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
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
0.70
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,506
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.70% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.99
Performance 7.54% · Measure score 0.99 · Achievement 0.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.43
Baseline 70.27% · Performance 43.33% · Measure score 5.43 · Achievement 4.98 · Improvement 5.43
Adjusted total nurse staffing
5.41
Baseline 4.96 hours · Performance 4.62 hours · Measure score 5.41 · Achievement 5.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 6.23% |
| Discharge to community | 53.47% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 47.22% · Lower 95% interval 39.54% |
| 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 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 77.78% |
53.69%
24.1 pts better
|
Numerator 21 · Denominator 27 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 18 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 11.21% |
8.2%
3 pts better
|
Numerator 12 · Denominator 107 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 64 · Denominator 128 |
| Discharge function score | 77.78% |
56.45%
21.3 pts better
|
Numerator 21 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 10 · Denominator 25 |
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 · Adjusted 2.1 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 95.8% · Q2 93.8% · Q3 73.1% · Q4 66.0% · 4Q avg 81.8% |
| 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 · 4Q avg 96.1% |
| 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 · Q1 0.0% · Q2 4.2% · Q3 5.8% · Q4 8.0% · 4Q avg 4.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 14.6% · 4Q avg 5.1% |
| 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 · Q1 5.0% · Q2 12.2% · Q3 6.7% · Q4 5.4% · 4Q avg 7.4% |
| 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 · Q1 10.0% · Q2 11.9% · Q3 8.5% · Q4 22.5% · 4Q avg 13.0% |
| 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 · Q1 16.1% · Q2 9.1% · Q3 16.2% · Q4 16.7% · 4Q avg 14.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% |
| 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 · Q1 19.4% · Q2 26.2% · Q3 18.3% · Q4 35.9% · 4Q avg 24.4% · Used in QM five-star |
| 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 · Q1 10.8% · Q2 32.5% · Q3 54.5% · Q4 27.0% · 4Q avg 32.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| 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 · 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 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 · Q1 25.9% · Q2 25.3% · Q3 31.5% · Q4 25.2% · 4Q avg 27.2% |
| 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 · Q1 2.2% · Q2 2.2% · Q3 2.5% · Q4 4.7% · 4Q avg 2.9% · Used in QM five-star |
| 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 · Q1 52.4% · Q2 38.7% · Q4 13.6% · 4Q avg 37.0% |
| 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 · Adjusted 7.2% · Observed 6.5% · 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 | 40.0% |
73.3%
33.3 pts worse
|
79.7%
39.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.0% |
| 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 · Adjusted 23.4% · Observed 19.4% · Expected 19.8% · Used in QM five-star |
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
Nearby options
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Granger Nursing & Rehabilitation Center
Granger, IA
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
On With Life Long Term Care
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Green Hills Health Care Center
Ames, IA
5-star overall rating with 4-star inspections with 1 fire-safety deficiencies in the latest cycle
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