Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Valley View Village during CMS and state inspections, most recent first.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with HTN, DM2, CVA, HF, and cardiomyopathy had an IPOST indicating CPR with limited interventions, including no intubation or mechanical ventilation. When the resident was found unresponsive, staff started CPR, called 911, and EMS took over; staff reported the IPOST was not presented to EMS and EMS intubated the resident. The DON confirmed the resident was full code with DNI and stated the IPOST or wishes should have been presented to EMS.
A resident with severe cognitive impairment was improperly transferred by two CNA students without using a gait belt, as required by facility policy. The resident's right leg became caught on the wheelchair wheel during the transfer, resulting in a ligament injury. The incident highlights a failure in supervision and adherence to safety protocols.
The facility failed to provide sufficient and properly trained staff to meet the behavioral health needs of a resident with advanced dementia, resulting in severe self-injurious behavior, including cellulitis and the loss of a finger. Staff frequently failed to implement care plan interventions or notify nursing staff, and the facility was reported to be understaffed, particularly in the Memory Care unit.
The facility failed to implement proper infection control measures during blood glucose monitoring for three residents. Staff placed items on surfaces without barriers, did not dispose of lancets in sharps containers, and used the same monitor for multiple residents without proper disinfection and storage.
A Culinary Assistant failed to perform hand hygiene before serving lunch, touching the tops of residents' plates and using his thumb to hold food in place. The staff member also handled paperwork without sanitizing hands before continuing to serve food. The Director of Food and Nutrition Services acknowledged the need for proper handwashing and adherence to the facility's policy prohibiting bare hand contact with food.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. A resident received medications late, another had missing weight records and unreported weight gain, and a third received a discontinued treatment. These issues highlight failures in medication administration, monitoring, and treatment adherence.
A resident with diabetes and other complex conditions did not receive necessary nail care, resulting in long, dirty fingernails. Despite the care plan and facility policy requiring regular grooming assistance, observations and interviews revealed a lack of documentation and action by staff to maintain the resident's nail hygiene.
A facility failed to document the rationale for not reducing a resident's Risperidone dose, despite recommendations. The resident, with severe cognitive impairment and Huntington's Disease, had a care plan for dose reduction. The PCP did not address the GDR for Risperidone on two occasions, and the rationale provided later was not documented in the medical record, leading to a deficiency.
The facility failed to protect medical records for two residents during medication administration. On two occasions, a medication cart with a laptop displaying resident medication lists was left unattended without a privacy screen, compromising confidentiality. The DON confirmed that staff are trained to lock screens and secure carts as per policy.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
IPOST Preferences Not Followed During Emergency Response
Penalty
Summary
The facility failed to ensure Resident #2’s end-of-life treatment preferences were followed as documented on the Iowa Physician Orders for Scope of Treatment (IPOST). Resident #2’s admission MDS listed diagnoses including hypertension, Type 2 diabetes, cerebral infarction, heart failure, and cardiomyopathy. The care plan initiated for the resident did not include information about end-of-life treatment for a Full Code CPR status with limited interventions. The EHR contained an IPOST signed on [DATE] indicating the resident wanted CPR attempted with limited additional interventions, including no intubation or mechanical ventilation. During interviews, staff described that Resident #2 was found unresponsive, CPR was started, and 911 was called. Staff reported the resident was treated as full code, the AED was applied, and EMS arrived and took over CPR. Staff stated EMS intubated the resident, and no staff tried to stop EMS from intubating. Staff also reported that the IPOST was not presented to EMS, although the resident’s POA was contacted and CPR was discontinued. The DON confirmed the resident was full code with DNI and stated the IPOST or wishes should have been presented to EMS. The facility policy stated staff should look at the resident’s code status and IPOST during a crisis and include the original IPOST with discharge papers or transfer.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in harm during a transfer. The resident, who had severe cognitive impairment and required substantial assistance for transfers, was improperly transferred by two CNA students. The students did not use a gait belt as required by facility policy and attempted to transfer the resident without adequate support, leading to the resident being lowered to the floor and sustaining a ligament injury. The resident's care plan specified that two staff members were required for transfers, and later updates required the use of a mechanical lift. However, the students, eager to assist, did not follow these directives. The resident's right leg became caught on the wheelchair wheel during the transfer, and the students were unable to safely lower her to the ground, resulting in the injury. The resident was subsequently sent to the emergency room for evaluation, where a ligamentous injury was suspected. The facility's policy on transfer assistance was not adhered to, as the students did not use a gait belt and attempted to lift the resident under her arms, contrary to the procedure outlined. The incident highlights a failure in supervision and adherence to established safety protocols, which led to the resident's injury and subsequent pain management issues.
