Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Arbor Springs Of West Des Moines L L C during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and depression had documented worsening behaviors, expressed suicidal thoughts, and engaged in self-harm with a screwdriver, as recorded in progress notes. Despite these events and existing policy requiring care plan review and revision with significant changes in condition, the comprehensive care plan and Kardex lacked any focus, goals, or interventions addressing suicidal ideation or self-harm. The DON and Administrator acknowledged that the care plan was not updated after the resident’s suicidal statements and self-harm incident.
A resident with severe cognitive impairment, dementia, and depression expressed suicidal intent, used a screwdriver to inflict a hand injury, and refused to relinquish the tool while stating he wanted to kill himself. A CNA notified an LPN, who confirmed the self-harm and suicidal statements and called the resident’s family, but did not notify management or the DON and did not initiate 15-minute checks or remove hazardous items that night. Oncoming staff were not fully informed of the event, no structured close monitoring was implemented overnight, and hazardous items remained in the resident’s room until the following day. The DON and Administrator later acknowledged there was no specific policy on self-harm or suicidal ideation and that expected safety measures were delayed, resulting in a failure to ensure adequate supervision and a hazard-free environment.
A resident with severe cognitive impairment and a history of weight loss was served a regular diet meal with large, tough meat chunks instead of the prescribed mechanically altered diet with ground meats. Staff identified the inconsistency during feeding, and interviews revealed confusion over dietary orders contributed to the error, as the meal did not meet the requirements for a mechanically soft diet.
A Certified Medication Aide did not complete the required dependent adult abuse training within six months of hire, and there was no documentation of annual training. The DON confirmed the lack of training records, which is not in accordance with facility policy requiring timely abuse prevention education for staff.
A resident with a history of Alzheimer's, peripheral vascular disease, and recent surgery was admitted with multiple skin concerns, including a stasis ulcer and bruising. Staff failed to consistently document follow-up skin assessments, measurements, and wound details in the EHR, and did not always complete required incident reports or follow facility protocols for new skin issues. Observations and interviews confirmed gaps in documentation and assessment, despite the resident's ongoing skin problems and discomfort.
A resident with Alzheimer's disease and muscle weakness, dependent on staff for wheelchair mobility, was repeatedly observed being pushed by a CNA with one or both feet dragging on the floor instead of being placed on the wheelchair foot pedals. Multiple staff interviews confirmed this practice was against facility protocol, and the DON stated that residents' feet should always be on the pedals during wheelchair movement. The facility could not provide a written policy on wheelchair locomotion.
Two residents were involved in medication errors when Certified Medication Aides crushed extended-release (ER) tablets—Metoprolol ER and Potassium Chloride ER—contrary to pharmacy guidance and manufacturer recommendations. These errors resulted in a medication error rate of 6.67%, exceeding the acceptable threshold. The facility's medication administration policy lacked specific instructions regarding the crushing of ER medications.
Staff did not follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer, as the care plan lacked EBP directives, there was no EBP signage, and the LPN did not wear a gown during wound care. Staff interviews revealed inconsistent understanding of EBP requirements, and facility policies did not adequately address EBP utilization.
A resident with a history of falls and severe cognitive impairment was lowered to the floor by staff and subsequently experienced significant pain. Despite vocal complaints and a care plan indicating fall risk, the LPN did not assess the resident, and the ADON delayed assessment. The DON obtained an order for pain medication but did not ensure its administration. An x-ray later revealed a hip fracture requiring surgery. Staff interviews highlighted communication failures and policy non-compliance in managing the resident's condition.
A facility failed to conduct required post-fall neurological assessments for three residents with severe cognitive impairments who experienced unwitnessed falls. Despite care plans indicating fall risks and protocols for neurological assessments, documentation was incomplete, with missing assessments in the EHR. Staff interviews confirmed the protocol requirements, but the Director of Nursing acknowledged the lack of completed assessments.
The facility failed to have an RN on duty for at least 8 consecutive hours a day, as required by CMS regulations. This was confirmed through CMS PBJ data and facility documents, revealing a 48-hour period without RN coverage. Staff interviews indicated awareness of the requirement, but the facility's policy did not explicitly mandate RN presence for the required hours.
A facility failed to notify the LTC ombudsman of a resident's transfer to an acute care hospital. The resident's transfer was not included in the February 2024 report due to an issue with the admission and discharge report generated by Point Click Care (PCC). Despite verifying the correct transfer dates in the EHR, the resident's name was missing from the report. The Administrator contacted IT to investigate the issue, and it was noted that the facility lacks a policy for ombudsman notification, relying on a monthly spreadsheet procedure.
