Inspection Reports for Calvin Community

4210 Hickman Rd, Des Moines, IA 50310, United States, IA, 50310

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Inspection Report Summary

The most recent inspection on January 9, 2026, found the facility in substantial compliance with health requirements and did not list any deficiencies. Earlier inspections showed a pattern of citations related mainly to care planning, medication management, infection control, and food safety practices. Complaint investigations were generally unsubstantiated, with no enforcement actions or fines noted in the available reports. Prior deficiencies included issues such as incomplete care plans for residents on psychotropic medications, unsafe wheelchair transport, unsecured medication carts, and failure to maintain proper food temperatures. The facility’s record shows some improvement over time, with the latest report indicating compliance following previous citations.

Deficiencies (last 7 years)

Deficiencies (over 7 years) 3.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

23% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2020
2021
2022
2023
2024
2025
2026

Census

Latest occupancy rate 55 residents

Based on a December 2025 inspection.

Census over time

36 42 48 54 60 Jul 2020 Sep 2020 Jan 2023 Apr 2023 Jan 2025 Dec 2025

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Jan 9, 2026

Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on January 9, 2026, related to the facility's compliance with health requirements.

Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance with health requirements effective January 9, 2026. No specific deficiencies are detailed in this document.

Inspection Report

Annual Inspection
Census: 55 Deficiencies: 8 Date: Dec 18, 2025

Visit Reason
The inspection was conducted as an annual recertification survey of the facility to assess compliance with federal regulations.

Findings
The facility was found deficient in multiple areas including failure to complete and provide discharge summaries, incomplete comprehensive care plans for residents on psychotropic medications, failure to transcribe and initiate a physician order, unsafe wheelchair transport practices, unsecured medication cart, improper food safety practices, incomplete resident medical records documentation, and inadequate infection prevention and control practices.

Deficiencies (8)
Failure to complete a discharge summary and provide it to resident/family for Resident #65.
Failure to develop and implement comprehensive care plans that include targeted behaviors and non-pharmacological interventions for residents on psychotropic medications (Residents #3, #6, #2, #44).
Failure to transcribe and initiate a physician order for Sertraline for Resident #44.
Failure to provide adequate supervision and assistance devices by transporting Resident #48 in a wheelchair without foot pedals.
Failure to store medications safely when medication cart was left unlocked and unattended.
Failure to prepare food under sanitary conditions by not covering facial hair during food preparation.
Failure to maintain complete and accurate resident records related to a urinary tract infection for Resident #10.
Failure to use proper hand hygiene and infection control practices during medication administration and wound care, and failure to use full Enhanced Barrier Precautions during wound care for Resident #38.
Report Facts
Census: 55 Deficiencies cited: 8

Employees mentioned
NameTitleContext
Assistant Director of NursingAssistant Director of NursingNamed in relation to failure to complete discharge summary and failure to transcribe physician order
Director of NursingDirector of NursingNamed in relation to expectations for care plans, hand hygiene, and medication cart security
Staff BRegistered NurseNamed in relation to failure to use foot pedals on wheelchair, improper hand hygiene, and wound care practices
Staff CLicensed Practical NurseNamed in relation to locking medication cart
Staff ADirector of Social ServicesNamed in relation to limited input on care plans
Staff DCookNamed in relation to failure to cover facial hair during food preparation

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Feb 14, 2025

Visit Reason
The document is a Plan of Correction submitted following an inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance with health requirements.

Findings
The facility was found to be in substantial compliance with health requirements as of February 14, 2025, based on acceptance of the Plan of Correction.

Inspection Report

Annual Inspection
Census: 52 Deficiencies: 3 Date: Jan 23, 2025

Visit Reason
The inspection was conducted as an Annual Recertification Survey to assess compliance with federal regulations and facility standards.

Findings
The facility was found deficient in maintaining resident dignity for one resident, accuracy of Minimum Data Set (MDS) assessments for one resident, and timely revision of care plans for three residents. The facility failed to ensure appropriate covering of a resident while waiting for a shower, accurately code prescribed medications in the MDS, and update care plans to reflect current resident needs.

Deficiencies (3)
Failure to maintain dignity for Resident #2 by not appropriately covering the resident while waiting for a shower, leaving the groin exposed.
Failure to accurately code the federally mandated Minimum Data Set (MDS) assessment for Resident #24 by omitting anticoagulant medication use.
Failure to timely update care plans for Residents #20, #22, and #38 to reflect hospice services and wanderguard alarm status.
Report Facts
Residents reviewed: 17 Residents reviewed: 19 Census: 52

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Apr 18, 2024

Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's certification compliance.

Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective April 18, 2024.

