Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Calvin Community during CMS and state inspections, most recent first.
Incomplete Psychotropic Medication Care Planning: The facility failed to develop resident-specific care plans for psychotropic medication use for multiple residents. Care plans for residents receiving antidepressants and antipsychotics did not identify targeted behaviors, resident-specific non-pharmacological interventions, or, for one resident, antipsychotic-related behaviors and side effects to monitor. One resident’s behavior log documented cursing, screaming, grabbing, hitting, kicking, scratching, and rejecting care, while staff interviews confirmed these details were not being incorporated into the care plans.
Hand hygiene and infection control practices were not followed during medication administration and wound care. A RN administered medications to multiple residents and used a shared wrist BP cuff without sanitizing hands or equipment between residents, while also touching multiple surfaces during the process. For wound care, a resident with a Stage 3 pressure wound on the right foot received treatment without full EBP; the RN removed gloves after cleansing the wound, did not perform hand hygiene, and reapplied gloves without a gown, despite CDC EBP signage calling for gloves and a gown for wound care and skin openings requiring a dressing.
Incomplete discharge summary and missing resident/family documentation: The facility failed to complete a discharge summary, including a recapitulation of stay, for a resident admitted with fractures and other multiple trauma after the resident discharged. The record lacked the discharge summary, lacked documentation that it was provided to the resident and/or family, and did not contain a signed discharge summary. The ADON stated the discharge summary is normally completed by the ADON and unit manager and signed by the resident/family, but acknowledged it was not completed for this resident.
Failure to transcribe and initiate a Sertraline order: A resident with severe cognitive impairment, depression, and stroke had provider-documented orders to increase Sertraline from 75 mg to 100 mg due to combative behaviors, but the order was missed and the EHR continued to show the lower dose. Nursing staff acknowledged the provider visit, and the ADON confirmed the increase was missed by the previous unit manager; the Administrator stated there was no specific policy for transcribing or initiating physician orders.
Wheelchair Transport Without Foot Pedals: A resident with intact cognition and diagnoses including HF and vascular dementia was pushed by an RN in a wheelchair without foot pedals while being transported over 100 feet to the dining room. The resident lifted their feet off the ground during the transport, and the RN later confirmed the foot pedals were not attached. The DON stated foot pedals should be used when staff push residents, and the Administrator reported there was no specific policy for wheelchair transport.
Unlocked Medication Cart Left Unattended: A medication cart was observed unlocked by the elevator with two residents nearby and a visitor able to access items from the cart and water pitcher while no staff member was in sight. An LPN later locked the cart and stated it was not his cart, while the RN responsible for the cart acknowledged leaving it unattended and unlocked. The DON and facility policy both stated medication carts are to be kept locked when out of sight.
A staff member prepared lunch food for two residents on a pureed diet while wearing a beard and mustache that were not covered by a net. The ADM stated facial hair should be covered in the kitchen, and the facility policy required a hairnet or facility hat. The FDA Food Code also requires effective hair restraints, including beard restraints, in food prep areas.
Incomplete documentation for antibiotic use related to UTI. A resident with intact cognition and frequent incontinence was given Cipro, but the EHR did not identify the reason for the antibiotic. There was no documentation of the resident’s symptoms, provider discussion before the antibiotic was started, or orders for additional testing, although nursing texted the ARNP about urinary frequency and burning and the ARNP agreed to a UA. The DON and ADON acknowledged the missing documentation.
A resident with severe cognitive impairment was left exposed in a hallway while waiting for a shower, as the blanket covering them slipped, leaving their groin area exposed. The resident, who has multiple diagnoses including Alzheimer's and Parkinson's, typically waits outside the shower room to avoid self-propelling away. The DON acknowledged the expectation for the resident to be covered appropriately.
A facility failed to accurately code the MDS assessment for a resident by omitting the use of an anticoagulant, despite the resident being prescribed and administered Warfarin for chronic atrial-fibrillation. The care plan included anticoagulant therapy, but the MDS only documented the use of a diuretic and an anti-platelet. An LPN acknowledged the discrepancy.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident receiving hospice services did not have this documented in their care plan. Two residents had inaccuracies in their care plans regarding the use of wanderguard devices, with one resident's care plan showing an incorrect implementation date and another's not updated to reflect the removal of the device. Staff interviews confirmed these discrepancies.