A resident with dementia and diabetes, at risk for pressure ulcers, did not receive consistent skin assessments as required by their care plan. The facility's records showed incomplete documentation, with missing wound measurements and additional unassessed wounds. Staff interviews revealed inconsistencies in the documentation process, and the facility's electronic health record lacked comprehensive assessments.
A resident with Alzheimer's and dementia did not receive proper incontinence care, leading to a deficiency. Two CNAs failed to follow infection control practices, such as changing gloves when contaminated and cleansing from front to back. The DON confirmed the expected procedures, which were not adhered to during the observed care.
Failure to Update Care Plan for Suicidal Ideation and Self-Harm
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to address suicidal ideation and self-harm behaviors, despite clear documentation of such behaviors in the clinical record. The resident had severe cognitive impairment, with a BIMS score of 2, and diagnoses including non-Alzheimer’s dementia and depression. The MDS documented that the resident’s behavior status had worsened compared to the prior assessment and that the resident sometimes felt lonely or isolated. Progress notes showed that on one occasion the resident became upset about being unable to leave, stated on a speakerphone call with family that he would kill himself, and was subsequently placed on 15-minute checks after the PCP was notified. The PCP advised continuing 15-minute checks and considering psychiatric follow-up for depression if the family allowed. A later progress note documented that at bedtime the resident picked up a screwdriver and inflicted a small skin tear on the back of his left hand, stating he wanted to kill himself, refused to relinquish the screwdriver, and threatened to harm anyone who tried to take it, while staff attempted to deescalate the situation. Despite these documented suicidal statements, ideations, and a self-harm incident, the resident’s care plan did not include a focus area, goals, or interventions related to suicidal ideation or self-harm. The Kardex used by staff on the household also lacked any information or interventions related to these behaviors. During interviews, the DON and the Administrator both acknowledged that the care plan was not updated after the suicidal statements and self-harm incident, even though facility policy required the comprehensive care plan to be reviewed and revised with significant changes in condition and as needed.
Failure to Implement Immediate Safety Measures After Resident’s Suicidal Statements and Self-Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of potential hazards after a resident made suicidal statements and engaged in self-harm. The resident had severe cognitive impairment with a BIMS score of 2, and diagnoses including non-Alzheimer’s dementia and depression. The MDS documented that the resident’s behavior status had worsened compared to the prior assessment and that the resident sometimes felt lonely or isolated. The care plan noted antidepressant use for depression and directed staff to monitor and report adverse reactions such as social isolation and suicidal thoughts. On the evening in question, after dinner, staff observed the resident with a small screwdriver in hand and a cut on the back of his left hand. The resident stated he wanted to kill himself and refused to relinquish the screwdriver, threatening to harm anyone who tried to take it. A CNA notified the floor nurse (an LPN), who came to the unit and confirmed the resident’s suicidal statements and self-inflicted injury. The LPN contacted the resident’s family, who arrived and were eventually able to get the screwdriver from the resident and help calm him. During this time, the resident remained in the common area with the screwdriver while staff attempted to deescalate the situation. The family member later reported that when she left around late evening, the resident was not on one-to-one observation and she was not informed of any specific safety measures in place. Multiple staff interviews and record reviews showed that no immediate safety interventions, such as initiating 15-minute checks or removing hazardous items from the resident’s room, were implemented the night of the incident. The LPN who managed the event did not notify management or the DON on call, and acknowledged that no safety measures were put in place until the following day. The oncoming night-shift LPN was told only that the resident had been upset and made a suicidal statement, and was not informed about the screwdriver or self-inflicted injury. The overnight CNA was not instructed to perform 15-minute checks and instead checked on the resident only as often as she could. Staff working the following morning, including the day-shift LPN and the social worker, learned of the suicidal incident only by reading the 24- or 72-hour reports, and both reported that no safety precautions were in place when they started their shifts. The DON later confirmed she was not informed until the next morning and acknowledged there was a delay in implementing protective steps, and both the DON and Administrator stated the facility did not have a policy on self-harm or suicidal ideation, relying instead on “standard practice of care.” The deficiency is further supported by documentation that 15-minute checks were not started until the late morning of the day after the incident, despite the resident’s explicit suicidal statements and self-harm the previous evening. Staff interviews indicated that in a prior episode months earlier, when the resident made verbal comments about wanting to hurt himself, 15-minute checks had been initiated immediately, contrasting with the lack of timely action in this event. The delay in removing hazardous items from the resident’s room and the absence of immediate, structured monitoring following the suicidal statements and self-inflicted injury demonstrate that the facility did not ensure an environment free from accident hazards or provide adequate supervision to prevent further accidents for this resident. The Administrator and DON both acknowledged that there was no specific facility policy addressing suicidal ideation or self-harm, and that staff were expected to follow a general standard practice that included immediate notification of management, physician contact, initiation of 15-minute checks, and removal of potentially harmful items. However, these expected steps were not carried out at the time of the incident. The lack of timely communication among nursing staff, failure to promptly notify the DON, and failure to implement enhanced supervision and environmental safety measures after the resident’s suicidal statements and self-harm directly contributed to the deficiency.
