Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Urbandale, IA
Deerfield Health Care Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
13731 Hickman Road, Urbandale, IA
(515) 331-6900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
30
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Immanuel
Operator or chain grouping
Approved since
2005-07-22
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
3 facilities
Chain averages 5 overall / 4 health / 5 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
1.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.35
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
5.82
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
2.47
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
5.29
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
1.24
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
5.82
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,287
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0046
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.01
Baseline 20.26% · Performance 20.50% · Measure score 2.01 · Achievement 2.01 · Improvement 0
Healthcare-associated infections
7.44
Baseline 5.38% · Performance 5.61% · Measure score 7.44 · Achievement 7.44 · Improvement 0
Total nurse turnover
5.68
Baseline 52.50% · Performance 40.48% · Measure score 5.68 · Achievement 5.68 · Improvement 3.85
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.02% · Lower 95% interval 6.34% |
| Discharge to community | 59.16% |
50.57%
8.6 pts better
|
Better than the National Rate · Eligible stays 112 · Observed rate 56.25% · Lower 95% interval 50.88% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.63% |
95.27%
3.4 pts better
|
Numerator 72 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 65.45% |
53.69%
11.8 pts better
|
Numerator 36 · Denominator 55 |
| Discharge mobility score | 74.55% |
50.94%
23.6 pts better
|
Numerator 41 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 73 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 61 |
| Staff flu vaccination coverage | 48.05% |
42%
6 pts better
|
Numerator 37 · Denominator 77 |
| Discharge function score | 74.55% |
56.45%
18.1 pts better
|
Numerator 41 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 44 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 51.11% |
25.2%
25.9 pts better
|
Numerator 23 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.3 · Expected 1.8 · 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 · 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 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
4.9%
2.5 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
20.6%
5 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
19.8%
16.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
18.3%
0.8 pts better
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.7%
About the same
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.5%
1 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
26.0%
3.8 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.3%
1.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
13.1%
0.8 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 12.9% · Expected 10.3% · 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 | 97.4% |
73.3%
24.1 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
21.3%
0.1 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 20.0% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-04-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-13
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 2024-05-16
E · Potential for more than minimal harm
2024-04-25
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 2024-05-06
E · 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 2024-05-07
E · Potential for more than minimal harm
2024-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-16
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-03-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-03-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-21
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2023-06-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-10
Penalties and ownership
What sits behind the stars
Ownership
Alloway, Cindy
Corporate Director · Individual
Balluff, Mary
Corporate Director · Individual
Bear, Scott
Operational/Managerial Control · Individual
Bear, Scott
Corporate Officer · Individual
Bear, Scott
Contracted Managing Employee · Individual
Benson, Ellsworth
Corporate Director · Individual
Bergman-Evans, Brenda
Corporate Director · Individual
Bothof, John
Corporate Director · Individual
Bothof, John
Corporate Officer · Individual
Bullock, Steve
Corporate Director · Individual
Burns, Randal
Corporate Director · Individual
Friedlund, Danny
Corporate Director · Individual
Gurley, Eric
Operational/Managerial Control · Individual
Gurley, Eric
Corporate Director · Individual
Gurley, Eric
Corporate Officer · Individual
Gurley, Eric
Contracted Managing Employee · Individual
Hanson, Scott
Contracted Managing Employee · Individual
Hawlik, Teresa
Corporate Director · Individual
Howerter, Scott
Corporate Director · Individual
Hudnutt, Kari
Operational/Managerial Control · Individual
Hudnutt, Kari
W-2 Managing Employee · Individual
Johnson, Scott
Corporate Director · Individual
Mason, Kimberly
Operational/Managerial Control · Individual
Mason, Kimberly
Contracted Managing Employee · Individual
Nichols, Clarence
Corporate Director · Individual
Nichols, Clarence
Corporate Officer · Individual
Paladino-Kaminski, Julie
Operational/Managerial Control · Individual
Paladino-Kaminski, Julie
Corporate Officer · Individual
Paladino-Kaminski, Julie
Contracted Managing Employee · Individual
Parker, Mary
Corporate Director · Individual
Powers, Jill
Corporate Director · Individual
Powers, Jill
Corporate Officer · Individual
Scanlan, Steven
Corporate Director · Individual
Sealer, Tamara
Operational/Managerial Control · Individual
Sealer, Tamara
Corporate Officer · Individual
Sealer, Tamara
Contracted Managing Employee · Individual
Skolkin, Andrea
Corporate Director · Individual
Thompson, Roger
Corporate Director · Individual
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Cedar Ridge Village
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4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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