Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Harmony West Des Moines during CMS and state inspections, most recent first.
Delayed reporting of abuse allegation: A resident with moderate cognitive impairment, Parkinson’s Disease, and Bipolar Disorder alleged that staff hit him and caused injury while cleaning up a spill. The OT documented the statement and said she reported it to nursing leadership and the NP, but the facility did not file the FRI or contact police until more than 24 hours later, despite policy requiring immediate reporting of abuse allegations.
Wheelchair foot pedals were not attached during staff-assisted transport for two residents. One resident with severe sensory impairment and total dependence for mobility was moved with a foot dangling and dragging on the floor, and another resident with dementia and paraplegia was transported in a wheelchair missing a foot pedal. Staff and the Administrator acknowledged that foot pedals should have been in place during transport.
The facility failed to follow its own policies and resident care plans for safe transfers and ambulation, including use of gait belts and mechanical lifts, and did not ensure adequate supervision or orientation of agency CNAs. A resident with severe cognitive impairment, muscle weakness, and a care plan requiring assisted ambulation with a gait belt and non‑mechanical lift transfers was instead assisted without a gait belt, found on the floor after attempting to walk to the bathroom, and was manually lifted to bed without a mechanical lift despite being unable to bear weight, later diagnosed with right humeral and olecranon fractures. Another resident with weakness and unsteadiness, whose care plan required one‑person assist with a gait belt and front‑wheeled walker, slid to the floor during peri care when an agency CNA assisted her by the arm without a gait belt, and two agency CNAs then struggled to lift her by the arms into a wheelchair before an LPN arrived; she was later found to have an acute trimalleolar ankle fracture. Agency CNAs reported minimal orientation, lack of access to PCC care information, unfamiliarity with facility lifts, and chaotic staffing conditions, contributing to these failures in accident prevention and supervision.
Ineffective QAPI process with repeated deficiencies. The facility failed to have an effective QAPI process to address previously identified quality issues, and survey history showed repeated citations including F609, F688, F689, F812, F865, and F880 across recertification surveys, complaint investigations, and facility-reported incident investigations. The Administrator stated the QA Committee met monthly and described audits, staff education, workload strategies, and the addition of an Infection Preventionist and Nurse Educator, but the report still documented recurring deficient practices.
MDS assessments were inaccurately completed for multiple residents. One resident was coded as having a feeding tube without supporting orders, care plan, or progress notes; another was marked as not having PASARR MH/ID despite diagnoses including anxiety, MDD, and schizoaffective disorder; a third had O2 coded but CPAP use was omitted despite orders and TAR evidence; and a fourth was coded for insulin and hypoglycemic meds without insulin orders or a DM dx, which the MDSC confirmed was miscoded.
An LTC facility failed to follow infection control practices for contact precautions, EBP, and standard precautions. Staff used an alcohol wipe on a stethoscope after caring for a resident with C-diff, and multiple staff failed to use proper hand hygiene, gloves, PPE, or EBP during insulin administration, blood glucose checks, g-tube medication administration, and wound care for residents with wounds or other care needs.
The facility failed to obtain informed consent for psychotropic medications with FDA black box warnings for two residents. One resident had Alzheimer’s disease, dementia, anxiety, and depression with severely impaired decision-making and was prescribed multiple psychotropics, but the record lacked consent despite a later psychotropic medication evaluation documenting education. Another resident had severe cognitive impairment, depression, and behavioral disturbance and received antidepressant and antipsychotic medications, but the chart also lacked psychotropic consent.
Failure to Separate Accused Staff After Abuse Allegations: Two residents with significant cognitive and mobility impairments were involved in incidents that led to a fracture and a fall with fractures, and staff gave conflicting accounts about the events. A roommate reported hearing a resident cry out and a thud during a transfer without the usual mechanical lift, while another resident fell during bathroom assistance and later had fractures of the shoulder and elbow. Despite the allegations, the CNAs involved continued working, even though the facility policy required the accused employee to be separated from all residents.
Failure to Report Injury of Unknown Origin and Allegation of Abuse: A resident with severe cognitive impairment, contractures, osteoporosis, and dependence on a Hoyer lift developed a right humeral neck fracture with no witnessed fall or clear cause. Staff documented increased pain and x-ray findings, and a roommate reported hearing a CNA transfer the resident without the mechanical lift and hearing the resident cry out and thud onto the bed. The Administrator concluded the fracture was spontaneous and did not report the injury or abuse allegation to DIAL within the required timeframe.
The facility failed to submit a significant change MDS for a resident whose condition declined after a fall that resulted in an acute ankle fracture, hospital transfer, pain management with fentanyl, and immobilization with a soft cast. The resident’s MDS later showed total dependence for transfers and toileting with no ambulation, and the MDS Coordinator stated a significant change MDS should have been submitted due to the change in condition.
Failure to Apply Ordered Hand Splint: A resident with hemiplegia and stroke had a care plan and MD order for a right resting hand splint to be applied each morning and removed at night, but observations showed the splint was not being worn and was left untouched on the bedside dresser. The resident stated staff did not offer or apply the splint and could not do it independently due to inability to move the affected arm; the ADON acknowledged the order and that nursing staff should offer it daily and document accordingly.
The facility failed to ensure new agency CNAs were oriented and competent before working independently. A resident with weakness, unsteady gait, and a care plan requiring a gait belt and assistance fell in the bathroom after waiting for help; the resident reported the CNA did not use a gait belt and that another new agency CNA also helped. The resident sustained an acute ankle fracture and was sent to the hospital. Interviews showed the agency CNAs were not shown how to use PCC or the facility’s mechanical lifts, were left on their own with multiple residents, and staff, including the DON and ADON, were unaware of any formal onboarding process.
Medication administration errors caused the facility’s medication error rate to exceed the allowed threshold. During observation, an RN administered Esomeprazole to one resident even though the MAR did not show that order, and for another resident the RN did not give ordered Lyumjev insulin and gave Tums in the morning instead of at bedtime. Review of the MARs and progress notes also showed missing documentation related to the insulin dose and blood glucose follow-up.
A cognitively intact resident with ESRD on dialysis, DM, CAD, and HF did not receive ordered Lyumjev insulin and did not have the ordered noon Velphoro dose sent with them to dialysis. During the med pass, the RN paused to review the insulin because the blood glucose was 98, but the MAR and nursing notes did not show follow-up documentation for the insulin dose. The DCE later confirmed both ordered doses were missed.
Inappropriate Candy Given to Residents on Mechanical Soft Diets: A maintenance staff member gave fun-sized Snickers candy bars to two residents who were on mechanical soft diets. Both residents had severe cognitive impairment and diagnoses including dysphagia, and one also had dementia and stroke. The staff member said they were unaware of the specialized diets and had seen other staff give the residents candy before, including Snickers. The RD stated Snickers are not allowed on a mechanical soft diet because they are too sticky and the nuts are difficult to chew.
Unsafe Food Handling During Breakfast Assistance: A CNA handled ready-to-eat toast with bare hands while assisting two residents at breakfast, and hand hygiene was not performed before the food was given to the residents. A fork and the CNA’s bare hand were used to place toast in one resident’s hand, and another piece of toast was folded and handed to a second resident with bare hands. Gloves were available in the dining room, and the Corporate Regional Nurse acknowledged staff should not handle resident food with bare hands.