Failure to Provide Prescribed Mechanically Altered Diet
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, a history of weight loss, and multiple diagnoses including GERD and seizure disorder, was not provided with the prescribed mechanically altered diet. The resident's care plan and diet card specified a mechanically soft diet with ground meats, but during a direct observation, the resident was served a regular diet soup containing large, tough chunks of beef and vegetables. Staff feeding the resident noticed the inconsistency, as the meat could not be easily cut or mashed, and confirmed it was not appropriate for the resident's ordered diet. Interviews with staff revealed that dietary staff were responsible for plating food according to diet cards, while CNAs served the food. Both the CNA and dietary manager confirmed the meal served did not meet the resident's dietary requirements. The dietary manager attributed the error to confusion stemming from a previous hospice provider's order, which had allowed for pleasure feedings of normal textured foods, whereas the current order required only mechanically altered foods. Facility policy required mechanically soft diets to include moist, ground meats and soft foods, which was not followed in this instance.
Failure to Complete Required Dependent Adult Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that a Certified Medication Aide completed dependent adult abuse training within six months of hire, as required by facility policy. Review of the employee file for this staff member showed no documentation of the required training, either within the initial six-month period or annually thereafter. During an interview, the Director of Nursing confirmed the absence of this documentation. The facility's policy mandates that employees complete two hours of training on identification and reporting of dependent adult abuse within six months of employment, and that all nurse aides receive initial and annual abuse prevention training.
Failure to Document and Follow Up on Skin Assessments
Penalty
Summary
The facility failed to document follow-up skin assessments for a resident with known skin concerns, including a stasis ulcer, skin tear, and bruising. The resident, who had a history of left femur fracture, Alzheimer's Disease, and peripheral vascular disease, was identified as being at risk for pressure ulcers. Upon admission, the resident had a stasis ulcer on the right ankle, a surgical incision to the left thigh, and a skin tear on the left elbow, but the initial skin observation tool did not include wound measurements. Subsequent skin and wound evaluations recorded limited measurements and lacked details such as drainage, odor, and wound appearance. There was also a gap in documentation of skin assessments for the right ankle ulcer between early and late May, and new skin concerns such as bruises and a skin tear were not fully documented or measured. Staff interviews revealed inconsistent practices regarding skin assessments and documentation. The DON acknowledged that weekly skin assessments were not consistently completed or documented in the electronic health record (EHR), and that incident reports were not always filled out when new skin concerns were identified. Nursing staff described procedures for reporting and assessing skin issues, but there were discrepancies in how and where assessments were documented. One LPN reported being unable to document or photograph bruises due to technical issues, and another staff member indicated that nothing in the EHR flagged the need for attention to the resident's skin concerns. Observations confirmed the presence of unreported or undocumented bruises and wounds on the resident, including a large dark purple bruise on the forearm and scabs on the arm. The resident expressed discomfort during care and indicated that certain areas were painful. The facility's policy required the use of a communication form and thorough assessment for any change in condition, including new skin issues, but these protocols were not consistently followed, resulting in incomplete documentation and follow-up of the resident's skin concerns.
