Inspection Report Summary
The most recent inspection on October 9, 2025, found no deficiencies during the recertification visit. Earlier inspections showed a mix of findings, with some deficiencies related to medication administration, staff training, record checks, and safety measures such as exit door alarms in dementia-specific areas. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in 2016 involving medication errors and incomplete documentation. Enforcement actions such as fines or license suspensions were not listed in the available reports. The overall trend indicates improvement, with recent inspections showing compliance after earlier issues were addressed.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
43 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 43
Deficiencies: 0
Date: Oct 9, 2025
Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit, indicating the facility was in compliance with certification rules.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 18
Total census: 43
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
The inspection was conducted to investigate Complaint #118394-C at the assisted living program for people with dementia.
Complaint Details
Complaint #118394-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 15
Total census: 47
Inspection Report
Renewal
Census: 44
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program serving people with dementia.
Complaint Details
The investigation of Complaints ##107881-C, 108710-C, and 108799-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation of three related complaints.
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 18
Total census: 44
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Aug 15, 2022
Visit Reason
The inspection was conducted to complete complaint investigations #102018-C and 106842-C during the on-site visit.
Complaint Details
Complaints #102018-C and 106842-C were investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigations.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 15
Total census: 42
Inspection Report
Renewal
Census: 41
Deficiencies: 1
Date: Jun 2, 2021
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including an onsite infection control survey.
Findings
The program failed to consistently perform record check evaluations prior to employment, affecting 1 of 4 staff reviewed. The deficiency involved failure to complete the Department of Human Services record check evaluation despite evidence of criminal history.
Deficiencies (1)
Program failed to consistently perform record check evaluations prior to employment for staff with criminal history.
Report Facts
Number of tenants without cognitive disorder (General Population): 26
Number of tenants with cognitive disorder (General Population): 4
Number of tenants without cognitive disorder (Memory Care Unit): 0
Number of tenants with cognitive disorder (Memory Care Unit): 11
Total Census of Assisted Living Program for People with Dementia: 41
Staff affected by record check deficiency: 1
Total staff reviewed: 4
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Oct 15, 2018
Visit Reason
Investigation of Incident #78311 at the assisted living program.
Complaint Details
Investigation of Incident #78311 found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #78311.
Report Facts
Number of tenants without cognitive disorder in General Population program: 42
Number of tenants with cognitive disorder in General Population program: 2
Total population of General Population program: 44
Number of tenants without cognitive disorder in Dementia-Specific Program: 4
Number of tenants with cognitive disorder in Dementia-Specific Program: 5
Total population of Dementia-Specific Program: 9
Total census of Assisted Living Program: 53
Inspection Report
Renewal
Census: 41
Deficiencies: 2
Date: Apr 18, 2018
Visit Reason
The recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection found regulatory insufficiencies related to medication administration, specifically inconsistent administration of sliding scale insulin for a tenant, and failure to ensure completion of dementia-specific education for staff within 30 days of employment.
Deficiencies (2)
Program failed to consistently ensure sliding scale insulin administered as ordered by the physician for Tenant #3.
Program failed to ensure completion of eight hours of dementia-specific education and training within 30 days of employment for 7 of 7 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 21
Total census of Assisted Living Program for People with Dementia: 41
Number of staff not completing dementia-specific education within 30 days: 7
Number of blood glucose monitoring times per day: 4
Units of Novolog Flexpen insulin per sliding scale dose: 100
Entries with incorrect dose of Novolog insulin documented: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Responsible for oversight of timely completion of dementia education for new hires; revealed eight hours of dementia-specific training was not completed for staff reviewed. | |
| RN | Program RN | Conducted in-service training on medication administration for staff. |
| Staff A | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff B | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff C | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff D | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff E | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff F | One of the seven staff who did not complete dementia-specific education within 30 days of employment. | |
| Staff G | One of the seven staff who did not complete dementia-specific education within 30 days of employment. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 5
Date: May 3, 2016
Visit Reason
The inspection was conducted as a Final Recertification and Complaint/Incident Investigation for the assisted living program at 3801 Grand, Des Moines, IA, triggered by a complaint intake #59692-I involving tenant safety and regulatory compliance.
Complaint Details
Complaint intake #59692-I involved an 85-year-old tenant with dementia who eloped from the memory care unit through an unalarmed exit door and courtyard gate. The tenant was missing for approximately two hours before being found at a medical center after a fall. The program failed to ensure hourly checks and alarm functionality as directed in the service plan.
Findings
The inspection found multiple regulatory insufficiencies including failure to ensure tenant rights, incomplete record checks, inadequate evaluation of tenants, failure to meet criteria for admission/retention of tenants, and life safety deficiencies related to alarm systems. Specific incidents included an 85-year-old tenant eloping through an unalarmed exit door and medication administration issues.
Deficiencies (5)
Tenant rights not met; tenants did not receive adequate care, treatment, and services as directed by service plans affecting 2 of 6 tenants reviewed.
Failure to complete criminal, dependent adult abuse, and child abuse record checks prior to employment for one staff member.
Failure to complete evaluations of tenant's functional, cognitive, and health status within required timeframes.
