Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Iowa Jewish Senior Life Center during CMS and state inspections, most recent first.
Kitchen sanitation and dining room table cleaning were not performed as directed. A dietary mgr had unlabeled sanitizer test strips and one labeled container was expired, and a dietary aide used a Quix Plus sanitizing towel in a bucket of water without squeezing it 10 times to activate the 200 ppm quaternary solution before wiping tables, chairs, and table items. Expired test strips prevented verification of the solution strength, and the ED agreed the tables were initially not sanitized as directed.
Hand Hygiene Not Performed During Medication Pass: A CMA failed to wash or sanitize hands before preparing and administering medications to four residents during a medication pass. The CMA gave oral meds, assisted with water and swallowing, took a BP, and documented the administrations in the EMR and narcotic binder without hand hygiene between residents. The DON and ADON/IP stated staff should wash hands or use hand sanitizer before medication administration and between residents, and the facility policy required hand hygiene before and after each medication administration.
A resident with severe cognitive impairment had inconsistent code status documentation across the IPOST, EHR, and Care Plan. The IPOST and EHR documented CPR, while the Care Plan listed DNR. RN/QA, an LPN, and the DON all acknowledged the mismatch and stated code status should match in all areas of the clinical record.
A resident’s hospice level of care was discontinued, but the facility did not complete a significant change MDS assessment. The EHR and ABN showed hospice services ended and the resident moved to private-pay status, yet the MDS tracking schedule lacked the required significant change assessment. The RN/QA and DON both acknowledged the assessment was expected under the RAI manual, which defines hospice enrollment as a significant change.
A facility failed to submit a Level II PASRR eval for a resident after a new PTSD dx was documented. The resident’s admission MDS, care plan, and medical record all reflected PTSD and a trauma history, but the later PASRR screening listed major depression and anxiety disorder without PTSD. The Administrator said the facility followed Maximus guidelines and did not have a PASRR policy, and the DON acknowledged the Level II PASRR should have been submitted but had focused on med changes rather than dx changes.
A facility failed to ensure proper infection control during meal service, as a cook used gloved hands to serve meals without changing gloves or performing hand hygiene consistently. The cook touched various surfaces and food items, including seasoned peas, parsley, spaghetti, sandwiches, and more, with the same gloves, contrary to the facility's policy requiring glove changes between tasks to prevent foodborne illness.
The facility failed to update care plans for two residents diagnosed with RSV, lacking directives for droplet precautions. Despite signs and protective equipment being present, interviews confirmed care plans were not updated to reflect current needs, contrary to facility policy.
A resident with Alzheimer's and dementia was found with a bruise on her left forearm, which was not documented or assessed by the facility staff. The bruise was discovered by a CNA and reported to an RN, but no follow-up was conducted. The resident's family raised concerns about protective sleeves covering the bruise, leading to an investigation that revealed a lack of communication and documentation among staff.
The facility failed to follow infection control practices for residents on droplet precautions, specifically for three residents diagnosed with RSV. Staff were observed feeding residents without wearing required PPE such as gowns and gloves, despite the presence of droplet precautions signs and available PPE. Additionally, a housekeeper improperly handled soiled linens by carrying them against her uniform instead of using a bag, contrary to the facility's linens policy.
A facility failed to notify the State LTC Ombudsman of a resident's transfer to the hospital. The transfer was not documented on the Notice of Transfer Form due to a reporting issue in the electronic health records system. The facility lacked a policy for notifying the LTC Ombudsman about transfers, although it was expected that all transfers be reported.
The facility failed to meet professional standards by not observing a resident take their medications. The resident, with diagnoses of heart failure, anxiety, and depression, was found holding a medication cup with several pills. Interviews with LPNs and the Director of Nursing confirmed that staff are expected to stay with residents until the medication is swallowed, as per facility policy.
A significant medication error occurred when a Certified Medication Aide, unfamiliar with a resident, mistakenly administered medication intended for another resident. The error was discovered when the aide realized the mistake during the medication pass. The resident was sent to the emergency room for evaluation, and hospital records indicated that the mental status change was likely related to pre-existing high potassium levels.
