Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of South Des Moines during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses suffered a nasal fracture and was instructed to follow up with ENT, but the facility failed to document the ENT referral and related communications in the EHR. The DON later acknowledged the omission and entered a late progress note after the deficiency was identified.
Failure to flush a g-tube before med administration was observed for a resident with dementia and hemiplegia who had an enteral tube. An RN mixed crushed and liquid meds with water, administered them via the g-tube, and then gave water afterward, despite a physician order for water before and after med administration and a facility policy requiring a pre-flush, medication administration, and final flush.
Failure to follow EBP and infection control practices during urinary catheter care for a resident with an SP catheter, UTI history, and MDRO risk. Two CNAs handled the catheter bag and leg bag without wearing gowns throughout the procedure, one CNA left the room without gown or gloves and did not perform hand hygiene before donning gloves, and staff handled catheter care while not fully compliant with the facility’s EBP and catheter care policy.
Delayed assessment of a surgical amputation site: A resident with an above-the-knee amputation, intact cognition, and moderate pain had an admission skin assessment noting a left leg amputation incision, but no further nursing skin assessments were documented for the first several days after admission. No physician orders were identified for the surgical site, and the first documented evaluation occurred only after an antibiotic was started. The ADON acknowledged the gap in surgical site assessments, and facility policy required weekly assessment and documentation of skin ulcers and non-ulcers.
A resident with dementia and anxiety was involved in multiple incidents of physical aggression towards other residents, including scratching and hitting. The facility's care plan lacked specific interventions to prevent these altercations, and staff reported difficulty in managing the resident's behavior. Despite attempts to separate residents and implement checks, the facility failed to protect residents from abuse.
The facility did not maintain hot holding temperatures above 135°F for meals served to residents. Food was placed in warming carts and transported to the CCDI unit, but upon distribution, the test tray showed mixed vegetables at 115°F and tuna casserole at 128°F, both below the required temperature. The facility's policy requires food to be delivered at temperatures above 135°F.
A facility failed to implement effective interventions to prevent resident-to-resident altercations, particularly involving a resident with a history of aggression. Despite existing policies, the care plan lacked specific strategies to manage the resident's behavior, leading to multiple incidents of physical aggression. Staff expressed uncertainty about handling the resident's unpredictable behavior, and the MDS Coordinator did not include details of aggression in care plans.
A resident with breast cancer and a history of ovarian cancer did not complete genetic testing due to the facility's failure to follow physician's orders. The facility canceled the first appointment due to transportation issues and missed the second appointment because the resident did not want to rush and felt unwell. There was no documentation or rescheduling of the appointment, and the facility lacked a specific policy for handling physician's orders.
The facility failed to uphold residents' dignity as staff were observed using personal cell phones during work hours, neglecting their duties. A CMA and a CNA were seen on their phones during meal times, leaving residents unattended. Interviews revealed that staff phone use in residents' rooms made them feel ignored and uncomfortable, with some staff speaking non-English languages, adding to the discomfort. The DON confirmed the expectation for staff to refrain from phone use unless on break, aligning with the facility's policy against phone use during work.
The facility failed to maintain a clean and homelike environment, with issues such as a wooden pallet with flooring boxes in a common area, damaged baseboard heaters, missing baseboards, and garbage left in a resident's room. A resident's bed had a loose headboard, and a divider curtain was stained. Staff interviews revealed delays in addressing maintenance and housekeeping issues, and the facility lacked a policy for a homelike environment.
The facility failed to supervise and provide necessary care for residents in the CCDI unit, as family members reported neglect, including residents being found soiled with dried feces. A CNA was observed asleep during a resident's behavioral episode and initially denied a resident's request for a beverage. The DON confirmed that sleeping on the job violated the facility's code of conduct.
The facility failed to follow infection control protocols for residents requiring catheter and wound care. A resident with a suprapubic catheter did not receive care with enhanced barrier precautions, and there was no soap available for hand hygiene. Another resident with a pressure ulcer had dressing changes without proper glove changes or equipment cleaning. Additionally, nebulizer equipment was not rinsed after use, and a resident with an indwelling catheter was transferred without proper hand hygiene. These deficiencies were confirmed by staff interviews.
A resident with dementia and other disorders reported thumb pain for two weeks before receiving an X-ray. Despite family concerns and staff awareness, the facility failed to document or report the pain adequately, and Tylenol was only documented as given once. The DON expected staff to document and report pain, but the facility lacked a policy for assessment and intervention.