Inspection Report

Annual Inspection
Census: 51 Deficiencies: 1 Date: Mar 28, 2024

Visit Reason
The inspection was conducted as an annual recertification survey of Calvin Community to assess compliance with federal regulations.

Findings
The facility failed to refer Resident #17 for a Level II PASRR evaluation after a new diagnosis of bipolar disorder was added, indicating a deficiency in coordinating PASARR assessments. The facility acknowledged the deficiency and outlined corrective actions including policy review and improved communication.

Deficiencies (1)
Failure to refer Resident #17 for a Level II PASRR evaluation after new mental health diagnosis.
Report Facts
Census: 51

Employees mentioned
NameTitleContext
Social Services DirectorSocial Services DirectorReported on PASRR review process and confirmed last PASRR completed for Resident #17
AdministratorAdministratorAcknowledged lack of PASRR policy and commitment to develop one

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Dec 12, 2023

Visit Reason
A complaint investigation for complaint #113988-C was conducted on December 12, 2023.

Complaint Details
Complaint #113998-C was unsubstantiated.
Findings
Complaint #113998-C was unsubstantiated. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Inspection Report

Deficiencies: 0 Date: May 2, 2023

Visit Reason
The inspection was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

Findings
The Calvin Community Nursing Home was found to be in compliance as of April 6, 2023. A discretionary denial of payment for new admissions was in effect from March 28, 2023 to April 5, 2023.

Report Facts
Discretionary Denial of Payment Period: From March 28, 2023 to April 5, 2023

Inspection Report

Annual Inspection
Census: 52 Deficiencies: 1 Date: Apr 4, 2023

Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and a Federal Comparative survey.

Findings
The facility was found non-compliant with 42 CFR Part 483 requirements related to food and drink temperature control. Observations revealed that food served on the second floor was not maintained within the safe temperature range, and staff failed to take food temperatures prior to serving after a process change. The facility implemented corrective actions including revised food temperature policies and ongoing monitoring.

Deficiencies (1)
Failure to ensure food served was within the safe temperature range (41 to 135 degrees Fahrenheit) for residents on the second floor.
Report Facts
Census: 52 Correction date: Apr 16, 2023 Food Handler Course deadline: Apr 30, 2023 Food Handler Course timeframe for new employees: 30 Monitoring period: 30 Audit period: 90

Employees mentioned
NameTitleContext
Staff LFood Service WorkerObserved delivering trays and taking food temperatures during inspection
Dietary ManagerReported on changes to food serving process and temperature taking
President/Chief Executive OfficerCEOExplained need to reheat trays due to unacceptable food temperatures and documented resident count
Director of Food ServicesResponsible for daily review and sign-off of food temperature logs during corrective action period
Health Center AdministratorConducts bi-weekly audits of food temperature logs during corrective action period

Inspection Report

Routine
Census: 52 Deficiencies: 5 Date: Mar 3, 2023

Visit Reason
A health comparative Federal Monitoring Survey (FMS) was conducted by the Centers for Medicare & Medicaid Services (CMS) on March 3rd, 2023 following an Iowa Department of Inspection and Appeals (IDIA) recertification survey on January 23rd, 2023. Complaint #IA00104759 and #IA00105043 were investigated and substantiated.

Findings
The facility failed to revise the comprehensive care plan for one resident (R44) after multiple falls, failed to provide services meeting professional standards for medication administration for one resident (R15), failed to prevent a fractured wrist for R15 due to inadequate supervision and repositioning, failed to document ongoing assessment and communication for one resident (R19) receiving dialysis, and failed to maintain an effective infection prevention and control program including hand hygiene and surveillance.

Deficiencies (5)
Failed to revise comprehensive care plan for resident R44 after multiple falls.
Failed to provide services meeting professional standards when LPN prepared medications and failed to observe full medication pass for resident R15.
Failed to prevent fractured wrist for resident R15 due to inadequate supervision and repositioning.
Failed to document ongoing assessment and communication with dialysis center for resident R19.
Failed to maintain infection prevention and control program including surveillance, tracking, hand hygiene, and proper infection control practices.
Report Facts
Residents sampled: 20 Census: 52 Antibiotics ordered: 5 Hand hygiene audits: 25

Employees mentioned
NameTitleContext
RN2Registered NurseObserved failing to perform hand hygiene before medication administration and tube feeding
LPN2Licensed Practical NurseObserved failing to place barrier when applying barrier cream to resident R15
LPN4Licensed Practical NurseObserved preparing medications in liquid nutrition without observing full medication pass
NA1Nurse AideObserved feeding resident R15 with bare hands touching food
Director of NursingDirector of NursingProvided interviews regarding fall prevention, dialysis communication, and infection control
Infection PreventionistInfection PreventionistProvided interview regarding infection control program and surveillance

Inspection Report

Annual Inspection
Census: 52 Deficiencies: 2 Date: Jan 23, 2023

Visit Reason
The inspection was an annual health recertification survey conducted from January 17, 2023 to January 23, 2023, which included a complaint investigation (#104759) that was not substantiated.