Failure to Provide Sufficient and Trained Staff for Behavioral Health Needs
Penalty
Summary
The facility failed to provide sufficient and properly trained staff to meet the behavioral health needs of a resident with self-injurious behavior. The resident, who had advanced dementia and other significant health issues, was observed to have repeatedly bitten her fingers, resulting in severe injuries including cellulitis and the loss of the distal portion of her left index finger. Despite the care plan interventions, such as offering food or a stuffed dog for redirection, the staff did not consistently implement these measures, leading to multiple instances of harm to the resident. The resident's clinical records and progress notes documented numerous occasions where she was found biting her fingers, leading to infections and severe injuries. The interventions, including bandages, gloves, and medications, were either ineffective or not consistently applied. Direct observations revealed that staff members frequently failed to redirect the resident or notify nursing staff when the resident was engaging in self-harm. This lack of intervention was noted even when the resident was visibly chewing on her bandages and fingers in the presence of staff. Interviews with staff and family members indicated a consensus that the facility was understaffed, particularly in the Memory Care unit. Staff members reported that the high demand for assistance with other residents left them unable to adequately monitor and intervene in the self-harming behaviors of the resident. The Director of Nursing acknowledged that the facility could not provide one-on-one care for the resident and that staff were expected to attempt redirection, although this was not consistently done. The facility's policies on behavioral health and dementia care were not effectively implemented, contributing to the resident's ongoing self-injurious behavior and resulting harm.
Infection Control Deficiencies in Blood Glucose Monitoring
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during blood glucose monitoring for three residents. Observations revealed that staff placed blood glucose items on surfaces without using a barrier, did not dispose of lancets in a sharps container after use, and wrapped the blood glucose monitor with a disinfecting wipe before placing it in a tray with clean items. Additionally, the same blood glucose monitor was used for multiple residents without proper disinfection and storage procedures being followed. These actions were observed on three separate occasions for three different residents. The Director of Nursing confirmed that staff should use a paper towel or barrier, that sharps containers are located on the medication cart, and that each resident should have their own monitor stored in individual bags. Facility policies also indicated that equipment should be placed on a clean barrier and that glucometers should be disinfected and stored individually. However, these policies were not followed, leading to the deficiencies observed during the survey.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
Based on observation, interview, and facility policy, the staff failed to perform hand hygiene to prevent the spread of possible foodborne illness during a meal observation. The facility, which reported a census of 75 residents, was found deficient in this area. During an observation on May 29, 2024, at 12:38 PM, a Culinary Assistant (CA), identified as Staff F, did not perform hand hygiene at the handwashing station before beginning to serve lunch plates. While serving, Staff F repeatedly touched the tops of the residents' plates and used his thumb to hold food in place on two occasions. Further observation at 12:41 PM revealed Staff F handling paperwork and then continuing to serve food without performing hand sanitation. In an interview on May 30, 2024, at 2:20 PM, the Director of Food and Nutrition Services acknowledged that Staff F should not have used his fingers to hold food in place and should have washed hands after handling other objects. The facility's policy, titled Food Preparation and Services, last reviewed on January 12, 2024, documented that staff should wash their hands before serving food to residents and that bare hand contact with food is prohibited.