The facility failed to refer a resident with a negative Level I PASRR result for a Level II PASRR evaluation after the resident was later identified with a serious mental disorder. The resident had diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, and was taking multiple psychiatric medications. The Social Services Director confirmed the last PASRR was completed over a year ago and acknowledged the oversight in updating the PASRR after new medications were added.
Incomplete Psychotropic Medication Care Planning
Penalty
Summary
The facility failed to develop comprehensive, resident-specific care plans for psychotropic medication use for 4 of 5 residents reviewed. For Resident #3, the care plan noted antidepressant use and a goal related to maintaining functional status, but it did not identify the targeted depressive behaviors being treated or monitored and did not include resident-specific non-pharmacological interventions. Resident #3 had a BIMS score of 15 and diagnoses including major depressive disorder, recurrent, and moderate, and was receiving Trazadone and Wellbutrin daily. For Resident #6, the care plan addressed antidepressant and antipsychotic use with goals related to avoiding medication-related sedation, hypotension, and anticholinergic symptoms, and included interventions such as administering medication as ordered, monitoring functional status, pharmacy consultation, AIMS testing, gradual dose reduction attempts, and monitoring behavior and response to medication. However, it did not identify the resident-specific targeted behaviors being treated or monitored, and it did not include resident-specific non-pharmacological interventions. Resident #6 had a BIMS score of 3 and diagnoses including dementia, anxiety disorder, depression, and delusional disorders, and was receiving Seroquel, Sertraline, and Melatonin. For Resident #2, the care plan addressed antidepressant use but did not identify targeted depressive behaviors, resident-specific non-pharmacological interventions, or the antipsychotic use, possible side effects, targeted behaviors, or non-pharmacological interventions. Resident #2 had a BIMS score of 15 and diagnoses including anxiety and major depressive disorder with psychotic symptoms, and was receiving Mirtazapine, Venlafaxine, and Aripiprazole. For Resident #44, the care plan addressed antidepressant use but did not identify targeted depressive behaviors or resident-specific non-pharmacological interventions. Review of the Behavior Analysis Report showed documented episodes of cursing, screaming, grabbing, hitting, kicking, scratching, and rejecting care, with staff interventions including back rub, calm environment, one-on-one, position change, and redirection. Interviews with the DON, MDS Coordinator, and Director of Social Services confirmed that resident-specific targeted behaviors and non-pharmacological interventions were not being included on the care plans.
Hand Hygiene and Wound Care Infection Control Failures
Penalty
Summary
The facility failed to use proper hand hygiene and infection control practices during medication administration. During continuous observation, a RN administered medications to multiple residents on the 3rd floor and used a shared wrist blood pressure cuff on residents without sanitizing her hands or the cuff before or after use. The RN was also observed touching several surfaces between medication administrations, including resident wheelchairs, residents’ hands and clothing, the medication cart, the wall railing, and the inside of cups used to carry medications. The DON stated staff are expected to sanitize or wash their hands between resident medication administrations and that shared equipment should be cleaned or sanitized between residents if it can be cleaned. The facility also failed to use full Enhanced Barrier Precautions during wound care for a resident with a Stage 3 pressure wound on the right foot. During observation, the RN removed the old dressing, cleansed the wound, removed gloves, and then reapplied gloves and continued treatment without hand hygiene and without a gown. The DON stated the wound did not require EBP because it was not a chronic, non-healing wound, while posted CDC EBP signage in the hallway stated gloves and a gown are required for wound care and any skin opening requiring a dressing. The RN later confirmed she did not perform hand hygiene after cleaning the wound and before applying treatment, and the ADON stated staff are expected to change gloves and complete hand hygiene after cleaning a wound and before applying the new treatment.
Incomplete discharge summary and missing resident/family documentation
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of stay, for Resident #65 and failed to provide a discharge summary to the resident and/or family after the resident discharged from the facility. The admission MDS documented that Resident #65 was admitted with diagnoses including fractures and other multiple trauma. Review of the clinical record showed the resident discharged on 9/23/25, but the record lacked a discharge summary, a recapitulation of stay, and documentation that a discharge summary was provided. The clinical record also did not contain a signed discharge summary. During interview, the ADON stated he and the unit manager complete the discharge summary, which includes the recapitulation of stay, for residents who discharge from the facility. He stated the discharge documents are printed, signed by the resident and/or family, and a copy is placed in the clinical record. The ADON acknowledged that the recapitulation of stay was not completed for Resident #65 and that a discharge summary was not fully completed or signed. The facility’s Discharge Checklist stated the unit manager completes the discharge summary/transition of care, prints it, places it in the discharge folder after it is signed by the resident/family, uploads discharge paperwork into the EHR, and the DON/ADON completes the discharge recapitulation/discharge summary in the EHR observations.