The facility failed to use a safe transfer technique with a mechanical lift for a resident with severe cognitive impairment, did not maintain adequate ventilation in a server room, and lacked accessible bathroom call lights for residents. The mechanical lift was improperly used, the server room was excessively warm due to a malfunctioning AC, and a bathroom call light was inaccessible, leaving a resident unable to request assistance.
A resident with dementia and severe cognitive impairment did not receive complete incontinence care as per facility policy. A CNA failed to follow proper peri-care procedures, including not changing gloves or sanitizing hands when moving from dirty to clean areas. The DON confirmed the expectation for staff to adhere to the peri-care policy.
A facility failed to maintain a medication error rate below 5%, with an LPN administering a cocktail of crushed medications through a PEG tube without individual administration or proper flushing, contrary to policy. The resident had no specific order for cocktailing medications, and the facility's policy required separate administration unless otherwise ordered.
A resident with a PEG tube was administered medications through the tube instead of orally, contrary to physician's orders. The facility's policy required separate administration of medications unless ordered otherwise, which was not followed. The DON confirmed the absence of an order to cocktail medications, and staff interviews highlighted the expectation for individual administration with water flushes.
The facility failed to notify two residents of the bed hold policy during hospital transfers. Both residents, with no cognitive impairment, were transferred and returned without documentation of notification. Interviews confirmed the absence of completed bed hold forms, despite the expectation for such documentation.
A facility failed to include necessary medications in a resident's Baseline Care Plan. The resident, with heart failure, anxiety, and mood disorders, was prescribed Apixaban, Duloxetine, and Risperdal, but these were not documented in the care plan. The DON acknowledged the expectation for inclusion, and the Administrator noted the lack of a facility policy for the Baseline Care Plan.
A resident with a history of aggressive behavior slapped another resident in the face in a common area, despite known interventions to prevent such incidents. The resident was in a wheelchair without the required alarm, and no staff were present to intervene. The facility failed to implement and evaluate the effectiveness of interventions to prevent harm, leading to a breach in resident safety and abuse prevention protocols.
The facility failed to implement adequate safety interventions for a resident with severe cognitive deficits, leading to incidents of abuse towards other residents. Despite having a care plan, the resident was left unsupervised, resulting in close proximity to female residents without staff intervention. Additionally, the facility did not effectively prevent falls for another resident, who experienced multiple falls, including one resulting in a hip fracture. The lack of a fall prevention policy and inconsistent staff adherence to care plans contributed to these deficiencies.
An incident of unwanted sexual touching between two residents led to immediate actions by the facility. A resident with a known history of inappropriate sexual behavior was later observed unsupervised with another vulnerable resident. The facility's failure to provide adequate supervision and a safe environment contributed to the risk of unwanted sexual advances, impacting residents' well-being.
A resident with multiple diagnoses had their medication, Tramadol, administered despite physician's orders to hold it 48 hours before a scheduled CT Myelogram. This error led to the rescheduling of the resident's appointment. The incident was confirmed by the Director of Nursing and reported by a Certified Medication Aide who mistakenly gave the medication.
The facility failed to provide two baths a week for two residents due to staffing issues. One resident did not receive baths for a week because the shower aide was on vacation, while another resident missed baths over a ten-day period. Both residents require assistance with bathing, and the Director of Nursing confirmed the lapses.
A resident with multiple diagnoses, including hypertension and psychotic disorder, was not seen by a primary care physician for over four months. The clinical record lacked documentation of required physician visits, which was confirmed by the Regional Clinical Nurse Specialist.
The facility staff failed to answer call lights within the expected 15 minutes for a resident with hypertension, anxiety, depression, and psychotic disorder. The resident reported delays of over half an hour, and multiple CNAs confirmed the issue. The administrator verified that the expectation is to respond within 15 minutes, as per regulations.
Failure to Document ENT Referral and Communication
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding an ENT referral for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's Disease, dementia, and behavioral issues. After the resident experienced a fall resulting in a nasal fracture, emergency department discharge instructions specified that the resident should be re-evaluated by ENT within the following week. However, a review of the resident's electronic health record (EHR) did not show any documentation of communication or referral to ENT as instructed. Interviews with the DON revealed that calls were made to the ENT clinic regarding the referral, and follow-up communication occurred, but these actions were not documented in the resident's EHR at the time. The DON acknowledged the lack of documentation for both the ENT referral and communication with the resident's family. A late entry progress note was later created to reflect the communication, but this was after the deficiency was identified.
