Inspection Reports for
Addington Place of Des Moines
5815 SE 27th St, Des Moines, IA 50320, United States, IA, 50320
Back to Facility Profile10 Reports
Inspection Report — Mar 23, 2026
Complaint Investigation
Date: Mar 23, 2026
Visit Reason
The visit was conducted to investigate Incident #143085-I involving a tenant elopement.
Complaint Details
Incident #143085-I
Findings
The program failed to follow established policy and procedure regarding Missing Persons Elopement for one tenant who eloped from the program. The investigation revealed staff did not properly respond to door alarms or check the area as required by policy.
Violations (1)
481-67.2(2) Program Policies and Procedures: The program failed to follow established policy and procedure regarding Missing Persons Elopement for one tenant who eloped. Staff did not promptly respond to door alarms or check the area as required by policy.
Inspection Report — Mar 18, 2026
Enforcement
Date: Mar 18, 2026
Visit Reason
Investigation #131735-I was conducted due to an elopement incident involving Tenant #1 who exited the memory care unit without supervision.
Findings
The program failed to follow established Missing Persons Elopement policies and procedures, resulting in Tenant #1 eloping and being unsupervised outside in unsafe weather conditions. Staff A did not respond promptly or properly to the door alarm as required by policy.
Violations (1)
481-67.2(2) The program failed to follow established policies and procedures regarding Missing Persons Elopement. Staff A did not investigate the door alarm or check for tenants, resulting in Tenant #1 eloping and being unsupervised outside in unsafe conditions.
Report Facts
Fine amount: 3000
Inspection Report — Dec 3, 2025
Date: Dec 3, 2025
Visit Reason
Investigation of Incident #130791-I.
Complaint Details
Incident #130791-I
Findings
No regulatory insufficiencies were cited during the investigation.
Inspection Report — Oct 8, 2025
Complaint Investigation
Date: Oct 8, 2025
Visit Reason
The inspection was conducted to investigate multiple complaints numbered #129942-C, #130073-C, #130252-C, #130297-C, and #130472-C at the assisted living facility.
Complaint Details
Investigation of Complaints #129942-C, #130073-C, #130252-C, #130297-C, and #130472-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Inspection Report — May 12, 2025
Complaint Investigation
Date: May 12, 2025
Visit Reason
The inspection was conducted to investigate complaints #124780-C, #125128-C, and #127223-C related to the assisted living program for people with dementia.
Complaint Details
The investigation involved complaints #124780-C, #125128-C, and #127223-C. No regulatory insufficiencies were found for the first two complaints. Deficiencies were cited during the investigation of complaint #127223-C.
Findings
No deficiencies were found for complaints #124780-C and #125128-C. Deficiencies were cited for complaint #127223-C involving failure to complete tenant evaluations after significant change, failure to update service plans for significant weight loss, failure to have service plans signed and dated by all parties, and failure to provide required dementia-specific education within 30 days of employment for staff.
Violations (4)
Failed to complete evaluations of tenants due to significant change for 1 of 6 tenants reviewed (Tenant 3).
Failed to ensure the service plan was updated to address needs of 1 of 1 tenants reviewed with significant weight loss (Tenant 3).
Failed to ensure service plans related to significant change were signed and dated by all parties for 1 of 6 tenants reviewed (Tenant 3).
Failed to provide staff the required eight hours of dementia-specific education within 30 days of employment for 3 of 3 staff reviewed (Staff B, Staff C, and Staff D).
Report Facts
Number of tenants with cognitive impairment: 12
Number of tenants without cognitive impairment: 0
Weight loss in Tenant 3: 30
Dementia-specific training hours completed by Staff B within 30 days: 6
Dementia-specific training hours completed by Staff C within 30 days: 7
Dementia-specific training hours completed by Staff D within 30 days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to complete required eight hours of dementia-specific education within 30 days of employment | |
| Staff C | Failed to complete required eight hours of dementia-specific education within 30 days of employment | |
| Staff D | Failed to complete required eight hours of dementia-specific education within 30 days of employment |
Inspection Report — Aug 7, 2024
Renewal
Date: Aug 7, 2024
Visit Reason
The visit was conducted as a recertification inspection to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #119849-C.
Findings
The inspection found no regulatory insufficiencies related to the complaint investigation. However, deficiencies were cited for failure to consistently perform required criminal history and abuse background checks prior to employment for 2 of 4 staff reviewed, and failure to update a tenant's service plan within 30 days of occupancy.
Violations (2)
Failed to consistently perform criminal history and abuse background checks as required prior to employment for 2 of 4 staff reviewed (Staff A and B).
Failed to consistently update service plans within 30 days of occupancy for 1 of 1 tenant who became an occupant within the previous 90 days (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 8
Staff reviewed for background checks: 4
Staff with deficient background checks: 2
Tenant service plan update timeframe: 30
Inspection Report — May 3, 2023
Complaint Investigation
Date: May 3, 2023
Visit Reason
The inspection was conducted to investigate regulatory insufficiencies related to incidents #110136-C and #112424-I, focusing on staff training, service plans, and dementia-specific education compliance.
