Cycle 1
Health 2025-03-13 · Fire 2025-03-13
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Johnston, IA
Brio of Johnston, LLC
5-star overall rating with 4-star inspections with $6,923 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6901 Peckham Street, Johnston, IA
(515) 253-2501
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wesleylife
Operator or chain grouping
Approved since
2018-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 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
0.98
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.87
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,696
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.32% · Performance 23.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.3
Baseline 5.92% · Performance 6.25% · Measure score 5.3 · Achievement 5.3 · Improvement 0
Total nurse turnover
0
Baseline 68.63% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
7.50
Baseline 4.81 hours · Performance 5.21 hours · Measure score 7.50 · Achievement 7.50 · Improvement 3.67
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.6% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 4.85% · Lower 95% interval 6.27% |
| Discharge to community | 70.04% |
50.57%
19.5 pts better
|
Better than the National Rate · Eligible stays 185 · Observed rate 67.57% · Lower 95% interval 62.21% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 128 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 70% |
53.69%
16.3 pts better
|
Numerator 70 · Denominator 100 |
| Discharge mobility score | 59% |
50.94%
8.1 pts better
|
Numerator 59 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 128 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.25% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 3.76% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 135 |
| Staff flu vaccination coverage | 21.69% |
42%
20.3 pts worse
|
Numerator 18 · Denominator 83 |
| Discharge function score | 71% |
56.45%
14.5 pts better
|
Numerator 71 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 30.91% |
25.2%
5.7 pts better
|
Numerator 17 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
94.0%
4.8 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| 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 | 12.9% |
3.7%
9.2 pts worse
|
3.3%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.0% · Q3 9.5% · Q4 18.2% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
20.6%
6.5 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
19.8%
16.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · 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 | 17.3% |
18.5%
1.2 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.9% |
18.3%
2.6 pts worse
|
14.9%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · 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 | 40.8% |
26.0%
14.8 pts worse
|
19.8%
21 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.2% · 4Q avg 40.8% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.3%
2.6 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
84.3%
12.6 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.3% · Q3 98.0% · Q4 98.0% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
13.1%
1.2 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 12.6% · Expected 9.9% · Used in QM five-star |
| 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 · 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 who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
73.3%
22.2 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
21.3%
2.7 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 19.4% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
4 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-02-02 · Fire 2023-02-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 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
2025-03-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-03-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-04-25
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-25
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-25
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-25
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 2024-05-15
F · Potential for more than minimal harm
2023-02-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-02-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-13
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-13
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 2025-04-07
D · Potential for more than minimal harm
2024-06-19
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 2024-07-18
D · Potential for more than minimal harm
2024-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-04-25
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 2024-05-11
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-11
K · Immediate jeopardy
2023-09-14
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 2023-04-28
D · Potential for more than minimal harm
2023-02-02
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 2023-03-17
D · Potential for more than minimal harm
2023-02-02
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 2023-03-17
D · Potential for more than minimal harm
2023-02-02
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-17
Penalties and ownership
What sits behind the stars
$6,923
2023-09-14
Fine
Fine · fine $6,923
Fine
Ownership
Wesleylife
5% Or Greater Direct Ownership Interest · Organization
Albertson, Kermit
Corporate Director · Individual
Flanagan, Craig
Corporate Officer · Individual
Gilroy, Abbey
Corporate Director · Individual
Hoeksema, Nicole
Corporate Director · Individual
Kretzinger, Robert
Operational/Managerial Control · Individual
Kretzinger, Robert
Corporate Officer · Individual
Rasmussen, Chad
Corporate Director · Individual
Ruch, Robert
Corporate Director · Individual
Stout, David
Corporate Director · Individual
Taylor, Christina
Corporate Director · Individual
Watson, Susan
Corporate Director · Individual
Wesley Retirement Services Inc
Operational/Managerial Control · Organization
Nearby options
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Bishop Drumm Retirement Center
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#2
Childserve Habilitation Center
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Royal Oaks Nursing and Rehabilitation Center
Urbandale, IA
1-star overall rating with 1-star inspections with $122,691 in total fines with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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