The facility failed to maintain infection control standards during meal assistance and catheter care for two residents. A CMA was observed using the same gloves while assisting two residents with their meals, and a CNA did not change gloves or perform hand hygiene after touching contaminated objects before performing catheter care. The DON confirmed that these actions violated the facility's infection control policies.
Kitchen Sanitizer Controls and Dining Table Sanitization Not Followed
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen and failed to properly sanitize dining room tables in one of the resident dining rooms. During a dietary manager interview, he produced sanitizer test strips from a small plastic container that had no label and stated he was not sure where the product label was. A second unlabeled container of sanitizer test strips was later found by the mechanical dishwasher, and a third container found by the three-compartment sink had a label showing quaternary ammonium test strip information and an expiration date of January 1, 2025, which was 15 months old at the time of the observation. The dietary manager could not confirm the expiration dates of the unlabeled containers. During observation of the dining room cleaning process, a dietary aide used a Quix Plus water release surface sanitizing towel in a red six-quart bucket with three quarts of tap water to clean the main dining room tables after the noon meal. She placed the towel in the water and began wiping tables, chair arms and seats, salt and pepper shakers, condiment trays, and vases without first squeezing the towel 10 times to activate the sanitizing solution as directed on the product label. She continued to place the towel back into the bucket and wring it out repeatedly while cleaning five tables before being informed that she had wrung out the towel ten times after wiping five tables. She agreed with that observation and then continued cleaning the remaining two tables and associated items. When the dietary aide was later asked to review the product directions, she agreed that she had not squeezed the towel ten times before using it to sanitize the dining room tables. A test of the sanitizing solution in the red bucket could not be completed because the available sanitizer test strips were expired. The dietary manager stated he could not find any sanitizer test strips with labels other than the expired strips and was unsure how long expired strips had been used. The executive director agreed staff were not able to ensure sanitizer ppm using expired test strips and agreed the dining room tables had initially not been sanitized as directed because the cloth had not been squeezed 10 times. Review of the product label showed the towels were to be immersed in one gallon of water, squeezed 10 times to activate a 200 ppm quaternary sanitizing solution, and tested regularly with quaternary test strips.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
The facility failed to perform appropriate hand hygiene during medication administration for four residents observed on 4/1/26. During a continuous observation from 7:28 a.m. to 8:25 a.m., Staff D, a CMA, did not clean or sanitize her hands before preparing medications for Resident #4, Resident #17, Resident #27, and Resident #24. For Resident #4, she prepared 13 medications, then gave the resident a medication cup containing 12 oral medications, an oral inhaler medication, and water, and later documented the administration in the EMR and narcotic binder. For Resident #17, she prepared six oral medications, assisted the resident with taking them, held the resident’s water mug while the resident sipped through a straw, and then documented the administration in the EMR and narcotic binder. Staff D also failed to clean and sanitize her hands before preparing five oral medications for Resident #27 and six oral medications for Resident #24. For Resident #27, she wheeled the resident to the medication cart, applied a blood pressure monitor to the resident’s left upper arm, took the resident’s BP, placed each pill in the resident’s mouth with a plastic spoon, and assisted with water through a straw before documenting the medications and BP in the EMR. For Resident #24, she walked into the dining room, gave the resident the medication cup with six oral medications, assisted the resident to take the pills with a plastic spoon and water, and documented the medication administration in the EMR and narcotic binder. Staff D acknowledged she had failed to clean and sanitize her hands during the medication pass, and the DON and ADON/IP stated staff should wash hands or use hand sanitizer before medication administration and between residents. The facility policy titled Administration of Medication, dated 7/9/24, instructed licensed nursing personnel and/or certified medication aides to wash hands or use hand sanitizer before and after each administration of medication.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure the resident's code status was consistent across the Iowa Physician Orders for Scope of Treatment (IPOST), the electronic health record (EHR), and the Care Plan for one resident reviewed for advance directives. Resident #46 had an admission MDS assessment showing a BIMS score of 6, indicating severe cognitive impairment. The IPOST, signed by the physician and the resident's responsible party, documented CPR. The EHR also documented CPR with limited additional interventions and no artificial nutrition by tube. However, the Care Plan for advanced directives, initiated and revised during the resident's stay, documented the code status as DNR. During interviews, RN/QA staff acknowledged that the Care Plan did not match the IPOST or EHR and stated code status should match word for word in all areas. An LPN stated she would review a resident's code status in the chart, IPOST, EHR, and Care Plan as needed. The DON also stated she would expect code status to match in all areas of the clinical record.