The facility received an Infection Prevention & Control deficiency for the fifth consecutive survey. Despite having a QAPI Plan with a monitoring process, it failed to address previously identified deficiencies. The Administrator noted staff education efforts, but the facility remained non-compliant.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, lacking personalized non-pharmacological interventions and specific target behaviors for monitoring. Staff interviews revealed gaps in communication and adherence to care plans, indicating deficiencies in care planning and monitoring processes.
The facility failed to provide appropriate serving sizes for puree diets and did not monitor final cooking temperatures for meal items. A cook prepared puree pea servings but did not communicate the correct portion size to other staff, resulting in residents receiving inadequate portions. Additionally, a staff member did not check the temperatures of macaroni and cheese and instant potatoes before serving, contrary to facility policy.
A resident with intact cognition was not given the opportunity to participate in recent care planning meetings, despite having attended a team meeting in October where they expressed concerns. Facility staff confirmed that no formal meeting occurred with the resident during the last annual updates, highlighting a failure to ensure resident involvement in care planning.
The facility failed to accurately document the status of three residents in their MDS assessments. A resident's PASRR Level II requirement due to Major Depressive Disorder was not reflected in the MDS, and another resident's Schizoaffective disorder was similarly undocumented. Additionally, a resident's hospice care status was not accurately recorded during the lookback period. The MDS Coordinator acknowledged an oversight, and the facility lacks a specific policy for MDS completion.
A facility failed to implement a complete Baseline Care Plan within 48 hours for a resident with intact cognition, as required by policy. The resident did not receive a copy of the care plan and expressed a need for discharge planning assistance. The baseline care plan lacked initial goals, therapy services, and additional physician orders, and the Comprehensive Care Plan was delayed. A Care Conference was held, but the care plan was not provided to the resident.
A hospice resident with severe cognitive impairment and multiple health conditions was left unattended with an uncovered lunch tray for 40 minutes. Despite needing assistance, the resident was not properly helped until prompted by a state surveyor. The facility lacked a specific policy for assisting residents with eating, and the DON acknowledged the oversight.
The facility failed to implement a Restorative Program for three residents requiring assistance with ADLs. A resident with intact cognition expressed a need for individualized leg exercises, which were not provided. Another resident was dependent on staff for several ADLs and required a mechanical lift, yet did not receive restorative services. A third resident had functional limitations in ROM and required substantial assistance, but their Care Plan lacked restorative programs. The facility administrator acknowledged the absence of restorative programs, with plans for future implementation.
A facility failed to follow professional standards for administering medications via a gastric tube for a resident with dysphagia. The RN did not use a table barrier, check tube placement, or follow Enhanced Barrier Precautions (EBP) during the process, as required by the care plan and facility policy. The Infection Control RN confirmed these deficiencies and noted the need for improved processes.
A facility failed to manage oxygen use for a resident with coronary artery disease and heart failure, as the MAR and TAR lacked documentation of the physician's order for oxygen therapy. The resident used oxygen continuously in the room, contrary to the order for bedtime use only. The DON and Administrator confirmed the transcription error and the need for staff and resident education.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident on psychotropic medications, including Sertraline and Olanzapine, over a nine-month period. Despite the prescribing provider's assessment of the regimen as appropriate, no trial of a lower dose was attempted. The Consultant Pharmacist admitted an oversight in not recommending a GDR for Olanzapine, which should have been suggested twice in the first year. The facility's policy requires consideration for dose reduction, which was not followed.
A CNA was observed using bare hands to assist a resident with eating, contrary to the facility's food handling policy. The resident, who required assistance due to severe impairments, was given food directly by hand, and a previously used paper towel was employed during the meal. The DON highlighted the need for hand hygiene and the use of barriers like gloves or utensils.
A resident with an indwelling urinary catheter experienced inadequate infection control practices by staff, leading to a deficiency in preventing UTIs. The resident, with a history of multiple UTIs and chronic conditions, did not receive proper catheter care as staff failed to perform hand hygiene at critical points and did not clean the catheter tubing as required. The facility's policies for hand hygiene and catheter care were not followed, contributing to the deficiency.
A resident with multiple medical conditions was not provided a barrier during personal care, resulting in dried cream flakes on the bed's blanket. The CNA did not change the blanket after care, and the ADON acknowledged the oversight, which violated the facility's dignity policy.
A resident with cirrhosis and failure to thrive was not properly monitored for bowel movements, leading to a lack of physician notification about the need for treatment change. The resident, who was on Lactulose, had only one bowel movement over four days, resulting in increased confusion and hallucinations, and was eventually sent to the ER. The facility lacked a standardized bowel protocol, and the failure to notify the physician violated the facility's policy on significant treatment changes.
A resident with a stage 3 pressure injury did not have wound care treatments documented on multiple occasions, despite orders for daily care. The resident confirmed he did not refuse treatment. The DON and ADON acknowledged the lack of documentation and could not verify if treatments were completed, despite the facility's policy requiring adherence to active orders.
The facility failed to follow infection control practices during catheter care for two residents. A CNA did not change gloves after touching potentially contaminated surfaces and did not change an incontinence brief for one resident. For another resident, the CNA did not wear a gown despite the requirement for Enhanced Barrier Protection. The ADON acknowledged these lapses.
A facility failed to ensure privacy for a resident during perineal care, as observed when two CNAs did not close the window curtains while providing care. The resident, who required total assistance and was incontinent, was exposed to public view from a busy street, violating her right to dignity and respect.
A resident with severe cognitive impairment and incontinence issues did not receive proper perineal care from CNAs, as observed during a survey. The CNAs failed to cleanse the resident's buttocks or hips after cleaning the mid gluteal region, which was against the facility's policy requiring thorough cleansing of all affected areas.
Facility staff failed to follow infection control protocols during care for two residents with severe cognitive impairment and incontinence. CNAs did not change gloves between different stages of care, contrary to facility policy, leading to potential contamination. The staff continued to use the same gloves for multiple tasks, including handling personal items and applying barrier cream.
Delayed reporting of abuse allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour time frame for one resident with moderate cognitive impairment, Parkinson’s Disease, Bipolar Disorder, mood symptoms, and frequent urinary incontinence. The resident’s care plan identified a mood state disturbance and noted a history of false accusations and derogatory remarks toward African American staff. On 4/28/26, the resident told the Occupational Therapist that staff had hit his head and leg and “sucked his guts out” while cleaning up spilled water or soda with a machine. The OT documented the statement in a therapy note and reported it to a nurse, the Assistant DON, and the NP when they were present together. Staff interviews showed conflicting recollections about when the allegation was reported and what was understood at the time. The RN stated the OT reported the allegation to her while she was on her way to a morning management meeting and that she then went to the meeting, where multiple managers were present. The OT stated she reported the allegation to a staff nurse and the RN, and said the ARNP was present. The ARNP stated she was not present when the allegation was made but recalled hearing it reported in the meeting and believed police were not called until the following day. The Administrator later stated the allegation was not acted on until the resident was re-interviewed the next day, when he confirmed concerns about a specific CNA. The facility’s FRI to the State Agency was filed on 4/29/26 at 12:42 pm, and the police report showed the facility called police at 12:45 pm that same day, more than 24 hours after the initial progress note documenting the allegation. The Administrator stated the resident initially described being bumped by a full mechanical lift and did not consider it abuse until he later added allegations about a specific CNA. The facility policy required immediate reporting of suspicions or allegations of abuse, including injuries of unknown source, and the survey findings showed the allegation was not reported within the required timeframe.
