Jefferson, IA

Regency Park Nursing & Rehab Center of Jefferson

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

100 Ram Road, Jefferson, IA

(515) 386-4107

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Campbell Street Services

Operator or chain grouping

Approved since

1994-09-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

16 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

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

0.67

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.58

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.25

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

3.50

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.25

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

3.19

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

3.57

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,724

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.35

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

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

2.81

Baseline 41.67% · Performance 52.17% · Measure score 2.81 · Achievement 2.81 · Improvement 0

Adjusted total nurse staffing

1.05

Baseline 3.83 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.91%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 5.93%
Discharge to community	49.79%	50.57% 0.8 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 48% · Lower 95% interval 37.62%
Medicare spending per beneficiary	0.87	1.02 0.2 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 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · 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 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 57
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 85
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · 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	0.6	1.5 0.9 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.8 · 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 1.1 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	94.0% 6 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	4.9%	3.7% 1.2 pts worse	3.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.1% · Q3 8.8% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	4.0% 1.8 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.0% · Q4 3.0% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	3.0%	4.9% 1.9 pts better	5.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 4.3% · Q4 4.2% · 4Q avg 3.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.0%	20.6% 1.4 pts worse	19.6% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 20.0% · Q3 13.0% · Q4 20.8% · 4Q avg 22.0%
Percentage of long-stay residents who received an antipsychotic medication	9.6%	19.8% 10.2 pts better	16.7% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q3 14.3% · Q4 4.8% · 4Q avg 9.6% · 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	19.2%	18.5% 0.7 pts worse	16.3% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 21.8% · Q4 30.5% · 4Q avg 19.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.2%	18.3% 3.1 pts better	14.9% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.0% · Q3 13.0% · Q4 13.0% · 4Q avg 15.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.7% 1.1 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	2.5% 0.3 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.1% · Q3 2.9% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.4%	26.0% 2.4 pts worse	19.8% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 26.7% · Q3 34.5% · Q4 28.5% · 4Q avg 28.4%
Percentage of long-stay residents with pressure ulcers	4.1%	4.3% 0.2 pts better	5.1% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 3.9% · Q3 4.7% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.8%	84.3% 13.5 pts better	81.7% 16.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 100.0% · Q3 100.0% · Q4 95.8% · 4Q avg 97.8%
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	90.9%	73.3% 17.6 pts better	79.7% 11.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-31 · Fire 2025-12-31

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2025-01-15 · Fire 2025-01-15

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-11-13 · Fire 2023-11-13

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-31

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2026-01-24

D · Potential for more than minimal harm 2025-12-31

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 2026-01-24

D · Potential for more than minimal harm 2025-12-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-01-24

F · Potential for more than minimal harm 2025-01-15

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-02-21

F · Potential for more than minimal harm 2025-01-15

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2025-02-21

F · Potential for more than minimal harm 2025-01-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-25

F · Potential for more than minimal harm 2025-01-15

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-02-21

E · Potential for more than minimal harm 2023-11-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-11-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-31

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 2026-01-30

D · Potential for more than minimal harm 2025-12-31

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 2026-01-30

D · Potential for more than minimal harm 2025-12-31

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-30

D · Potential for more than minimal harm 2025-12-31

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2026-01-30

D · Potential for more than minimal harm 2025-12-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-30

E · Potential for more than minimal harm 2025-01-15

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 2025-02-15

D · Potential for more than minimal harm 2025-01-15

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-15

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-15

F948 · Nursing and Physician Services Deficiencies

Health

Ensure that paid feeding assistants have the training they need.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-09-11

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-09-11

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-01-11

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-01-11

D · Potential for more than minimal harm 2024-01-11

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-01-11

G · Actual harm 2023-11-13

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 2023-12-13

E · Potential for more than minimal harm 2023-11-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-12-13

E · Potential for more than minimal harm 2023-11-13

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-12-14

E · Potential for more than minimal harm 2023-11-13

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 2023-12-13