Failure to discharge a tenant who exceeded criteria for admission and retention.
Life safety deficiency: Operating alarm system not connected to each exit door in dementia-specific program.
Report Facts
Total census: 60
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 8
Civil penalty amount: 3000
Reduced civil penalty amount: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for the Department of Inspections and Appeals regarding the inspection and penalty |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter for civil penalty |
| Debbie L. Fisher | Chief Operating Officer | Signed the Plan of Correction response letter |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jan 7, 2016
Visit Reason
The inspection was conducted following complaints and incidents reported (Complaint/Incident Intake #56269-I and 57085-C) involving tenant safety and medication administration at 3801 Grand, Des Moines, Iowa.
Complaint Details
Complaint 57085-C was substantiated with findings of medication errors and incomplete tenant documentation. Incident 56269-I related to elopement was investigated and found to have no regulatory insufficiencies.
Findings
The investigation found regulatory insufficiencies related to program policies and procedures, medications, and tenant documents. Specifically, medication errors were identified due to lack of proper policies and failure to administer medications as ordered to tenants. No regulatory insufficiencies were found related to the elopement incident.
Deficiencies (3)
Program policies and procedures did not include direction for staff regarding identification and reporting of medication errors.
Medications were not administered as ordered to tenants, with multiple instances of medication not available or not given.
Tenant documents, including incident reports related to medication errors, were incomplete or not maintained.
Report Facts
Census: 56
Tenants without cognitive disorder: 45
Tenants with cognitive disorder: 1
Tenants without cognitive disorder: 5
Tenants with cognitive disorder: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter accompanying the Final Complaint/Incident Investigation Report |
| Director of Nursing | Confirmed lack of medication error policy and medication administration issues during interview on 1-7-16 |
Inspection Report
Monitoring
Census: 53
Deficiencies: 0
Date: Dec 9, 2014
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to determine compliance with certification for the Assisted Living Program at 3801 Grand Assisted Living, Des Moines, IA.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 42
Number of tenants with cognitive disorder in General Population Program: 2
Total population of General Population Program: 44
Number of tenants without cognitive disorder in Dementia-Specific Program: 4
Number of tenants with cognitive disorder in Dementia-Specific Program: 5
Total population of Dementia-Specific Program: 9
Total census of Assisted Living Program: 53
Inspection Report
Monitoring
Census: 46
Deficiencies: 7
Date: Mar 20, 2012
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals to review the Assisted Living Program's compliance and Plan of Correction following a Preliminary Recertification Monitoring Evaluation Report.
Findings
The program was dementia-specific by definition for two consecutive certification periods with some regulatory insufficiencies noted, including incomplete health evaluations, medication administration issues, and exit door alarm deficiencies. The program's Plan of Correction was accepted by DIA, and the Assisted Living Program Certificate was issued with effective dates from June 1, 2012 through May 31, 2014.
Deficiencies (7)
Health evaluation form did not document Tenant #2's respiratory rate or lung status following pneumonia hospitalization.
Functional, cognitive, and health evaluations were not completed after 2-22-12 for Tenant #3 despite multiple falls and a change of condition.
Service plan did not include identified needs of Tenant #3 and Tenant #4, including individualized assistance and fall interventions.
Medication administration was not consistently provided by licensed nurses and medication was not given as ordered for Tenant #2.
Exit doors were not alarmed during the onsite visit despite requirements for dementia-specific assisted living programs.
An unattended cleaning cart containing hazardous materials was left in the hallway, creating a potential hazard.
Buildings and grounds were not well-maintained, clean, safe, and sanitary as required.
Report Facts
Total census: 46
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 6
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Total population: 36
Total population: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Pierce | Administrator | Administrator of 3801 Grand Assisted Living named in report |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Hal Chase | RN BSN MPH | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Signed letter transmitting the report |
| Staff #1 | Observed administering medication during monitoring | |
| Staff #2 | Interviewed staff regarding Tenant #4 | |
| Staff #3 | Interviewed staff regarding Tenant #4 |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Aug 17, 2011
Visit Reason
The inspection was conducted as a complaint investigation following allegations that Tenant #1 had sores, needed assistance with repositioning, and was not fed enough by staff.
Complaint Details
The complaint alleged that Tenant #1 had sores on buttocks, needed assistance out of bed and repositioning to prevent bed sores, and was often hungry due to insufficient feeding by staff. The investigation found no regulatory insufficiencies and no evidence of open sores or neglect.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 was evaluated and monitored, with no open sores or need for repositioning noted. Staff and nurse notes indicated appropriate care and no deficiencies.
Report Facts
Current number of tenants in Dementia Specific Program: 16
Current number of tenants without cognitive disorder: 34
Total Census of Assisted Living Program: 50
Tenant age: 103
Admission date: Oct 25, 2010
Cognitive evaluation date: Apr 4, 2011
Nurse notes date: Apr 1, 2011
Nurse notes date: Apr 11, 2011
Nurse notes date: Jul 26, 2011
Nurse review date: Jul 21, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 48
Deficiencies: 0
Date: Jul 7, 2010
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with Iowa Administrative Code chapters governing assisted living programs.
