Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Edgewater, A Wesleylife Community during CMS and state inspections, most recent first.
A resident with AFib, prior stroke, traumatic brain injury, and valvular disease had a hospital-ordered diuretic discontinued on admission, but the facility did not document notifying the family of this medication change. The resident later developed 3+ arm edema that affected ADLs, yet provider notification was not documented until a later date and without mention of the ADL impact. The resident also expressed new end-of-life–type statements to family, but there was no documentation of provider notification or further assessment, despite staff and facility policies requiring timely MD and family notification and progress note documentation for changes in condition and treatment.
A resident with moderately impaired cognition, cardiac and neurologic comorbidities, and recent hospitalization received new diuretic orders after staff documented increased weight, bilateral lower extremity edema, shortness of breath with exertion, and phlegm. Although nurses and the DON reported that treatment changes, including medications, should be added to the care plan within 24–48 hours and that the MDS Coordinator manages medication updates, the revised care plan did not include the resident’s diuretic therapy or instructions for monitoring or intervention, contrary to the facility’s comprehensive care plan policy.
A resident with CHF, AFib, prior stroke, traumatic brain injury, and a narrowed heart valve experienced progressive edema, weight gain, and respiratory changes, including audible wheezing and shortness of breath with exertion, while on diuretic therapy. Nursing notes documented increasing edema in the arms and lower extremities, respiratory wheezing, and family concerns that led to a change in diuretic. After the last note indicating continued wheezing, the clinical record contained no further lung sound assessments, despite staff statements and facility policy that CHF residents should receive ongoing monitoring of weight, lung status, edema, breathing, congestion, and shortness of breath. This lack of continued assessment and documentation following a change in condition led to the cited deficiency.
A resident with moderate cognitive impairment and a history of wandering exited the facility through an unalarmed patio door that had not been relocked after family use. The resident was outside briefly before being noticed and brought back inside by staff. The care plan included monitoring and diversional activities, but staff had not completed required door checks at the time of the incident.
A resident with a history of respiratory failure and metastatic cancer experienced acute respiratory distress, including low oxygen saturation and fever. Despite family and CNA requests for help, the LPN delayed assessment for about 45 minutes. CNAs initiated oxygen and notified the nurse, but the care plan lacked respiratory interventions and the facility's policy for prompt response to changes in condition was not followed.
The facility failed to secure medications from unauthorized access. A medication room door was found propped open, with medications left on the counter. An LPN stated the medications were left due to a resident's preference, and the door was meant to be closed. The DON confirmed the door should be closed when unattended. The facility's policy requires medications to be stored in locked areas, which was not followed.
A facility failed to protect resident information when a document containing sensitive data was left unattended in an open area. An LPN admitted to leaving the 24-hour nurses' report sheet out because residents were asleep, but acknowledged it should not be left unattended. The DON confirmed that staff should ensure such paperwork is not visible when unattended, aligning with the facility's policy to protect resident privacy.
A resident with intact cognition and multiple medical conditions did not receive a physician-ordered dressing change for her right shoulder. Despite the order for daily dressing changes, the care plan lacked directives, and progress notes did not document the change. Staff interviews revealed inconsistencies, with one RN advising the resident to leave the wound open and signing off on the TAR without performing the change. The facility lacked a policy for following physician's orders.
The facility failed to serve correct portions of mashed potatoes to five residents during lunch, using incorrect serving utensils that did not match the planned menu's specified portion size. Staff used a green-handled scoop identified as a 3.3 oz serving size instead of the required 1/2 cup, and the Dietary Manager later confirmed the error. The facility's guidelines for checking trays before serving were not followed.
The facility failed to maintain sanitary practices in food storage and service, with unlabeled and uncovered food items in storage areas. Staff members were observed handling food and dishes without proper hand hygiene, and some prepared food with uncovered facial hair. These actions violate FDA Food Code and facility policies, as confirmed by the dietary manager and director of food and beverage.