Failure to Flush G-Tube Before Medication Administration
Penalty
Summary
The facility failed to flush an enteral gastrostomy tube per the physician order before administering medications through the tube for 1 of 1 resident reviewed, Resident #7. Resident #7 had diagnoses of Non-Alzheimer's Dementia and hemiplegia, and the annual MDS dated 7/3/25 documented that the resident had a g-tube. During observation on 7/22/25 at 9:50 AM, Staff A, RN, placed crushed medications and liquid medications into a cup, added 30 mL of water to the medications, and administered the mixture through Resident #7's g-tube. Staff A then administered 30 mL of water into the g-tube. The physician order in the clinical record, with a start date of 7/22/25, directed 30 mL of water before medication administration and 30 mL of water after medication administration for the g-tube. The facility's Medication Administration via Enteral Tube Policy revised 1/31/24 stated to flush the enteral tube with at least 15 mL of water prior to administering medications, dilute the solid or liquid medication as appropriate and administer, and flush the tube with a final flush of at least 15 mL of water to ensure drug delivery and clear the tube. In interview on 7/23/25 at 4:05 PM, the DON stated her expectation was to flush the g-tube with water only per physician order, then add water to dilute the crushed and liquid medications and administer the diluted medications mixed with water, followed by a flush of water only.
Failure to Follow EBP During Catheter Care
Penalty
Summary
The facility failed to use appropriate infection control practices and Enhanced Barrier Precautions during urinary catheter care for one resident with an indwelling suprapubic catheter. The resident’s MDS reflected intact cognition and documented diagnoses including other neurological conditions, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. The care plan identified the resident as having an SP catheter and a history of UTI, with interventions to change the catheter bag twice a month and as needed, monitor output every shift, and use Enhanced Barrier Precautions because the resident was at risk for MDRO colonization. The EHR also showed orders for Enhanced Barrier Precautions and for changing the catheter bag to a leg bag in the morning for UTI prevention, and the MAR showed the resident was receiving cefdinir for UTI. During observation of catheter care, two CNAs were in the resident’s room and did not maintain the required gown use throughout the procedure. One CNA left the room without a gown or gloves, carried a room tray to the ADON, and then donned a gown outside the room without sanitizing or washing her hands before putting on gloves. She brought additional gowns and gloves into the room for the other CNA, who placed them on the sink counter while holding the resident’s catheter bag and standing in front of the resident without a gown on. The second CNA had gloves on but no gown while handling the catheter bag. Staff later donned gowns, removed gloves, sanitized hands, and continued the catheter care. The ADON stated staff were expected to wear gowns during the entirety of catheter care and to sanitize or wash hands before putting on gloves. Facility policy for catheter care and Enhanced Barrier Precautions required hand hygiene, gloves before cleansing the access port, and gowns and gloves for high-contact care activities including urinary catheter care.
Delayed Assessment of Surgical Amputation Site
Penalty
Summary
The facility failed to initiate nursing assessments of a surgical above-the-knee amputation site in a timely manner for one resident. The resident’s admission MDS showed intact cognition, diagnoses including an above-the-knee amputation and hypertension, and pain assessed as moderate. The hospitalization discharge paperwork documented the amputation and a follow-up vascular surgery appointment. The admission skin assessment noted a left leg amputation incision, and the baseline care plan identified an incision site to the resident’s left knee, but no physician orders were identified for care of the surgical site. After the admission skin assessment, no additional skin assessments were found in either the paper Skin/Wound Book or the electronic medical record. The first documented evaluation of the left leg amputation site occurred only after clindamycin was started, and later communication with the vascular surgeon’s office resulted in orders to monitor the incision and keep it clean and dry. During interview, the ADON acknowledged the recent surgical left leg amputation and the lack of nursing surgical site skin assessments during the first nine to thirteen days of admission. The facility policy stated that skin ulcers and non-ulcers are to be assessed and documented weekly and that treatment orders and care plan updates are to be implemented per the facility protocol.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically in cases involving resident-to-resident altercations. Resident #4, who has a history of non-Alzheimer's dementia, anxiety, and depression, was involved in multiple incidents of physical aggression towards other residents. These incidents included scratching, hitting with a plastic bottle, and kicking other residents. The facility's care plan for Resident #4 lacked specific interventions to prevent these altercations, despite the resident's known history of aggressive behavior. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident #4. Staff interviews revealed that they were aware of Resident #4's aggressive tendencies but were unable to consistently prevent altercations. The care plan for Resident #4 included general strategies for managing mood and behavior but did not address the specific issue of physical aggression towards other residents. Staff members reported difficulty in managing Resident #4's behavior, noting that the resident could become aggressive without provocation. Despite attempts to separate residents and implement 15-minute checks, the facility did not have a concrete plan to prevent future incidents. The lack of effective interventions and documentation in the care plan contributed to the facility's failure to protect residents from abuse.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain hot holding temperatures above 135 degrees Fahrenheit for meals served to residents. On the observed date, the Dietary Services Manager placed plated food into warming carts, which were then transported to the Chronic Confusion Dementing Illness (CCDI) unit. Upon arrival, staff began distributing the trays to residents. However, when the State Agency (SA) checked the temperatures of the test tray, the mixed vegetables were at 115 degrees Fahrenheit and the tuna casserole at 128 degrees Fahrenheit, both below the required temperature. The facility's policy, dated 2021, mandates that foods be transported and delivered at temperatures above 135 degrees Fahrenheit. The Dietary Services Manager later stated that she expected hot foods to be held above 140 degrees Fahrenheit.
