Cycle 1
Health 2025-09-11 · Fire 2025-09-11
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Williamsburg, IA
Highland Ridge Care Center, LLC
4-star overall rating with 2-star inspections with $36,752 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
102 Highland Circle, Williamsburg, IA
(319) 668-3800
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
59
Certified beds
Average residents
51
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2006-01-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 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
0.86
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.39
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.06
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
5.53
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,656
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0022
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.45
Performance 20.30% · Measure score 2.45 · Achievement 2.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.50
Baseline 5.63% · Performance 6.79% · Measure score 3.50 · Achievement 3.50 · Improvement 0
Total nurse turnover
4.2
Baseline 31.25% · Performance 46.51% · Measure score 4.2 · Achievement 4.2 · Improvement 0
Adjusted total nurse staffing
9.25
Baseline 5.71 hours · Performance 5.71 hours · Measure score 9.25 · Achievement 9.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 13.33% · Lower 95% interval 7.44% |
| Discharge to community | 33.94% |
50.57%
16.6 pts worse
|
Worse than the National Rate · Eligible stays 31 · Observed rate 22.58% · Lower 95% interval 22.3% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 13 · Denominator 24 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 9 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 3.94% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 186 |
| Staff flu vaccination coverage | 21.79% |
42%
20.2 pts worse
|
Numerator 39 · Denominator 179 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 16 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
94.0%
3.7 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 100.0% · Q3 100.0% · Q4 96.1% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.7% |
95.2%
15.5 pts worse
|
95.5%
15.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.7%
3.3 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.8% · Q3 7.3% · Q4 7.8% · 4Q avg 7.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.9%
0.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 7.8% · Q4 7.1% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
20.6%
5.1 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 12.5% · Q3 15.7% · Q4 24.4% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
19.8%
13.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.7% · Q3 5.4% · Q4 9.4% · 4Q avg 6.2% · 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 | 15.2% |
18.5%
3.3 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 7.7% · Q3 9.3% · Q4 16.2% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
18.3%
0.3 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 14.9% · Q3 12.2% · Q4 22.7% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.7%
1.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.5%
0.4 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.9% · Q3 3.6% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.7% |
26.0%
7.7 pts worse
|
19.8%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 35.5% · Q3 30.2% · Q4 25.8% · 4Q avg 33.7% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.3%
1.9 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 4.6% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.2% |
84.3%
0.9 pts better
|
81.7%
3.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 85.2% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-03 · Fire 2024-10-03
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-09-20 · Fire 2023-09-20
6 health deficiencies
Top issue: Quality of Life and Care (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
2025-09-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-10-03
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-10-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-10-03
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-10
F · Potential for more than minimal harm
2024-10-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-10-03
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-10-03
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-10-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-10-03
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 2024-10-17
F · Potential for more than minimal harm
2023-09-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-24
F · Potential for more than minimal harm
2023-09-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-06
F · Potential for more than minimal harm
2023-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-24
Inspection history
Recent health citations
G · Actual harm
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-18
G · Actual harm
2025-11-19
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 2025-12-18
D · Potential for more than minimal harm
2025-11-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-19
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 2025-12-18
E · Potential for more than minimal harm
2025-09-11
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 2025-10-01
D · Potential for more than minimal harm
2025-09-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-10-01
D · Potential for more than minimal harm
2024-05-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-18
J · Immediate jeopardy
2023-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-17
J · Immediate jeopardy
2023-09-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-17
F · Potential for more than minimal harm
2023-09-20
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-20
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 2023-10-17
D · Potential for more than minimal harm
2023-09-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-17
Penalties and ownership
What sits behind the stars
$36,752
2023-08-22
Fine
Fine · fine $36,752
Fine
Ownership
Williamsburg Retirement Community Inc
5% Or Greater Direct Ownership Interest · Organization
Blythe, Curtis
Corporate Director · Individual
Blythe, Mary
Corporate Director · Individual
Fletcher, Jonathan
Corporate Officer · Individual
Hadley, Victoria
Operational/Managerial Control · Individual
Hills Bank And Trust Company
5% Or Greater Security Interest · Organization
Hills Bank And Trust Company
5% Or Greater Mortgage Interest · Organization
Hudson, Jerry
Operational/Managerial Control · Individual
Kinzenbaw, Marcia
Corporate Director · Individual
Larson, Duane
Corporate Director · Individual
Lindh, Daniel
Corporate Director · Individual
Mccurry, Susan
Corporate Director · Individual
Meyer, Mark
Operational/Managerial Control · Individual
Meyer, Mark
Corporate Officer · Individual
Olson, Daniel
Corporate Director · Individual
Phelps, Brandon
Operational/Managerial Control · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Rose Haven Nursing Home
Marengo, IA
2-star overall rating with 2-star inspections with $10,062 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
English Valley Nursing Care Center
North English, IA
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Colonial Manor of Amana
Amana, IA
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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