Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Rehabilitation Center Of Des Moines during CMS and state inspections, most recent first.
Incorrect MDS Coding for Vaccines and Code Alert Use The facility inaccurately coded MDS assessments for several residents. A resident with intact cognition, two residents with severely impaired cognition, and another resident with moderate impairment had pneumococcal vaccine status coded inconsistently with consent forms, immunization records, physician orders, and progress notes. Two residents were also coded as not using a wander/elopement alarm even though orders, care plans, and direct observations showed Code Alert bracelets in use.
Failure to Administer Pneumococcal Vaccines: Multiple residents with documented consent, physician orders, and vaccine eligibility did not receive indicated pneumococcal immunizations. The EHR showed prior vaccine history for some residents, but immunization tabs and progress notes lacked documentation of updated PCV/PPSV administration, and one resident later had pneumonia documented in the chart.
A facility failed to offer and provide the recommended COVID-19 vaccine to 5 residents reviewed for immunizations and failed to document their vaccination status. The records showed consent for COVID-19 vaccination, but no corresponding order, immunization entry, or progress note documenting administration; one resident also had a confirmed COVID-19 infection in the chart, yet no vaccine was documented after recovery. The Administrator stated the COVID and pneumonia vaccines had not been given and only flu shots had been administered.
Incomplete neurocheck documentation after unwitnessed falls. Two residents with significant cognitive and medical histories, including dementia, psychotic disorders, and seizure disorder, had falls with and without head injury, but the EHR did not show the required neurochecks were fully completed or documented at the ordered intervals. Records included missing assessments, incomplete entries, and gaps after an ER transfer, despite facility policy requiring scheduled neuro assessments after unwitnessed falls or head injury.
A resident receiving dialysis with ESRD, DM, HF, hyperkalemia, and respiratory failure had a liberalized regular diet ordered, while dialysis staff repeatedly documented requests for a low potassium or renal diet due to high potassium levels. The facility RD did not contact the dialysis RD or document communication, the CDM reported no diet communication or directive, and the dialysis RD believed a renal diet was in place after speaking with facility staff.
A resident with intact cognition and multiple chronic conditions, including respiratory failure and heart failure, had an order for continuous O2 at 2L/min via NC, but the EHR did not consistently document the O2 setting with saturation checks. Survey observations found the concentrator set at 4L, later turned off and then reset to 4L by the resident, and later set at 3L, with no corresponding charting or explanation. Staff reported they did not routinely document O2 settings, and the administrator confirmed the ordered O2 level was 2L.
Hand hygiene was not performed during medication administration for a resident receiving pain meds for chronic pain syndrome. A CMA gave oral meds, later applied pain patches with gloves, and did not clean hands after resident contact, before or after glove use, or between residents while continuing med prep and entering another resident's room. Facility policy and CDC guidance required hand hygiene before and after resident contact, before handling meds, after glove removal, and between patients.
A resident who was dependent on staff for personal care was left exposed during care when CNAs failed to close the window blinds, allowing visibility from a nearby parking lot. The resident, who was cognitively intact, reported that this occurred frequently. Facility leadership acknowledged the incident as a violation of dignity and resident rights, and the facility's policy required privacy measures that were not followed.
A resident's code status was inconsistently documented, with an IPOST indicating DNR and a physician's order listing Full Code, leading to staff confusion during a medical emergency. The care plan reflected the resident's DNR wishes, but conflicting orders in the system caused uncertainty about the appropriate response when the resident experienced a health crisis.
A resident with a history of falls and weakness was observed being pushed in a manual wheelchair by a CNA without foot pedals, resulting in her feet skimming the floor. The resident, who is cognitively intact and usually self-propels, had requested to be pushed. Staff interviews revealed uncertainty about the availability of wheelchair pedals and confirmed understanding that residents should not be pushed without their feet on the pedals, in accordance with facility policy.
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures, with staff not wearing gowns and gloves during high-contact care activities. Observations and interviews revealed inconsistencies in following EBP protocols, a lack of signage and PPE supplies, and inadequate hand hygiene practices. Staff expressed a need for further education and training on EBP to ensure compliance and improve infection control practices.
A resident with intact cognition and a history of traumatic brain injury, schizophrenia, and bilateral lower leg amputation was observed being pulled backwards in a wheeled shower chair through the hall by a CNA, covered only with a blanket. This action failed to maintain the resident's dignity, as required by the facility's policy on dignity and privacy.
