Cycle 1
Health 2025-04-17 · Fire 2025-04-17
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grinnell, IA
St Francis Manor
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
2021 Fourth Avenue, Grinnell, IA
(641) 236-7592
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
55
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
1.29
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.50
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
1.44
CMS adjusted RN staffing hours
Adjusted total hours
5.21
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,040
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.68
Composite VBP score used to determine payment impact.
Payment multiplier
1.0158
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.08
Baseline 19.01% · Performance 19.54% · Measure score 4.08 · Achievement 4.08 · Improvement 0
Healthcare-associated infections
6.83
Baseline 6.23% · Performance 5.79% · Measure score 6.83 · Achievement 6.83 · Improvement 3.05
Total nurse turnover
4.92
Baseline 25.37% · Performance 43.56% · Measure score 4.92 · Achievement 4.92 · Improvement 0
Adjusted total nurse staffing
8.44
Baseline 5.20 hours · Performance 5.48 hours · Measure score 8.44 · Achievement 8.44 · Improvement 4.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.07% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 4.12% · Lower 95% interval 5.98% |
| Discharge to community | 54.7% |
50.57%
4.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 52.5% · Lower 95% interval 46.08% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge self-care score | 38.6% |
53.69%
15.1 pts worse
|
Numerator 22 · Denominator 57 |
| Discharge mobility score | 29.82% |
50.94%
21.1 pts worse
|
Numerator 17 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 62 · Adjusted rate 4.35% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 0% · Lower 95% interval 2.81% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 4 · Denominator 192 |
| Staff flu vaccination coverage | 40.08% |
42%
1.9 pts worse
|
Numerator 95 · Denominator 237 |
| Discharge function score | 56.14% |
56.45%
0.3 pts worse
|
Numerator 32 · Denominator 57 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 54.55% |
25.2%
29.3 pts better
|
Numerator 18 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · 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 | 0.5% |
3.7%
3.2 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 0.0% · Q2 7.4% · Q3 5.9% · Q4 4.3% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.9%
2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 4.7% · Q4 2.4% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
20.6%
3.8 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 15.6% · Q3 14.0% · Q4 17.1% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
19.8%
4.8 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 18.4% · Q3 11.1% · Q4 11.4% · 4Q avg 15.0% · 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 | 17.3% |
18.5%
1.2 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 26.2% · Q3 17.4% · Q4 8.2% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
18.3%
0.8 pts better
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 15.9% · Q3 18.6% · Q4 19.5% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.7%
0.1 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 4.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.4% |
2.5%
3.9 pts worse
|
1.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 5.7% · Q3 5.8% · Q4 4.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
26.0%
6.5 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 23.7% · Q3 25.3% · Q4 6.3% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.3%
3 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
13.1%
7.6 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.7% · Expected 9.5% · 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% · 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 | 100.0% |
73.3%
26.7 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.0% |
21.3%
12.3 pts better
|
23.9%
14.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 7.0% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-04-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-04-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-23
F · Potential for more than minimal harm
2024-06-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-06-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-06
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 2024-06-17
E · Potential for more than minimal harm
2024-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-13
F · Potential for more than minimal harm
2023-07-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-07-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-07-13
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 2023-08-13
Penalties and ownership
What sits behind the stars
Ownership
St Francis Manor Inc
5% Or Greater Direct Ownership Interest · Organization
Brown, Kent
Corporate Director · Individual
Brown, Kent
Corporate Officer · Individual
Bryan, Samantha
Corporate Director · Individual
Conn, Frances
Corporate Director · Individual
Conn, Frances
Corporate Officer · Individual
Heineman, Brian
Contracted Managing Employee · Individual
Honold, Todd
Corporate Director · Individual
Mcfee, Lee
Corporate Director · Individual
Mcfee, Lee
Corporate Officer · Individual
Schrack, Dion
W-2 Managing Employee · Individual
Scurr, Connie
Corporate Director · Individual
Shebeck, Gary
Corporate Director · Individual
St Francis Manor Inc
Operational/Managerial Control · Organization
Thorndike, James
Corporate Director · Individual
Verploeg, Teryl
Corporate Director · Individual
Warnick, Lyndsey
Corporate Director · Individual
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5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
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