Failure to Implement Effective Interventions for Resident Aggression
Penalty
Summary
The facility failed to implement resident-centered care plan interventions to protect residents from physical abuse, specifically in cases of resident-to-resident altercations. The report highlights incidents involving Resident #4, who has a history of verbal and physical aggression towards other residents. Despite the facility's policy on abuse prevention and the requirement for comprehensive care plans, the care plan for Resident #4 lacked specific interventions to prevent future altercations. The facility continued to use interventions such as resident separation and 15-minute checks, but these measures were insufficient in preventing further incidents. Resident #4, diagnosed with non-Alzheimer's dementia, anxiety, and depression, exhibited aggressive behaviors towards other residents on multiple occasions. The incidents included scratching Resident #13, hitting Resident #5 with a plastic bottle, striking Resident #6, and physically assaulting Resident #11. The care plan for Resident #4 did not document the history of these altercations or provide clear guidance for staff on preventing future incidents. Staff interviews revealed a lack of concrete interventions and uncertainty about handling Resident #4's aggressive behavior. Staff members, including a Certified Medication Aide, LPNs, and the interim DON, acknowledged the challenges in managing Resident #4's behavior. They reported that Resident #4's aggression was often unprovoked and difficult to predict, making it challenging to prevent altercations. The facility's efforts to intervene were described as inadequate, with staff expressing uncertainty about effective strategies to manage the resident's behavior. The MDS Coordinator admitted to not including specifics about physical aggression in care plans, further highlighting the deficiency in addressing the resident's needs and ensuring the safety of other residents.
Failure to Follow Physician's Orders for Genetic Testing Referral
Penalty
Summary
The facility failed to follow a physician's order for a genetic testing referral for a resident diagnosed with breast cancer, who also had a history of ovarian cancer and an extensive family history of cancer. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, was scheduled for genetic testing on two occasions. The first appointment was canceled by the facility due to a lack of transportation, and the second appointment was missed because the resident did not want to rush and was not feeling well. There was no documentation of these events or any rescheduling of the appointment. Staff interviews revealed a lack of communication and documentation regarding the resident's appointments. The Staffing Coordinator did not see the initial appointment on the calendar and assumed another driver would take the resident to the second appointment. When this did not happen, the resident declined to rush to the appointment. The Driver mentioned that appointments were sometimes rescheduled if the nurse forgot to note them. The interim DON acknowledged that the facility should follow physician's orders, including referrals, but the Administrator admitted there was no specific policy for physician's orders, relying instead on standards of practice.