Failure to Ensure Safe Wheelchair Locomotion
Penalty
Summary
Staff failed to ensure safe wheelchair locomotion for a resident diagnosed with Alzheimer's disease and muscle weakness, who was dependent on staff for mobility. Multiple direct observations showed a certified nurse aide (CNA) pushing the resident in a wheelchair without both feet properly placed on the foot pedals. The resident's feet were seen dragging on the floor in socks, sometimes erratically kicking, and at one point nearly being run over by the wheelchair wheels. These incidents occurred during transfers between the living room and dining room, and while moving the resident between tables. Interviews with several staff members, including CNAs and a certified medication aide, confirmed that facility protocol requires residents' feet to be elevated on foot pedals during wheelchair movement to prevent injury. Staff acknowledged awareness of the proper procedure and the risks associated with non-compliance, such as falls and abrasions. The Director of Nursing also confirmed the expectation that staff ensure residents' feet are on the foot pedals during wheelchair locomotion. The facility was unable to provide a written policy regarding wheelchair locomotion during the survey.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of ER Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 observed opportunities, resulting in an error rate of 6.67%. In one instance, a resident with a diagnosis of hypertension was prescribed Metoprolol Succinate Extended Release (ER) 25 mg daily. During medication administration, a Certified Medication Aide (CMA) crushed the Metoprolol ER tablet along with other medications and administered the mixture to the resident. The pharmacist later confirmed that ER tablets should not be crushed, as this could result in the resident receiving too much medication at once. In another case, a CMA prepared and crushed a Potassium Chloride ER tablet for a resident, mixing it with other medications. The surveyor intervened before administration, instructing the CMA not to give the crushed medication, as Potassium Chloride ER should not be crushed. The facility's medication administration policy did not provide guidance on which medications should not be crushed, such as extended-release formulations. These actions led to the facility exceeding the acceptable medication error rate.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer located on the right fourth finger. The resident's care plan, revised to reflect the presence of the pressure area, did not include directives for EBP. During wound care observation, there was no signage indicating EBP in the resident's room, and the LPN performing wound care did not wear a gown as required by EBP protocols. Interviews with staff revealed inconsistent understanding and application of EBP, with some staff unaware that wounds required EBP and others acknowledging that wounds, catheters, and MDROs should be included. The DON confirmed that the resident should have been under EBP but was not. Review of facility policies showed that the infection control program did not mention EBP utilization, and the EBP policy itself specified that EBP should be used for residents with wounds during high-contact care activities, such as wound care, with gown and gloves required. The CDC guidance referenced also directs EBP implementation for residents with wounds or indwelling devices during high-contact care, regardless of MDRO status.
Failure to Assess and Manage Resident's Pain After Fall
Penalty
Summary
The facility failed to provide a thorough assessment and timely intervention for a resident who was lowered to the floor by staff. The resident, who had a history of falls and severe cognitive impairment, was in pain after the incident, but the LPN did not complete a thorough assessment. The ADON was notified of the resident's pain but did not assess the resident until several hours later, and the DON obtained an order for pain medication but failed to ensure it was administered. An x-ray later revealed a displaced hip fracture requiring surgical intervention. The resident's care plan indicated they were a wander and fall risk, requiring moderate assistance with care and ambulation. Despite vocal complaints of pain, the resident's pain management was inadequate, with no PRN pain medications administered on certain days. The progress notes documented various instances of the resident's pain and the lack of effective pain management, including the discontinuation of Oxycodone due to side effects and the failure to administer it when ordered. Interviews with staff revealed a lack of communication and follow-through regarding the resident's condition. The CNA reported the resident's pain to the LPN, who did not assess the resident or complete an incident report. The ADON and DON were informed of the resident's pain but delayed in assessing and addressing it. The facility's policy on fall assessment was not followed, as the charge nurse did not assess the resident immediately after the fall, and the physician was not notified promptly. This series of inactions and miscommunications led to the resident's delayed diagnosis and treatment of a hip fracture.
