West Des Moines, IA

Cedar Ridge Village

4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

8950 Coachlight Drive, West Des Moines, IA

(515) 369-2100

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

40

Certified beds

Average residents

38

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pivotal Health Care

Operator or chain grouping

Approved since

2021-08-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.22

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.54

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.58

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

4.34

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.76

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

3.79

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.76

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

1.37

CMS adjusted RN staffing hours

Adjusted total hours

4.88

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,082

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

51.94

Composite VBP score used to determine payment impact.

Payment multiplier

1.0064

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.38

Baseline 17.76% · Performance 20.33% · Measure score 2.38 · Achievement 2.38 · Improvement 0

Healthcare-associated infections

8.31

Baseline 5.29% · Performance 5.35% · Measure score 8.31 · Achievement 8.31 · Improvement 0

Total nurse turnover

2.74

Performance 52.50% · Measure score 2.74 · Achievement 2.74 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

7.36

Performance 5.17 hours · Measure score 7.36 · Achievement 7.36 · This facility did not have sufficient data to calculate a baseline period measure result.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.2%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 168 · Observed rate 10.12% · Lower 95% interval 7.4%
Discharge to community	56.07%	50.57% 5.5 pts better	No Different than the National Rate · Eligible stays 164 · Observed rate 54.27% · Lower 95% interval 49.9%
Medicare spending per beneficiary	0.72	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 97 · Denominator 97
Falls with major injury	1.03%	0.77% 0.3 pts worse	Numerator 1 · Denominator 97
Discharge self-care score	71.43%	53.69% 17.7 pts better	Numerator 55 · Denominator 77
Discharge mobility score	58.44%	50.94% 7.5 pts better	Numerator 45 · Denominator 77
Pressure ulcers or injuries, new or worsened	3.09%	2.29% 0.8 pts worse	Numerator 3 · Denominator 97 · Adjusted rate 3.65%
Healthcare-associated infections requiring hospitalization	5.35%	7.12% 1.8 pts better	No Different than the National Rate · Eligible stays 109 · Observed rate 1.83% · Lower 95% interval 2.81%
Staff COVID-19 vaccination coverage	0.99%	8.2% 7.2 pts worse	Numerator 1 · Denominator 101
Staff flu vaccination coverage	37.23%	42% 4.8 pts worse	Numerator 35 · Denominator 94
Discharge function score	68.83%	56.45% 12.4 pts better	Numerator 53 · Denominator 77
Transfer of health information to provider	90.48%	95.95% 5.5 pts worse	Numerator 19 · Denominator 21
Transfer of health information to patient	87.04%	96.28% 9.2 pts worse	Numerator 47 · Denominator 54
Resident COVID-19 vaccinations up to date	51.61%	25.2% 26.4 pts better	Numerator 16 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.5 About the same	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	2.1 1 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.1%	94.0% 1.1 pts better	93.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.0% · Q3 85.7% · Q4 96.9% · 4Q avg 95.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.0%	95.2% 1.8 pts better	95.5% 1.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.7% 2.9 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.4%	4.0% 0.6 pts better	11.4% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 3.7% · Q4 3.1% · 4Q avg 3.4%
Percentage of long-stay residents who lose too much weight	1.1%	4.9% 3.8 pts better	5.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.1%	20.6% 13.5 pts better	19.6% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 4.2% · Q4 8.3% · 4Q avg 7.1%
Percentage of long-stay residents who received an antipsychotic medication	9.1%	19.8% 10.7 pts better	16.7% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.5% · Q3 10.0% · Q4 4.8% · 4Q avg 9.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	21.5%	18.5% 3 pts worse	16.3% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 21.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.5%	18.3% 0.8 pts better	14.9% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.0% · Q3 12.5% · Q4 21.7% · 4Q avg 17.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	1.7% 1.2 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.7%	2.5% 0.8 pts better	1.7% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.7%	26.0% 7.7 pts worse	19.8% 13.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 29.7% · Q3 26.8% · Q4 48.7% · 4Q avg 33.7%
Percentage of long-stay residents with pressure ulcers	4.4%	4.3% 0.1 pts worse	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.6% · Q3 5.7% · Q4 2.7% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.0%	84.3% 6.7 pts better	81.7% 9.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 85.7% · Q3 92.6% · Q4 95.8% · 4Q avg 91.0%
Percentage of short-stay residents who had an outpatient emergency department visit	7.4%	13.1% 5.7 pts better	12.0% 4.6 pts better	Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.8% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.9% 1.9 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.9%	73.3% 3.6 pts better	79.7% 2.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.4%	21.3% 1.1 pts worse	23.9% 1.5 pts better	Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 20.3% · Expected 21.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-12 · Fire 2025-08-12

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-08-01 · Fire 2024-08-01

2 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-12-11 · Fire 2023-12-11

11 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-19

F · Potential for more than minimal harm 2025-08-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-08-19

F · Potential for more than minimal harm 2024-08-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-19

D · Potential for more than minimal harm 2024-08-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-08-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-02

F · Potential for more than minimal harm 2023-12-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-12-19

E · Potential for more than minimal harm 2023-12-11

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-12-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-12

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-08-12

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-12

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-08-26

D · Potential for more than minimal harm 2025-08-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-26

E · Potential for more than minimal harm 2024-08-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-08-16

D · Potential for more than minimal harm 2024-08-01

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-08-16

E · Potential for more than minimal harm 2023-12-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-29