Below 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 Trinity Center At Luther Park during CMS and state inspections, most recent first.
Staff failed to follow COVID infection control practices, including proper mask use, PPE use, linen handling, and transmission-based precautions. Surveyors observed an LPN, CNA, therapy staff, and others with masks worn incorrectly or not at all, and staff moved between rooms with the same gloves or PPE while carrying unbagged linens. Records also showed inconsistent testing and separation of residents exposed to COVID-positive roommates, with multiple residents having COVID-positive results, TBP, and related symptoms.
A facility failed to complete ordered COVID monitoring for multiple residents who were COVID-positive or exposed to COVID-positive roommates, with missing MAR/TAR documentation and incomplete nursing notes for required every-shift assessments. The record review also found that exposed residents did not have documented risk recognition or monitoring, and the facility failed to complete required neuro checks after an unwitnessed fall for most residents reviewed.
Food was not stored and prepared according to standards during a kitchen observation. Staff were observed thawing ham in standing water, leaving delivery boxes on a food prep surface, and storing unlabeled food items in the refrigerator. A resident-labeled coldpak was also found in the food storage refrigerator, and staff stated they did not know who placed it there. The CDM stated the ham was placed in the oven to speed thawing, while facility policy required thawing in the refrigerator or a cold-water bath and required food containers to be labeled.
Failure to Document Non-Pharmacological Interventions Before PRN Antianxiety Medication: A resident with dementia, anxiety, and behavioral symptoms received PRN lorazepam for anxiety/restlessness, but the record did not document non-pharmacological interventions before administration on two occasions. Staff interviews showed they expected interventions to be documented in the progress notes or EMAR before giving PRN antianxiety meds, and the facility policy identified non-pharmacological interventions as first-line treatment for dementia-related behaviors.
Failure to provide written transfer and bed hold notification: A resident with severely impaired cognition, dementia, kidney failure, a hip fracture, and TBI fell, had R hip pain, and was transferred to the ED. Although a family member was noted as notified and a bed hold was mentioned in progress notes, the record lacked a signed or dated written transfer notice and bed hold policy with reserve payment information, and staff stated the required forms were not completed.
MDS coding was inaccurate for two residents whose bed rails were coded as physical restraints even though the rails were partial side rails that did not restrict movement and were documented as being present at the residents’ request to improve safety or mobility. In addition, a resident with diagnoses including bipolar disorder, psychotic disorder, anxiety, depression, and a Level II PASRR outcome was not coded on the MDS for serious mental illness, despite staff stating they relied on the PASRR and RAI Manual for coding decisions.
Failure to use a gait belt during a resident transfer: A resident with dementia, TBI, visual loss, syncope, collapse, poor balance, and a history of falls required assistance with transfers and wheelchair mobility, but a CNA assisted a visitor with transferring the resident from a recliner to a wheelchair without using the gait belt. Staff later stated gait belts are required for residents needing transfer assistance, and the care plan and notes did not document education for the resident's friend about gait belt use.
A facility failed to complete a discharge summary and plan for a resident with vertebral fractures and intact cognition at the time of their planned discharge. The resident's EHR lacked necessary documentation, and the administrator confirmed the omission. The facility's policy required a discharge care plan for resident-initiated discharges but did not specify directives for discharge summaries.
The facility failed to cover food during transportation from unit B1 to unit C1, leading to potential contamination. The steam table with uncovered sweet potatoes, peas, and partially uncovered bread was moved through resident hallways and main areas before serving meals in unit C1. Interviews with the CDM and Administrator confirmed the expectation for food to be covered, aligning with the facility's food handling policy.
A resident with a history of UTIs and moderate cognitive impairment received inadequate catheter and peri-care from two CNAs, who failed to follow proper hand hygiene protocols. The facility's policies on peri-care and hand hygiene were not adhered to, leading to a deficiency in infection prevention and control.
