Cycle 1
Health 2025-05-15 · Fire 2025-05-15
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cedar Falls, IA
Martin Health Center, INC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
410 East 10th Street, Cedar Falls, IA
(319) 277-2141
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-12-01
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
0.66
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.41
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
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
799
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0183
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
5.96
Performance 6.05% · Measure score 5.96 · Achievement 5.96 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.18
Baseline 44.26% · Performance 34.33% · Measure score 7.18 · Achievement 7.18 · Improvement 4.62
Adjusted total nurse staffing
5.95
Baseline 5.07 hours · Performance 4.77 hours · Measure score 5.95 · Achievement 5.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 7.16% |
| Discharge to community | 46.5% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 45.65% · Lower 95% interval 36.91% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 74.36% |
95.27%
20.9 pts worse
|
Numerator 29 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 45.16% |
53.69%
8.5 pts worse
|
Numerator 14 · Denominator 31 |
| Discharge mobility score | 38.71% |
50.94%
12.2 pts worse
|
Numerator 12 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 3.47% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 79.78% |
42%
37.8 pts better
|
Numerator 71 · Denominator 89 |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 18 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 63.64% |
25.2%
38.4 pts better
|
Numerator 14 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
94.0%
5.2 pts worse
|
93.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.9% · Q2 78.6% · Q3 97.7% · Q4 95.3% · 4Q avg 88.8% |
| 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 | 1.8% |
3.7%
1.9 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 0.0% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
4.0%
0.5 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.5% · Q3 7.7% · Q4 2.6% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.9%
0.2 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 5.6% · Q4 5.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
20.6%
2.2 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 24.2% · Q3 21.6% · Q4 12.8% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
19.8%
2.8 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.9% · Q3 25.0% · Q4 25.0% · 4Q avg 22.6% · 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 | 29.6% |
18.5%
11.1 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 39.1% · Q3 24.8% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.4% |
18.3%
7.1 pts worse
|
14.9%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 25.0% · Q3 27.8% · Q4 28.9% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.7%
0.1 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 4.6% · Q4 0.0% · 4Q avg 1.8% · 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 | 31.8% |
26.0%
5.8 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 43.5% · Q3 40.3% · Q4 16.4% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.3%
2.8 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.9% · Q3 6.4% · Q4 2.7% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
84.3%
4.6 pts better
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 91.2% · Q3 96.6% · Q4 100.0% · 4Q avg 88.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
13.1%
4.5 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 7.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.9%
0.7 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
73.3%
23.8 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
21.3%
0.3 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 19.2% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 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
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-19
F · Potential for more than minimal harm
2024-07-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-07-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-11
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 2024-07-24
D · Potential for more than minimal harm
2024-07-11
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-22
F · Potential for more than minimal harm
2023-06-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-06-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-06-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-06-15
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 2023-07-19
F · Potential for more than minimal harm
2023-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
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 2025-06-02
D · Potential for more than minimal harm
2025-05-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-15
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-06-02
G · Actual harm
2024-12-17
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 2024-09-03
E · Potential for more than minimal harm
2024-07-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-11
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 2024-08-01
D · Potential for more than minimal harm
2023-06-15
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 2023-07-06
D · Potential for more than minimal harm
2023-06-15
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-15
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 2023-07-06
D · Potential for more than minimal harm
2023-06-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-06
Penalties and ownership
What sits behind the stars
Ownership
Ager, Wendy
Operational/Managerial Control · Individual
Behn, Marlene
Corporate Director · Individual
Bennett, Kevin
Operational/Managerial Control · Individual
Billman, Emily
Operational/Managerial Control · Individual
Bittner, Scott
Corporate Director · Individual
Brown, Sarah
Corporate Director · Individual
Coil, Joyce
Corporate Director · Individual
Evans, Angela
Operational/Managerial Control · Individual
Evans, Angela
Corporate Officer · Individual
Ferguson, Kathleen
Corporate Director · Individual
Firman, Steve
Corporate Director · Individual
First Interstate Bank
5% Or Greater Direct Ownership Interest · Organization
First Interstate Bank
5% Or Greater Mortgage Interest · Organization
Fox, Larry
Corporate Director · Individual
Frankhauser, Richard
Operational/Managerial Control · Individual
Frankhauser, Richard
Corporate Officer · Individual
Gaines, Ronald
Corporate Officer · Individual
Garcia, Jenny
Operational/Managerial Control · Individual
Gibbs, Stacy
Operational/Managerial Control · Individual
Hansen, Kris
Corporate Director · Individual
Harris, Jerry
Operational/Managerial Control · Individual
Harris, Jerry
Corporate Officer · Individual
Jenkins, Glenn
Corporate Director · Individual
Mccormick, Darrell
Operational/Managerial Control · Individual
Meier, Catherine
Operational/Managerial Control · Individual
Meier, Catherine
Corporate Officer · Individual
O'leary, Patrick
Operational/Managerial Control · Individual
O'leary, Patrick
Corporate Officer · Individual
Sannes, Aaron
Corporate Director · Individual
Schmitz, Gregory
Corporate Director · Individual
Schroeder, Heather
Corporate Director · Individual
Schultz, Dianne
Corporate Officer · Individual
Susong, Katherine
Corporate Director · Individual
Tjaden, Tabitha
Operational/Managerial Control · Individual
Winter, Floyd
Corporate Director · Individual
Witt, William
Corporate Director · Individual
Nearby options
Other facilities in reach
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Newaldaya Lifescapes
Cedar Falls, IA
3-star overall rating with 2-star inspections with $132,074 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cedar Falls Health Care Center
Cedar Falls, IA
3-star overall rating with 2-star inspections with $129,025 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
The Suites at Western Home Communities
Cedar Falls, IA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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