Staff Cell Phone Use Disrupts Resident Care and Dignity
Penalty
Summary
The facility failed to respect residents' dignity and self-determination by allowing staff to use personal cell phones during work hours, which distracted them from providing proper care. Observations revealed that a Certified Medication Aide (CMA) and a Certified Nurse Aide (CNA) were frequently on their phones during meal times and while assisting residents, neglecting their duties and failing to attend to residents' needs promptly. This behavior was noted in the dining room, where staff were observed using their phones instead of engaging with residents, leading to situations where residents were left unattended or had to be assisted by other staff members. Interviews with residents and family members corroborated these observations, with reports of staff being on their phones even while in residents' rooms, which made residents feel ignored and uncomfortable. Additionally, some staff members were reported to speak in languages other than English in front of residents, further contributing to feelings of discomfort and disrespect. The Director of Nursing (DON) acknowledged the issue, stating that staff were expected to refrain from using phones unless on break, and no exceptions to this policy were known. The facility's cell phone usage policy also emphasized that personal phone use during work negatively impacts resident care.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as observed during a survey. Several deficiencies were noted, including a wooden pallet with boxes of flooring left in a common area, bent and torn metal flaps on baseboard heaters, and missing baseboards in hallways. Additionally, a clear plastic bag of garbage containing a soiled brief and other waste was found on the floor in a resident's room, along with soiled washcloths. A divider curtain in another room had a dried brown stain, and a resident's bed had a loose and slanted headboard with rough wood and black ties holding it together. The bathroom light in one room was not functioning. Interviews with staff revealed that maintenance and housekeeping issues were reported but not always addressed promptly. The Maintenance Assistant mentioned that repairs were reported through a work order system or verbally, and the Regional Maintenance Director noted ongoing renovations. However, some issues, like the broken headboard, had persisted for a while. The housekeeping staff reported cleaning divider curtains when they appeared dirty, but the stained curtain remained unchanged during the survey period. The facility administrator acknowledged the challenges in completing renovations and confirmed the absence of a policy for maintaining a homelike environment.
Neglect and Inadequate Supervision in CCDI Unit
Penalty
Summary
The facility failed to appropriately supervise and provide necessary interventions for residents in the Chronic Confusion and Dementing Illnesses (CCDI) unit, as evidenced by direct observations and interviews. Family members reported that they had to take over care duties due to neglect by the facility staff, with instances of residents being found heavily soiled with dried feces. Staff reportedly claimed that residents refused care, leading to prolonged periods without showers. These reports indicate a pattern of neglect in attending to the residents' basic hygiene needs. During a direct observation, a Certified Nurses Aide (CNA), identified as Staff N, was found asleep in a chair in the CCDI unit while a resident was having a behavioral episode. Despite attempts by another staff member, Staff O, to wake her, Staff N continued to sleep until directly addressed. Additionally, Staff N was observed denying a resident's request for a beverage, only relenting after persistent requests. The Director of Nursing confirmed that sleeping on the job was against the facility's code of conduct, as outlined in their work rules.
Infection Control Deficiencies in Catheter and Wound Care
Penalty
Summary
The facility failed to implement proper infection control techniques for residents requiring catheter care, treatments, and dressing changes. Resident #6, who had a suprapubic catheter and a history of urinary tract infections, was observed during catheter care without the use of enhanced barrier precautions. Staff C, a certified nursing assistant, did not don an isolation gown, failed to use a barrier for the graduate container, and did not cleanse the catheter port with alcohol after emptying it. Additionally, there was no soap available in the resident's room for proper hand hygiene, and the soap dispenser was found to be non-functional. Resident #28, diagnosed with diabetes and a stage 3 pressure ulcer, was observed during a dressing change where infection control protocols were not followed. Staff A, an LPN, used scissors from her uniform pocket without cleaning them, and handled supplies without changing gloves or sanitizing hands between tasks. The supplies were carried against her uniform, which is against infection control practices. The Infection Preventionist confirmed that Resident #28 was on enhanced barrier precautions, which were not adhered to during the procedure. The facility also failed to properly clean nebulizer equipment after use for Resident #17, as the nebulizer chamber and mask were not rinsed with water post-treatment. Additionally, Resident #41, who had an indwelling catheter, was transferred using a mechanical lift without proper hand hygiene between tasks, and the lift was not cleaned after use. These observations indicate a lack of adherence to infection control protocols, as confirmed by interviews with staff and the Director of Nursing.