Failure to Follow Physician Orders for Three Residents
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in care. Resident #20, who had intact cognition, consistently received medications significantly past the ordered time. Despite expressing a preference for earlier administration to avoid being woken up, the medications were often given late, sometimes after midnight. The facility's policy allowed for liberalized medication pass times, but the administration still fell outside the acceptable range, indicating a failure to respect the resident's preferences and adhere to the medication schedule. Resident #67, also with intact cognition, had a physician order for daily weights due to medically complex conditions, including diabetes and respiratory failure. The facility failed to record weights on two consecutive days, and there was no documentation explaining the omission. Additionally, a significant weight gain was not reported to the physician as required. The lack of documentation and communication with the physician regarding the weight gain and missed recordings highlighted a failure to follow physician orders and ensure proper monitoring of the resident's condition. Resident #30, at moderate risk for pressure wounds, received a discontinued treatment for a healed wound. The resident had an active order for a different wound care treatment, but during an observation, the incorrect treatment was applied. The staff did not have the correct treatment supplies ready, and there was no treatment administration record available for verification. This oversight in treatment administration demonstrated a failure to follow current physician orders and ensure appropriate care for the resident's skin integrity.
Failure to Provide Nail Care for Resident with Diabetes
Penalty
Summary
The facility failed to provide necessary grooming services for a resident, specifically in maintaining nail care. The resident, who had intact cognition and was diagnosed with medically complex conditions including diabetes mellitus, hip fracture, and respiratory failure, required assistance with activities of daily living (ADL) due to a recent hospitalization and surgery. The care plan indicated that staff should assist with grooming, yet observations on two consecutive days revealed the resident's fingernails were long, jagged, brown, and dirty. The resident confirmed that the facility had not trimmed his nails in a while and expressed reliance on the facility for nail care due to his diabetes. The facility's electronic health record (EHR) showed that skin inspection forms completed on two prior dates directed staff to observe and provide nail care as needed, but there was no documentation that nail care was performed. Interviews with the Administrator and the Director of Nursing (DON) confirmed the lack of documentation and the expectation that the resident's nails should have been trimmed regularly, especially given the resident's diabetes. The facility's policy on nail care required that all residents receive medically indicated nail care to maintain cleanliness and dignity, which was not adhered to in this case.
Failure to Document GDR Rationale for Antipsychotic Medication
Penalty
Summary
The facility failed to document a reason for declining a Gradual Dose Reduction (GDR) for a resident with severe cognitive impairment and multiple diagnoses, including Huntington's Disease and anxiety disorder. The resident's care plan included interventions for dose reduction of antipsychotic medication as per regulatory guidelines. However, the clinical record review revealed that the primary care provider (PCP) did not address the GDR recommendation for Risperidone on two separate occasions, despite agreeing to dose reductions for other medications. An email from the PCP later provided a rationale for not addressing the Risperidone, but this was not documented in the clinical medical record or on the Pharmacist's Recommendation to Prescriber forms. The facility's policy on Psychotropic Medication Monitoring and Medication Review Management outlines the procedures for regulatory compliance, including documentation requirements for the attending physician and follow-up actions by the Director of Nursing (DON) if the physician does not respond. Despite these policies, there was no further documented attempt by the nursing staff to address the lack of response regarding the Risperidone dose reduction. This oversight led to a deficiency in the facility's compliance with its own medication review policies and procedures.
Failure to Secure Resident Medical Records
Penalty
Summary
The facility failed to protect medical records in a confidential and secure manner for two residents during medication administration. Observations revealed that on two separate occasions, a medication cart with a laptop displaying resident medication lists was left unattended without a privacy screen. This occurred for two residents, compromising the confidentiality of their medical information. The Director of Nursing confirmed that staff are trained to lock their computer screens and secure their carts before leaving them unattended, as per the facility's policy on maintaining the privacy and security of protected health information.
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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) |
|---|---|---|---|---|
| Trinity Center At Luther Park | 1.5 mi | ★★★★★ | 17 | 1 |
| Azria Health Park Place | 2.1 mi | ★★★★★ | 25 | 2 |
| Rehabilitation Center Of Des Moines | 2.4 mi | ★★★★★ | 14 | 0 |
| University Park Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 4 | 0 |
| Parkridge Specialty Care | 3.9 mi | ★★★★★ | 18 | 0 |
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