Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 University Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to disinfect a mechanical lift between resident uses and after use, and staff also failed to follow PPE requirements for EBP and enteric isolation. A CNA moved the lift between multiple residents without sanitizing it, and staff entered rooms of residents with C-diff and EBP needs without the required gown-and-glove precautions during medication administration, mail delivery, and feeding tube care.
Surveyors found that staff failed to ensure safe positioning and equipment use during multiple resident transfers. A resident with hemiplegia and stroke history was raised in a mechanical stand lift without the knees positioned against the shin pads. Two other residents with severe cognitive impairment and multiple comorbidities were transferred with mechanical lifts while their wheelchairs or Broda chair were not locked, and one of these residents was transported in a wheelchair without foot pedals. Another resident dependent for all ADLs was also transferred with a mechanical lift into an unlocked wheelchair. CNAs and the DON acknowledged that wheelchairs should be locked during transfers and that residents should not be transported without foot pedals.
A resident with diabetes, arthritis, reduced mobility, and a below-the-knee amputation required 2-person assist for bathing and was supposed to be showered twice weekly, but bath and shower records showed long gaps with no documented bath, shower, or refusal. Staff said bath sheets were used to track showers and refusals, yet the ADON, DON, CNAs, and an LPN acknowledged missing documentation, and the resident stated he had only been offered and given two showers and one bed bath since admission.
Medication error rate exceeded 5 percent. During an observed med pass, an LPN prepared 8 meds for a resident and obtained Omeprazole from both the resident’s med card and OTC floor stock, and obtained Vitamin D3 from OTC floor stock instead of the resident-specific med card. Review of the orders showed Omeprazole was ordered daily and Vitamin D was ordered weekly, and the pharmacist confirmed the Vitamin D was sent via a resident-specific med card.
A resident with severe cognitive impairment and dysphagia was not served the correct pureed diet portions or all required menu items during a meal service. The dietary aide initially provided an incorrect portion size and omitted several menu items, only serving them after being prompted by the dietary manager, with one item never served. This was not in accordance with the facility's menu and portion control policy.
Staff failed to consistently use required PPE, such as gowns and gloves, and did not always perform hand hygiene during high-contact care activities for residents with wounds on Enhanced Barrier Precautions. Observations included an LPN and CNAs providing wound care and transfers without donning gowns, and one staff member not performing hand hygiene between resident contacts, contrary to facility policy.
The facility failed to document food temperatures consistently, with several meal temperatures missing over a three-month period. This lapse in documentation made it unclear if food reached safe temperatures, violating the facility's policy and FDA guidelines.
The facility failed to employ a certified dietary manager, as the Dietary Director lacked the required certification. Despite being in the position for three weeks, the Dietary Director had not completed the necessary certification, although he was enrolled in coursework. The facility also lacked a policy for having a certified dietary manager, as required by the FDA Food Code 2022.
The facility failed to maintain professional standards in food preparation and service. Observations revealed an unclean ice machine, utensils placed on unclean countertops, and uncovered drinks delivered to residents' rooms. Staff interviews indicated a lack of awareness and adherence to facility policies, contributing to these deficiencies.
Two residents experienced a lack of dignity and timely assistance in a facility. One resident, with intact cognition and requiring assistance due to a stroke, was left exposed and missed an activity due to delayed staff response. Another resident, with severe visual impairment, was not promptly assisted after dropping oatmeal during breakfast, and staff failed to offer a replacement meal. These incidents highlight a failure to adhere to the facility's dignity and respect policy.
The facility failed to maintain a homelike environment, as observed in the shared bathrooms of two pairs of residents, which had significant damage including holes in walls and doors, and splintered wood. The Administrator was unaware of these issues, which were not reported in the facility's tracking system, TELS, used for monitoring repairs.
A resident's cellphone was stolen in an LTC facility, with the theft discovered when the family activated an old phone and received unfamiliar text messages. The facility's investigation pointed to a staff member, who was subsequently terminated for non-cooperation. The resident, with cognitive impairments, was unable to report the theft, highlighting a deficiency in protecting resident property.
A resident with intact cognition and multiple health conditions, including hemiplegia and osteoporosis, was found to have their call light placed over three feet away, making it inaccessible while they were seated in a recliner. The facility's policy requires call lights to be within easy reach, and staff are expected to ensure this, but the expectation was not met in this instance.
Two residents with intact cognition experienced significant delays in receiving assistance after activating their call lights. One resident waited 45 minutes for toileting help, while another was left in an undignified state for nearly an hour. Staff interviews confirmed that call lights should be answered within 15 minutes, but this standard was not met.