A facility failed to notify the LTC Ombudsman of a resident's transfer to a hospital, as required. The resident was transferred and later reentered the facility, but the clinical record lacked documentation of notification to the Ombudsman. The DON confirmed the omission, which was contrary to the facility's policy requiring such notifications for facility-initiated discharges.
A resident with Parkinson's and mild cognitive impairment developed a bruise on the upper right arm, which was documented but not reported to the physician or emergency contact. The facility's policy requires such notifications, but the Administrator confirmed that no incident report was completed, and the necessary notifications were not made.
A resident with dementia and anxiety reported being assaulted by two teenage girls she believed were her roommates. The facility's investigation concluded the allegation was unsubstantiated without conducting staff interviews, contrary to its policy. Staff members were not interviewed and were unaware of the incident.
Infection Control and COVID-19 Precaution Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program related to COVID-19. Survey observations and record review showed staff not following transmission-based precautions, not wearing masks properly, and not handling contaminated linens correctly. Staff were observed at the nurses’ station and in resident care areas with masks below the nose, under the chin, hanging off one ear, or not worn at all until approached by the surveyor. A contracted therapy assistant and a CNA were also observed moving between resident rooms while wearing the same gloves or PPE, and linens were carried unbagged through the hallway to the soiled laundry bin. The report also documented failures involving residents exposed to COVID-19. Residents in semi-private rooms with COVID-positive roommates were not consistently separated, and documentation did not show exposure follow-up, testing, or interventions to reduce transmission for some exposed roommates. One resident with a COVID-positive roommate had no documentation of exposure management in the nursing notes, while another resident’s record showed cohorting with a COVID-positive roommate and staff discussion that the roommate had been tested and monitored, but the infection prevention process was inconsistent across residents. The facility’s COVID tracking spreadsheet showed multiple residents with positive tests and TBP, but the survey findings described gaps in testing exposed residents and in separating positive residents from roommates. Several resident records were reviewed in detail. One resident with severe cognitive impairment, COPD, CAD, CKD, diabetes, prior stroke, and hospice care tested positive for COVID and died the next day. Another resident with CAD, DVT, heart failure, PVD, diabetes, and pleural effusion had cold symptoms, tested negative initially, then later tested positive for COVID and was removed from isolation after symptoms resolved. Other residents with MS, dementia, Parkinson’s disease, heart failure, respiratory failure, asthma, and hypertension also had COVID-positive results and TBP documented. The survey findings included observations of residents’ rooms left open during care, roommates present during COVID-related care, and staff handling linens and PPE in ways that did not follow the facility’s stated infection control practices and CDC-based precautions.
Incomplete COVID Monitoring and Missing Neuro Assessments
Penalty
Summary
The facility failed to provide consistent and thorough COVID-19 monitoring assessments for multiple residents who tested positive for COVID-19 or were exposed to COVID-positive roommates. The report states that for residents including #11, #12, #32, #42, #59, #68, #74, #85, #91, and #96, the MAR/TAR orders required every-shift monitoring for 10 days, including temperature, pulse oximetry, lung sounds, shortness of breath or labored breathing, changes in baseline alertness, and monitoring for new symptoms such as cough, sore throat, fatigue, gastrointestinal symptoms, headache, congestion, and runny nose. For each of these residents, the MAR/TAR and nursing progress notes did not document the ordered assessments for the full 10-day period, and in several cases the notes did not show complete symptom monitoring, lung assessments, or baseline alertness checks every shift as ordered. The report also identifies residents who were exposed to COVID through shared rooms but did not have documentation showing the required monitoring or risk recognition. Resident #27 shared a room with a COVID-positive resident, but the care plan did not indicate COVID risk, the MAR/TAR did not show COVID monitoring, the progress notes did not document exposure or cohorting, and the tracking spreadsheet did not show COVID testing. Resident #75 shared a room with a COVID-positive resident, but the MAR/TAR and nursing notes did not document exposure-related monitoring, attempts to separate the residents, or interventions to reduce transmission risk. Resident #97 also shared a room with a COVID-positive resident, but the care plan did not indicate COVID risk, the MAR/TAR did not show symptom monitoring, and the progress notes did not document exposure, separation efforts, or interventions. The report further states that the facility failed to complete a neurological assessment after an unwitnessed fall for 17 of 21 residents reviewed, although the narrative provided in the excerpt primarily details the COVID monitoring failures. Several of the affected residents had significant medical histories, including heart failure, atrial fibrillation, COPD, chronic respiratory failure, asthma, kidney disease, diabetes, stroke, dementia, and mobility dependence. The deficiencies were identified through review of clinical records, MAR/TAR documentation, facility COVID tracking spreadsheets, care plans, and nursing progress notes, along with staff and policy review.
