Cycle 1
Health 2024-12-12 · Fire 2024-12-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Wall Lake, IA
Twilight Acres
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
600 West 6th Street, Wall Lake, IA
(712) 664-2488
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
39
Certified beds
Average residents
21
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-09-01
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
1.00
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.83
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
4.80
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.35
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.65
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 6.65% |
| 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 | 0.82 |
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 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · 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 12 · 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 40 |
| Staff flu vaccination coverage | 18.37% |
42%
23.6 pts worse
|
Numerator 9 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · 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 6 · 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 | 2.2 |
1.5
0.7 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.3 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
94.0%
0.9 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
95.2%
About the same
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
3.7%
3.9 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
4.0%
2.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
4.9%
1.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
20.6%
11.4 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
19.8%
13.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.7% |
18.5%
3.8 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
18.3%
8.6 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.2% |
1.7%
3.5 pts worse
|
1.0%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.2% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
26.0%
0.3 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.3%
2.4 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
84.3%
10.5 pts worse
|
81.7%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 73.8% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
2 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-02 · Fire 2022-08-02
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-12-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-12-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-12-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-12-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-17
F · Potential for more than minimal harm
2024-12-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-12-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-17
E · Potential for more than minimal harm
2023-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-19
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-10-26
F · Potential for more than minimal harm
2022-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-11
F · Potential for more than minimal harm
2022-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-05
F · Potential for more than minimal harm
2022-08-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-08-02
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-08-04
E · Potential for more than minimal harm
2022-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-15
E · Potential for more than minimal harm
2022-08-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2023-10-19
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-19
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-20
L · Immediate jeopardy
2022-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-08-02
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 2022-08-19
E · Potential for more than minimal harm
2022-08-02
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 2022-08-19
E · Potential for more than minimal harm
2022-08-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
Ownership
Aschinger, Marilyn
Corporate Director · Individual
Geibe, Nicole
Operational/Managerial Control · Individual
Harman, Tony
Operational/Managerial Control · Individual
Helm, Cindy
Operational/Managerial Control · Individual
Horsley, Alison
Operational/Managerial Control · Individual
Hundling, Melanie
Corporate Officer · Individual
Pek, Zoltan
Operational/Managerial Control · Individual
Schmitz, Sandra
Corporate Officer · Individual
Schroeder, Diane
Corporate Officer · Individual
Steinkamp, Jenna
Operational/Managerial Control · Individual
Stoltenberg, Ann
Corporate Director · Individual
Vilhauer, Ann
Corporate Director · Individual
Nearby options
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Odebolt, IA
4-star overall rating with 3-star inspections with $14,433 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Park View Rehabilitation Center
Sac City, IA
2-star overall rating with 2-star inspections with 9 recent health deficiencies
#3
Accura Healthcare of Carroll
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1-star overall rating with 1-star inspections with 23 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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