Wheelchair Foot Pedals Not Attached During Resident Transport
Penalty
Summary
The facility failed to ensure wheelchair foot pedals were attached during staff-assisted transport for 2 of 3 residents observed for transfers. Resident #2 had diagnoses including seizure disorder, legal blindness, bilateral hearing loss, and hydrocephalus, and his MDS showed he was dependent for all ADLs and mobility except supervision with eating; his care plan directed staff to use foot pedals with his wheelchair. During observation, Staff E transported Resident #2 from the nurses’ station to the dining room with only his right foot on a pedal while his left foot dangled between the pedals and dragged on the floor. Later, Staff I moved the resident at the dining table and his left foot was again observed dragging the floor during transport. Resident #7 had diagnoses including non-Alzheimer’s dementia, paraplegia, seizure disorder, and psychotic disorder, and his MDS showed severely impaired cognition and dependence for all ADLs and mobility except limited setup assistance with eating and oral hygiene; his care plan also directed use of a wheelchair. During observation, Staff E transported Resident #7 in his wheelchair to another position at the dining table even though the wheelchair did not have a left foot pedal, and the resident was able to transport himself in the wheelchair. Staff interviews confirmed that two foot pedals were required during transport and that Resident #2’s foot should have been placed on a pedal before movement, while the Administrator stated staff should have ensured the foot pedals were on the residents’ wheelchairs during transports.
Failure to Use Gait Belts, Lifts, and Adequate Supervision Resulting in Resident Falls With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, follow its own transfer and ambulation policies, and use appropriate assistive devices to prevent accidents for multiple residents. For one resident with diabetes, stroke, heart failure, severe cognitive impairment (BIMS 3), muscle weakness, and limited ROM, the MDS showed she did not walk 10 feet due to medical/safety concerns and normally used a manual wheelchair. Her care plan identified a brain injury, impulsivity, and non‑compliance with directions, and directed staff to assist her to ambulate with a gait belt and front‑wheeled walker and to transfer using a non‑mechanical lift. She was not on a restorative program, and staff interviews indicated she was mostly in bed, required significant assistance, and had not been ambulating to the bathroom for some time, with CNAs typically changing her in bed and transferring her to a recliner with assistance of two and a gait belt. On the date of the fall, an incident report and nursing progress notes documented that a CNA reported the resident lost her balance and fell while ambulating to the bathroom, and that the resident was found on the floor on her right side, screaming in pain, without a gait belt, with her walker tipped over nearby and her wheelchair by the bathroom wall. The RN and CNA assisted her back to bed without using a mechanical lift, despite her inability to bear weight, by grabbing her pants and sliding and lifting her into bed. EMS documentation and ED records described that EMS found her after a fall from her wheelchair with severe right shoulder pain, and the ED history stated she fell when trying to use her wheelchair for support while getting out of the shower. Imaging revealed an impacted right humeral fracture and a comminuted olecranon fracture with elbow effusion, and she was admitted for trauma management. The resident’s daughter reported that her mother had been mostly bedbound, could not walk during prior visits, and that she was told by the RN that the CNA had followed the resident with a wheelchair as she walked to the bathroom, which conflicted with her understanding of her mother’s abilities. Staff interviews revealed inconsistent accounts of the event and failures to follow policy and care plan directions. The RN stated the resident had not gotten up by herself in a long time, that she was found on the floor without a gait belt, and that a mechanical lift was not used to get her off the floor, contrary to facility policy for non‑weight‑bearing or extensive‑assist residents. The CNA involved gave differing versions of the incident, at one point stating the resident was assisted up from the recliner with a gait belt and walker and that a mechanical lift was used to get her into bed, which was contradicted by another CNA who entered the room and observed the resident being placed in bed without a gait belt and without a mechanical lift present. Investigative notes documented that the resident was impulsive, did not always follow directions or wait for staff, and had been caught ambulating on her own, yet the facility’s own documentation also stated she had not been ambulating and required significant assistance, indicating a lack of consistent implementation of care plan interventions and safe transfer policies. A second resident with weakness, unsteadiness on feet, and intact cognition required one‑person assistance with ambulation and maximal assistance for hygiene and toileting. Her care plan directed staff to assist with ambulation and transfers with moderate assistance of one staff using a gait belt and front‑wheeled walker. On the day of her incident, she walked to the bathroom with her walker, used the toilet, and activated the call light to request staff assistance for peri care. She reported that she waited a long time for help, that when the CNA arrived and began assisting her, she felt herself slipping and told the CNA, who responded "I've got you" but did not prevent her from sliding to the floor. She stated the CNA held her by the arm rather than using a gait belt, and that a second agency CNA came in and both attempted to get her into the wheelchair by her arms while she was unable to stand due to right leg pain, before the nurse arrived. Facility documentation of this fall described that the resident’s legs became weak during peri care and she was lowered to the floor, and that she was later found in the bathroom in a wheelchair with a gait belt on. The NP’s progress note, however, recorded the resident’s description that she slid down between the toilet and wheelchair when the caregiver did not use a gait belt despite her warnings that she was slipping. X‑rays revealed an acute trimalleolar fracture of the right ankle, and she required hospital evaluation, pain management with Fentanyl, and stabilization with a soft cast. The facility’s fall report and physician form characterized the event as a fall during transfer from toilet to wheelchair with legs becoming weak, but did not reconcile the resident’s account that a gait belt was not used and that she was lifted by her arms by two agency CNAs. Interviews with the agency CNAs involved in this second resident’s care showed that they were new to the facility, had not been oriented to the electronic record (PCC), did not know resident‑specific information, and were unfamiliar with the facility’s equipment and procedures. One agency CNA described the day as hectic, with staff sick and leaving, and stated that she answered a bathroom call light for a resident she did not know, assisted with peri care, and the resident started to fall. She called another agency CNA for help, and together they struggled to get the resident into the wheelchair before a nurse arrived; she reported that no one asked her what happened and she was not contacted afterward. The second agency CNA similarly described the shift as chaotic, stated she had no idea how to operate the facility’s mechanical lifts, and reported that she found the first CNA with the resident on the floor in front of the toilet, called for a nurse, and helped get the resident up. Nursing and administrative staff interviews acknowledged that agency CNAs were working with minimal orientation, that the ADON and DON were not directly overseeing their onboarding, and that there was uncertainty about how agency staff accessed care plans and fall‑prevention information, contributing to failures to use gait belts and appropriate transfer methods as required by facility policy. Facility policies on fall occurrences, gait belts, mechanical lifts, and non‑mechanical transfers specified that gait belts should be used when a patient is weak but can bear some weight and is a fall risk, and that mechanical lifts should be used for non‑weight‑bearing or total/extensive assist transfers, while non‑mechanical lifts are appropriate only when a patient can bear partial weight and follow commands. In both residents’ cases, the documented conditions (weakness, impaired balance, need for significant assistance, and in one case inability to bear weight after the fall) and the care plan directions were not consistently followed. Staff failed to use gait belts during transfers and ambulation, did not use mechanical lifts when residents could not safely bear weight, and did not ensure that agency CNAs were adequately oriented to resident needs and facility safety policies, leading to falls with significant injuries for the residents involved.