Food Storage and Preparation Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards during a kitchen observation on 12/15/25. Surveyors observed one pack of frozen ham thawing in an aluminum pan full of standing water in the sink and seven packs of thawed ham in an aluminum pan of standing hot water. Three flattened delivery boxes were also observed lying on a kettle used for food preparation. In addition, two clear plastic containers in the refrigerator were unlabeled, one containing sliced white oval items and the other containing sliced light green disk-shaped items. A unit refrigerator also contained a multicolored cloth item with a resident label, later identified as a coldpak. At 9:10 AM, an RN stated she did not know who placed the item in the refrigerator, and the CDM informed the unit nurse that resident healthcare items cannot be placed in the resident food storage refrigerator. Staff later stated items should be dated and labeled when stored and delivery boxes should be stored appropriately. The CDM stated the ham in standing hot water was present because the cook placed the seven frozen hams in the oven to speed thawing. The facility policy required frozen items to be thawed in the refrigerator or in a cold-water bath, prohibited soiled cloths, boxes, cartons, or other contaminating items on food preparation surfaces, and required leftover food to be labeled with the food name, date placed in the container, and allergen information.
Failure to Document Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure staff documented the non-pharmacological interventions attempted before administering PRN lorazepam for one resident reviewed for unnecessary medications. Resident #39 had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety, with impaired short-term and long-term memory, severely impaired cognitive skills for daily decision making, inattention, disorganized thinking, and rejection of care during the look-back period. The resident's care plan identified behaviors of anxiety and aggression related to senile degeneration of the brain, including physical aggression, combativeness during cares, resistance to cares, pacing, and wandering, and directed staff to administer medications as ordered at the lowest therapeutic dosage and observe for side effects. The record showed PRN lorazepam 0.5 mg PO was given for anxiety and/or restlessness on two occasions. On one occasion, the resident was restless and anxious when approached to change clothing, and on another occasion food was given, but no other non-pharmacological interventions were documented before the PRN lorazepam was administered. Staff interviews indicated they expected non-pharmacological interventions to be documented in the progress notes or on the EMAR before giving PRN antianxiety medication, and the facility's psychotropic medication monitoring policy stated that non-pharmacological interventions based on individual resident needs, preferences, and routines were the first-line treatment for dementia-related behaviors.
Failure to Provide Written Transfer and Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification to the resident's representative of a transfer to the hospital and failed to provide a written bed hold policy with reserve bed payment information for Resident #3. Resident #3's MDS dated 11/01/25 showed a BIMS score of 05 out of 15, indicating severely impaired cognition, and listed diagnoses including kidney failure, non-Alzheimer's dementia, Alzheimer's disease, a hip fracture, and traumatic brain injury. The care plan identified impaired cognitive function related to dementia and directed staff to discuss confusion, dementia progression, and nursing home placement with the resident's family members. Progress notes dated 8/03/25 documented that the resident fell, sustained right hip pain, and was transferred to the Emergency Department. A note at 11:24 AM stated that a family member was notified of the transfer and a bed hold, but the medical record did not include a signed or dated written notification of the transfer or bed hold policy with reserve payment. On 12/18/25, the Social Services Worker stated the bed hold was documented in progress notes but the form was not completed, and an RN stated the bed hold and representative notification of transfer form were not completed. The facility did not have a policy available for bed hold and transfer notification, although a bed hold policy effective 12/2025 stated the facility shall inform residents or their representative prior to transfer to the hospital and provide the bed hold policy within 24 hours of an emergency transfer.