The facility failed to update comprehensive care plans for two residents, leading to inaccuracies and omissions. One resident's care plan incorrectly documented amputation sites and catheter use, while another's plan lacked current fall prevention measures and mental health services. Staff interviews confirmed these discrepancies, highlighting a lapse in the facility's care planning process.
A resident with multiple health issues, including renal insufficiency and diabetes, experienced a delay in follow-up blood work ordered by their PCP. The facility failed to conduct the lab test within the specified timeframe, resulting in a critical sodium level being identified only after the resident showed symptoms of lethargy. This oversight led to the resident's hospitalization for hypernatremia. Facility staff interviews revealed the missed lab work and lack of PCP notification.
A resident with intact cognition and multiple health conditions reported worsening vision, but the facility failed to ensure a timely referral to an optometrist. Despite documentation of blurry vision by a Nurse Practitioner, the resident's complaints were not addressed promptly, and staff were unaware of the issue until much later, resulting in a delayed appointment.
A facility failed to ensure an emergency tracheostomy kit was available at the bedside for a resident with a tracheostomy, who was dependent on staff for care and required oxygen. The absence of the kit was confirmed by a nurse and the DON, despite the care plan requiring it to be present.
A resident with intact cognition was not properly secured in a van during transport, leading to a fall when the vehicle moved. Despite the facility's policy requiring seat belts, the resident fell forward, resulting in soreness and head pain. The resident was evaluated at the ER and returned to the facility without fractures.
A facility failed to honor a resident's DNR status by initiating CPR when the resident became non-responsive. Despite the resident's advance directive and EHR indicating DNR, staff performed CPR following the resident's daughter's instructions. The facility lacked a signed IPOST and did not have the resident's code status in the nursing station binder, leading to confusion during the emergency.
A facility failed to notify a resident's family about an increase in pain and a new order for Oxycodone. The resident, with a BIMS score of 15, had multiple diagnoses including Alzheimer's and arthritis. Despite the facility's policy to inform families of significant changes, there was no documentation of family notification after the resident's pain increased and Tramadol was ineffective, leading to a new Oxycodone order.
A resident with impaired cognition reported that a CNA grabbed her face and used inappropriate language. The facility failed to report this abuse allegation to the State Agency within the required 2-hour timeframe. Despite the facility's policy to suspend accused staff, the CNA continued working on the floor, separated from the accuser. The delay in reporting and failure to suspend the staff member led to the deficiency.
A resident with impaired cognition reported abuse by a CNA, but the facility failed to suspend the accused staff member as per policy. Instead, the CNA was reassigned within the same floor, and the incident was not reported to the State Agency in a timely manner. Misunderstandings of policy by the DON and Administrator contributed to the deficiency.
Incorrect MDS Coding for Pneumococcal Vaccination and Code Alert Use
Penalty
Summary
The facility failed to accurately complete MDS assessments for 5 of 18 residents reviewed, including incorrect coding related to pneumococcal vaccination status and Code Alert (wander guard) use. The report identified that Residents #1, #3, #6, #8, and #13 had MDS entries that did not match the EHR, physician orders, consent documents, immunization records, care plans, or direct observations. The facility census was 72. Resident #1’s MDS, completed on 7/10/25, showed a BIMS score of 15 and indicated the pneumococcal vaccination was not up to date and had been offered and declined. However, the EHR contained a signed consent form dated 10/09/24 for influenza, pneumococcal, and COVID-19 vaccination, and the physician’s order directed staff to administer the pneumonia vaccination with informed consent. The progress notes did not document that the resident received a pneumococcal vaccine. Resident #6’s MDS, completed on 6/13/25, indicated the pneumococcal vaccination was up to date, but the immunization record showed only Prevnar13 on 4/25/22 and no further pneumococcal vaccinations, despite a physician order for vaccination with informed consent and a signed consent form. Resident #8’s MDS also indicated pneumococcal vaccination was up to date, but the immunization record showed PPSV23 on 8/26/20 and no further pneumococcal vaccinations, with no documentation in the progress notes that an updated vaccine was given. Resident #3’s MDS, completed on 8/1/25, showed a BIMS score of 5 and diagnoses including non-Alzheimer’s dementia, PTSD, and a psychotic disorder. The MDS indicated the resident was independent with a manual wheelchair and without a wander/elopement alarm, yet the physician order summary required Code Alert checks and placement every shift, the care plan addressed wandering/elopement risk, and the resident was observed with a Code Alert bracelet on the right ankle. Resident #13’s MDS showed a BIMS score of 12 with diagnoses including anxiety disorder, schizophrenia, and traumatic brain injury; it also indicated no wander/elopement alarm and that pneumococcal vaccination was not up to date and had been offered and declined. The physician order summary required Code Alert checks and placement every shift, the care plan addressed wandering/elopement risk, and the resident was observed wearing a Code Alert bracelet on the right wrist. The MDS Coordinator acknowledged the lack of coding for the Code Alert bracelets and stated they believed the bracelets were restraints and therefore not coded.
