Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| University Park Nursing And Rehabilitation Center | 0.6 mi | — | 4 | 0 |
| Azria Health Park Place | 0.9 mi | — | 24 | 1 |
| Trinity Center At Luther Park | 1.5 mi | — | 17 | 1 |
| Ramsey Village | 2.3 mi | — | 4 | 0 |
| Valley View Village | 2.4 mi | — | 4 | 0 |
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