3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Burlington, IA
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1212 Indian Hills Drive, Burlington, IA
(319) 752-4100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-07-20
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
RN hours / resident day
0.57
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.20
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.24
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
3,241
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.53
Baseline 19.80% · Performance 18.87% · Measure score 5.53 · Achievement 5.53 · Improvement 2.84
Healthcare-associated infections
4.62
Baseline 6.84% · Performance 6.45% · Measure score 4.62 · Achievement 4.62 · Improvement 1.58
Total nurse turnover
4.03
Baseline 66.15% · Performance 47.46% · Measure score 4.03 · Achievement 3.97 · Improvement 4.03
Adjusted total nurse staffing
3.95
Baseline 3.68 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 1.99
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.64% |
10.72%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 15.85% · Lower 95% interval 10.46% |
| Discharge to community | 47.92% |
50.57%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 44.8% · Lower 95% interval 38.37% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 81.32% |
95.27%
14 pts worse
|
Numerator 74 · Denominator 91 |
| Falls with major injury | 3.3% |
0.77%
2.5 pts worse
|
Numerator 3 · Denominator 91 |
| Discharge self-care score | 57.97% |
53.69%
4.3 pts better
|
Numerator 40 · Denominator 69 |
| Discharge mobility score | 57.97% |
50.94%
7 pts better
|
Numerator 40 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 4.4% |
2.29%
2.1 pts worse
|
Numerator 4 · Denominator 91 · Adjusted rate 4.91% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 4.81% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 2.67% |
42%
39.3 pts worse
|
Numerator 6 · Denominator 225 |
| Discharge function score | 56.52% |
56.45%
0.1 pts better
|
Numerator 39 · Denominator 69 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.15% |
25.2%
10 pts worse
|
Numerator 5 · Denominator 33 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
94.0%
22.6 pts worse
|
93.4%
22 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 69.4% · Q3 64.7% · Q4 69.0% · 4Q avg 71.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.9% |
95.2%
10.3 pts worse
|
95.5%
10.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.7%
About the same
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 5.9% · Q4 2.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 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 who lose too much weight | 8.8% |
4.9%
3.9 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 13.3% · Q3 12.8% · Q4 2.8% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
20.6%
6.8 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 27.7% · Q3 29.2% · Q4 24.3% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
19.8%
6.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.2% · Q3 16.2% · Q4 10.0% · 4Q avg 13.0% · 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 | 18.1% |
18.5%
0.4 pts better
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.2% · Q3 13.7% · Q4 22.6% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
18.3%
5.1 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 28.3% · Q3 10.6% · Q4 37.8% · 4Q avg 23.4% · 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 | 0.5% |
2.5%
2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
26.0%
1.3 pts better
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 23.7% · Q3 24.0% · Q4 28.0% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
4.3%
5.5 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 9.6% · Q3 11.3% · Q4 9.4% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.2% |
84.3%
32.1 pts worse
|
81.7%
29.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.6% · Q2 44.4% · Q3 52.5% · Q4 65.0% · 4Q avg 52.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
13.1%
1.5 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.7% · Expected 11.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 25.0% |
73.3%
48.3 pts worse
|
79.7%
54.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.1% |
21.3%
10.8 pts worse
|
23.9%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 30.0% · Expected 22.3% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-25
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-11
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-22
Inspection history
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-07
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-18
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 2024-07-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-18
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-18
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-16
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-26
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-26
Health
Assess the resident when there is a significant change in condition
Corrected 2023-05-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-26
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-05-26
Penalties and ownership
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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