The facility failed to notify the Long Term Care Ombudsman of resident discharges or transfers as required by federal regulation. Five residents were transferred to the hospital without proper documentation, and staff interviews revealed the facility lacked a policy for reporting these events.
The facility failed to maintain a sanitary environment, as staff did not follow proper hand hygiene and glove use protocols while providing care to residents, including those with catheters and incontinence. This included not changing gloves between dirty and clean tasks and placing items directly on the floor without a barrier.
A resident with chronic obstructive pulmonary disease received oxygen therapy without a physician's order, and the oxygen tubing was not changed as required. The facility's policy mandated weekly changes of the oxygen cannula and tubing, which was not followed. The Assistant Director of Nursing confirmed these deficiencies.
Failure to Disinfect Shared Equipment and Follow PPE Precautions
Penalty
Summary
The facility failed to disinfect a mechanical lift between resident uses and after use. During observation, a CNA moved the lift from a storage room to one resident’s room, then to a second resident’s room without sanitizing it between uses. The same lift was then taken to a third resident’s room and later to the shower room without being sanitized after resident use. When interviewed, the CNA stated the lift should be sanitized before and after resident use and acknowledged it should have been sanitized between residents but was not. The facility also failed to use appropriate PPE for Enhanced Barrier Precautions and enteric isolation precautions for two residents. One resident had a BIMS score of 15, diagnoses including hemiplegia, asthma, and C-diff enterocolitis, and was receiving a daily antibiotic for C-diff; the care plan directed enteric isolation and signage outside the room. During observation, an RN entered the room to administer medications without PPE, and an Activities Director entered without PPE to deliver mail and then went into another resident’s room. Another resident had a BIMS score of 3, diagnoses including obstructive uropathy, seizure disorder, and ulcerative colitis, and had a urinary catheter and feeding tube. An RN entered that resident’s room, performed care involving the feeding tube, and wore only gloves; an EBP sign was posted at the door directing staff to wear gloves and a gown for high-contact care activities, including device care or use.
Improper Mechanical Lift Positioning and Unlocked Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision during resident transfers and wheelchair use. One resident with hemiplegia, diabetes, stroke history, and intact cognition required maximal assistance for most ADLs and was care planned for transfer with an EZ Stand. During observation of a transfer by two CNAs, the resident’s knees were not positioned against the EZ Stand shin pads as the resident was raised from the wheelchair, contrary to safe positioning expectations. The facility’s mechanical lift policy required a test lift to check sling fit, attachment security, and weight distribution, but the observation focused on improper positioning of the resident’s knees during the lift. Additional deficiencies involved failure to lock wheelchairs during transfers and transporting a resident without wheelchair foot pedals. One resident with severe cognitive impairment, non‑Alzheimer’s dementia, and Down Syndrome, who required extensive assistance and mechanical lift transfers, was transferred twice by CNAs using a mechanical lift while the Broda chair or its rear wheel remained unlocked. Another resident with severe cognitive impairment, dementia, seizure disorder, and mild intellectual disabilities, who used a self‑propelled wheelchair, was transported without foot pedals and then transferred with a mechanical lift while the wheelchair remained unlocked. A further resident with hemiplegia, diabetes, COPD, and intact cognition, who was dependent for all ADLs and required a mechanical lift with two‑person assist, was transferred from bed to wheelchair with the wheelchair unlocked throughout the transfer. Staff involved in these incidents acknowledged that wheelchairs should be locked during transfers and that residents should not be transported without foot pedals, and the DON stated staff should lock wheelchair brakes during transfers and follow transfer policy.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to provide showers for a dependent resident who required two-person assistance for bathing and showering. Resident #58 had diagnoses including diabetes mellitus and arthritis, was a below-the-knee amputee, had reduced mobility, and needed assistance with personal cares. The resident’s care plan directed staff to encourage bathing or showering twice weekly, but bath and shower records showed multiple gaps in documentation where there was no record of a bath, shower, bed bath, or refusal for extended periods. The resident also reported that he had only been offered and given two showers and one bed bath since admission. Facility staff stated that bath and shower sheets were used to track showers and refusals, and that nurses and CNAs were expected to sign them each time a bath, shower, or refusal occurred. However, the ADON, DON, CNAs, and an LPN all acknowledged missing documentation, and the DON stated staff admitted they had been forgetting to fill out refusals for Resident #58. Nursing progress notes documented only two refusals, one of which was for a bed bath request, while the Kardex plan of care response history showed only one day in the last 30 days and indicated the resident did not receive a shower or bath on that date. The facility’s shower policy stated residents would be provided showers as requested or per schedule, but it did not address shower sheets or refusal documentation.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
Medication error rates were not maintained below 5%, as 27 ordered medications were reviewed and 2 errors were identified, resulting in a 7.4% error rate. The facility’s census was 74. During an observed medication pass, Staff B, an LPN, prepared 8 medications for Resident #33 and obtained Omeprazole 20 mg from both the resident’s medication card and an over-the-counter floor stock bottle. Staff B also obtained two Vitamin D3 125 mcg/500 IU pills from an over-the-counter floor stock bottle, and these medications were administered along with 6 others. When the observed medication pass was reconciled with the current physician orders, Omeprazole was ordered as 20 mg, 1 capsule daily, and Vitamin D was ordered as 1.25 mg (50,000 IU), 1 capsule one time a week. Staff B confirmed the Omeprazole order and later acknowledged that the pill should have been administered from the medication card only, not also from the stock bottle. The pharmacist confirmed the Vitamin D order was sent via a resident-specific medication card, and Staff B later acknowledged the Vitamin D pill should have come from the medication card rather than the stock bottle. The facility policy on medication administration required use of the six rights, review of the MAR, comparison of the medication source with the MAR, and administration as ordered.