Failure to Transcribe and Initiate Sertraline Order
Penalty
Summary
The facility failed to transcribe and initiate a physician order for Sertraline for one resident reviewed for medications. Resident #44 had a BIMS score of 3, indicating severe cognitive impairment, and diagnoses included depression and stroke. The MDS also indicated the use of an antidepressant. Review of scanned provider notes showed that the ARNP documented Sertraline 75 mg daily on 7/1/25 and wrote a new order to increase the dose to 100 mg daily because the resident was often combative with cares. The scanned progress note was acknowledged by an unidentified facility staff member. The Medical Director later documented that Sertraline was to be increased to 100 mg, but current orders still showed 75 mg. Another ARNP note documented the resident having episodes of pinching and hitting staff and again wrote an order to increase Sertraline to 100 mg. The EHR showed nursing staff acknowledged the 7/1/25 visit and documented new orders, but the Sertraline order history reflected doses of 50 mg daily, 75 mg daily, 100 mg daily, and later 125 mg daily. During interview, the ADON stated non-emergent orders from ARNP visits are transcribed from dictated visit notes and acknowledged the increase to 100 mg on 7/1/25 was missed by the previous unit manager. The Administrator stated there was no specific policy regarding transcribing or initiating physician orders.
Wheelchair Transport Without Foot Pedals
Penalty
Summary
The facility failed to provide services to protect a resident from accident hazards by transporting Resident #48 in a wheelchair without foot pedals. Resident #48’s MDS dated 11/28/25 showed a BIMS score of 15, indicating intact cognition, and diagnoses included heart failure and vascular dementia. The MDS stated the resident utilized a wheelchair independently, while the care plan last updated 11/21/25 documented that the resident required assistance with ambulation and included use of a wheelchair for longer distances, such as going to the dining room. During an observation on 12/17/25 at 12:20 PM, a RN pushed the resident from the nursing station to the dining room, a distance of over 100 feet, without foot pedals attached to the wheelchair. Staff B did not assess whether the wheelchair had foot pedals before pushing the resident, and the resident immediately lifted their feet off the ground and held them up during transport, with the feet dangling very close to the floor. Staff B later confirmed the wheelchair did not have foot pedals and acknowledged they should have been used when pushing the resident. The DON stated foot pedals should be on wheelchairs when staff push residents, and the Administrator stated there was no specific policy regarding transporting or assisting residents in wheelchairs.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store medications in a safe manner when a medication cart was left unlocked and unattended by the RN responsible for it. During a continuous observation on 12/18/25 at 10:00 AM, the medication cart located by the elevator on the 3rd floor was observed unlocked. Two residents were near the cart, and a male person who appeared to be a visitor retrieved a cup from the cart and the water pitcher and poured a glass of water, touching the unlocked cart while no staff member was by the cart or within eyesight of it. At 10:04 AM, an LPN walked by and locked the cart, stating at interview that it was not his cart that morning and that he locked it because he noticed it was unlocked. He identified the cart as the RN's cart and said the RN was in another room with a resident. At 10:10 AM, the RN acknowledged she had left the medication cart unattended and unlocked. The DON stated the expectation that all medication carts are locked, especially when unattended and out of view of staff. The facility policy stated that during medication administration, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.
Uncovered Facial Hair During Food Preparation
Penalty
Summary
Food was not prepared under sanitary conditions when Staff D prepared lunch food for two residents on a pureed diet while having a beard and mustache that were not covered by a net. During observation on 12/17/25 at 10:00 AM, Staff D was seen preparing food for the two residents without facial hair restraints. The Administrator later stated that if a staff member could grab a handful of beard, the facial hair would be expected to be covered in the kitchen, and also stated the facility had not previously had an issue with staff facial hair and had not thought about it. The facility’s Uniforms/Hair Restraints policy required employees to wear a hairnet or facility hat, and the FDA Food Code requires effective hair restraints, including beard restraints, in food preparation areas.
