Cycle 1
Health 2024-10-31 · Fire 2024-10-31
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Des Moines, IA
Trinity Center at Luther Park
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1555 Hull Avenue, Des Moines, IA
(515) 262-5639
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.54
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.28
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
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,233
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0050
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.77
Baseline 19.10% · Performance 19.69% · Measure score 3.77 · Achievement 3.77 · Improvement 0
Healthcare-associated infections
3
Baseline 6.35% · Performance 6.94% · Measure score 3 · Achievement 3 · Improvement 0
Total nurse turnover
8.99
Performance 26.92% · Measure score 8.99 · Achievement 8.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.56
Baseline 3.89 hours · Performance 4.37 hours · Measure score 4.56 · Achievement 4.56 · Improvement 2.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 9.41% · Lower 95% interval 6.88% |
| Discharge to community | 52.06% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 47.83% · Lower 95% interval 41.19% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 79.49% |
53.69%
25.8 pts better
|
Numerator 31 · Denominator 39 |
| Discharge mobility score | 64.1% |
50.94%
13.2 pts better
|
Numerator 25 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 6.12% |
2.29%
3.8 pts worse
|
Numerator 3 · Denominator 49 · Adjusted rate 6.7% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 14.53% |
8.2%
6.3 pts better
|
Numerator 26 · Denominator 179 |
| Staff flu vaccination coverage | 70.18% |
42%
28.2 pts better
|
Numerator 200 · Denominator 285 |
| Discharge function score | 79.49% |
56.45%
23 pts better
|
Numerator 31 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 27 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 66.67% |
25.2%
41.5 pts better
|
Numerator 16 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.0%
5.3 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.2%
2 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.7%
0.9 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 5.1% · Q4 5.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
4.0%
2.2 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 2.1% · Q4 1.9% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
4.9%
2.1 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.1% · Q3 8.3% · Q4 1.1% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
20.6%
5.9 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 15.4% · Q3 14.3% · Q4 14.1% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.0% |
19.8%
9.2 pts worse
|
16.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 29.9% · Q3 27.7% · Q4 27.9% · 4Q avg 29.0% · 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 | 27.5% |
18.5%
9 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 30.9% · Q3 20.0% · Q4 25.4% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.9% |
18.3%
11.6 pts worse
|
14.9%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 29.4% · Q3 21.2% · Q4 32.6% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.7%
0.8 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.6% · Q3 3.1% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
2.5%
1.9 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.1% · Q3 5.1% · Q4 3.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
26.0%
9.9 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 36.4% · Q3 35.4% · Q4 38.9% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.3%
1.2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.8% · Q3 3.8% · Q4 2.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
84.3%
3.9 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 77.5% · Q3 96.5% · Q4 98.6% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
13.1%
7.8 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 4.8% · Expected 10.1% · 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 | 88.0% |
73.3%
14.7 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
21.3%
4.4 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 19.0% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-25 · Fire 2023-09-25
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-16 · Fire 2022-08-16
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-18
E · Potential for more than minimal harm
2023-09-25
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 2023-10-02
E · Potential for more than minimal harm
2023-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-02
F · Potential for more than minimal harm
2022-08-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-20
F · Potential for more than minimal harm
2022-08-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-20
F · Potential for more than minimal harm
2022-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-16
F · Potential for more than minimal harm
2022-08-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-20
E · Potential for more than minimal harm
2022-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-31
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-31
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 2024-11-22
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
B · Minimal harm
2024-10-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-06
D · Potential for more than minimal harm
2022-08-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
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 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
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 2022-10-08
D · Potential for more than minimal harm
2022-08-16
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 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-08
Penalties and ownership
What sits behind the stars
Ownership
Blackburn, Kelley
Corporate Director · Individual
Bratvoid, Tim
Corporate Director · Individual
Bratvoid, Tim
Corporate Officer · Individual
Brown, Paul
Corporate Director · Individual
Brown, Paul
Corporate Officer · Individual
Hyland, Keith
Corporate Director · Individual
Krause, William
Corporate Director · Individual
Krause, William
Corporate Officer · Individual
Lee, Christopher
Corporate Director · Individual
Mays, Tira
Corporate Director · Individual
Mays, Tira
Corporate Officer · Individual
Miller, Duane
Corporate Director · Individual
Oben, Patrick
Contracted Managing Employee · Individual
Rieke, John
W-2 Managing Employee · Individual
Smith, Casey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Azria Health Park Place
Des Moines, IA
1-star overall rating with 1-star inspections with Special Focus status with $22,490 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Rehabilitation Center of Des Moines
Des Moines, IA
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Valley View Village
Des Moines, IA
3-star overall rating with 2-star inspections with $9,110 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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