Failure to Follow Prescribed Pureed Diet Menu and Portion Sizes
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dysphagia, requiring a pureed diet, was not served meals according to the prescribed menu and portion sizes. The resident's care plan and physician orders specified a pureed diet, and the facility's menu for the day included specific pureed items and portion sizes. However, during lunch service, the dietary aide initially served only one 4oz scoop of chili instead of the required two 4oz scoops. The dietary manager later clarified that the correct serving size was two 4oz scoops, but this information had not been communicated to the aide prior to service. Further observations revealed that the resident did not receive all menu items as required. The dietary aide failed to serve the pureed cinnamon roll, pureed vegetables, and pureed dessert until prompted by the dietary manager, and the pureed cinnamon roll was never served at all. The facility's portion control policy required food to be served according to standard portion sizes and menu requirements, but this was not followed. The administrator confirmed that the expectation was for meals to be served according to the menu.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP). Specifically, staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with chronic wounds, pressure ulcers, and surgical wounds. Observations included a Licensed Practical Nurse performing a dressing change for a resident with an unstageable pressure ulcer without donning a gown, despite the resident being on EBP due to the presence of a chronic wound. Further observations revealed that two staff members transferred a resident with pressure and surgical wounds without wearing gowns, as required by EBP protocols. After completing the transfer, one staff member failed to perform hand hygiene before proceeding to care for another resident with a surgical wound and wound vacuum, also on EBP. During this subsequent care, staff again did not don gowns as required, although gloves were used and hand hygiene was performed at certain points. The facility's policies, reviewed by surveyors, clearly stated that gowns and gloves must be worn during high-contact care activities for residents on EBP, and that hand hygiene should be performed before and after resident contact, as well as when moving between contaminated and non-contaminated areas. Interviews with the Director of Nursing and the Administrator confirmed that staff did not follow these protocols during the observed care activities, resulting in a failure to adhere to established infection prevention and control measures.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, and distribution of food, as evidenced by incomplete documentation of food temperatures. Over a three-month period, the kitchen meal temperature logs revealed that several meal temperatures were not recorded: 4 out of 90 meals in November, 8 out of 93 meals in December, and 25 out of 78 meals in January. The Dietary Director acknowledged that all temperatures should be logged both in the kitchen and dining rooms prior to food distribution and serving, but this was not consistently done. This lack of documentation made it unclear whether the food reached the required temperatures to ensure safety. The facility's policy on Food Preparation and Service, revised in October 2017, outlined specific temperature requirements to inactivate pathogenic microorganisms and prevent foodborne illness. However, the failure to document these temperatures as required by the policy and the FDA Food Code 2022, which mandates daily oversight of cooking temperatures, indicates a lapse in following proper food safety practices. The Administrator confirmed the necessity of maintaining current food temperature logs to verify that temperatures were taken before food distribution or serving, highlighting a deficiency in the facility's food safety procedures.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional, as the Dietary Director did not possess the required certification. The personnel document review, staff interviews, and facility policy review revealed that the Dietary Director, who had been in the position for three weeks, had not completed the necessary certification. Although he had previously held a Serve Safe Certification, it had expired, and he was currently enrolled in coursework to complete the certification. The Administrator acknowledged the Dietary Manager's new employment status and ongoing coursework. Additionally, the facility lacked a policy related to having a certified dietary manager, which is a requirement according to the Food and Drug Administration Food Code 2022.