Failure to Administer Eligible Pneumococcal Vaccinations
Penalty
Summary
The facility failed to vaccinate eligible residents with pneumococcal vaccine despite physician orders, documented consent, and vaccine eligibility noted in the medical record for five reviewed residents. Resident #1 had diagnoses including anemia, CAD, diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, and COPD, and the MDS documented that the resident had not received pneumococcal vaccination. Although the EHR contained a consent form indicating the resident consented to the pneumococcal vaccine, there was no documentation that the vaccine was administered, and the resident later had pneumonia documented in the record. Resident #3 had diagnoses including anemia, CAD, kidney failure, non-Alzheimer's dementia, and COPD, and the MDS documented the resident had not received pneumococcal vaccination. The EHR contained consent from the resident's POA for pneumococcal vaccination, but the clinical immunization record and progress notes did not show that the vaccine was given. Resident #6 had diagnoses including anemia, CAD, heart failure, diabetes mellitus, non-Alzheimer's dementia, and morbid obesity. The record showed prior PCV13 administration, consent from the POA for pneumococcal vaccination, and an MDS that later coded the resident as up to date, but the immunization record and progress notes did not document any updated pneumococcal vaccine being administered. Resident #8 had diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia. The record showed prior PPSV23 administration, consent from the POA for pneumococcal vaccination, but no declination form and no documentation that another pneumococcal vaccine was given. Resident #13 had diagnoses including anemia, schizophrenia, and traumatic brain injury, and the MDS documented the resident had not received pneumococcal vaccination. The EHR contained consent for pneumococcal vaccination, but the clinical immunization record and progress notes did not show administration. The Administrator stated that the Covid and pneumonia vaccines had not been administered and that only flu shots had been given.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents and failed to document vaccination status for 5 of 5 residents reviewed for vaccines. The residents reviewed included individuals with a range of diagnoses and cognitive status, including intact cognition in some residents and severely impaired cognition in others. The Minimum Data Set assessments for these residents did not show current COVID-19 vaccination, and the most recent assessments for each coded them as out of date for COVID-19 vaccinations. For each of the five residents, the chart contained physician orders for influenza and pneumococcal vaccines with consent, but no order for COVID-19 vaccination. The electronic record included a consent form dated 10/09/24 showing consent for influenza, pneumococcal, and COVID-19 vaccination, including consent from a POA for residents with impaired cognition. However, the Clinical Immunizations tab did not show a COVID-19 vaccination after the dates of prior vaccinations listed for each resident, and the Progress Notes did not document that the vaccine was administered. One resident had a confirmed COVID-19 diagnosis noted in the record, but the notes still did not show a COVID-19 vaccination after the recovery period referenced in the report. The Care Plans for the residents did not include documented vaccinations, except for one resident whose care plan included a resolved intervention to ensure immunizations were up to date. On 9/9/25, the Administrator stated the facility had verified that the COVID and pneumonia vaccines had not been administered and that only flu shots had been given. The facility policy required residents to be screened for vaccine status, educated on benefits and side effects, offered COVID-19 immunization unless contraindicated or already immunized, and documented in the medical record whether the vaccine was given, declined, or medically contraindicated.