Failure to Notify Physician and Family of Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely notification to the physician and family regarding changes in a resident’s condition and treatment. Resident #1 had a history of atrial fibrillation, stroke, traumatic brain injury, and a narrowed heart valve, and had been receiving a diuretic during a recent hospitalization. The hospital discharge summary ordered the diuretic to continue for a defined period, but on admission the facility physician discontinued the diuretic, and a nurse’s note documented provider clarification to discontinue the PRN diuretic. The clinical record, however, lacked any documentation that the resident’s family or representative was notified of this medication discontinuation, despite staff interviews indicating that whoever processes a medication change is expected to notify the family and document the communication in the progress notes. Subsequently, the resident developed 3+ edema in the left arm from elbow to hand, as documented on the Summary of Daily Skilled Services. During a care conference, the occupational therapist reported edema in the resident’s arms that made ADLs more difficult, and the DON reviewed the resident’s weights and medications with the resident and her representatives. Despite these observations, the progress notes did not show that the provider was notified of the edema until a later date, and the note at that time did not include that the resident was having increased difficulty performing ADLs due to the edema. The resident’s care plan also lacked directives to notify the family or provider of anything other than abnormal labs to the MD. Later documentation showed that the resident told her daughter she wanted all her children to come see her and that she wanted to hear the voice of Jesus, indicating a change in behavior. The progress notes lacked any notification to the provider about this request or behavioral change. Multiple staff, including RNs and an LPN, stated in interviews that such comments and requests, if new for the resident, would constitute a change of condition requiring further assessment, provider notification, and documentation. The DON and other staff confirmed that facility policy required notifying the physician and family of changes in condition and documenting the time of call, person spoken to, reason for call, and response, but the resident’s record did not contain this required documentation for the medication discontinuation, the onset of edema, or the behavioral change.
Failure to Incorporate Diuretic Therapy Into Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to individualize a resident’s comprehensive care plan by omitting the resident’s diuretic medication therapy and related monitoring needs. The resident had moderately impaired cognition with a BIMS score of 12 and required varying levels of assistance with ADLs and mobility. Diagnoses included atrial fibrillation, prior stroke, traumatic brain injury, and a narrowed heart valve. The resident received a diuretic during a hospital stay, with discharge orders directing its use for a defined period. Upon admission, the facility physician discontinued the diuretic, but subsequent nursing documentation showed the resident developed increased bilateral lower extremity edema, shortness of breath with exertion, and phlegm, prompting provider notification. Following these changes, nursing staff documented new diuretic orders due to the resident’s increased weight and edema. Despite this, the care plan revised on a later date did not include the resident’s diuretic therapy or provide staff with directions on what to monitor or when to intervene. Multiple nursing staff and the DON stated that changes in treatment, including medication changes, should be reflected in the care plan within 24–48 hours of initiation, and that any nurse could update the care plan, with the MDS Coordinator designated to manage medication updates. The facility’s Comprehensive Care Plan Process policy required that the care plan describe services furnished to attain or maintain the resident’s highest practicable well-being, but the resident’s care plan lacked the diuretic-related interventions and monitoring despite the new orders and documented clinical changes.
Failure to Ongoingly Assess CHF Resident After Respiratory and Edema Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing assessments and interventions for a resident with a history of CHF and multiple cardiac and neurologic diagnoses. The resident’s MDS showed moderately impaired cognition, independence with eating, and need for assistance with transfers and ADLs. Diagnoses included AFib, prior stroke, traumatic brain injury, and a narrowed heart valve, and the resident was receiving a diuretic. Clinical documentation showed progressive edema and respiratory concerns: 3+ edema in the left arm, increased edema in both lower extremities, and shortness of breath with exertion and phlegm. During a care conference, the OT reported arm edema affecting the resident’s ability to perform ADLs, and the DON reviewed weights and medications. Subsequent nursing notes documented increased weight, fluid buildup in the forearms, audible wheezing, and a family request to change the diuretic, which led to a new diuretic order. Despite these documented changes in condition, including ongoing wheezing noted in the early morning hours, the clinical record lacked further assessments of the resident’s lung sounds after that point. Staff interviews indicated that for residents with CHF, nurses were expected to assess daily weights, lung status, edema, breathing, congestion, and shortness of breath. The facility’s Change of Condition Monitoring Process policy defined a significant change in status as requiring immediate nurse assessment, intervention, documentation, and physician notification and follow-up. However, the record did not contain continued respiratory assessments following the last documented wheezing, indicating a failure to follow the facility’s own assessment and monitoring expectations for a resident with CHF and documented respiratory and edema changes.
