Cycle 1
Health 2025-03-06 · Fire 2025-03-06
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Washington, IA
Halcyon House
4-star overall rating with 2-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1015 South Iowa Avenue, Washington, IA
(319) 653-7264
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
54
Certified beds
Average residents
51
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wesleylife
Operator or chain grouping
Approved since
2003-04-01
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
0.85
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.13
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
5.21
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,021
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9998
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
2.34
Performance 7.13% · Measure score 2.34 · Achievement 2.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.74
Baseline 28.33% · Performance 44.29% · Measure score 4.74 · Achievement 4.74 · Improvement 0
Adjusted total nurse staffing
6.83
Baseline 4.72 hours · Performance 5.02 hours · Measure score 6.83 · Achievement 6.83 · Improvement 2.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.71% |
| Discharge to community | 61.48% |
50.57%
10.9 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 58.54% · Lower 95% interval 49.28% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 29 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 62.07% |
53.69%
8.4 pts better
|
Numerator 18 · Denominator 29 |
| Discharge mobility score | 65.52% |
50.94%
14.6 pts better
|
Numerator 19 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 2 · Denominator 30 · Adjusted rate 8.41% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 6 · Denominator 6 |
| Staff flu vaccination coverage | 94.12% |
42%
52.1 pts better
|
Numerator 112 · Denominator 119 |
| Discharge function score | 72.41% |
56.45%
16 pts better
|
Numerator 21 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · 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 | 98.1% |
95.2%
2.9 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.7%
2.8 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.9% · Q3 4.4% · Q4 4.4% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.0%
0.2 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 9.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.9%
2.8 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.4% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.1% |
20.6%
3.5 pts worse
|
19.6%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 24.3% · Q3 27.0% · Q4 24.2% · 4Q avg 24.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
19.8%
0.6 pts better
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 20.0% · Q3 17.2% · Q4 17.2% · 4Q avg 19.2% · 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 | 17.4% |
18.5%
1.1 pts better
|
16.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 27.0% · Q3 12.6% · Q4 11.2% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
18.3%
2.1 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 22.2% · Q3 11.1% · Q4 6.1% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.7%
0.3 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.5%
0.3 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 0.0% · Q4 4.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.6% |
26.0%
7.6 pts worse
|
19.8%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 43.5% · Q3 27.4% · Q4 37.4% · 4Q avg 33.6% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.3%
3.4 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
84.3%
3.3 pts better
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 88.0% · Q3 93.9% · Q4 85.3% · 4Q avg 87.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
13.1%
8.8 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.8% · Expected 10.1% · 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 | 88.5% |
73.3%
15.2 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.8% |
21.3%
12.5 pts better
|
23.9%
15.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.7% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-03-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-06
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 2025-03-07
F · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
E · Potential for more than minimal harm
2023-02-23
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 2023-03-10
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-10-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-29
D · Potential for more than minimal harm
2024-10-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-04-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-24
D · Potential for more than minimal harm
2023-02-23
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 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
Wesleylife
5% Or Greater Direct Ownership Interest · Organization
Albertson, Kermit
Corporate Director · Individual
Flanagan, Craig
Corporate Director · Individual
Gilroy, Abbey
Corporate Director · Individual
Hoeksema, Nicole
Corporate Director · Individual
Kretzinger, Robert
Corporate Officer · Individual
Lagree, Roger
Corporate Director · Individual
Marshall, Christine
W-2 Managing Employee · 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
Other facilities in reach
#1
United Presbyterian Home
Washington, IA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Parkview Home
Wayland, IA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Pleasantview Home
Kalona, IA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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