Cycle 1
Health 2024-10-03 · Fire 2024-10-03
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Galena, IL
Galena Stauss Nursing Home
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
215 Summit Street, Galena, IL
(815) 776-7254
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-02-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.59
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.48
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.24
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 61 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.6%
9 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.1% |
91.6%
0.5 pts better
|
95.5%
3.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.0% |
3.3%
8.7 pts worse
|
3.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.3% · Q3 11.8% · Q4 8.6% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
50.3%
46.1 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.3% · Q4 9.1% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.5%
3.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.3% · Q3 0.0% · Q4 3.7% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.9% |
18.5%
13.4 pts worse
|
19.6%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 36.7% · Q3 31.0% · Q4 22.2% · 4Q avg 31.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
22.8%
2 pts better
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 27.3% · Q3 24.0% · Q4 16.7% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 38.3% |
17.2%
21.1 pts worse
|
16.3%
22 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.7% |
15.0%
23.7 pts worse
|
14.9%
23.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 39.3% · Q3 37.0% · Q4 52.0% · 4Q avg 38.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.1%
2.4 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 7.1% · Q4 3.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
21.3%
10.1 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 26.7% · Q3 27.4% · Q4 40.1% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.2%
3.9 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 2.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.2% |
68.8%
9.6 pts worse
|
81.7%
22.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 65.5% · Q3 69.2% · 4Q avg 59.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 21.6% |
2.3%
19.3 pts worse
|
1.6%
20 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 7.7% |
63.0%
55.3 pts worse
|
79.7%
72 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 7.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
6 health deficiencies
Top issue: Infection Control (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-10-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-12
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-01-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-08
F · Potential for more than minimal harm
2023-01-06
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-17
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 2024-10-18
F · Potential for more than minimal harm
2024-10-03
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-03
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 2024-10-31
D · Potential for more than minimal harm
2024-10-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-03
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 2024-10-31
G · Actual harm
2024-09-04
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 2024-09-25
D · Potential for more than minimal harm
2024-09-04
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 2024-09-20
D · Potential for more than minimal harm
2024-04-30
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 2024-05-01
D · Potential for more than minimal harm
2024-04-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-30
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 2024-05-01
D · Potential for more than minimal harm
2023-10-31
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 2023-12-15
F · Potential for more than minimal harm
2023-10-12
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 2023-12-01
E · Potential for more than minimal harm
2023-10-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-12
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 2023-11-16
D · Potential for more than minimal harm
2023-10-12
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 2023-11-16
D · Potential for more than minimal harm
2023-10-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-16
L · Immediate jeopardy
2023-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-31
F · Potential for more than minimal harm
2023-01-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-31
F · Potential for more than minimal harm
2023-01-06
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-01-20
D · Potential for more than minimal harm
2023-01-06
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 2023-01-20
D · Potential for more than minimal harm
2023-01-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-20
Penalties and ownership
What sits behind the stars
Ownership
Midwest Medical Foundation
5% Or Greater Indirect Ownership Interest · Organization
Bauer, Tracy
Corporate Officer · Individual
Hey, David
Corporate Director · Individual
Holland, Joel
Corporate Director · Individual
Kilgore, Helen
Corporate Director · Individual
Lorenzen, John
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Sheahen, Mary
Corporate Director · Individual
Sloan, Barbara
Corporate Director · Individual
Thompson, Garry
Corporate Director · Individual
Toepfer, Vince
Corporate Director · Individual
Wamsley, Marie
Corporate Officer · Individual
Wamsley, Marie
W-2 Managing Employee · Individual
Wrabl, Carol
Corporate Director · Individual
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#3
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