Cycle 1
Health 2025-05-29 · Fire 2025-05-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Grinnell, IA
Mayflower Home
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
616 Broad Street, Grinnell, IA
(641) 236-6151
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
40
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-01-01
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
1.07
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.65
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,413
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0120
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.35
Baseline 57.69% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 1.84
Adjusted total nurse staffing
8.02
Baseline 4.69 hours · Performance 5.36 hours · Measure score 8.02 · Achievement 8.02 · Improvement 5.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 128 |
| Staff flu vaccination coverage | 53.85% |
42%
11.9 pts better
|
Numerator 84 · Denominator 156 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 0.8 |
1.5
0.7 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.0 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
94.0%
3.1 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 96.2% · Q4 96.2% · 4Q avg 97.1% |
| 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 | 3.8% |
3.7%
0.1 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 3.8% · Q4 7.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.0%
1 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 4.0% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
4.9%
1.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 4.8% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
20.6%
0.1 pts better
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 19.0% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.7% |
19.8%
17.1 pts better
|
16.7%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 2.7% · 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 | 25.8% |
18.5%
7.3 pts worse
|
16.3%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
18.3%
10.6 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 33.3% · 4Q avg 28.9% · 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 | 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 | 30.5% |
26.0%
4.5 pts worse
|
19.8%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 35.0% · Q3 32.8% · Q4 29.7% · 4Q avg 30.5% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.3%
1.8 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 0.0% · Q3 9.2% · Q4 3.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.6% |
84.3%
3.7 pts worse
|
81.7%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 76.2% · Q3 83.3% · Q4 71.4% · 4Q avg 80.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.1%
13.1 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 8.8% · 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 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
73.3%
17.6 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
21.3%
5.6 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 9.5% · Expected 14.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-29
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 2025-05-29
D · Potential for more than minimal harm
2025-05-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-29
F · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-07-11
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 2024-07-15
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 2024-07-15
E · Potential for more than minimal harm
2024-07-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-07-26
F · Potential for more than minimal harm
2023-05-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-05-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-05-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-16
E · Potential for more than minimal harm
2024-07-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-11
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 2024-08-02
D · Potential for more than minimal harm
2024-07-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-02
Penalties and ownership
What sits behind the stars
Ownership
Mayflower Homes Inc
5% Or Greater Direct Ownership Interest · Organization
Carlson, Paige
Corporate Director · Individual
Dillon, Jessica
Corporate Director · Individual
Dillon, Jessica
Corporate Officer · Individual
Fairchild, Diane
Corporate Director · Individual
Gruhn, Scott
Operational/Managerial Control · Individual
Heineman, Brian
Operational/Managerial Control · Individual
Jaworski, Leslie
Operational/Managerial Control · Individual
Jepsen, Lisa
Corporate Director · Individual
Jepsen, Lisa
Corporate Officer · Individual
Mahaffey, Patrick
Corporate Director · Individual
Marsho, Peter
Corporate Director · Individual
Mayflower Homes Inc
Operational/Managerial Control · Organization
Mcgriff, Kellie
Operational/Managerial Control · Individual
Mcgriff, Kellie
Corporate Officer · Individual
Mutti, John
Corporate Director · Individual
Mutti, John
Corporate Officer · Individual
Ramsey, James
Corporate Director · Individual
Ramsey, James
Corporate Officer · Individual
Staroska, Jacob
Operational/Managerial Control · Individual
Vosburg, Pamela
Corporate Officer · Individual
Wieck, Vicki
Operational/Managerial Control · Individual
Wiltfang, Anneliese
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Francis Manor
Grinnell, IA
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Montezuma Specialty Care
Montezuma, IA
4-star overall rating with 4-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
Brooklyn Community Estates
Brooklyn, IA
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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