Incomplete Documentation for Antibiotic Use Related to UTI
Penalty
Summary
The facility failed to document and update the medical record for one resident related to a change in medical condition associated with a UTI. Resident #10 had intact cognition and was frequently incontinent. The Physician Order Report showed Ciprofloxacin was started and ended for the resident, but the EHR did not identify the rationale for its use. There was no documentation explaining the resident’s symptoms, any discussion with a care provider before the antibiotic was used, or acceptance and initiation of orders for additional testing. The resident stated that nursing staff were notified of UTI symptoms, including increased frequency, urgency, and burning. The DON and ADON acknowledged the lack of documentation regarding the use of Cipro. A screenshot of a text conversation showed nursing staff requested a urine analysis from the ARNP due to frequency and burning, and the ARNP agreed.
Failure to Maintain Resident Dignity During Shower Preparation
Penalty
Summary
The facility failed to maintain the dignity of a resident with severe cognitive impairment, as evidenced by an incident involving the resident waiting in a hallway outside the shower room. The resident, who has diagnoses including anxiety, paranoid personality disorder, Alzheimer's Disease, and Parkinson's Disease, was observed sitting in a shower chair with a blanket that had slipped, leaving the groin area exposed. This exposure occurred for an unknown amount of time until an unidentified employee adjusted the blanket. The resident typically waits outside the shower room due to a preference to avoid self-propelling away from the area, which could delay the shower. The Director of Nursing acknowledged the situation and stated that the expectation is for the resident to be appropriately covered while waiting in the hallway.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately code the federally mandated Minimum Data Set (MDS) assessment for one resident. The Quarterly MDS assessment for a resident indicated the use of a diuretic and an anti-platelet but did not document the use of an anticoagulant. However, the resident's care plan, reviewed and revised on January 21, 2025, included a problem statement indicating that the resident was prescribed anticoagulant therapy, with interventions to administer anticoagulants as ordered by the physician and to monitor/report labs. The care plan also noted a diagnosis of chronic atrial-fibrillation, which is commonly treated with anticoagulants. The Medication Administration Record for November and December 2024 showed that Warfarin, an anticoagulant, was prescribed and administered to the resident throughout both months. A Licensed Practical Nurse acknowledged in an interview that the MDS did not reflect the use of an anticoagulant, despite it being actively prescribed.
Failure to Update Care Plans for Hospice and Wanderguard Interventions
Penalty
Summary
The facility failed to update and revise care plans for three residents, leading to deficiencies in their care. Resident #20, who had a diagnosis of cancer with metastasis, was receiving hospice services, but this was not documented in the care plan. Despite the completion of a Significant Change MDS due to the resident's choice for hospice, the care plan was not updated to reflect the hospice services being provided. This oversight was confirmed during interviews with the resident and staff, who acknowledged the care plan should have been updated. For Resident #22, the care plan inaccurately documented the implementation date of a wanderguard device, which was intended to prevent elopement. The care plan stated the device was implemented on 10/29/24, but records and staff interviews indicated it was actually placed on 11/28/24 after the resident exhibited wandering behaviors. Similarly, Resident #38's care plan included a wanderguard intervention that was no longer applicable, as the device had been removed in November following an evaluation that showed no signs of elopement. Staff interviews confirmed the care plan was not updated to reflect the removal of the wanderguard.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident with a negative Level I PASRR result for a Level II PASRR evaluation and determination after the resident was later identified with newly evident or possible serious mental disorder. The resident, who entered the facility with diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, was documented to have taken antipsychotic, antidepressant, and hypnotic medications. Despite these indicators, the clinical record lacked documentation of a referral for a Level II evaluation when the resident's diagnosis of bipolar disorder was added. The Social Services Director confirmed that the resident's last PASRR was completed on 2/28/22 and acknowledged that a new medication had been added to the resident's treatment plan. The SS Director reported that nursing staff were supposed to inform her of any new medications or psychiatric diagnoses so she could update the PASRR. However, this process was not followed, leading to the deficiency. The facility did not have a policy for PASRR at the time of the incident, and the SS Director had to resubmit a request for a PASRR review only after the deficiency was identified.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ramsey Village | 1.2 mi | ★★★★★ | 44 | 0 |
| Iowa Jewish Senior Life Center | 1.5 mi | ★★★★★ | 20 | 0 |
| Scottish Rite Park Inc | 2.1 mi | ★★★★★ | 1 | 0 |
| Wesley On Grand | 2.2 mi | ★★★★★ | 0 | 0 |
| Karen Acres Care Center | 2.6 mi | ★★★★★ | 1 | 0 |
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