Ineffective QAPI Process With Repeated Deficiencies
Penalty
Summary
The facility failed to have an effective QAPI process to address previously identified quality deficiencies and support substantial compliance with Federal regulations and State rules. Review of CASPER and DIAL visit history showed repeated deficient practices across multiple surveys, complaint investigations, and facility-reported incident investigations, including F609, F688, F689, F812, F865, and F880. These deficiencies were cited on prior recertification surveys, complaint investigations, and incident investigations, and were again cited during the current survey and complaint investigations. During an interview, the Administrator stated the QA Committee met monthly and that the QAPI Committee had identified areas needing work. The Administrator reported he had only worked at the facility since 11/2025 and described efforts such as staff scheduling and workload strategies, audits, staff education, and the recent addition of an Infection Preventionist and Nurse Educator. The facility's QAPI Plan, dated 5/23/25, stated that regulatory outcomes are monitored and trended, and that PIPs are developed as needed, with areas of opportunity corrected through the PIP process; however, the report documented repeated deficiencies despite these stated processes.
MDS Assessments Were Inaccurately Completed for Multiple Residents
Penalty
Summary
The facility failed to accurately complete MDS assessments for 4 of 21 residents reviewed. For Resident #3, the Quarterly MDS completed on 12/17/25 indicated the presence of a feeding tube by checking K0520B, but the EHR review found no current or discontinued physician orders for tube feedings, no care plan evidence of current or prior tube feeding use, and no progress notes identifying a feeding tube. The RAI User Manual states K0520B should be checked only if a feeding tube was present during the assessment period. For Resident #7, the Annual MDS completed on 10/31/25 was marked No for A1500, indicating no Level II PASARR mental illness and/or intellectual disability, despite diagnoses of generalized anxiety disorder, major depressive disorder, recurrent, and schizoaffective disorder, bipolar type. For Resident #8, the MDS completed on 12/10/25 coded continuous oxygen therapy but did not identify CPAP use, even though physician orders showed nightly CPAP and oxygen therapy, and the TAR showed CPAP use during 2 days of the 7-day look-back period. For Resident #61, the Annual MDS completed on 12/31/25 indicated insulin use and hypoglycemic medication use, but the record showed no current or discontinued insulin orders for December 2025, no diabetes diagnosis, and the MDS Coordinator confirmed the resident did not receive insulin injections and that the assessment was miscoded.
Infection Control and Barrier Precautions Not Followed
Penalty
Summary
The facility failed to follow infection control policies, procedures, and guidelines for contact precautions, enhanced barrier precautions (EBP), and standards of care. Resident #5 had a physician order dated 2/23/26 directing isolation for Clostridioides difficile (C-diff), and a progress note documented that the resident was positive for C-diff, would start Vanco, and would be on isolation for 10 days. A sign outside the room directed staff to use gown and gloves for any interaction with the resident and the resident’s environment, and noted that alcohol-based hand sanitizer was not acceptable for this infection. During an observation on 2/26/26, an RN completed dialysis fistula site care on Resident #5 and used a stethoscope on the resident’s arm to assess the fistula. After the care was completed, the RN disinfected the stethoscope with an alcohol wipe. The Director of Clinical Education acknowledged that alcohol wipes are not recommended for this type of infection and stated bleach wipes or Super Sani-cloths should be used instead; the facility stocked Super Sani-cloth disinfectant wipes. The facility’s Infection Control Practice Guide stated that resident-specific non-disposable items such as stethoscopes should be disinfected between resident use with an EP-registered disinfectant or hypochlorite solution. The facility also failed to follow barrier precautions during resident care. Resident #4 had multiple diagnoses including heart disease, diabetes mellitus, Alzheimer’s disease, dementia, and stroke, required partial to supervised assistance, had a BIMS score of 5, and received insulin injections 7 days a week. During an observation, an RN administered insulin without hand sanitizing, without gloves, and without performing hand hygiene before leaving the room. Additional observations showed an LPN failed to use a barrier when checking Resident #54’s blood glucose and failed to wear PPE while administering medication via g-tube to Resident #6. The facility also failed to use EBP PPE during wound care for Resident #9 and Resident #97, both of whom had wound treatment orders and were identified for EBP; staff and leadership acknowledged the failures, and the facility administrator stated he could not find a policy related to disinfecting equipment and shared medical devices.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications with black box warnings for 2 of 5 residents reviewed. Resident #110 had diagnoses of Alzheimer’s disease, dementia, anxiety disorder, and depression, with impaired short- and long-term memory and severely impaired decision-making skills. The record showed orders for multiple psychotropic medications, including sertraline, trazodone, risperidone, and olanzapine, and a psychotropic medication monthly review that lacked consent for these medications. Although the electronic record later contained a Psychotropic Medication Evaluation documenting education to the resident and/or representative about risks, benefits, and alternatives, the record still lacked a consent for the prescribed psychotropic medications. Resident #4’s admission MDS showed severe cognitive impairment with a BIMS score of 5, along with diagnoses of depression and behavioral disturbance, and the resident received antidepressant and antipsychotic medications during the look-back period. The clinical record lacked documentation of psychotropic consent for this resident as well. The Administrator stated the facility searched for original paper consents after transitioning to an electronic system, but the signed consents for Residents #4 and #110 were not available.
Failure to Separate Accused Staff After Abuse Allegations
Penalty
Summary
The facility failed to protect residents from potential abuse by not separating staff from residents when allegations of suspected abuse were reported for two residents. For one resident with arthritis, a right hand contracture, severely impaired cognition, impaired range of motion, and dependence on staff for bed mobility and transfers, the record showed a right humeral neck fracture after staff and a roommate raised concerns about how she had been transferred and placed into bed. The roommate, who had intact cognition, reported hearing the resident cry out and hearing a thud when a CNA entered the room without the mechanical lift that was normally used. Staff interviews described conflicting accounts of who assisted with the transfer and whether the resident was moved with the mechanical lift, while the Administrator stated he investigated the matter and ruled out abuse. The investigation records and timecard review showed that the CNA identified in the concern continued to work and clock in/out on multiple shifts after the allegation was reported. The facility policy stated that when an allegation of abuse by an employee is made, the accused employee will be separated from all residents, but that did not occur in this case. Staff interviews also reflected that the resident was in pain, was positioned oddly in bed after the event, and later had x-ray findings showing an acute or subacute fracture of the right humeral neck. For a second resident with diabetes, stroke, heart failure, severe cognitive impairment, limited mobility, and a care plan directing assistance with transfers, the record showed a fall while being assisted to the bathroom and subsequent fractures of the right shoulder and elbow. Staff accounts differed about whether the resident was walking with a walker, being followed with a wheelchair, or was not supposed to ambulate to the bathroom at all. Interviews with staff and the resident’s daughter indicated the resident was weak, often bedbound, and had required substantial assistance, yet the CNA involved continued to work after the incident. The facility’s own investigative notes documented that the resident stood up, began walking to the bathroom, lost balance, and fell onto her right side, while other staff stated she had not gotten up by herself in a long time.