MDS Coding Errors for Bed Rails and Serious Mental Illness
Penalty
Summary
The facility failed to ensure accurate MDS coding for physical restraints by coding two residents as having bed rails as restraints when the rails were not restrictive. Resident #9’s and Resident #21’s MDS assessments indicated a physical restraint in the form of a bed rail in P0100, but the record also showed the bed rails were present at the residents’ request and were intended to make them feel safer and, for Resident #21, to enhance mobility in bed. A direct observation found the bed rails were partial side rails that did not restrict the ability to get in or out of bed. Staff interviews showed the MDS staff were unsure how to code the bed rails and acknowledged they had been coding bed rails as restraints in error, relying on the RAI Manual rather than a facility policy. The facility also failed to code a resident’s mental illness on the MDS when indicated. Resident #4’s annual MDS showed diagnoses including bipolar disorder, psychotic disorder, intermittent explosive disorder, anxiety, and depression, but the MDS indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or related condition. The resident’s care plan documented anxiety disorder, major depression, and dementia with behavioral disturbance, and the PASRR dated 10/7/25 showed a Level II outcome with diagnoses including major depressive disorder, delusional disorder, bipolar disorder, anxiety disorder, and Alzheimer’s dementia. Staff stated they reviewed the PASRR to determine whether to mark the MDS, and the RAI Manual stated that if PASRR Level II screening determined the resident has a serious mental illness, the MDS should be coded accordingly.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to use a gait belt while transferring Resident #103, who required assistance with mobility, when a visitor attempted to transfer the resident from a recliner to a wheelchair. On 12/16/25, Staff I, CNA, was observed watching the visitor attempt the transfer without assistance, and when the resident began losing balance, Staff I assisted with the transfer without using the gait belt that was wrapped around the resident's waist. Staff interviews later confirmed that gait belts should be used for residents who are off balance, cannot stand by themselves, or require transfer assistance for safety. Resident #103's MDS dated 11/01/25 showed diagnoses including non-Alzheimer's dementia, traumatic brain injury, age-related mental decline, visual loss, syncope, and collapse. It also showed the resident was dependent with toileting, required moderate assistance with chair-to-chair transfers, maximal assistance with other ADLs and mobility, had a fall since admission, and used a wheelchair in the prior 7-day look-back period. The care plan identified the resident's fall risk related to generalized weakness, decreased mobility, poor safety awareness, and non-compliance with transfer status, but did not include the resident's friend resisting staff assistance with transfers or education provided to the friend about the safety importance of gait belt use. The resident care conference summary and progress notes also did not document such education, and staff interviews indicated they did not know whether the friend had been educated.
Failure to Complete Discharge Summary and Plan
Penalty
Summary
The facility failed to complete a discharge summary and discharge plan for a resident, identified as Resident #113, at the time of their planned discharge. The resident was admitted for skilled services and had a Brief Interview for Mental Status (BIMS) score indicating completely intact cognition. The resident's electronic health record (EHR) documented diagnoses of vertebral fractures and detailed their level of independence with various activities of daily living (ADLs). However, the EHR lacked the necessary discharge plan and summary documentation. The facility's administrator acknowledged that these documents were not completed due to the circumstances surrounding the resident's discharge. The facility's policy on admission, transfer, and discharge required a discharge care plan for resident-initiated discharges but did not specify directives for discharge summaries.