Resident Exited Facility Through Unsecured Patio Door Due to Inadequate Supervision
Penalty
Summary
A resident with moderately impaired cognition, as indicated by a BIMS score of 12 out of 15 and diagnoses including diabetes mellitus, dementia, Parkinson's disease, and encephalopathy, was able to exit the facility into a patio area without staff knowledge. The resident required varying levels of assistance with daily activities and was identified as an elopement risk with a history of wandering. The resident's care plan included interventions for wandering, such as offering diversional activities and monitoring a wander management device, which was in place and functioning at the time of the incident. The incident occurred when the resident exited through an unalarmed patio door that was supposed to remain locked but had not been relocked after use by a family member. Staff had not yet completed the required door checks for that shift, which contributed to the resident's unsupervised exit. The resident was outside for a short period before being noticed and assisted back inside by staff. Facility documentation and staff interviews confirmed that the door was not secured as required, and the care plan did not include additional interventions for wandering beyond those already in place.
Delayed Nursing Assessment and Intervention for Acute Respiratory Change
Penalty
Summary
A deficiency occurred when staff failed to provide timely assessment and intervention for a resident who experienced a significant change in condition. The resident, who had diagnoses including anxiety, depression, respiratory failure, and metastatic cancer, was observed by a family member to be breathing abnormally and complaining of being cold. The family member alerted a CNA and requested a nurse, but the LPN on duty delayed responding for approximately 45 minutes. During this time, CNAs measured the resident's temperature at 102°F and oxygen saturation at 75% on room air, then initiated supplemental oxygen and notified the LPN. The LPN arrived later, assessed the resident, and administered medications as ordered, but the delay in assessment and intervention was documented by both staff and family accounts. The resident's care plan did not include respiratory-related interventions, despite the resident's history and acute symptoms. Documentation showed that the LPN recorded improved oxygen saturation after intervention, but EMS later found the resident's oxygen saturation had dropped again, requiring increased oxygen support. Facility policy required prompt nurse assessment and physician notification for changes in condition, but this was not followed in this instance, as confirmed by staff interviews and review of the facility's change of condition monitoring process.
Medication Security Lapse
Penalty
Summary
The facility failed to secure prescribed medications from unauthorized access, as observed during a survey. On October 16, 2024, at 2:38 am, the medication room door was found propped open with a floor stopper, and a small basket of over-the-counter medications was on top of a cart. Additionally, two medication packets, Prednisone and Furosemide, were lying on the counter. Staff A, an LPN, stated that medications were not stored in the medication room and explained that the resident did not want staff in her room before 6:00 am, so he left the medications there. He also mentioned that the door was supposed to be closed to prevent resident access, but it was propped open. On October 17, 2024, the DON confirmed that the medication room door should be closed if the nurse is not present. The facility's policy, revised in September 2020, requires all prescription medications to be kept in a locked cabinet and all other medications to be stored in a locked area not accessible to anyone other than employees responsible for administration and storage. This policy was not adhered to, leading to the deficiency.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed during a survey. A document containing resident information was found on a table in an open area of the unit without any staff present. This incident occurred at 2:55 am, and the document was identified as the 24-hour nurses' report sheet. Staff A, an LPN, admitted to leaving the document out because all residents were asleep, acknowledging that it should not be left unattended. Later, the Director of Nursing confirmed that staff should ensure paperwork with resident information is not visible to others when unattended. The facility's policy, revised in January 2015, emphasizes the commitment to protecting the privacy and confidentiality of residents' Protected Health Information. Despite this policy, the observed incident indicates a lapse in adherence to these standards, as the document was left exposed in a public area, potentially compromising resident privacy.