Findings
No regulatory insufficiencies were found during the evaluation. The program was accepted, and the State Fire Marshal's inspection and evacuation plans were approved.
Report Facts
Current number of tenants without cognitive disorder: 10
Current number of tenants with cognitive disorder: 29
Total Population of General Population Program: 39
Total Population of Dementia Specific Program: 9
Total Census of Assisted Living Program: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the Final Recertification Monitoring Evaluation |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Nov 18, 2008
Visit Reason
A complaint investigation was conducted at 3801 Grand Assisted Living on November 18, 2008, in response to allegations regarding tenant behaviors and staff practices.
Complaint Details
The complaint alleged that Tenant 1 wandered into other tenants' rooms and was combative; Tenant 2 often got lost and exited through an unalarmed door; Tenant 3 fell often requiring two staff to lift; Tenant 4 required two-person transfers and staff lacked gait belts for assistance. Monitoring observations did not substantiate these allegations, and no regulatory insufficiencies were found.
Findings
The investigation found no regulatory insufficiencies. Observations addressed tenant wandering, falls, transfer assistance needs, and staff use of gait belts. Staff and documentation supported that tenants' needs were met according to regulations, and no violations were identified.
Report Facts
Current number of tenants with dementia or cognitive disorder: 16
Current number of tenants without cognitive disorder: 35
Total population: 51
Complaint Intake Number: 20713
Number of falls reported for Tenant 3: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting complaint investigation |
| Connie Schaffer | Certification Coordinator - Central Iowa | Signed cover letter for complaint investigation report |
Inspection Report
Monitoring
Census: 56
Deficiencies: 1
Date: May 14, 2008
Visit Reason
An on-site monitoring evaluation was conducted at 3801 Grand Assisted Living to assess compliance with assisted living program regulations as part of the recertification process.
Findings
The program had no substantiated regulatory insufficiencies during the certification period except for a regulatory insufficiency related to individualized service plans not including outside service providers such as physical therapy. A plan of correction was submitted to address this issue.
Deficiencies (1)
The program did not individualize the service plan and indicate, at a minimum, the service provider(s) if other than the program.
Report Facts
Tenants without cognitive disorder: 43
Tenants with cognitive disorder: 13
Total population: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sherod | Administrator | Administrator named in relation to the facility and plan of correction oversight |
| Lincoln Newsom | RN | Monitor conducting the on-site evaluation |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Feb 21, 2007
Visit Reason
A complaint investigation on-site visit was conducted at 3801 Grand on February 21, 2007, to investigate allegations related to medication administration and staff conduct.
Complaint Details
The complaint alleged that Tenant #1 was given a medication for months after it was discontinued, and that a staff person came to work drunk, drank at work, watched TV instead of working, burned food, and did not get meals out on time. The complaint was not substantiated.
Findings
The investigation found no regulatory insufficiencies regarding medication administration or food service. The medication in question was administered only during the period with a valid order, and the staff alcohol-related issue was addressed with disciplinary action. Food service quality and timeliness problems were reported to have been resolved with positive tenant feedback.
Report Facts
Current number of tenants without cognitive disorder: 41
Current number of tenants with cognitive disorder: 12
Total Population: 53
Inspection Report
Monitoring
Census: 42
Deficiencies: 0
Date: Mar 24, 2006
Visit Reason
An on-site monitoring evaluation was conducted to assess compliance with assisted living program regulations and to evaluate tenant satisfaction and complaint history.
Complaint Details
There were substantiated complaints in the areas of medication and nurse review during this certification period.
Findings
No regulatory insufficiencies were found during this monitoring evaluation. Tenant feedback was positive, highlighting staff professionalism and program support for autonomy. There were substantiated complaints related to medication and nurse review during the certification period.
Report Facts
Current number of tenants without cognitive disorder: 41
Current number of tenants with cognitive disorder: 1
Total Population: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ann Martin | RN | Monitor conducting the evaluation |
| Jan O’Briant | LISW | Monitor conducting the evaluation |
| Mary Ann Larsen | Administrator | Facility administrator |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
Date: Oct 25, 2004
Visit Reason
A complaint investigation on-site visit was conducted at 3801 Grand on October 25, 2004, to investigate allegations related to nursing care and medication administration for Tenant #1.
Complaint Details
The complaint alleged that Tenant #1 was receiving daily dressing changes from the program nurse, but the nurse was unavailable from October 21–24, 2004 due to illness, and wound care was not provided or delegated during that time. It was also found that medication administration and storage were not properly controlled.
Findings
The investigation found regulatory insufficiencies including lack of a current physician order for wound care, failure to provide agreed care or delegate it during nurse absence, and improper medication administration and storage practices.
Deficiencies (3)
The program did not ensure that a physician order was current.
The program did not provide the care as agreed to in the service plan and did not delegate or make a referral to an outside agency for care in the event of the nurse’s absence.
The program did not administer and store medications according to accepted medication protocol.
Report Facts
Current number of tenants without cognitive disorder: 44
Current number of tenants with cognitive disorder: 3
Total Population: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
| Mary Ann Larsen | Administrator | Facility administrator named in the report |
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