10

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-03-10

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-04

F · Potential for more than minimal harm 2024-05-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-09

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-06-07

D · Potential for more than minimal harm 2024-05-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-07

F · Potential for more than minimal harm 2023-01-19

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-02-10

F · Potential for more than minimal harm 2023-01-19

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2023-02-08

F · Potential for more than minimal harm 2023-01-19

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 2023-02-08

D · Potential for more than minimal harm 2023-01-19

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 2023-02-06

D · Potential for more than minimal harm 2023-01-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-02-06

D · Potential for more than minimal harm 2023-01-19

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 2023-02-06

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-03-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-03-10

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 2025-03-28

E · Potential for more than minimal harm 2025-03-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-03-10

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 2025-03-28

E · Potential for more than minimal harm 2025-03-10

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 2025-03-28

D · Potential for more than minimal harm 2025-03-10

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-03-10

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-03-10

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 2025-03-28

D · Potential for more than minimal harm 2025-03-10

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 2025-03-28

D · Potential for more than minimal harm 2025-03-10

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 2025-03-28

D · Potential for more than minimal harm 2025-03-10

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 2025-03-28

D · Potential for more than minimal harm 2025-03-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-03-10

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 2025-03-28

G · Actual harm 2024-05-09

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 2024-05-10

F · Potential for more than minimal harm 2024-05-09

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 2024-05-10

F · Potential for more than minimal harm 2024-05-09

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 2024-05-10

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 2024-05-10

D · Potential for more than minimal harm 2024-05-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-05-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-05-10

C · Minimal harm 2024-05-09

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2024-05-10

D · Potential for more than minimal harm 2023-12-19

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2023-12-20

D · Potential for more than minimal harm 2023-01-19

F578 · Resident Rights Deficiencies

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 2023-02-16

D · Potential for more than minimal harm 2023-01-19

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2023-02-16

D · Potential for more than minimal harm 2023-01-19

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 2023-02-16

Penalties and ownership