Failure to Provide Timely Assessment and Intervention for Resident Pain
Penalty
Summary
The facility failed to provide appropriate assessment and timely intervention for a resident, identified as Resident #61, who reported pain in her right thumb. Despite the resident's family member communicating concerns about the pain to staff over a two-week period, the nursing staff did not contact the resident's physician promptly or provide adequate treatment. The resident, who has diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and bipolar disorder, was dependent on staff for her emotional, intellectual, physical, and social needs. The care plan was last updated on 07/15/2024, but the staff did not adhere to the necessary protocols for managing the resident's reported pain. Interviews with staff members revealed that the resident had been complaining of thumb pain for approximately two weeks before an X-ray was ordered on 07/25/2024. Staff M, an RN, assessed the resident but did not find any impairment or swelling, and provided Tylenol as needed. However, the Medication Administration Record indicated that Tylenol was only documented as administered once between 07/01/2024 and 08/22/2024. Staff K, a CMA, and Staff L, a CNA, also acknowledged the resident's complaints but failed to document or report them adequately. The Director of Nursing stated that the expectation is for staff to document and report new pain complaints, but the facility lacked a policy for assessment and intervention, as confirmed by the facility administrator.
Deficiencies in Safe Transfer, Ventilation, and Call Light Accessibility
Penalty
Summary
The facility staff failed to utilize a safe transfer technique when using a mechanical lift for a resident with severe cognitive impairment and dependence on staff for transfers. The resident, diagnosed with dementia, muscle weakness, and anxiety, was observed being transferred by two CNAs using a mechanical lift. However, the CNAs did not follow the proper procedure as outlined in the facility's Hoyer Lift Competency and the manufacturer's user manual. Specifically, the mechanical lift legs were not kept open during the transfer, which is necessary to ensure the resident's safety and prevent the lift from tipping. Additionally, the facility failed to maintain adequate ventilation and temperature control in a room containing servers and electronic devices. Observations revealed that the server room was extremely warm, with the door propped open and fans used to circulate air. Interviews with staff indicated that the air conditioning unit in the server room was not functioning properly, and there were challenges in keeping the room cool due to outdated equipment and structural limitations. The temperature in the server room was recorded at 78 degrees Fahrenheit, and the air conditioning unit required resetting to function. Furthermore, the facility did not ensure that bathroom call lights were accessible for residents and staff in one of the units observed. A resident reported being left in a bathroom without a call light to request assistance. Observations confirmed that the bathroom had a call light fixture with a small metal lever but no string or device for activation, making it inaccessible for residents needing help.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility staff failed to provide complete incontinence care for a resident with severe cognitive impairment and incontinence. The resident, diagnosed with dementia, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition, and required maximum assistance for bed mobility and dressing. The care plan directed staff to clean the peri-area after each incontinence episode. However, during an observation, a certified nursing assistant (CNA) did not follow the facility's peri-care procedure. The CNA cleansed the resident's groin and peri-area but left soiled wipes in place before removing them, and did not change gloves or sanitize hands when moving from a dirty to a clean area. The Director of Nursing (DON) confirmed that staff are expected to follow the peri-care policy, which includes changing gloves and sanitizing hands when transitioning from dirty to clean areas. The facility's Peri Care Competency outlines specific steps for providing care, including using a new wipe for each area, removing gloves before turning the resident, and washing hands. The CNA's actions did not align with these procedural steps, leading to the deficiency in providing appropriate incontinence care for the resident.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 5 errors out of 37 opportunities, resulting in a 13.51% error rate. During an observation, a Licensed Practical Nurse (LPN) prepared medications for a resident with a PEG tube by crushing pills and mixing them with liquid medications and warm water in a Styrofoam cup. The LPN then administered the mixture through the PEG tube without measuring the water used for flushing and without individual administration of each medication, contrary to the facility's policy. The resident involved was on a mechanical soft diet and had an active verbal order allowing medications to be given through the PEG tube as needed. However, there was no specific order permitting the cocktailing of medications. Interviews with the Director of Nursing (DON) and another LPN confirmed that the facility's policy required medications to be administered separately unless a physician's written order allowed them to be combined. The policy also specified that the enteral tube should be flushed with at least 15 ml of water after each medication, which was not followed in this instance.