Complaint Details
Complaint #104759 was investigated during the survey and was not substantiated.
Findings
The facility failed to update the care plan for one resident following a change in condition and failed to ensure food temperatures were checked before serving, resulting in food being served at unsafe temperatures for 11 of 52 residents reviewed.

Deficiencies (2)
Failed to update the Care Plan for Resident #15 following a change in condition, including unaddressed pressure ulcers and a wrist fracture.
Failed to assess and ensure hot food temperatures before serving meals to residents, with food served below safe temperature standards.
Report Facts
Census: 52 Pressure ulcer measurement: 1.3 Pressure ulcer measurement: 0.8 Pressure ulcer measurement: 0.1 Food temperature: 140 Food temperature: 147 Food temperature: 108 Food temperature: 98 Food temperature: 98 Food temperature: 98 Food temperature: 130 Food temperature: 100

Employees mentioned
NameTitleContext
Staff ICertified Nurse Aide (CNA)Observed providing proper peri care and repositioning Resident #15
Staff JCertified Nurse Aide (CNA)Observed providing proper peri care and repositioning Resident #15
Staff KLicensed Practical Nurse (LPN)Observed providing wound care to Resident #15
Staff ELicensed Practical Nurse (LPN)Reported Resident #15 had a wrist fracture in May 2022
Staff DLicensed Practical Nurse (LPN)Reported Resident #15's wrist fracture should have been added to Care Plan within a week
Staff HDirector of Food ServicesObserved preparing pureed meals and acknowledged dietary staff lacked education on food temperature checks
Staff GDietary AidePrepared residents' plates without assessing meal temperatures and served food
Staff FDietary CookAcknowledged food should be temperature checked and retrieved thermometer

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Apr 7, 2022

Visit Reason
A complaint investigation was conducted for multiple complaints (#99983-C, #101443-C, #101526-C, #102743-C, #103084-C, #103737-C, #103777-C) from April 7-20, 2022.

Complaint Details
Complaints #99983-C, #101443-C, #101526-C, #102743-C, #103084-C, #103737-C, and #103777-C were all investigated and found not substantiated.
Findings
The facility was found to be in substantial compliance and none of the complaints were substantiated.

Inspection Report

Annual Inspection
Census: 48 Deficiencies: 4 Date: Aug 5, 2021

Visit Reason
The inspection was conducted as an annual health survey of the facility from August 2 to August 5, 2021.

Findings
The facility was found deficient in several areas including failure to provide bed-hold notices for residents upon transfer, failure to ensure staff followed physician orders to prevent infection, insufficient nursing staff response times to call lights, and failure to hold required Quality Assurance Performance Improvement (QAPI) meetings. The facility reported a census of 48 residents at the time of the survey.

Deficiencies (4)
Failure to provide bed-hold notice for 2 of 2 residents reviewed upon transfer to hospital.
Failure to ensure staff followed physician orders to prevent infection and subsequent hospitalization of Resident #6.
Failure to ensure sufficient nursing staff responded timely to call lights for seven residents.
Failure to ensure required Quality Assurance Performance Improvement (QAPI) committee meetings were held as required.
Report Facts
Census: 48 Residents reviewed for bed-hold notice: 2 Residents with call light response issues: 7 QAPI meetings reviewed: 5

Employees mentioned
NameTitleContext
Staff C, Registered NurseInterviewed regarding bed-hold notices and dialysis care
Assistant Director of Nursing (DON)Verified facility expectations for staff to follow physician orders and call light response times
Director of Quality Assurance Performance Improvement (QAPI)Interviewed regarding QAPI meetings and attendance
Health Center Director of Nursing (DON)Received resident concerns about call light response times

Inspection Report

Routine
Census: 42 Deficiencies: 0 Date: Sep 9, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 9/9/20 and 9/10/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.

Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Inspection Report

Routine
Census: 54 Deficiencies: 0 Date: Aug 20, 2020

Visit Reason
A COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals from 08/18/2020 through 08/20/2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.

Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Report Facts
Total Residents: 54

Inspection Report

Routine
Census: 54 Deficiencies: 0 Date: Jul 1, 2020

Visit Reason
A COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.

Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Report Facts
Total Residents: 54

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