Complaint Details
The inspection was triggered by complaints related to incidents #110136-C and #112424-I. No regulatory insufficiencies were cited for incident #110136-C, but deficiencies were found related to incident #112424-I.
Findings
The program failed to consistently ensure staff were trained/delegated within 30 days of employment, complete dependent adult abuse training within six months, update service plans to meet tenant needs, and provide required dementia-specific education and continuing education to staff.
Violations (5)
Program failed to consistently ensure staff were trained/delegated within 30 days of employment.
Program failed to ensure staff completed dependent adult abuse training within six months of employment.
Program failed to consistently update service plans to meet tenant needs.
Program failed to ensure staff received eight hours of dementia-specific training within 30 days of employment.
Program failed to ensure all staff received eight hours of dementia-specific continuing education annually.
Report Facts
Number of tenants with cognitive impairment: 8
Staff training deadlines: 30
Dependent adult abuse training timeframe: 180
Dementia-specific education hours: 8
Dementia-specific continuing education hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to nurse delegation training and dementia-specific education deficiencies | |
| Staff B | Named in findings related to dependent adult abuse training deficiency and no longer employed as of 04/30/2023 | |
| Staff C | Named in findings related to dementia-specific continuing education deficiency | |
| Staff D | Named in findings related to dementia-specific continuing education deficiency |
Inspection Report — Aug 3, 2022
Complaint Investigation
Date: Aug 3, 2022
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program for People with Dementia. Additionally, complaint investigations #100899-C, 103358-C, and 106309-C were completed during the visit.
Complaint Details
Complaints #100899-C, 103358-C, and 106309-C were investigated during the recertification visit. The findings included failure to provide adequate care and services, training deficiencies, and lack of proper policies and activities.
Findings
The Program failed to provide adequate and appropriate care for one tenant, failed to ensure food service staff completed required food protection training, failed to provide required dementia-specific education and continuing education for staff, lacked written procedures for alarm systems, and failed to provide consistent and appropriate activities or activity schedules for tenants.
Violations (7)
Failed to provide services which were adequate and appropriate for 1 of 1 former tenants reviewed (Tenant C3), including failure to monitor bowel movements and follow up on medication orders.
Failed to ensure at least one staff responsible for food preparation had successfully completed an approved food protection program.
Failed to ensure all staff received eight hours of dementia-specific education/training within 30 days of employment for 1 of 5 staff reviewed (Assistant Healthcare Coordinator).
Failed to ensure direct contact staff both employed by the program and contracting agency received eight hours of dementia-specific continuing education annually.
Failed to produce written procedures regarding alarm systems.
Failed to consistently provide appropriate activities for all tenants; no Activity Director or activity calendar/schedule was in place.
Failed to develop and make available a monthly written schedule of activities for tenants and their legal representatives.
Report Facts
Tenants without cognitive disorder: 3
Tenants with cognitive disorder: 12
Contract/agency staff without required dementia training: 16
Staff reviewed for dementia-specific education: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selena Edmondson | Director | Signed the Plan of Correction letter |
| Assistant Healthcare Coordinator | Failed to receive eight hours of dementia-specific education/training within 30 days of employment | |
| Healthcare Coordinator | Interviewed regarding failure to monitor tenant bowel movements and training documentation | |
| Acting Director | Confirmed lack of Activity Director and activity schedules | |
| Culinary Coordinator | Certified Food Protection Professional | Hired to assist with direction of food service staff as part of Plan of Correction |
Inspection Report — Jun 9, 2021
Date: Jun 9, 2021
Visit Reason
The inspection was conducted as an on-site infection control survey and investigation of incident 97438-C at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation of incident 97438-C or the on-site infection control survey.
Report Facts
Number of tenants without cognitive disorder: 5
Number of tenants with cognitive disorder: 18
Inspection Report — Dec 9, 2019
Recertification
Date: Dec 9, 2019
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program and included investigation of incident #86752-1 and Complaint #86607-C.
Complaint Details
The visit included investigation of Complaint #86607-C and incident #86752-1. The complaint was substantiated based on findings of medication errors and incomplete background checks.
Findings
The inspection found regulatory insufficiencies related to failure to complete criminal, child, and dependent adult abuse background checks prior to employment for 1 of 8 staff, and failure to ensure staff administered medications correctly to a tenant, resulting in a medication error and subsequent emergency care.
Violations (2)
Program failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 1 of 8 staff reviewed.
Program failed to ensure staff administered medications to the correct individual as prescribed, resulting in a medication error for Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 20
Staff reviewed: 8
Tenant #1 medication error date: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff whose file revealed incomplete background checks and medication error involvement | |
| Staff B | Staff who administered wrong medications to Tenant #1 | |
| Executive Director | Executive Director | Confirmed findings and was involved in background check audit and follow-up |
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