Cycle 1
Health 2025-04-03 · Fire 2025-04-03
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Lansing, IA
Thornton Manor Nursing and Care Center
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1329 Main Street, Lansing, IA
(563) 538-4236
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
5.27
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,028
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9997
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
5.39
Baseline 22.58% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 0
Adjusted total nurse staffing
3.89
Baseline 3.94 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 0.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · 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 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.07% |
8.2%
3.9 pts better
|
Numerator 7 · Denominator 58 |
| Staff flu vaccination coverage | 42.62% |
42%
0.6 pts better
|
Numerator 26 · Denominator 61 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 2.1 |
1.5
0.6 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.3 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.0%
5.1 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 0.9% |
3.7%
2.8 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
4.0%
1.3 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 0.0% · Q4 3.8% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.9%
0.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.1% · Q3 3.6% · Q4 4.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
20.6%
3.4 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.6% · Q3 17.9% · Q4 15.4% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
19.8%
2.3 pts better
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 16.0% · Q3 16.7% · Q4 18.2% · 4Q avg 17.5% · 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 | 4.1% |
18.5%
14.4 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
18.3%
10.7 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 15.4% · Q4 8.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
1.7%
2.5 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.0% · Q3 3.2% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.5%
0.8 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 3.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
26.0%
9.9 pts better
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.1% · Q3 34.2% · Q4 16.9% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.3%
0.7 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.3% · Q3 4.5% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
84.3%
2 pts better
|
81.7%
4.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 86.3% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-15 · Fire 2023-02-15
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-05
F · Potential for more than minimal harm
2025-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-06
F · Potential for more than minimal harm
2025-04-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-05-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-26
F · Potential for more than minimal harm
2024-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-02-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-27
F · Potential for more than minimal harm
2023-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-27
E · Potential for more than minimal harm
2023-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-03
E · Potential for more than minimal harm
2023-02-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-04-03
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 2025-04-23
D · Potential for more than minimal harm
2025-04-03
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-04-25
D · Potential for more than minimal harm
2025-04-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-03
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2025-04-23
E · Potential for more than minimal harm
2024-05-30
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 2024-06-30
E · Potential for more than minimal harm
2023-02-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
Ownership
Imhoff, Gerald
5% Or Greater Indirect Ownership Interest · Individual
Berns, Margaret
Corporate Officer · Individual
Brennan, Karen
Corporate Director · Individual
Brown, Connie
Corporate Officer · Individual
Hartley, Brent
Operational/Managerial Control · Individual
Heim, Rita
Corporate Officer · Individual
Hoffman, Christine
Operational/Managerial Control · Individual
Imhoff, Gerald
Corporate Officer · Individual
Kuhn, Samuel
Operational/Managerial Control · Individual
Mulholland, Catherine
Operational/Managerial Control · Individual
Perkins, Steven
Operational/Managerial Control · Individual
Peters, Darrell
Corporate Officer · Individual
Seitz, Rebecca
Corporate Officer · Individual
Severson, Chloe
Operational/Managerial Control · Individual
Ulrich, Karen
Operational/Managerial Control · Individual
Weymiller, Bonita
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Northgate Care Center
Waukon, IA
3-star overall rating with 3-star inspections with 8 recent health deficiencies
#2
Good Samaritan Society - Waukon
Waukon, IA
3-star overall rating with 3-star inspections with $8,281 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Prairie Maison
Prairie Du Chien, WI
1-star overall rating with 1-star inspections with $152,525 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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