Failure to Conduct Post-Fall Assessments
Penalty
Summary
The facility failed to provide adequate post-fall assessments and interventions for three residents who experienced unwitnessed falls. Resident #1, with severe cognitive impairment due to Alzheimer's Disease and depression, had an unwitnessed fall on 10/19/24. Although the resident's care plan indicated a risk for falls and directed staff to follow the facility's fall protocol, the electronic health record (EHR) showed only 12 of the 14 required follow-up neurological assessments were completed. No further follow-up assessments were documented in the progress notes. Resident #2, also with severe cognitive impairment and multiple diagnoses including Non-Alzheimer's Dementia and diabetes, fell on 9/27/24. The care plan highlighted the resident's fall risk due to confusion and balance issues. Despite this, the EHR documented only 3 of the 14 required follow-up neurological assessments. The resident refused an assessment at one point, and a subsequent assessment lacked vital signs documentation. Resident #3, with severe cognitive impairment and a history of falls, experienced an unwitnessed fall on 11/12/24. The care plan noted the resident's fall risk due to confusion. The EHR showed only 7 of the 14 required follow-up neurological assessments were completed. Staff interviews confirmed the protocol for unwitnessed falls required neurological assessments, but documentation was incomplete. The Director of Nursing acknowledged the lack of completed assessments and stated that neurological assessments were documented only in the EHR, not in hard charts.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to maintain a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, as required by CMS regulations. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) data, facility documents, and staff interviews. The facility, which reported a census of 51, did not have an RN present for a 48-hour period from November 4, 2023, to the end of November 5, 2023. The staffing schedule provided by the Administrator confirmed the absence of an RN during this period. Additionally, the facility's assessment, last updated in December 2023, did not specify daily staffing requirements. Interviews with staff revealed that the facility informs staff if there is no RN on duty, and CNAs inquire about the nurse in charge when they start their shifts. The Director of Nursing (DON) acknowledged the requirement for an RN to be present for 8 consecutive hours daily and stated that she and the Assistant Director of Nursing (ADON) have alternating on-call schedules to ensure coverage. However, she did not recall the specific period of non-compliance. The Administrator confirmed via email that the facility did not have RN coverage on the specified dates and that their scheduling policy did not explicitly require an RN to be on the premises for 8 consecutive hours daily.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the long-term care ombudsman regarding a resident's transfer to an acute care hospital. The clinical record review and staff interviews revealed that the resident was transferred on February 4, 2024, and returned on February 8, 2024. However, the Notice of Transfer Form to the Long Term Care Ombudsman did not include this resident in the report for February 2024 transfers. The Business Office Manager (BOM) explained that her procedure involves running an admission and discharge report using Point Click Care (PCC), but the resident's name did not appear on the report. Despite verifying the correct transfer dates in the Electronic Health Record (EHR), the issue persisted. The Administrator contacted Information Technology (IT) to investigate potential errors in the report settings. It was also noted that the facility lacks a policy for ombudsman notification, relying instead on a monthly spreadsheet procedure.
Inadequate Documentation of Skin Assessments
Penalty
Summary
The facility failed to document skin assessments for a resident with a history of non-Alzheimer's dementia and diabetes, who was at risk for pressure ulcers and had a Stage 2 pressure ulcer upon admission. The care plan required weekly skin assessments, but the facility's records showed inconsistent documentation of these assessments. Only three out of several assessments included wound measurements, and there were no measurements for a moisture-associated skin disorder on the resident's thigh. Observations revealed additional wounds and redness, indicating a lack of comprehensive and timely skin assessments. Interviews with staff, including a Certified Medication Aide, Registered Nurses, and the Director of Nursing, revealed inconsistencies in the documentation process and a lack of adherence to the facility's policy for weekly skin assessments. The Director of Nursing acknowledged the deficiency in documenting wound measurements and noted that a Performance Improvement Plan was in place. However, the facility's electronic health record lacked comprehensive skin or wound assessments, highlighting a gap in the facility's adherence to its own policies and procedures.
Improper Incontinence Care and Infection Control Practices
Penalty
Summary
The facility failed to provide proper incontinence care to minimize the risk of cross-contamination and urinary tract infections for Resident #26, who has Alzheimer's Disease and dementia, with severely impaired cognition. The resident requires substantial to maximum assistance for toileting hygiene, bed mobility, and transfers. During an observation, two certified nursing assistants (CNAs), Staff A and Staff B, were involved in providing incontinence care to the resident. Staff B placed wet washcloths in a plastic bag by the bed, and both staff members used a mechanical lift to transfer the resident from a Broda chair to the bed. Staff A used a wet washcloth with peri-wash foam to cleanse the resident's lower abdomen and groin, leaving the soiled washcloth between the resident's inner thighs. Staff B removed the soiled brief and used the soiled washcloth to clean the resident's buttocks, failing to change gloves when contaminated. Staff B continued to cleanse the resident's buttocks and gluteal creases, wiping in a downward fashion from back to front, which is against the expected procedure. Staff A instructed Staff B to change gloves, which she did after obtaining additional washcloths. Staff B then applied barrier ointment to the buttocks, again wiping in a downward and circular motion toward the perineum, before removing her gloves. The Director of Nursing (DON) stated that staff are expected to cleanse from front to back during incontinence care and change gloves whenever they become soiled or contaminated. The facility's peri-care skills checklist outlines the proper procedure, which was not followed in this instance, leading to the deficiency.
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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 West Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Ridge Village | 0.7 mi | ★★★★★ | 9 | 0 |
| Edgewater, A Wesleylife Community | 1.4 mi | ★★★★★ | 4 | 0 |
| The Village Of Legacy Pointe Nursing Facility | 2.8 mi | — | 0 | 0 |
| Deerfield Health Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Walnut Ridge | 3.5 mi | ★★★★★ | 0 | 0 |
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