Incomplete Neurocheck Documentation After Unwitnessed Falls
Penalty
Summary
The facility failed to complete and document neurological exams (neurochecks) as scheduled after unwitnessed falls for two residents reviewed. One resident had severe cognitive impairment with a BIMS score of 5, diagnoses including non-Alzheimer's dementia, PTSD, and a psychotic disorder, and had unwitnessed falls with injury and without visible injury. The record did not show that neurochecks were initiated and/or completed for the full scheduled timeframe after the falls, despite the care plan identifying fall risk and impaired cognitive function. The second resident had a BIMS score of 13 and diagnoses including anxiety disorder, depression, malnutrition, non-Alzheimer's dementia, dysphasia, seizure disorder/epilepsy, and schizophrenia, and required maximum assistance for transfers. After a fall with head impact and later fracture-related hospital transfer, the neurocheck record showed missing documentation for scheduled checks, including an incomplete first-hour sequence, no resumed checks after return from the ER, no documentation for an entire day, and additional missing or incomplete assessments on later dates. The facility policy required full neuro assessments for unwitnessed falls or falls with head injury at specified intervals, but the documentation reviewed did not reflect completion of those scheduled checks.
Failure to Coordinate Renal Diet Communication With Dialysis Unit
Penalty
Summary
The facility failed to coordinate nutritional care with the dialysis unit for a resident receiving dialysis. The resident had end stage renal disease, diabetes, heart failure, hyperkalemia, and respiratory failure, and the MDS did not indicate a therapeutic diet. The care plan included a liberalized regular textured diet with thin liquids and honoring the resident’s dietary choices, and the physician order summary also listed a liberalized regular textured diet with thin liquids. From May 2025 through September 2025, dialysis staff documented on the Nursing Dialysis Communication Records on 13 occasions to offer a low potassium or renal diet because of high potassium levels. The record lacked documentation of communication between the facility RD and the dialysis center RD. The CDM reported no written or verbal communication from the dialysis center or facility regarding diet and no directive to offer a low potassium diet. The facility RD acknowledged reviewing the dialysis communication records and knowing the resident declined dietary restrictions, but had not contacted dialysis staff or the dialysis RD and did not have the dialysis RD’s contact information. The dialysis RD stated monthly lab work was faxed to the facility with contact information attached and reported calling the facility on July 30, 2025, where staff answered that the resident was on a renal diet. The Administrator stated they were not aware of specific labs or faxes from the dialysis unit and believed any diet-specific items should be addressed by the facility RD.
Failure to Document and Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for one resident with intact cognition and multiple diagnoses including end stage renal disease on dialysis, diabetes, heart failure, respiratory failure, and a seizure disorder. The physician order, started 7/11/25, directed continuous O2 at 2L/min via nasal cannula to keep O2 saturation above 90% every shift. However, the EHR clinical O2 saturation summary did not consistently document the O2 setting when saturations were obtained, and no O2 settings were documented in August or September, with only two settings documented in July after the order began; those July entries were documented at 3L. Survey observations showed the resident's O2 concentrator set at 4L on 9/8/25, turned off on 9/11/25 and then turned back on by the resident at 4L, and set at 3L on 9/15/25. The EHR lacked documentation for the increased settings or, in the case of the concentrator being off, why it was off. During interviews, the resident stated they needed O2 therapy especially when sleeping and acknowledged they may remove or adjust the O2 themselves but would not set it above 3L. Staff stated CMAs cannot adjust O2 settings, nurses would need a physician order for increases above the ordered amount, and staff may not routinely chart O2 settings when obtaining O2 saturations. The administrator confirmed the current O2 order was 2L and that staff should be documenting O2 settings in the EHR.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to perform appropriate hand hygiene during medication administration for one resident. The resident had a diagnosis of chronic pain syndrome, and the care plan indicated the resident was receiving pain medication for that condition. During observation, a CMA administered oral medications to the resident and did not perform hand hygiene afterward. The resident then requested pain patches for the back, and the CMA told the resident to go to the room while he would return to apply them. The CMA later documented the oral medications, removed the patches from the medication cart, donned gloves, and applied the patches to the resident's back. He then doffed his gloves and charted the medications without performing hand hygiene before donning or after removing gloves. After completing care for this resident, the CMA continued preparing medications and entered another resident's room without completing hand hygiene between residents. An RN stated hand hygiene should be performed when removing gloves, after touching a resident, and between residents. Facility policy and CDC guidance both stated hand hygiene should be performed before and after direct resident contact, before preparing or handling medications, after removing gloves, and when moving from one patient to another.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to maintain privacy and dignity for a resident who required assistance with personal care, including toileting, bathing, and dressing. During the provision of care while the resident was lying in bed, both upper and lower areas of her body, including her breasts, buttocks, and genitals, were exposed. The window blinds in the resident's room were left open, and the window faced a parking lot, making it possible for people outside to see into the room. This was observed during care by two CNAs, and a car parked nearby with a person exiting, although the person did not approach the window. The resident, who had diagnoses including bipolar disorder and muscle weakness, was cognitively intact and able to communicate her concerns. She reported that staff often left the blinds open during care, which compromised her privacy. Facility leadership, including the LNHA and DON, acknowledged the issue as a violation of dignity and resident rights. The facility's policy required staff to maintain privacy during care, including closing doors or drawing curtains or blinds, but this procedure was not followed in this instance.
