Cycle 1
Health 2025-06-19 · Fire 2025-06-19
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
West Des Moines, IA
Edgewater, A Wesleylife Community
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
9225 Cascade Avenue, West Des Moines, IA
(515) 978-2400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
Non-Profit
Publicly displayed owner type
Chain
Wesleylife
Operator or chain grouping
Approved since
2009-10-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.68
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,056
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0065
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.82
Baseline 19.05% · Performance 20.13% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Healthcare-associated infections
6.93
Baseline 4.43% · Performance 5.76% · Measure score 6.93 · Achievement 6.93 · Improvement 0
Total nurse turnover
3.35
Baseline 54.55% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 1.03
Adjusted total nurse staffing
7.72
Baseline 4.43 hours · Performance 5.28 hours · Measure score 7.72 · Achievement 7.72 · Improvement 5.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 314 · Observed rate 7.32% · Lower 95% interval 6.96% |
| Discharge to community | 71.5% |
50.57%
20.9 pts better
|
Better than the National Rate · Eligible stays 306 · Observed rate 71.24% · Lower 95% interval 66.48% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 88.35% |
95.27%
6.9 pts worse
|
Numerator 182 · Denominator 206 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 206 |
| Discharge self-care score | 64.88% |
53.69%
11.2 pts better
|
Numerator 109 · Denominator 168 |
| Discharge mobility score | 55.36% |
50.94%
4.4 pts better
|
Numerator 93 · Denominator 168 |
| Pressure ulcers or injuries, new or worsened | 1.46% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 206 · Adjusted rate 1.8% |
| Healthcare-associated infections requiring hospitalization | 5.76% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 196 · Observed rate 3.57% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 1.41% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 71 |
| Staff flu vaccination coverage | 8.93% |
42%
33.1 pts worse
|
Numerator 10 · Denominator 112 |
| Discharge function score | 66.07% |
56.45%
9.6 pts better
|
Numerator 111 · Denominator 168 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 44 · Denominator 46 |
| Transfer of health information to patient | 99.29% |
96.28%
3 pts better
|
Numerator 140 · Denominator 141 |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 28 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.7%
0.7 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
20.6%
7 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
19.8%
14.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
18.3%
6.7 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 44.0% |
26.0%
18 pts worse
|
19.8%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 44.0% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.3%
About the same
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
84.3%
11 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 95.9% · Q3 95.8% · Q4 97.2% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
13.1%
2.3 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.4% |
73.3%
10.1 pts better
|
79.7%
3.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
21.3%
1.6 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 15.8% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-15 · Fire 2024-07-15
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-30 · Fire 2023-11-30
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-06-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-07-15
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-05
F · Potential for more than minimal harm
2023-11-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-11-30
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-11-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-11-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-30
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-16
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.
Not marked corrected
D · Potential for more than minimal harm
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-10-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-07-15
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 2024-07-24
E · Potential for more than minimal harm
2024-07-15
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 2024-07-24
Penalties and ownership
What sits behind the stars
Ownership
Wesleylife
5% Or Greater Direct Ownership Interest · Organization
Albertson, Kermit
Corporate Director · Individual
Edgewater, A Wesley Active Life Community, LLC
Operational/Managerial Control · Organization
Gilroy, Abbey
Corporate Director · Individual
Hoeksema, Nicole
Corporate Director · Individual
Kretzinger, Robert
Corporate Officer · Individual
Lagree, Roger
Corporate Director · Individual
Rasmussen, Chad
Corporate Director · Individual
Ruch, Robert
Corporate Director · Individual
Simpson, Janet
W-2 Managing Employee · Individual
Stout, David
Corporate Director · Individual
Taylor, Christina
Corporate Director · Individual
Watson, Susan
Corporate Director · Individual
Wesley Retirement Services Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Cedar Ridge Village
West Des Moines, IA
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Arbor Springs of West Des Moines L L C
West Des Moines, IA
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Harmony West Des Moines
West Des Moines, IA
1-star overall rating with 1-star inspections with Special Focus status with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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