Cycle 1
Health 2025-03-20 · Fire 2025-03-20
5 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madrid, IA
Madrid Home for the Aged
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
613 West North Street, Madrid, IA
(515) 795-3007
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing
LPN hours / resident day
0.48
Licensed practical nurse staffing
Aide hours / resident day
2.94
Nurse aide staffing
Weekend hours
3.58
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
94.0%
12.2 pts worse
|
93.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.2%
0.9 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.7%
0.8 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
4.0%
1.1 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.9%
2.5 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
20.6%
7.6 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
19.8%
5.3 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 1.0% |
0.2%
0.8 pts worse
|
0.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.4% |
18.5%
5.9 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.3% |
18.3%
14 pts worse
|
14.9%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.7%
0.5 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
26.0%
1.2 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.3%
1.4 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.0% |
84.3%
47.3 pts worse
|
81.7%
44.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
13.1%
5.9 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.0% |
73.3%
33.3 pts worse
|
79.7%
39.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
21.3%
2.1 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-03-27 · Fire 2023-03-27
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-19
E · Potential for more than minimal harm
2025-03-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-19
E · Potential for more than minimal harm
2025-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-19
D · Potential for more than minimal harm
2025-03-20
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-04-19
F · Potential for more than minimal harm
2024-06-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-06-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-06-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-06-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-10
F · Potential for more than minimal harm
2023-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-29
F · Potential for more than minimal harm
2023-03-27
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 2023-04-29
F · Potential for more than minimal harm
2023-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-29
E · Potential for more than minimal harm
2023-03-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-29
E · Potential for more than minimal harm
2023-03-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-29
E · Potential for more than minimal harm
2023-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
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 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-18
D · Potential for more than minimal harm
2024-06-06
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 2024-06-23
D · Potential for more than minimal harm
2024-06-06
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 2024-06-23
D · Potential for more than minimal harm
2024-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-23
E · Potential for more than minimal harm
2023-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-03-27
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 2023-04-27
D · Potential for more than minimal harm
2023-03-27
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-27
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 2023-04-27
D · Potential for more than minimal harm
2023-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-27
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-27
Penalties and ownership
What sits behind the stars
$0
2024-06-06
Payment Denial
Payment Denial · denial start 2024-06-28 · 12 days
12 day denial
Ownership
Ager, Wendy
Operational/Managerial Control · Individual
Bollinger, Hannah
Operational/Managerial Control · Individual
Brockelsby, Sheri
Corporate Officer · Individual
Brown, Sarah
Corporate Officer · Individual
Colby, Richard
Operational/Managerial Control · Individual
Elsberry, Brandon
Operational/Managerial Control · Individual
Evans, Angela
Operational/Managerial Control · Individual
Frankhauser, Richard
Corporate Officer · Individual
Gaines, Ronald
Corporate Officer · Individual
Hansen, Kris
Operational/Managerial Control · Individual
Hansen, Kris
Corporate Officer · Individual
Harris, Jerry
Operational/Managerial Control · Individual
Hau, Matthew
Corporate Officer · Individual
Hau, Matthew
W-2 Managing Employee · Individual
Mccormick, Darrell
Operational/Managerial Control · Individual
Moore, Anthony
Operational/Managerial Control · Individual
O'leary, Patrick
Operational/Managerial Control · Individual
Peterson, Rebecca
Operational/Managerial Control · Individual
Phipps, Molly
Operational/Managerial Control · Individual
Pies, Jennifer
Operational/Managerial Control · Individual
Ridder, Lisa
Operational/Managerial Control · Individual
Ross, Krystal
Operational/Managerial Control · Individual
Sannes, Aaron
Corporate Director · Individual
Schroeder, Heather
Corporate Director · Individual
Schultz, Dianne
Corporate Officer · Individual
Susong, Katherine
Corporate Director · Individual
Western Home Services Inc
Operational/Managerial Control · Organization
Whyms, Brian
Operational/Managerial Control · Individual
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#3
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