Failure to Ensure Consistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure clear and consistent direction regarding the code status of a resident, resulting in conflicting documentation and confusion among staff during a medical emergency. The resident had an IPOST indicating Do Not Resuscitate (DNR) status, while a physician's order in the facility's system listed the resident as Full Code, directing that CPR should be performed if the resident's heart or respirations stopped. The care plan also indicated the resident's desire to be DNR per IPOST, with instructions for regular review and updates. During an incident where the resident exhibited abnormal respirations and changes in color, staff responded by calling a code blue and preparing to send the resident to the hospital. Staff members discovered the discrepancy between the IPOST (DNR) and the physician's order (Full Code) at that time, leading to uncertainty about the appropriate response. Staff interviews revealed that the IPOST was signed after the resident's return from a prior hospitalization, while the Full Code order was entered upon that return, possibly due to hospital requirements for a procedure. The facility's policy required that advance directives be respected and that any such documents be included in the medical record, with periodic review and updates. However, the lack of alignment between the IPOST, physician's order, and care plan resulted in staff confusion during a critical event, as they were unsure which directive to follow. The issue was acknowledged by facility leadership, who noted the discrepancy and began reviewing other residents' records for similar issues.
Failure to Ensure Safe Wheelchair Transport for Resident
Penalty
Summary
A deficiency was identified when a resident with a history of repeated falls, bilateral upper limb carpal tunnel syndrome, and weakness was observed being pushed in her manual wheelchair by a CNA without wheelchair pedals attached. During this incident, the resident's feet were skimming the floor as she was transported down the hall. The resident confirmed she had requested to be pushed, and the CNA acknowledged knowing that wheelchair pedals should be used when pushing residents. The CNA was unsure if the resident even had pedals for her wheelchair, and another staff member, new to the facility, was unaware of the incident. The MDS documented that the resident was cognitively intact and typically propelled herself in the wheelchair or walked behind it. Facility policy, reviewed in October 2024, directs staff to position residents' feet on wheelchair footrests when needed and to ensure a safe environment for wheelchair mobility. The MDS coordinator and other staff interviewed understood that residents should not be pushed in wheelchairs without their feet on the pedals, as this could result in injury. The DON and LNHA acknowledged the concern when informed of the observation, and the nurse practitioner confirmed that the resident should not have been pushed with her feet skimming the ground.
Infection Control Deficiencies in EBP Compliance
Penalty
Summary
The facility failed to maintain infection control standards by not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff did not wear gowns and gloves during high-contact care activities for three residents who were supposed to be on EBP. Observations revealed that staff only wore gloves and not gowns while providing care, and there was a lack of EBP signage and PPE supplies at the residents' doorways. Interviews with staff and family members confirmed inconsistencies in following EBP protocols, and staff expressed a lack of understanding and training regarding EBP requirements. Additionally, the facility did not ensure proper hand hygiene during care procedures. In one instance, a registered nurse failed to perform hand hygiene after removing gloves and before putting on new gloves while providing wound care to a resident. This lapse in infection control was acknowledged by the Director of Nursing, who admitted that the facility struggled with EBP compliance and had concerns about maintaining resident dignity while implementing these precautions. The report highlights multiple instances where staff did not wear gowns during procedures that required them, such as tracheostomy and wound care. Despite the presence of EBP signs and supplies in some areas, staff did not consistently follow the required protocols. Interviews with staff indicated a need for further education and training on EBP to ensure compliance and improve infection control practices within the facility.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to ensure the dignity of a resident, who was observed being pulled backwards in a wheeled shower chair through the hall by a Certified Nursing Aide (CNA). The resident was covered with only a blanket, with their head uncovered and lower legs partially exposed, revealing both legs were amputated. This incident involved a resident with intact cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and who had a history of traumatic brain injury, schizophrenia, and bilateral lower leg amputation. The resident required substantial to maximal assistance with bathing, as documented in their care plan. The facility's policy on dignity and privacy, revised in May 2007, mandates that all residents be treated with dignity, respect, and privacy, and that their bodies be examined and treated in a manner that maintains privacy.