Failure to Complete Significant Change MDS After Hospice Discontinued
Penalty
Summary
The facility failed to complete a significant change MDS assessment after Resident #25’s hospice level of care was discontinued. The EHR showed the resident transitioned from hospice private care to private-pay status on 9/24/25, and an ABN dated 9/22/25 stated hospice services would end on 9/24/25. Review of the resident’s MDS assessments showed the resident was not receiving hospice services, but the MDS tracking schedule did not include a significant change assessment after hospice was discontinued. During interview, the RN/QA acknowledged that a significant change MDS had not been completed as expected after the resident discontinued hospice level of care and stated she would have expected one to be completed in accordance with the RAI manual. The DON also stated she would expect a significant change MDS when a resident discontinued hospice level of care and reported the facility does not have a policy for MDS significant changes because it follows the RAI manual. The RAI manual states the MDS assessment must be completed no later than 14 calendar days after the determination of a significant change in the resident’s status, and hospice enrollment is defined as a significant change.
PASRR Evaluation Not Submitted for New PTSD Diagnosis
Penalty
Summary
The facility failed to submit a Level II PASRR evaluation for one resident with a new mental health diagnosis. A Level 1 PASRR screening completed by a local hospital prior to admission identified depression/depressive disorder and stated that a Level II evaluation was not required, but also indicated that if new information refuted the findings, a new screen must be submitted. The resident’s admission MDS later documented PTSD, and the care plan noted a history of trauma and life events with actual/potential for PTSD, including a daughter’s suicide, another daughter serving in Iraq with PTSD, and the death of the resident’s husband when the resident was [AGE] years old. The medical diagnoses record also listed PTSD, and a later Level II PASRR screening identified major depression and anxiety disorder but did not include PTSD. During interview, the Administrator stated the facility did not have a PASRR policy and followed Maximus guidelines. The DON acknowledged that a Level II PASRR evaluation should have been submitted for the resident’s PTSD diagnosis and stated her focus had been on medication changes rather than diagnosis changes.
Inadequate Infection Control Practices During Meal Service
Penalty
Summary
The facility failed to ensure proper infection control practices during meal service, as observed on March 11, 2025. Staff J, a cook, used gloved hands to serve meals but did not change gloves or perform hand hygiene consistently throughout the meal service. Staff J touched various surfaces and food items with the same pair of gloves, including plates, utensils, refrigerators, lids, and transportation carts. He also directly handled food items such as seasoned peas, parsley, spaghetti, sandwiches, toaster waffles, lettuce, grilled cheese sandwiches, and breadsticks with his gloved hands, which could lead to contamination. The facility's policy on food preparation and service, which lacked a date, stated that food preparation staff should adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The policy also indicated that gloves could become contaminated and should be changed between tasks, as they are single-use items. However, the actions of Staff J during the meal service did not align with these guidelines, as he failed to change gloves between tasks, potentially increasing the risk of foodborne illness among the 40 residents in the facility.