Failure to Report Injury of Unknown Origin and Allegation of Abuse
Penalty
Summary
The facility failed to report an injury of unknown origin and an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing within the required 2-hour timeframe for one resident who had a right humeral neck fracture. The resident had diagnoses of arthritis, a right hand contracture, osteoporosis, tremors, impaired mobility, and severely impaired cognition, and required staff assistance with bed mobility and transfers using a Hoyer lift and two staff. The resident was also on hospice and had no documented skin issues on the MDS. On 2/17/26, the resident was seen for increased right shoulder pain and limited ROM, and x-rays showed an acute or subacute subcapital fracture of the right humeral neck with diffuse osteoporosis. The resident was sent to the ED, where the provider documented a right humerus fracture of unknown cause. The ED note stated the resident was bed bound, used a mechanical lift to transfer, staff were not aware of any injury, there were no witnessed falls, and the resident could not recall the incident. The resident was discharged back to the facility with a sling. Facility staff documented increased pain, x-ray results, and concerns about how the fracture occurred. A roommate reported hearing a CNA enter the room without the mechanical lift, hearing the resident cry out, and hearing a thud on the bed. Staff interviews reflected that multiple staff members heard concerns from the roommate and from others that the resident may have been transferred improperly. The Administrator reviewed the situation, spoke with staff, the provider, hospice, and family, and concluded the fracture was spontaneous and not reportable. The Administrator confirmed the fracture and injury of unknown origin were not reported to DIAL because he believed spontaneous fractures were not reportable, despite the facility policy stating that injuries of unknown origin and allegations of abuse must be reported immediately and no later than 2 hours after the allegation is made when there is bodily injury.
Failure to Submit Significant Change MDS After Resident’s Fracture
Penalty
Summary
The facility failed to submit a significant change MDS for 1 of 2 residents reviewed for a significant change in condition. Resident #2’s quarterly MDS showed diagnoses of weakness and unsteadiness on feet, with assistance needed from one staff member for supervision with ambulation and maximal assistance for hygiene and toileting, and a BIMS score of 15 indicating intact cognition. A later quarterly MDS showed the resident was totally dependent on staff for transfers and toileting and had no ambulation. The progress note documented that after a fall, the resident sustained an acute ankle fracture, was transported to the hospital, received fentanyl for pain management, had additional x-rays, and the fracture was stabilized with a soft cast with possible transition to a boot. The resident also reported ongoing pain from the fracture. During interview, the MDS Coordinator stated the resident did qualify for a significant change MDS and that one should have been submitted due to the change in condition after the fall.
Failure to Apply Ordered Hand Splint
Penalty
Summary
The facility failed to offer and apply a right-hand splint for Resident #7, who had diagnoses of hemiplegia and stroke and a Quarterly MDS that noted the need for splint assistance under restorative nursing programs. The care plan directed staff to use a right resting hand splint and assist with application every morning until bedtime as tolerated, and a physician order also directed staff to assist with putting on the splint in the morning and removing it at night. The TAR documented that staff applied the right hand splint every morning and removed it every night from 2/1/26 through 2/26/26, with no documentation that the resident refused the splint. However, during multiple observations on 2/23/26, 2/25/26, and 2/26/26, Resident #7 was not wearing the splint, and the blue splint with the resident's name was observed sitting untouched on top of the bedside dresser. During interview, the resident stated staff did not offer or put the splint on in the morning and said they could not put it on or take it off independently because they were unable to move the right arm. The ADON acknowledged the resident had orders for a splint and that nursing staff should offer to put it on daily and document accordingly.
Failure to Orient and Competency-Check New Agency CNAs
Penalty
Summary
The facility failed to ensure that new agency nursing staff received timely orientation and demonstrated competency in the use of facility systems and equipment before being expected to work independently. The report states that agency CNAs were placed on the unit without clear onboarding, were not shown how to use Point Click Care, and were not oriented to the facility’s mechanical lifts or resident-specific information. Multiple staff members, including the DON, ADON, LPN, MDS Coordinator, and scheduler, described uncertainty about who was responsible for agency orientation and what training, if any, was provided. Resident #2 had diagnoses including weakness and unsteadiness on feet, required assistance with ambulation and hygiene, and had a care plan directing staff to assist with transfers and ambulation using a gait belt and front wheeled walker. After a bathroom incident, the resident reported that she had waited for assistance, told the CNA she was slipping, and was reassured that she would not fall. The resident stated the CNA did not use a gait belt and that another new agency CNA also assisted. The resident slid down and became stuck between the toilet and wheelchair, then required help from multiple caregivers to get back to bed. The NP documented that the resident sustained an acute ankle fracture after the fall and was transported to the hospital, where she received pain medication and additional x-rays. During interviews, both agency CNAs stated they were new to the facility, had not been properly oriented, and were left to work on their own with multiple residents and call lights. One CNA stated she did not know how to use the PCC system or the mechanical lifts, and both described the day as chaotic and unsafe. Facility staff also stated they were unaware of any formal training process for agency staff and that the orientation packet was simply signed by agency staff on arrival.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to assure a medication error rate of less than 5%, with 3 errors identified among 42 ordered medications reviewed for an error rate of 7.14%. During observation of medication administration for five residents, errors were observed for 2 residents. For Resident #6, Staff U, RN prepared and administered Esomeprazole, but the February 2026 MAR did not show an order for Esomeprazole and instead listed Zegerid. For Resident #106, Staff U, RN prepared 65 units of Tresiba and Tums chewable tablets, and stated she needed to review the resident’s Lyumjev insulin because the blood glucose reading was 98. The MAR for Resident #106 showed an order for Lyumjev insulin, 5 units subcutaneously one time in the morning every Monday, Wednesday, and Friday for diabetes mellitus, and an order for Calcium Carbonate (Tums) 500 mg, 2 tablets by mouth at bedtime for low calcium. Review of nursing progress notes failed to show follow-up documentation related to the resident’s morning blood glucose level or whether Lyumjev had been administered or held. Staff S, RN, Director of Clinical Education, later confirmed that Lyumjev had not been administered as ordered and that the Tums given in the morning should have been given at bedtime per the physician’s order. The facility administrator stated he could not find a facility policy related to medication administration and that the facility follows standard of care.