Improper Food Handling During Meal Transportation
Penalty
Summary
The facility failed to ensure proper food handling procedures during lunch service, leading to potential contamination. During an observation, it was noted that the steam table was transported from unit B1 to unit C1 with sweet potatoes and peas uncovered, and bread partially uncovered. This transportation occurred through a resident hallway and main area before reaching the dining room in unit C1, where meals were served to residents. Interviews with the Certified Dietary Manager (CDM) and the Administrator confirmed that food should be covered during transportation for infection control purposes. The facility's policy on Food Handling, revised in July 2024, also documented that food should be covered when delivered to residents' rooms or dining areas.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter and peri-care for a resident, leading to a deficiency in infection prevention and control. The resident, who had an indwelling catheter, was observed receiving care from two CNAs. During the procedure, one CNA did not perform hand hygiene between peri-care and catheter care, which is a critical step in preventing infections. The facility's policy on peri-care and hand hygiene was not followed, as the CNA did not wash hands or use an alcohol-based hand rub before and after handling the invasive device. The resident involved had a history of urinary tract infections and was moderately cognitively impaired, with a BIMS score of 10 out of 15. The resident required moderate assistance with various activities, including toileting hygiene. The care plan directed staff to use extended barrier precautions, but the observed care did not adhere to these guidelines. The facility's failure to ensure proper hand hygiene and adherence to infection control policies during catheter and peri-care contributed to the deficiency.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer as required. This deficiency was identified for one of the three residents reviewed who were transferred from the facility. Specifically, Resident #75 was transferred from the facility to a hospital on March 30, 2024, and reentered the facility on April 8, 2024. The clinical record for Resident #75 lacked documentation of notification to the LTC Ombudsman regarding the transfer to the hospital. During an interview, the Director of Nursing (DON) confirmed that the facility did not report the transfer to the Ombudsman. The facility's policy, revised on September 4, 2024, instructed staff to notify the State Ombudsman of any facility-initiated discharges for assistance with transition and support of the resident and representative.
Failure to Report and Notify of Resident's New Bruise
Penalty
Summary
The facility failed to complete an incident report and notify the physician and the resident's emergency contact regarding a new bruise observed on a resident. The resident, who has diagnoses of Parkinson's and Non-Alzheimer's, was dependent on staff for daily activities and had mild cognitive impairment. The bruise, measuring 3.5 cm by 3.5 cm, was documented in the resident's progress notes, but there was no record of notification to the physician or the resident's emergency contact. The facility's policy, revised in February 2024, mandates prompt consultation with the resident's physician and notification of the resident's representative when there is a change requiring notification. However, the Administrator confirmed that no incident report was completed, and the necessary notifications were not made at the time the bruise was observed. The Administrator stated that the expectation is for staff to complete an incident report and notify the physician and family for any bruise larger than a quarter.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged abuse incident involving a resident with diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, and depression. The resident, who had no cognitive impairment for decision-making, reported being physically assaulted by two teenage girls she believed were her roommates. The resident described being beaten, having her arms hurt, and being dragged across the floor. Despite the resident's detailed account, the facility's investigation summary concluded that the allegation was unsubstantiated without documenting any staff interviews. The facility's incident folder for the resident lacked documentation of staff interviews, which was confirmed by the Administrator. Interviews with staff members, including a Certified Medication Aide, a Certified Nurse Aide, and a Licensed Practical Nurse, revealed that none were interviewed regarding the incident and were unaware of the allegation. This oversight was contrary to the facility's Abuse Prevention, Identification, Investigation, and Reporting Policy, which requires attempts to obtain witness statements from all known witnesses.
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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) |
|---|---|---|---|---|
| Azria Health Park Place | 0.8 mi | ★★★★★ | 25 | 2 |
| Rehabilitation Center Of Des Moines | 1.5 mi | ★★★★★ | 14 | 0 |
| Valley View Village | 1.5 mi | ★★★★★ | 4 | 0 |
| University Park Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 4 | 0 |
| Ramsey Village | 3.2 mi | ★★★★★ | 44 | 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.