Medication Administration Error via PEG Tube
Penalty
Summary
The facility failed to administer medications as per the physician's orders for a resident with a history of stroke, non-Alzheimer's dementia, seizure disorder, and dysphagia. The resident, who had impaired memory and decision-making skills, was observed receiving medications through a gastrostomy tube instead of orally as ordered. The care plan indicated the resident had a PEG tube placed during hospitalization, and the medication administration record showed that medications were given through the tube without a specific order to do so. The facility's policy required medications to be administered separately unless there was a physician's written order to combine them, which was not present in this case. During the observation, an LPN crushed and mixed several medications in a Styrofoam cup with hot water and administered them through the resident's PEG tube. Interviews with the Director of Nursing and other staff confirmed that the medications should have been given individually with water flushes, as per the facility's policy. The Director of Nursing acknowledged the lack of an order to cocktail the medications. Additionally, a family member and a speech therapist provided insights into the resident's condition and the decision to keep the PEG tube in place, although the resident was able to eat with encouragement.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital for two out of three residents reviewed. Resident #36, who had diagnoses of heart failure and diabetes, was admitted to the hospital and returned to the facility without documentation of bed hold policy notification. Similarly, Resident #43, with diagnoses of diabetes and cancer, was also transferred to the hospital and returned without such notification. Both residents had a Brief Interview for Mental Status score indicating no cognitive impairment for decision-making. Interviews with the facility's Administrator and Director of Nursing confirmed that no bed hold forms were completed for these residents, despite the expectation that a bed hold should be completed with any hospital transfer. The facility reported a census of 71 residents at the time of the survey.
Failure to Include Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan that included necessary medications and monitoring for a resident. The resident, who had diagnoses of heart failure, anxiety disorder, and mood disorder, was prescribed Apixaban (an anticoagulant), Duloxetine (an antidepressant), and Risperdal (an antipsychotic). However, the Baseline Care Plan did not document these medications. This omission was identified during a clinical record review and staff interviews. The Director of Nursing acknowledged the expectation for these medications to be included in the care plan, and the Administrator confirmed the absence of a facility policy for the Baseline Care Plan, stating that the facility is expected to follow regulations.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of Resident #2, who had a known history of aggressive behaviors, including physical and sexual abuse towards other residents and staff. Despite these known behaviors, the facility did not effectively implement or evaluate interventions to prevent harm. On the day of the incident, Resident #2, who was in a wheelchair without the required alarm, self-propelled towards Resident #3 and slapped her in the face. This occurred in the lounge area where no staff were present to intervene in time. Resident #2's Minimum Data Set (MDS) assessment indicated severe cognitive deficits and documented a history of physical and behavioral symptoms, including wandering and aggression. The care plan for Resident #2 included interventions such as the use of a silent alarm in his chair, frequent visual checks, and ensuring he was not left in his wheelchair unsupervised. However, these interventions were not effectively implemented, as evidenced by the absence of the alarm and lack of staff presence during the incident. Interviews with staff revealed that they were aware of Resident #2's behavioral issues and the interventions required, yet these were not consistently followed. Staff reported that Resident #2 was supposed to be monitored closely and not allowed near female residents, but on the day of the incident, these protocols were not adhered to. The facility's failure to enforce these measures resulted in Resident #2 being able to approach and physically harm Resident #3, highlighting a significant lapse in resident safety and abuse prevention protocols.
Inadequate Supervision and Safety Interventions in LTC Facility
Penalty
Summary
The facility failed to implement adequate safety interventions to prevent further abuse by a resident with severe cognitive deficits, identified as Resident #2. This resident had a history of physical and sexual abusive behaviors towards staff and other residents. Despite having a care plan that included the use of alarms and frequent visual checks, observations revealed that Resident #2 was left unsupervised in common areas, leading to incidents where he was in close proximity to female residents, including Resident #3, without staff intervention. Interviews with staff confirmed that they were aware of the interventions but failed to consistently apply them, resulting in a lack of protection for other residents. Additionally, the facility did not effectively prevent falls for Resident #6, who had severe cognitive impairments and required assistance for transfers and ambulation. Despite being identified as a fall risk, the resident experienced multiple falls, including one that resulted in a head injury and a subsequent hip fracture. The investigation into the fall incidents revealed that staff did not maintain appropriate physical contact or supervision, as required by the care plan, and there was confusion among staff regarding the level of assistance needed. The facility lacked a fall prevention policy, contributing to the inadequate management of the resident's fall risk. The report highlights the facility's failure to update care plans and implement necessary interventions following incidents of abuse and falls. The lack of staff presence and supervision in common areas, combined with insufficient adherence to care plans, resulted in repeated safety hazards for residents. The absence of a comprehensive fall prevention policy further exacerbated the risk of injury for residents with cognitive impairments.