Deficiencies in Food Preparation and Service Standards
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, serving, and distribution, as observed during a survey. On one occasion, the ice machine was found to have a light pink substance throughout, indicating a lack of proper cleaning and maintenance. Staff were observed placing cooking utensils directly on countertops without any barrier, and there was uncertainty about when the countertops were last cleaned. Additionally, drinks were delivered to residents' rooms uncovered, which was against the facility's policy. Interviews with staff and residents revealed further issues. A resident mentioned that drinks are usually served without covers, contrary to the facility's policy. The Dietary Director, who was new to the position, was unaware of the need to monitor and clean the ice machine. The Dietary Manager could not confirm when the countertops were last wiped down. The Administrator expected the ice machine to be clean and utensils to be placed on clean surfaces, but could not ensure this was happening. The facility's policies on ice machine maintenance and food preparation were not being followed, contributing to the deficiencies observed.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the incidents involving two residents. Resident #84, who had intact cognition and required assistance with activities of daily living due to a stroke, was left sitting in his reclining chair with his pants down and his brief exposed for an extended period. Despite having his call light on and expressing a desire to attend an activity, staff did not promptly assist him, resulting in him missing the event. Staff interviews confirmed that the resident was left in an undignified state, contrary to the facility's policy on dignity and respect. Resident #54, who also had intact cognition but suffered from severe visual impairment, experienced a lack of timely assistance during breakfast. After accidentally dropping a bowl of oatmeal, staff did not immediately address the spill or offer a replacement meal. The resident was left without interaction or acknowledgment of the incident, and by the time staff inquired if they were finished with their meal, the resident chose to return to their room instead of receiving another serving. This lack of timely response and interaction did not align with the facility's expectations for maintaining dignity and communication with residents. The facility's policy on Quality of Life-Dignity, revised in August 2009, emphasizes the importance of caring for residents in a manner that promotes dignity, respect, and individuality. However, the incidents involving Residents #84 and #54 demonstrate a failure to adhere to these standards, as staff did not provide the necessary assistance and communication to ensure the residents' dignity and participation in activities.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain resident living areas in good repair and provide a homelike environment, as observed during a survey. Specifically, the shared bathrooms of two pairs of residents were found to have significant damage. One bathroom had wall damage on the floorboard, a hole in the wall, and the border coming off by the floor, creating a large gap and hole. Another bathroom had a hole in the door, with the bottom of the door falling apart, featuring jagged edging and splintered wood, and a hole along the floorboard by the sink. The Administrator, upon observation, was not aware of the condition of these bathrooms and acknowledged that the damage was not reported in the facility's tracking system, TELS, which is used to report, track, and monitor repairs and maintenance issues. The Administrator stated that the damage was not homelike and could be a safety concern, and expressed an expectation that such damage should be reported and repaired. The facility's policy on providing a homelike environment, revised in May 2017, emphasizes the importance of maintaining a safe, clean, and comfortable environment for residents.
Misappropriation of Resident's Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically a cellphone. The resident, who was rarely or never understood due to cognitive impairments and other medical conditions, was unable to communicate the loss of their cellphone. The resident's care plan had noted the potential for diversional activity due to cognitive impairment, and interventions included encouraging family involvement and social interaction. However, the care plan was revised to include an allegation of theft of the resident's cellphone, indicating a failure to protect the resident's belongings. The incident came to light when the resident's daughter, who is the responsible party, attempted to Facetime the resident and discovered the phone was missing. Initially, the family believed the phone was misplaced within the facility, as had happened in the past. However, upon activating an old phone with the same number, they received unfamiliar text messages, leading them to suspect theft. The facility conducted an internal investigation, which included reviewing text messages and interviewing staff. A staff member, identified as Staff F, was suspected of taking the phone, as a text message from her number was found on the resident's phone. Staff F did not admit to the theft and failed to cooperate with the investigation, leading to her termination. The facility's investigation revealed that the phone was last seen approximately two weeks before the family activated the old phone. Despite the facility's efforts to locate the phone and identify the perpetrator, the family chose not to press charges. The facility's policy on abuse prevention and misappropriation of property was not effectively implemented, resulting in the resident's property being stolen. The facility's failure to protect the resident's belongings and ensure a secure environment for their property constitutes a deficiency in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident #68. This resident had a Brief Interview for Mental Status score indicating intact cognition and was diagnosed with conditions such as anemia, heart failure, hemiplegia/hemiparesis, hip fracture with an artificial hip joint, and osteoporosis. The resident required moderate assistance with transfers and was assessed as a fall risk. The care plan for Resident #68 included interventions such as keeping the call light within reach and removing wheelchair pedals to prevent self-transfers. During a family interview, it was reported that the call light was out of reach when the resident was sitting in a recliner. An observation confirmed that the call light was placed over three feet away from the resident, on a bedside table, making it inaccessible. The Assistant Director of Nursing stated that staff are expected to ensure call lights are within reach of residents. The facility's policy on answering call lights, revised in March 2021, also required that call lights be within easy reach when a resident is in bed or confined to a chair.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to respond to residents' needs in a timely manner, as evidenced by two separate incidents involving residents with intact cognition who required assistance. Resident #50, who was dependent on staff for toileting hygiene, activated his call light while on the toilet and waited approximately 45 minutes for assistance, despite having called the front desk for help. This delay in response caused the resident discomfort, as he had experienced similar delays in the past. Similarly, Resident #84, who required substantial assistance for transfers and toileting, was left sitting in a reclining chair with his pants partially down for nearly an hour. Despite activating his call light and requesting assistance to transfer to his wheelchair, staff did not return promptly, leaving him in an undignified state. Interviews with staff confirmed that call lights are expected to be answered within 15 minutes, yet these expectations were not met, as documented in the facility's Resident Council meeting minutes.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of discharge or transfer of residents as required by federal regulation. This deficiency was identified through clinical record review, staff interviews, and policy review. Specifically, the facility did not document the discharge or transfer of five residents to the hospital. Resident #5 had an unplanned discharge to the hospital and reentered the facility, but the Notice of Transfer Form lacked documentation of this event. Similarly, Resident #23 had multiple unplanned discharges to the hospital, none of which were documented in the Notice of Transfer Form. Resident #14, who had a seizure disorder and diabetes, was also transferred to the hospital without proper documentation. Resident #42 and Resident #59 experienced unplanned discharges to the hospital, but their transfers were not reported to the Ombudsman as required. Interviews with staff revealed that the facility did not have a policy for reporting discharges or transfers to the Long Term Care Ombudsman. The Administrator admitted that the reports sent to the Ombudsman were incomplete and did not include all residents who were discharged or transferred. The Administrator also acknowledged that the facility's electronic software program did not generate accurate reports of all discharges and transfers. As a result, the facility failed to comply with federal regulations requiring timely notification to the Ombudsman for all resident discharges and transfers.
Infection Control Deficiencies
Penalty
Summary
The facility failed to provide a sanitary environment to help prevent the spread of communicable diseases and infections. For Resident #51, a CNA did not perform hand hygiene before applying gloves and placed a graduate directly on the floor without a barrier while draining a catheter bag. The facility's policy required placing a paper towel on the floor beneath the drainage bag. Additionally, an Environmental Services staff member wore gloves while pushing a cleaning cart and touching elevator buttons, failing to change gloves between tasks, which could lead to cross-contamination. For Resident #11, two CNAs did not change gloves between dirty and clean tasks while providing peri-care, despite the facility's policy requiring glove changes between such tasks. Similarly, for Resident #61, two CNAs wore the same gloves throughout the entire process of transferring the resident, removing soiled briefs, and cleaning the resident, contrary to the facility's hand hygiene and glove use policies. These actions indicate a failure to adhere to proper infection control practices, as confirmed by the Assistant Director of Nursing.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care and services in accordance with professional standards of practice. Specifically, the resident was provided with oxygen therapy without a physician's order, and the oxygen tubing was not changed as required. The resident, who had a diagnosis of chronic obstructive pulmonary disease and mild cognitive impairment, was observed on two separate occasions with oxygen administered at 2.5 liters per nasal cannula, but the tubing lacked a date mark. A review of the resident's active orders confirmed the absence of a physician's order for oxygen. The facility's policy required oxygen cannula and tubing to be changed every 7 days, which was not adhered to. The Assistant Director of Nursing confirmed these deficiencies during an interview.
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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) |
|---|---|---|---|---|
| Rehabilitation Center Of Des Moines | 0.6 mi | ★★★★★ | 14 | 0 |
| Azria Health Park Place | 1.3 mi | ★★★★★ | 25 | 2 |
| Ramsey Village | 1.8 mi | ★★★★★ | 44 | 0 |
| Trinity Center At Luther Park | 2 mi | ★★★★★ | 17 | 1 |
| Scottish Rite Park Inc | 2.1 mi | ★★★★★ | 1 | 0 |
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