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to revise and update comprehensive person-centered care plans for two residents, leading to inconsistencies and omissions in their care documentation. Resident #27's care plan contained incorrect information regarding amputation sites and the presence of a urinary catheter. Despite the resident having a left leg amputation and no urinary catheter since a hospital visit in July, the care plan inaccurately documented a right foot amputation and the presence of a Foley catheter. Observations and staff interviews confirmed these discrepancies, highlighting a lack of updates to the care plan following significant changes in the resident's condition. Resident #61's care plan also exhibited deficiencies, as it failed to reflect current fall prevention interventions and mental health services. The care plan included an intervention for a fall mat, which was not in use, and did not document the actual fall prevention measures being implemented, such as increased supervision and keeping the room door open. Additionally, the care plan did not include the resident's ongoing counseling services for depression, despite receiving these services since June. Interviews with staff confirmed these omissions and the need for care plan updates to accurately reflect the resident's current care needs. The facility's policy on care planning requires the interdisciplinary team to develop and update comprehensive care plans within seven days of the resident's MDS assessment and as needed for changes in condition. However, the facility did not adhere to this policy, resulting in outdated and inaccurate care plans for Residents #27 and #61. The Director of Nursing indicated that responsibility for care plan updates shifted to the DON and MDS coordinator in August, but the deficiencies persisted, indicating a lapse in the facility's care planning process.
Failure to Timely Obtain Follow-Up Blood Work Leads to Hospitalization
Penalty
Summary
The facility failed to obtain follow-up blood work for a resident within the timeframe ordered by the Primary Care Provider (PCP), which contributed to the resident's hospitalization. The resident, who had multiple diagnoses including renal insufficiency, diabetes, and respiratory failure, had a low potassium level identified on 8/6/24. The PCP ordered a potassium supplement and a follow-up lab test to be conducted on 8/13/24. However, the facility scheduled the lab for 8/15/24 and did not complete it until 8/20/24, five days after the scheduled date. There was no documentation indicating that the PCP was notified of the missed and delayed lab work. The delay in obtaining the lab work resulted in the resident's critical sodium level being identified only after the resident became tired and lethargic, leading to their hospitalization for hypernatremia. Interviews with facility staff, including a Registered Nurse and the Director of Nursing (DON), revealed that the oversight was noticed on 8/20/24, and the lab work was obtained immediately thereafter. The DON acknowledged the missed lab work and the lack of documentation regarding PCP notification. An Advanced Registered Nurse Practitioner was unable to recall if the facility staff had notified them of the missed lab work and could not determine if the delay would have prevented the hospitalization.
Failure to Ensure Timely Vision Care Referral
Penalty
Summary
The facility failed to ensure a specialist referral for a resident who complained of worsening vision. Resident #38, who had intact cognition and a history of heart and respiratory disease, non-Alzheimer's dementia, anxiety, depression, and PTSD, reported difficulty seeing out of the left eye. Despite a progress note from a Nurse Practitioner on 6/27/23 documenting blurry vision in the resident's left eye, no referral to an optometrist was made until much later. The resident continued to express concerns about vision deterioration, which were not addressed in a timely manner by the facility staff. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's vision issues. The Director of Nurses was unaware of the resident's complaints, and the Social Services staff only became aware of the issue shortly before the resident was finally scheduled for an optometrist appointment. The facility's policy required arrangements for services not provided in-house, but this was not followed, leading to a delay in addressing the resident's vision concerns.
Failure to Provide Emergency Tracheostomy Kit at Bedside
Penalty
Summary
The facility failed to ensure an emergency tracheostomy kit was available at the bedside for a resident with a tracheostomy. The resident, who was totally dependent on staff for all care, had diagnoses of anoxic brain damage and respiratory failure, and required oxygen. During an observation, it was noted that the resident was in a wheelchair with a tracheostomy and an oxygen mask, but no emergency tracheostomy kit was present at the bedside. The resident's care plan, initiated previously, required a tracheostomy tube and obturator to be kept at the bedside. Interviews with a registered nurse and the Director of Nursing confirmed the absence of the emergency tracheostomy kit, which was against the facility's expectations for residents with tracheostomies. The facility reported a census of 66 residents, and this deficiency was identified for one of the three residents reviewed during the survey.