Inadequate Supervision Leading to Resident Safety Concerns
Penalty
Summary
The report details a concerning incident of sexual abuse involving Resident #1 and Resident #2 in a long-term care facility. Resident #1 reported unwanted sexual touching by Resident #2 on 3/16/24, leading to immediate actions being taken by the facility. Resident #2, known for sexual behavior and comments, was observed unsupervised with Resident #4, a vulnerable resident with poor cognitive status, on 4/23/24. The facility failed to provide a safe environment, putting residents at risk for unwanted sexual advances. Resident #2's history of inappropriate sexual behaviors and comments towards others, as well as the lack of proper supervision, contributed to the deficiency in protecting residents from sexual abuse. The facility's failure to adequately supervise Resident #2, despite being aware of his history of sexual behavior, highlights a critical lapse in ensuring resident safety. Resident #1's fear and reluctance to leave her room following the incident further underscore the impact of the deficiency on residents' well-being. The facility's policies and interventions, such as the installation of motion alarms and staff education, indicate a reactive approach to addressing the deficiency rather than a proactive one that could have potentially prevented the abuse from occurring.
Failure to Hold Medication as Directed by Physician
Penalty
Summary
The facility failed to hold a medication as directed per the physician's orders, which caused a resident to reschedule an appointment. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, was supposed to have Tramadol held 48 hours prior to a scheduled CT Myelogram. Despite the physician's orders and documentation in the Medication Administration Record (MAR) and Progress Notes, the medication was administered on multiple occasions within the 48-hour window before the appointment, leading to the need for rescheduling the procedure. The resident's Annual Minimum Data Set (MDS) indicated no impairments with decision-making or memory problems, and the resident required partial to moderate assistance with personal hygiene. The After Visit Summary and Progress Notes clearly documented the need to hold Tramadol, but this directive was not followed by the staff, resulting in the medication being given on 4/2/24 and 4/3/24, and the morning of 4/4/24, contrary to the physician's orders. The error was reported by a Certified Medication Aide (CMA) who mistakenly administered the medication, and the incident was confirmed by the Director of Nursing during an interview on 4/25/24. The failure to follow the physician's orders led to the resident's appointment being rescheduled to May 2nd, with the same instructions to hold Tramadol 48 hours prior to the new appointment date.
Failure to Provide Required Baths Due to Staffing Issues
Penalty
Summary
The facility failed to provide two baths a week as directed for two residents. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, did not receive baths between April 8, 2024, and April 15, 2024. The resident, who has no impairments with decision-making or memory problems, reported that the baths were missed because the shower aide was on vacation and there was not enough staff to cover. This was confirmed by the resident during an interview on April 23, 2024. Resident #4, who has diagnoses including hypertension, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, and depression, did not receive baths between April 3, 2024, and April 13, 2024. The resident has short and long-term memory impairments and requires substantial to maximal assistance with bathing. A CNA confirmed that the baths were not completed due to insufficient staffing. The Director of Nursing acknowledged that the baths were not completed as required for both residents and stated that the expectation is for staff to complete baths twice a week.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 60 days. Resident #1, who had diagnoses including hypertension, anxiety, depression, and psychotic disorder, was not seen by the primary care physician between October 26, 2023, and March 11, 2024. The resident's Minimum Data Set (MDS) indicated no impairments in decision-making or memory, and the resident required partial to moderate assistance with personal hygiene. The clinical record showed a behavioral health visit on October 26, 2023, and a physician assistant visit on March 11, 2024, but lacked documentation of any primary care physician visits during the intervening period. This deficiency was confirmed by the Regional Clinical Nurse Specialist during an interview on April 25, 2024.
Delayed Response to Call Lights
Penalty
Summary
The facility staff failed to answer resident call lights in a timely manner, specifically within the expected 15 minutes, for one of the three residents reviewed. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, reported that it could take staff over half an hour to respond to call lights. This resident has no impairments with decision-making or memory, as indicated by a BIMS score of 13, and requires partial to moderate assistance with personal hygiene and bathing. Multiple staff members, including three CNAs, confirmed that it often takes over 15 minutes to answer call lights. The facility's administrator also verified that the expectation is to respond to call lights within 15 minutes, as per state and federal regulations.
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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) |
|---|---|---|---|---|
| Greater Southside Health And Rehabilitation | 1 mi | ★★★★★ | 16 | 1 |
| Wesley On Grand | 3.3 mi | ★★★★★ | 0 | 0 |
| Scottish Rite Park Inc | 3.5 mi | ★★★★★ | 1 | 0 |
| Iowa Jewish Senior Life Center | 4.3 mi | ★★★★★ | 20 | 0 |
| Regency Care Center | 4.3 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.