Failure to Follow Physician Orders for Dressing Changes
Penalty
Summary
The facility failed to follow physician orders for dressing changes for a resident, leading to a deficiency. The resident, who had a BIMS score indicating intact cognition, reported that her right shoulder dressing was not changed as ordered on a specific date. The resident's medical history included cancer, depression, a right artificial shoulder joint, morbid obesity, and osteoarthritis, requiring moderate to maximum assistance with ADLs. The physician's order specified a daily dressing change for the right shoulder, but the care plan lacked wound care directives, and the progress notes did not document the dressing change on the specified date. Staff interviews revealed inconsistencies in the dressing change process. One RN admitted to advising the resident to leave the wound open to air and did not apply a dressing, despite signing off on the TAR indicating the dressing change was completed. Another RN confirmed changing the dressing on a different date, while a third RN stated she did not apply the current dressing. The facility lacked a policy specific to following physician's orders, and the DON emphasized that orders should not be signed off until treatments are completed.
Inadequate Portion Control in Meal Service
Penalty
Summary
The facility failed to serve the appropriate portions of mashed potatoes to five residents during lunch service, as observed on 7/14/24. The planned menu specified a 1/2 cup serving of mashed potatoes, but the staff used a green-handled scoop, which was later identified as a 3.3 oz serving size, instead of the correct portion size. The Dietary Manager (DM) noticed the incorrect serving scoop was used, which did not align with the therapeutic spreadsheet that staff should have followed to ensure the correct diet serving size. During the lunch preparation and service, Staff G, a homemaker cook, used various serving utensils but was unable to identify the serving size of the short, green-handled scoop used for mashed potatoes. The DM later confirmed the error in serving portions. Additionally, Staff B, another homemaker cook, used a gray-handled serving scoop, identified as a 4-oz serving size, further contributing to the inconsistency in portion sizes. The facility's document titled 'Feeding a Resident' directed staff to check trays before serving to ensure compliance with the resident's diet, which was not adhered to in this instance.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and service, as observed during a survey. In the walk-in cooler, several food items, including American cheese, butter, beef base, blue cheese, and milk, lacked open date labels. Similarly, in the dry storage room, items such as spaghetti noodles, elbow noodles, penne noodles, orange gelatin mix, coconut topping, pecan nuts topping, and graham cracker cookie crumble were not labeled with open dates. Additionally, spaghetti noodles were not properly covered. In the freezer, ready-to-bake cookie dough and tenderloin patties were also found uncovered and without open date labels. These practices violate the FDA Food Code, which requires food packages to be in good condition to prevent contamination. Further observations revealed improper hand hygiene and food handling by staff members. A homemaker cook was seen wiping her ungloved hand on her jacket before handling plates and food, without performing hand hygiene. She also handled used dishes and served drinks without washing her hands. Another staff member, a sous chef, was observed preparing food with uncovered facial hair. Additionally, a homemaker cook opened a cereal package, disposed of it, and handled milk without washing her hands, and her thumb contacted the inside of a bowl while serving a resident. The facility's dietary manager and director of food and beverage confirmed that staff should wash hands before and after glove use, after touching trash, and that all food should be labeled, dated, and covered. The facility's hand hygiene policy also mandates hand washing after contact with contaminated items and after glove removal.
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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 West Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Ridge Village | 0.7 mi | ★★★★★ | 9 | 0 |
| Arbor Springs Of West Des Moines L L C | 1.4 mi | ★★★★★ | 2 | 0 |
| Harmony West Des Moines | 3.4 mi | ★★★★★ | 21 | 0 |
| The Village Of Legacy Pointe Nursing Facility | 4.1 mi | — | 0 | 0 |
| Deerfield Health Care Center | 4.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.