Missed insulin and phosphate binder doses
Penalty
Summary
Resident #106, who had end stage kidney disease requiring dialysis on Mondays, Wednesdays, and Fridays, diabetes mellitus, coronary artery disease, and heart failure, was identified as cognitively intact with a BIMS score of 15. The resident’s care plan included interventions for end stage kidney disease and diabetes medications as ordered by the physician. During an observed medication pass, the RN prepared seven medications for the resident and stated she needed to review the resident’s Lyumjev insulin because the blood glucose reading was 98. Review of the February 2026 MAR showed orders for Velphoro 500 mg, 2 tablets by mouth with meals and a noon dose to be sent with the resident on dialysis days, as well as Lyumjev insulin 5 units subcutaneously every morning on Mondays, Wednesdays, and Fridays. The MAR showed the noon Velphoro dose was not given because the resident was out of the facility, and nursing progress notes did not document follow-up related to the morning blood glucose level or whether Lyumjev was administered or held. The Director of Clinical Education later confirmed that Lyumjev had not been administered as ordered and that the Velphoro noon dose had not been sent with the resident to dialysis as ordered.
Inappropriate Candy Given to Residents on Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs when staff offered and gave fun-sized Snickers candy bars to two residents who were on mechanical soft diets. During an observation, a maintenance staff member asked one resident if they wanted another Snickers and then gave the resident a candy bar; the same staff member then offered a Snickers to a second resident, who accepted it. Both residents were observed receiving the candy despite being on altered-texture diets. Review of the EHR showed both residents were ordered mechanical soft diets. One resident had diagnoses including dysphagia, dementia, and stroke, and the other had diagnoses including dementia and dysphagia; both had BIMS scores of 4, indicating severe cognitive impairment. The maintenance staff member acknowledged giving the candy bars and stated they were not aware the residents were on specialized diets, and also noted they had seen other staff give these residents candy before, including Snickers. The Dietary Manager stated that acceptable snack items for residents on specialized diets were kept at each nursing station, and the RD stated that Snickers would not be allowed on a mechanical soft diet because they are too sticky and the nuts would be difficult to chew.
Unsafe Food Handling During Breakfast Assistance
Penalty
Summary
The facility failed to apply appropriate food handling practices when assisting residents to eat during breakfast for 2 of 4 residents observed. During a continuous breakfast observation, a CNA reached over a table to assist a resident pick up food from a plate, using a fork and the staff member’s bare hand to place toast in the resident’s hand. In another instance, the same CNA folded a piece of toast and gave it to another resident using bare hands. In both instances, hand hygiene was not performed before handling the toast. A box of gloves was observed in the dining room next to the table where the CNA was assisting residents. During interview, the Corporate Regional Nurse acknowledged staff should not handle resident food with bare hands. The facility’s Food Handling policy, revised 10/2023, states employees perform hand hygiene prior to handling food, ready-to-eat food must not be touched with bare hands, and disposable gloves, tongs, or other dispensing devices must be used properly in accordance with safe food handling practices.
Repeated Infection Control Deficiency
Penalty
Summary
The facility failed to ensure an effective process to address previously identified quality deficiencies, resulting in an Infection Prevention & Control deficiency for the fifth consecutive recertification survey. The CASPER Report indicated that the facility had received this deficiency in August 2019, December 2021, March 2023, and December 2023. At the conclusion of the recertification survey on February 20, 2025, the facility was again found to be non-compliant in this area. The facility's QAPI Plan, dated June 23, 2024, included a monitoring process with multiple data sources but did not identify a process to address previously identified quality deficiencies. The Administrator stated that the facility had provided staff education on enhanced barrier precautions, conducted staff audits on peri care, and offered one-on-one education on infection control issues as needed.
Deficiencies in Personalized Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, as required by the 2024 Resident Assessment Instrument (RAI) Manual and facility policy. For Resident #22, the care plan did not specify personalized non-pharmacological interventions for managing anxiety and depression, nor did it detail the target behaviors or potential side effects of the psychotropic medications prescribed. Similarly, Resident #86's care plan lacked personalization in non-pharmacological interventions and failed to identify specific target behaviors for monitoring. Resident #7's care plan did not include specific target behaviors associated with the use of antipsychotic medication, nor did it provide non-pharmacological interventions for staff to attempt if behaviors were observed. Staff interviews revealed a lack of awareness of the resident's target behaviors, indicating a gap in communication and documentation. Resident #25's care plan also lacked interventions for monitoring psychotropic targeted behaviors and did not personalize interventions for acute expressions of behavior. For Resident #87, the care plan required staff assistance of two for bed mobility, but staff interviews indicated that care was being provided by a single staff member, contrary to the care plan. This inconsistency suggests a lack of adherence to the care plan and potential risk to the resident. Overall, the facility's failure to personalize and implement comprehensive care plans for these residents highlights deficiencies in care planning and monitoring processes.
Deficiency in Puree Diet Serving Sizes and Food Temperature Monitoring
Penalty
Summary
The facility failed to provide appropriate side dish serving sizes for residents on puree diets and did not obtain final cooking temperatures for resident meal items. During an observation, a cook prepared puree pea servings for residents on a puree diet, using a #12 scoop size to determine the portion. However, there was no communication to other kitchen staff regarding the appropriate serving size, leading to another cook providing only one scoop instead of the required two scoops for the puree diets. This lack of communication resulted in residents not receiving the correct portion sizes as per the facility's policy. Additionally, during the lunch service, a kitchen staff member prepared a frozen individual serving of macaroni and cheese and instant potatoes without obtaining the final cooking temperatures before plating them for resident trays. The Certified Dietary Manager acknowledged the oversight and stated that the expectation was for kitchen staff to ensure food temperatures reach 165 degrees Fahrenheit before serving. The facility's policy requires that food temperatures be taken and documented to ensure proper serving temperatures, which was not adhered to in this instance.
Resident Participation in Care Planning Not Ensured
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in the development and implementation of their person-centered plan of care. Specifically, Resident #9, who has intact cognition as indicated by a BIMS score of 15 out of 15, did not recall attending any recent care conference meetings or meetings to discuss concerns or changes. The resident, who has diagnoses of anemia, arthritis, and vision deficits, reported attending resident council meetings but not any recent care discussions. The last documented participation of the resident in a team meeting was on 10/29/24, where the resident expressed concerns about new insurance. Interviews with facility staff confirmed that the resident had not been involved in a formal care conference since the last annual updates were completed in December 2024. The Social Worker acknowledged that the last care conference the resident participated in was in October 2024, and the RN confirmed that while the required MDS assessments and care plan updates were completed, a formal meeting with the resident did not occur. The facility's Administrator acknowledged the need for process improvements to ensure residents have the option to participate in their care planning.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to accurately reflect the status of three residents in their Minimum Data Set (MDS) assessments, as identified through clinical record review and staff interviews. Resident #83's Pre Admission Screening and Resident Review (PASRR) indicated a requirement for Level II services due to a diagnosis of Major Depressive Disorder, but the MDS dated 11/21/24 did not document this requirement. Similarly, Resident #95's PASRR identified a need for Level II services due to Schizoaffective disorder, but the MDS dated 1/20/25 failed to document this. These discrepancies suggest a failure to follow the 2024 Resident Assessment Instrument (RAI) Manual's guidelines for accurately coding PASRR Level II conditions. Additionally, Resident #86's records showed inconsistencies regarding hospice care documentation. The resident was initially enrolled in hospice care on 5/1/24, discharged on 10/6/24 due to hospital admission, and re-enrolled on 10/9/24. However, the Quarterly MDS dated 11/6/24 did not reflect the resident's hospice status during the lookback period. The MDS Coordinator acknowledged the oversight in Resident #83's assessment, attributing it to a change in PASRR status and a different employee completing the assessment. The facility lacks a specific policy for MDS completion, relying instead on the RAI manual guidelines.