Failure to Update Care Plans for Residents with RSV
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents diagnosed with RSV, a respiratory infection. Resident #3, who had Alzheimer's Disease and diabetes, tested positive for RSV and was placed on droplet precautions. However, the care plan for this resident lacked specific information or directives for staff to follow the current policy and protocol guidelines related to RSV and droplet precautions. Similarly, Resident #32, who had dementia and diabetes, was diagnosed with RSV and placed on droplet precautions, but their care plan did not include information about the RSV infection or necessary interventions such as droplet precautions. Observations revealed that droplet precaution signs were posted, and protective equipment was available outside the residents' rooms. Interviews with the Director of Nursing, a Licensed Practical Nurse, and the MDS Coordinator confirmed that the care plans were not updated to reflect the residents' current needs and precautions. The facility's policies required that care plans be updated to include any medical and nursing needs, including isolation precautions for transmittable diseases, but this was not done for the two residents in question.
Failure to Document and Assess Resident's Injury
Penalty
Summary
The facility staff failed to assess and document an injury of unknown origin for a resident with Alzheimer's disease, dementia, and muscle weakness. The resident, who had severely impaired cognition and required substantial assistance for daily activities, was found to have a bruise on her left forearm. Despite the resident's dependence on staff for care, the bruise was not documented in the clinical records, and there was no initial skin assessment or incident report completed by the staff. The bruise was first noticed by a CNA during rounds, who reported it to an RN. However, the RN did not follow up on the report, and the bruise was not documented until the resident's family raised concerns. The family discovered the bruise when they noticed protective sleeves on the resident's arms, which were not ordered or documented. The facility's investigation revealed that the bruise was not reported or assessed in a timely manner, and there was confusion among staff about the resident's condition and the use of protective sleeves. Interviews with staff indicated a lack of communication and documentation regarding the resident's bruise. The MDS Coordinator and ADON were informed of the bruise by the resident's family, prompting an investigation. Despite the facility's efforts to determine the cause of the bruise, the investigation was inconclusive, and the facility recognized the need for improvement in reporting and assessing injuries of unknown origin.
Infection Control Deficiencies in Droplet Precautions and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control practices for residents on droplet precautions, specifically for three residents diagnosed with respiratory syncytial virus (RSV). Resident #3, diagnosed with Alzheimer's Disease and diabetes, was on droplet precautions due to RSV but lacked a care plan with directives for staff to follow. Despite being on droplet precautions, staff were observed feeding the resident without wearing the required personal protective equipment (PPE) such as gowns and gloves. Similarly, Resident #30, with Alzheimer's Disease and dementia, was placed on droplet precautions without a corresponding care plan or order summary detailing the necessary interventions. Staff were observed feeding this resident without wearing gowns, contrary to the facility's infection control policy. Resident #32, diagnosed with dementia and diabetes, was also on droplet precautions for RSV. The care plan for this resident did not include information about the RSV infection or necessary interventions like droplet precautions. Observations showed that staff did not consistently wear gowns or gloves when interacting with the resident, despite the presence of a droplet precautions sign and available PPE. The facility's infection control policy, based on CDC guidelines, requires staff to wear masks, gowns, and gloves when entering the room of a resident on droplet precautions to prevent the spread of infection. Additionally, the facility failed to handle soiled linens properly, as observed with Staff B, a housekeeper, who carried soiled linens against her uniform instead of placing them in a bag before transporting them to the soiled linen cart. This practice contradicts the facility's linens policy, which emphasizes minimizing direct contact with contaminated linens to prevent pathogen transmission. The Infection Preventionist confirmed that soiled linens should be placed in a bag at the point of use to ensure infection prevention and control.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care (LTC) Ombudsman regarding the transfer of a resident to the hospital. Specifically, the facility did not document the transfer of a resident, who was on hospital leave, on the Notice of Transfer Form to the LTC Ombudsman for November 2024. The resident was readmitted to the facility from the hospital, but the transfer was not captured in the report generated from the facility's electronic health records system. Interviews with the Accounting Manager and Admission Coordinator revealed that the report used to notify the LTC Ombudsman did not include hospitalizations. Additionally, the Administrator confirmed that the facility lacked a policy for notifying the LTC Ombudsman about transfers or hospitalizations, although it was expected that any resident being sent out of the facility should be included on the Notice of Transfer Form.