Resident Not Secured in Vehicle During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in an accident. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, was not properly secured with a seat belt in a van. This oversight occurred despite the facility's Fleet Safety Program policy, which mandates that all occupants must wear safety belts and that the driver is responsible for ensuring passengers are properly secured. As a result, when the vehicle began to move, the resident fell forward, landing on her stomach at the front of the vehicle. The incident report noted that the resident was sore all over but had no visible bruising and could move all extremities without difficulty. Following the incident, the resident was transferred to the ER for evaluation. A subsequent provider encounter note indicated that the resident had hit the right side of her head during the fall and reported persistent head pain, as well as exacerbated chronic shoulder and knee pain. The Director of Nursing confirmed that residents should be securely strapped into vehicles and noted that the resident did not sustain a fracture but was assessed at the hospital.
Failure to Honor Resident's DNR Status
Penalty
Summary
The facility failed to honor a resident's advance directive wish to be a Do Not Resuscitate (DNR) by initiating cardiopulmonary resuscitation (CPR) when the resident became non-responsive. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had documented advance directives stating DNR status in both the Initial Admission Record and a hospital Discharge Summary. However, the resident's Care Plan and electronic health record (EHR) did not reflect this DNR status, leading to confusion during the emergency. When the resident became non-responsive, a Registered Nurse (RN) initiated CPR despite the EHR indicating DNR status, as the resident's daughter instructed staff to continue CPR. The facility lacked a signed Iowa Physician Orders for Scope of Treatment (IPOST) at the time, which contributed to the confusion. The Director of Nursing acknowledged that the code status paperwork was not completed due to the resident's recent hospital visit. The absence of a clear and accessible record of the resident's DNR status in the facility's binder at the nursing station further compounded the issue.
Failure to Notify Family of Resident's Increased Pain and Medication Change
Penalty
Summary
The facility failed to notify the family of a resident about an increase in pain and the need for additional pain medication. The resident, who had a BIMS score of 15 out of 15, was diagnosed with Alzheimer's disease, anxiety disorder, depression, arthritis, joint contracture, and muscle weakness. According to the facility's policy, the family should be informed of significant changes in the resident's physical status. On November 2, 2023, a nurse reported to the Nurse Practitioner that the resident refused care, refused to get out of bed, and that Tramadol was ineffective. The NP ordered Oxycodone 5 milligrams three times daily. However, there was no documentation of family notification regarding the resident's increased pain level and the new medication order. The Director of Nursing confirmed that such a situation would warrant a call to the family.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required 2-hour timeframe for a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who had diagnoses including anxiety, depression, and psychotic disorder, reported that a CNA grabbed her face and used inappropriate language. This incident was reported to staff on the following day, but the facility did not document the submission of the allegation to the State Agency until later that afternoon. The facility's policy required immediate reporting of abuse allegations to the Administrator and relevant agencies, and the removal of the accused staff member from resident care. However, the accused CNA continued to work on the floor with other residents, although separated from the accuser. The Director of Nursing and Administrator acknowledged the delay in reporting and the failure to suspend the staff member, which contributed to the deficiency.
Failure to Properly Address Allegation of Abuse
Penalty
Summary
The facility failed to appropriately handle an allegation of abuse involving a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who had diagnoses including anxiety, depression, and a psychotic disorder, reported that a CNA grabbed her face and used inappropriate language. Despite the facility's policy requiring immediate removal and suspension of the accused staff member pending investigation, the CNA continued to work on the same floor, albeit separated from the specific resident who made the accusation. The facility did not document the submission of the abuse allegation to the State Agency until the day after the incident was reported. Interviews with the DON and the Administrator revealed a misunderstanding of the facility's policy and regulatory requirements. The DON acknowledged that the usual procedure would involve suspending the accused staff member, but in this case, the staff member was merely reassigned to a different section of the same hall. The Administrator believed that separating the staff member from the specific resident was sufficient, although the staff member continued to have access to other residents. This misinterpretation of policy and failure to act in accordance with established procedures contributed to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 416 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| University Park Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Azria Health Park Place | 0.9 mi | ★★★★★ | 25 | 2 |
| Trinity Center At Luther Park | 1.5 mi | ★★★★★ | 17 | 1 |
| Ramsey Village | 2.3 mi | ★★★★★ | 44 | 0 |
| Valley View Village | 2.4 mi | ★★★★★ | 4 | 0 |
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