Failure to Implement Timely Baseline Care Plan
Penalty
Summary
The facility failed to implement a complete Baseline Care Plan within 48 hours of admission for a resident, as required by their policy. The resident, who had an intact cognition as indicated by a BIMS score of 14, reported not having seen his care plan and expressed a need for assistance with discharge planning, meals, and laundry. The facility's process involved creating a baseline care plan from the User-Defined Assessment (UDA) for admission, which was integrated into the Electronic Health Record. However, the baseline care plan did not include the resident's initial goals, therapy services, or additional physician orders beyond psychotropic and diuretic medications. The Comprehensive Care Plan, which was supposed to be developed within 48 hours, was delayed and only included discharge planning and additional cardiac medications after the deadline. Furthermore, a Care Conference was held with the resident and a nursing staff member, but a copy of the care plan was not offered to the resident. The facility's policy, revised in July 2023, mandates that the baseline care plan should minimally include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not adhered to in this case.
Failure to Assist Hospice Resident with Eating
Penalty
Summary
The facility failed to provide necessary eating assistance to a hospice resident with severely impaired cognition and multiple health conditions, including congestive heart failure, coronary artery disease, diabetes mellitus, and chronic respiratory failure. The resident, who was unable to feed himself, was observed with an uncovered lunch tray set up on his bedside table while he was asleep in an upright position. Despite being identified as needing assistance, the resident was left unattended with his meal for 40 minutes. Staff interactions included a CNA and an LPN, who eventually assisted the resident with drinking and attempted to feed him, but the food was not reheated until prompted by a state surveyor. The resident's care plan indicated the need for set-up assistance with eating, and the hospice care plan directed the hospice aide to assist with meals. However, the facility did not have a specific policy for assisting residents with eating. The Director of Nursing acknowledged that the tray should not have been left in the resident's room and should have been reheated when the resident was ready to eat. The resident eventually ate about 50% of his lunch after the food was reheated.
Failure to Implement Restorative Program for Residents
Penalty
Summary
The facility failed to implement and maintain a Restorative Program for three residents who required assistance with their Activities of Daily Living (ADL). Resident #22, with intact cognition, required supervision for various ADLs but did not receive any Restorative Nursing services. The resident expressed a desire for more individualized exercise, particularly for leg exercises, which were not provided. The Care Plan for Resident #22 did not document any restorative nursing programs, despite the resident being at risk for pain and falls due to limited mobility. Resident #74 was dependent on staff for several ADLs and required substantial assistance for others, yet did not receive Restorative Nursing services. The Care Plan noted the resident's risk of falls and need for a mechanical lift but lacked any restorative programs. Similarly, Resident #86 had functional limitations in range of motion and required substantial assistance for multiple ADLs. The Care Plan identified risks related to limited mobility but did not include restorative programs. The facility administrator acknowledged the absence of restorative programs and stated that the therapy department was not writing any programs at the time, with plans for future implementation.
Failure to Follow Protocols for Gastric Tube Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident requiring medications via a gastric tube. The resident, who had a feeding tube due to dysphagia, was observed during a medication administration process where the registered nurse did not use a table barrier for the medication cups and supplies, did not check the tube placement, and did not follow Enhanced Barrier Precautions (EBP) by wearing a gown and gloves. The care plan for the resident directed staff to check gastric-tube placement prior to feeding and to follow EBP to minimize the risk of transmission during high-contact care activities. During the observation, the registered nurse placed the medication supplies on the bedside table without a barrier, leading to water spillage. The nurse also failed to check the tube placement or residual as per the physician's orders documented in the Medication Administration Record (MAR). The facility's policy on medication administration via enteral tubes required verification of tube placement, checking residuals, and flushing the tube with a minimum of 30 milliliters of water. The Infection Control RN confirmed the failure to follow EBP and the lack of a barrier for supplies, acknowledging the need for education to improve the process.
Failure to Manage Oxygen Use for a Resident
Penalty
Summary
The facility failed to manage oxygen use for a resident, as evidenced by the lack of proper documentation and adherence to physician orders. The resident, who had intact cognition and multiple diagnoses including coronary artery disease and heart failure, was prescribed oxygen therapy at 2 liters per nasal cannula at bedtime. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February did not include this order, indicating a failure in transcription and documentation. The resident reported using oxygen at all times while in the room and expressed confusion about the need for oxygen outside the room. Observations confirmed the resident was using oxygen at 2 liters per nasal cannula both day and night. The Director of Nursing and the Administrator acknowledged the oversight in transcription and agreed that staff and the resident should be educated about the physician's orders. The facility's policy on transcription of physician orders was not followed, contributing to the deficiency.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for a resident diagnosed with non-Alzheimer's dementia, depression, psychotic disorder, and PTSD. The resident received antipsychotic and antidepressant medications, including Sertraline and Olanzapine, without any attempt to reduce the dosage over a nine-month period. The prescribing provider deemed the medication regimen appropriate and consistent with the diagnosis, stating the resident was stable at the optimal dose. However, the facility did not attempt a trial of a lower dose to determine if the resident could maintain stability on a reduced dosage. The Consultant Pharmacist acknowledged an oversight in not recommending a GDR for the resident's Olanzapine, which should have been suggested twice within the first year of admission. The Director of Nursing (DON) mentioned that the resident's family had not previously voiced concerns about medication dosage reductions, despite a past incident where lowering dosages was unsuccessful. The facility's policy on Medication Regimen Review requires consideration for dose reduction and optimal dosing, which was not adhered to in this case.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling practices were followed while assisting a resident to eat. During lunch, a Certified Nursing Assistant (CNA) was observed using their bare hand to give a resident a sandwich and hash brown patty, despite eating utensils being available on the resident's plate. The CNA also used a paper towel, which they had previously used to dry their hands, to assist the resident throughout the meal. This action was contrary to the facility's policy, which requires the use of gloves, tongs, or other dispensing devices to handle ready-to-eat food. The resident involved was severely impaired in daily decision-making and had multiple diagnoses, including adult failure to thrive, depression, epilepsy, and hydrocephalus. The resident also had severe vision impairment and moderate hearing difficulties, requiring supervision or touching assistance when eating. The Director of Nursing (DON) stated that staff should complete hand hygiene before and after meal assistance and use a barrier, such as gloves or utensils, to hand food to residents. The DON also emphasized the importance of separating dirty items, like a used paper towel, from clean areas, such as a meal place setting.