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to meet professional standards by not observing a resident take their medications. This was identified for one of eight residents reviewed. The resident, who had diagnoses of heart failure, anxiety, and depression, was observed holding a medication cup with several pills and stated that the staff always leave the medications for them to take later. The resident's Medication Administration Record documented multiple medications ordered and administered at noon, including ascorbic acid, aspirin, buspirone, cholecalciferol, diltiazem, duloxetine, ferrous gluconate, furosemide, L-Lysine, metoprolol, Tylenol, and Zyrtec. Interviews with two Licensed Practical Nurses (LPNs) revealed that they claimed to always stay with residents until they take and swallow their medications, following the facility's protocol. However, the observation contradicted these statements. The facility's policy on medication administration directed staff to remain with the resident to ensure that the medication is swallowed. The Director of Nursing also confirmed that staff are expected to stay with residents until the medication is swallowed and mentioned that recent education had been provided to the staff regarding this protocol.
Significant Medication Error Due to Incorrect Resident Identification
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was unable to easily communicate with staff and had vision and hearing impairments. The error occurred when a Certified Medication Aide, unfamiliar with the resident, mistakenly administered 650 mg of Tylenol and 0.25 milliliters of morphine intended for another resident. The aide did not correctly identify the resident, who responded to the wrong name, and the medication was given without verifying the resident's identity. The error was discovered when the aide went to the resident's room for the medication pass and realized the mistake, subsequently notifying the nurse on duty. The resident's family chose to send her to the emergency room for evaluation following the error. Hospital records indicated that the resident had high potassium and creatinine levels prior to the medication error, and the mental status change was likely related to hyperkalemia rather than the morphine administration. The facility's Medication Error/Omission Report indicated that the error could have been prevented by having identification on wheelchairs and asking residents for their name and date of birth before administering medication. The facility's policy on medication administration emphasized the importance of administering medications safely and appropriately.
Infection Control Deficiencies During Meal Assistance and Catheter Care
Penalty
Summary
The facility failed to maintain infection control standards during meal assistance and catheter care for two residents. During a dining room observation, a Certified Medication Aide (CMA) was seen wearing the same pair of gloves while assisting two residents with their meals. The CMA alternated between feeding the residents, touching various surfaces, and handling food without changing gloves or performing hand hygiene. This included touching the residents' silverware, cups, and food, as well as other surfaces like the table and chair, which led to cross-contamination risks. The Director of Nursing (DON) confirmed that the staff should have performed hand hygiene and changed gloves to avoid cross-contamination. In another instance, a Certified Nursing Aide (CNA) was observed performing catheter care for a resident with severe cognitive impairment and an indwelling catheter. The CNA washed her hands and donned gloves and a gown but then touched a floor mat, cabinet door, and dirty garbage bag with the same gloves before proceeding with catheter care. The CNA did not change gloves or perform hand hygiene after touching these contaminated objects, which violated the facility's policy on catheter care. The DON confirmed that the CNA should have changed gloves and performed hand hygiene before continuing with the catheter care. The facility's policies on feeding residents and emptying catheter drainage bags were not followed, leading to these deficiencies. The policies clearly state that gloves should be changed, and hand hygiene should be performed when there is a risk of contamination. The observations and interviews with the DON confirmed that the staff did not adhere to these infection control standards, resulting in potential cross-contamination and increased risk of infection for the residents involved.
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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) |
|---|---|---|---|---|
| Wesley On Grand | 1.1 mi | ★★★★★ | 0 | 0 |
| Scottish Rite Park Inc | 1.3 mi | ★★★★★ | 1 | 0 |
| Calvin Community | 1.5 mi | ★★★★★ | 12 | 0 |
| Ramsey Village | 1.8 mi | ★★★★★ | 44 | 0 |
| Pine Acres Rehabilitation And Care Center | 2.1 mi | — | 23 | 0 |
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