Cycle 1
Health 2025-08-28 · Fire 2024-10-31
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Denison, IA
Gracewell, An Eventide Community
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
114 South 20th Street, Denison, IA
(712) 263-3114
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.92
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.97
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
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.03
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
20%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0156
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
5.05
Baseline 6.54% · Performance 6.33% · Measure score 5.05 · Achievement 5.05 · Improvement 0.90
Total nurse turnover
9.37
Baseline 38.09% · Performance 25.40% · Measure score 9.37 · Achievement 9.37 · Improvement 9
Adjusted total nurse staffing
3.73
Baseline 4.11 hours · Performance 4.14 hours · Measure score 3.73 · Achievement 3.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 6.61% |
| Discharge to community | 42.21% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 40% · Lower 95% interval 31.77% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 14 · Denominator 26 |
| Discharge mobility score | 61.54% |
50.94%
10.6 pts better
|
Numerator 16 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 0% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 4.26% |
8.2%
3.9 pts worse
|
Numerator 6 · Denominator 141 |
| Staff flu vaccination coverage | 44.31% |
42%
2.3 pts better
|
Numerator 74 · Denominator 167 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 14 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.2 · 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 | 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 | 3.9% |
3.7%
0.2 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.8% · Q3 5.8% · Q4 5.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.0%
3.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 3.3% · Q2 5.0% · Q3 0.0% · Q4 1.5% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
20.6%
2.7 pts worse
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 26.2% · Q3 21.3% · Q4 25.4% · 4Q avg 23.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
19.8%
2.8 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 21.6% · Q3 22.6% · Q4 25.0% · 4Q avg 22.6% · 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 | 9.0% |
18.5%
9.5 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.5% · Q3 13.6% · Q4 9.1% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
18.3%
9.3 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 10.0% · Q3 6.7% · Q4 16.7% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.7%
1.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.5%
About the same
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 2.9% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
26.0%
5.5 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 17.7% · Q3 22.6% · Q4 31.0% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.3%
0.8 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.4% · Q3 4.1% · Q4 3.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
84.3%
13.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 95.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
13.1%
0.3 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.0% · Expected 10.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
73.3%
10 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 4.8% |
21.3%
16.5 pts better
|
23.9%
19.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.0% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-31 · Fire 2023-09-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-09-21 · Fire 2022-07-21
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-09-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-09-21
F · Potential for more than minimal harm
2022-07-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-25
F · Potential for more than minimal harm
2022-07-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-15
E · Potential for more than minimal harm
2022-07-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-07-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-07-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-31
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 2024-11-30
D · Potential for more than minimal harm
2024-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-30
E · Potential for more than minimal harm
2023-09-21
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 2023-10-21
E · Potential for more than minimal harm
2023-09-21
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 2023-10-21
E · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
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 2023-10-21
D · Potential for more than minimal harm
2023-09-21
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 2023-10-21
D · Potential for more than minimal harm
2023-09-21
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 2023-10-21
Penalties and ownership
What sits behind the stars
Ownership
Baker, Mindi
Corporate Officer · Individual
Baker, Mindi
W-2 Managing Employee · Individual
Eller, Tonya
Corporate Director · Individual
Gray, Mark
Corporate Director · Individual
Jepsen, Danyl
Corporate Director · Individual
Schultz, Amy
Corporate Officer · Individual
Schultz, Amy
W-2 Managing Employee · Individual
Schultz, Todd
Corporate Director · Individual
Spiegel, Mark
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Denison Care Center
Denison, IA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Dunlap Specialty Care
Dunlap, IA
2-star overall rating with 1-star inspections with $39,361 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Odebolt Specialty Care
Odebolt, IA
4-star overall rating with 3-star inspections with $14,433 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out