Inadequate Infection Control Practices for Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a history of chronic kidney disease, heart failure, obstructive uropathy, diabetes mellitus, and quadriplegia, was observed with an indwelling catheter and had experienced multiple UTIs in the past. The care plan for the resident included specific instructions for catheter care, which were not adequately followed by the staff. During an observation, two staff members, a Certified Nurse Aide (CNA) and a Certified Medication Aide (CMA), performed catheter and perineal care for the resident. They failed to perform hand hygiene at critical points, such as after touching potentially contaminated surfaces and before handling clean supplies. Additionally, the CNA did not clean the catheter tubing or the part of the resident's scrotum that contacted the catheter tubing, which was contrary to the facility's policy for catheter care. The Director of Nursing (DON) and the Infection Preventionist (IP) were present during the observation and acknowledged the lapses in infection control practices. The CNA admitted to not performing hand hygiene between certain tasks and not cleaning the catheter tubing unless there was bowel incontinence, which was incorrect according to the facility's policy. The facility's hand hygiene policy and catheter care policy were not adhered to, contributing to the deficiency in infection prevention and control.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to uphold the dignity of a resident during personal care activities. A Certified Nursing Assistant (CNA) was observed assisting a resident with personal care without providing a barrier on the bed's blanket, resulting in flakes of dried cream landing on the blanket. The resident, who had intact cognition and required assistance with activities of daily living due to various medical conditions, was not offered a towel barrier during the care process. After completing the care, the CNA did not change the blanket, leaving the dried cream flakes on it. The Assistant Director of Nursing (ADON) acknowledged the oversight, noting that a barrier should have been provided and the blanket should have been changed after the care was completed. The facility's policy on Resident Rights-Dignity and Respect emphasizes treating residents with dignity and respect, which was not adhered to in this instance. The incident involved a resident with multiple medical diagnoses, including heart failure and morbid obesity, who required partial to moderate assistance for personal care.
Failure to Notify Physician of Treatment Change for Resident with Cirrhosis
Penalty
Summary
The facility failed to notify the physician of a needed change in treatment for a resident diagnosed with cirrhosis and failure to thrive. The resident was prescribed Lactulose, a laxative, to be administered four times a day to help manage cirrhosis by removing toxins from the blood. However, the resident's bowel movement record indicated only one bowel movement over a four-day period, from July 12 to July 15, 2024. Despite this, there was no communication with a medical prescriber regarding the lack of bowel movements until the fourth day. On July 16, 2024, the resident was sent to the emergency room due to increased confusion, slow processing of information, and hallucinations. The hospital discharge summary noted the resident was admitted for acute metabolic encephalopathy secondary to hepatic encephalopathy, with an abdominal x-ray revealing a large amount of colonic stool and a distended gastrointestinal tract. The facility's Director of Nursing stated there was no standardized bowel protocol, and each resident had an individualized protocol. The facility's policy required immediate notification of the physician when there was a need to alter treatment significantly, which was not adhered to in this case.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for a resident with a stage 3 pressure injury on the right heel. The resident, who had intact cognition and diagnoses including heart failure, diabetes, and morbid obesity, was supposed to receive daily wound care treatments. However, there were multiple instances where documentation of the wound care was missing, specifically on 6/7/24, 6/26/24, 6/29/24, 8/7/24, 8/21/24, 9/11/24, 9/14/24, and 10/30/24. The resident confirmed that he did not refuse or decline the wound care treatments. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that they were aware of the lack of documentation for the wound care treatments. They acknowledged that a combination of agency staff and permanent facility staff were working on the dates in question, but neither could verify if the treatments were completed. The facility's policy required that active orders be followed and carried out as written, but this was not adhered to in the case of the resident's wound care.
Infection Control Lapses in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control practices during urinary catheter care for two residents. Resident #8, who has intact cognition and multiple diagnoses including heart failure and renal failure, was observed receiving catheter care from a CNA. The CNA did not change gloves after touching potentially contaminated surfaces such as the resident's shoes and bed blankets before handling the catheter. Additionally, the CNA did not change the resident's incontinence brief after completing the care. The Assistant Director of Nursing (ADON) acknowledged these lapses in infection control practices. Resident #5, also with intact cognition and similar medical conditions, was observed during a catheter care procedure where the CNA did not wear a gown, despite the presence of an Enhanced Barrier Protection (EBP) sign indicating the need for such precautions. The CNA cited the absence of gowns in the bathroom as the reason for not wearing one. The ADON confirmed the requirement for gown use during high-contact care activities, as outlined in the facility's policy on Enhanced Barrier Precautions.
Failure to Provide Privacy During Perineal Care
Penalty
Summary
The facility failed to provide privacy for a resident during perineal care, which is a violation of the resident's right to dignity and respect. During an observation, two Certified Nursing Assistants (CNAs) were seen transferring a resident from a wheelchair to her bed using a lift device. The CNAs then proceeded to provide perineal care without closing the shade or curtains of the resident's window, which faced a busy street. This lack of privacy exposed the resident to public view, compromising her dignity. The resident involved required total assistance for personal hygiene, lower body dressing, and toileting hygiene, as documented in the Quarterly Minimum Data Set (MDS). The MDS also noted that the resident was always incontinent of bowel and bladder. The facility's policy on Resident's Rights emphasizes the importance of treating residents with dignity and respect, which was not adhered to in this instance.
Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to properly provide perineal care for one resident, identified as Resident #9, who was observed to have several medical conditions including Benign Prostatic Hyperplasia, Aphasia, Cerebrovascular Accident, and Non-Alzheimer's Dementia. The resident had a severely impaired cognitive status with a BIMS score of 7 out of 15 and was frequently incontinent of bowel and bladder, requiring staff assistance for toileting hygiene. During an observation, two CNAs, Staff A and Staff B, were seen providing perineal care to the resident. Staff A cleaned the anterior perineal area but failed to cleanse the resident's buttocks or hips after cleaning the mid gluteal region, despite the presence of stool. This action was contrary to the facility's Incontinent Care policy, which requires cleansing from the perineum toward the rectum and turning the resident to cleanse all affected areas.
Infection Control Breach During Resident Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols during personal care for two residents. Resident #9, who has severe cognitive impairment and is frequently incontinent, was observed receiving care from two CNAs. During the care, one CNA did not change gloves after providing initial care and before repositioning the resident and cleansing the gluteal region, which involved contact with stool. The CNA only changed gloves after removing the soiled brief, which is contrary to the facility's policy that requires glove removal and hand hygiene before changing gloves. Similarly, Resident #10, who also has severe cognitive impairment and is always incontinent, was observed receiving care from two CNAs. One CNA failed to change gloves after cleansing the resident's anterior perineal area and before proceeding to cleanse the gluteal region and apply barrier cream. The CNA continued to use the same gloves to handle the resident's clothing and bedding, and to access items from the bedside stand. This practice was inconsistent with the facility's policy, which mandates glove removal and hand hygiene before donning new gloves during the care process.
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What surveyors actually found near you
We read the 418 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 3.3 mi | ★★★★★ | 9 | 0 |
| Edgewater, A Wesleylife Community | 3.4 mi | ★★★★★ | 4 | 0 |
| Arbor Springs Of West Des Moines L L C | 3.6 mi | ★★★★★ | 2 | 0 |
| Pine Acres Rehabilitation And Care Center | 4 mi | — | 23 | 0 |
| Walnut Ridge | 4.4 mi | ★★★★★ | 0 | 0 |
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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.