Cycle 1
Health 2025-01-09 · Fire 2025-01-09
4 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Grimes, IA
Kennybrook Village
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
200 SW Brookside Drive, Grimes, IA
(515) 369-3900
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pivotal Health Care
Operator or chain grouping
Approved since
2012-03-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 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
1.06
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.89
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.43
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.71
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
1.15
CMS adjusted RN staffing hours
Adjusted total hours
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,339
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0126
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.09
Performance 19.54% · Measure score 4.09 · Achievement 4.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7.21
Performance 5.68% · Measure score 7.21 · Achievement 7.21 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.46
Baseline 50.94% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 1.60
Adjusted total nurse staffing
7.22
Baseline 4.57 hours · Performance 5.13 hours · Measure score 7.22 · Achievement 7.22 · Improvement 4.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.59% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 6.85% · Lower 95% interval 6.02% |
| Discharge to community | 53.88% |
50.57%
3.3 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 49.02% · Lower 95% interval 44.33% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 26 · Denominator 39 |
| Discharge mobility score | 41.03% |
50.94%
9.9 pts worse
|
Numerator 16 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 1.92% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 52 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 5.68% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 0% · Lower 95% interval 3.01% |
| Staff COVID-19 vaccination coverage | 15.66% |
8.2%
7.5 pts better
|
Numerator 13 · Denominator 83 |
| Staff flu vaccination coverage | 23.4% |
42%
18.6 pts worse
|
Numerator 33 · Denominator 141 |
| Discharge function score | 69.23% |
56.45%
12.8 pts better
|
Numerator 27 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35.48% |
25.2%
10.3 pts better
|
Numerator 11 · Denominator 31 |
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 0.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.1
1.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · 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 | 3.1% |
3.7%
0.6 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 9.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.0%
3.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
4.9%
0.4 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q3 4.2% · Q4 8.7% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
20.6%
6.5 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 29.2% · Q3 25.0% · Q4 25.0% · 4Q avg 27.1% |
| 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 0.0% · Q2 9.5% · Q3 5.0% · 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 · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
18.3%
5.7 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.5% · Q3 8.3% · Q4 17.4% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.5%
0.2 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.9% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
26.0%
1.4 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 30.1% · Q3 26.8% · Q4 28.0% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.3%
1.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.0% · Q3 1.5% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
84.3%
13.9 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.3% · Q4 97.9% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
13.1%
0.2 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 12.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.9%
1.1 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 4.0% · Q4 4.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
73.3%
22.2 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
21.3%
3 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 19.5% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-21
F · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
E · Potential for more than minimal harm
2023-09-28
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 2023-10-16
E · Potential for more than minimal harm
2023-09-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-16
F · Potential for more than minimal harm
2022-06-23
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-07-01
F · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-24
F · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-06-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-09
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-09
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 2025-01-31
E · Potential for more than minimal harm
2023-09-28
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 2023-10-20
D · Potential for more than minimal harm
2023-09-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-28
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-20
D · Potential for more than minimal harm
2022-06-23
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-07-11
B · Minimal harm
2022-06-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-11
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Jordan
Operational/Managerial Control · Individual
Gulledge, Scott
Operational/Managerial Control · Individual
Gulledge, Travis
Operational/Managerial Control · Individual
Oconner, Michael
Operational/Managerial Control · Individual
Pivotal Health Care LLC
Operational/Managerial Control · Organization
Scenic Development LLC
Operational/Managerial Control · Organization
Wilson, Jayce
Operational/Managerial Control · Individual
Wood, Gilbert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Brio of Johnston, LLC
Johnston, IA
5-star overall rating with 4-star inspections with $6,923 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Royal Oaks Nursing and Rehabilitation Center
Urbandale, IA
1-star overall rating with 1-star inspections with $122,691 in total fines with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Deerfield Health Care Center
Urbandale, IA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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