Inspection Reports for Addington Place of Des Moines
5815 SE 27th St, Des Moines, IA 50320, United States, IA, 50320
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 0
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.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaints #129942-C, #130073-C, #130252-C, #130297-C, and #130472-C found no regulatory insufficiencies.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
Renewal
Census: 10
Deficiencies: 2
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.
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.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #119849-C.
Deficiencies (2)
| Description |
|---|
| 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
Total census: 10
Staff reviewed for background checks: 4
Staff with deficient background checks: 2
Tenant service plan update timeframe: 30
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 5
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.
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.
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.
Deficiencies (5)
| Description |
|---|
| 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
Total census: 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
Complaint Investigation
Census: 15
Deficiencies: 7
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.
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.
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.
Deficiencies (7)
| Description |
|---|
| 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
Total census: 15
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
Census: 23
Deficiencies: 0
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
Total Census: 23
Inspection Report
Recertification
Census: 22
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
Total census: 22
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 |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Feb 21, 2019
Visit Reason
The inspection was conducted as an investigation of Complaint #87053-C at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation at the facility.
Complaint Details
Complaint #87053-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 1
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 9
Total Census: 42
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Dec 17, 2018
Visit Reason
Investigation of Complaint #79882 regarding the Assisted Living Program at Prairie Hills at Des Moines.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #79882.
Complaint Details
Complaint #79882 was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population program: 34
Number of tenants with cognitive disorder in General Population program: 0
Total population of General Population program: 34
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 11
Total population of Dementia-Specific Program: 11
Total census of Assisted Living Program: 45
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Mar 1, 2018
Visit Reason
Investigation of Complaint #73884-C at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #73884-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in general population: 38
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 1
Number of tenants with cognitive disorder in memory care unit: 15
Total census: 56
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Jan 16, 2018
Visit Reason
The inspection was conducted as an investigation of complaint #72932 at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #72932 was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 9
Number of tenants with cognitive disorder in General Population Program: 0
Total population of General Population Program: 43
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 19
Total population of Dementia-Specific Program: 19
Total census of Assisted Living Program: 62
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Dec 4, 2017
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, investigating Incident 71691-1, Complaint 71656-C, and Complaint 72272-C.
Findings
The program failed to consistently ensure tenants were treated with consideration and respect, affecting one tenant. Additionally, the program failed to ensure adequate and appropriate care, treatment, and services for two tenants, including failure to document blood pressure checks and delayed removal of sutures/staples.
Complaint Details
The complaint investigation involved incidents and complaints numbered 71691-1, 71656-C, and 72272-C. The complaint was substantiated as the program failed to treat tenants with respect and provide adequate care.
Deficiencies (2)
| Description |
|---|
| Failure to treat tenants with consideration, respect, and full recognition of personal dignity and autonomy. |
| Failure to provide adequate and appropriate care, treatment, and services, including failure to document blood pressure checks and delayed removal of sutures/staples. |
Report Facts
Number of tenants without cognitive disorder in General Population Program: 41
Number of tenants with cognitive disorder in General Population Program: 1
Total Population of General Population Program: 42
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 18
Total Population of Dementia-Specific Program: 19
Total census of Assisted Living Program: 61
Number of tenants affected by inadequate care: 2
Number of tenants affected by disrespectful treatment: 1
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Sep 7, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during the investigation of Complaint #69718-C at Prairie Hills at Des Moines.
Findings
The program failed to ensure medications were administered as prescribed for 9 out of 44 tenants reviewed, with multiple medication errors documented in incident reports. Additionally, the program failed to update service plans annually for at least one tenant reviewed.
Complaint Details
The investigation was triggered by Complaint #69718-C. The findings included medication administration errors and failure to update service plans. The Administrator confirmed findings and reported termination of responsible staff. No substantiation status explicitly stated.
Deficiencies (2)
| Description |
|---|
| Program failed to ensure medications were administered as prescribed for 9 out of 44 tenants reviewed, including multiple medication errors and omissions documented in incident reports and medication administration records. |
| Program failed to update service plans at least annually for 1 of 4 tenants reviewed. |
Report Facts
Total census: 66
Tenants reviewed for medication errors: 44
Tenants with medication errors: 9
Tenants reviewed for service plans: 4
Tenants with service plan deficiency: 1
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 5
Jul 13, 2017
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#68740-C, 68556-C, 68324-C, 68141-C, and 68902-C) regarding the care and services provided to tenants at Prairie Hills at Des Moines.
Findings
The program failed to ensure adequate care, treatment, and services for tenants, including failure to report and properly document incidents, failure to provide timely nurse training, failure to update occupancy agreements, and failure to complete nurse reviews for significant changes in tenant conditions. Specific findings included inadequate response to a tenant's fall resulting in a fractured bone and failure to ensure staff training and documentation compliance.
Complaint Details
The investigation was triggered by complaints #68740-C, 68556-C, 68324-C, 68141-C, and 68902-C. The findings substantiated failures in care and documentation related to a tenant's fall and injury, staff training, and documentation compliance.
Deficiencies (5)
| Description |
|---|
| Tenant rights not met; failure to ensure tenants received adequate care and treatment, including proper incident reporting and follow-up. |
| Staffing deficiencies; failure to ensure staff received required training within 30 days of employment. |
| Occupancy agreement not reviewed and updated to reflect admission/retention criteria changes. |
| Tenant documentation incomplete; failure to complete incident reports after tenant injury. |
| Nurse review not completed for tenant with significant change in condition (pelvic fracture). |
Report Facts
Number of tenants without cognitive disorder: 46
Number of tenants with cognitive disorder: 26
Total census: 72
Staff training compliance: 2
Tenants affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding incident reporting and staff training findings |
| Patte Hayes | Executive Director | Signed the report on 08/11/17 |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Jan 26, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during the investigation of Complaint #63876-C and Complaint #64099-C.
Findings
The facility failed to individualize service plans to indicate identified needs and preferences for assistance for 3 of 5 tenants reviewed. Specific issues included failure to update service plans for fall prevention interventions, discontinuation of physical and occupational therapy services, and discontinuation of home health nursing services.
Complaint Details
Complaint #64099 was investigated with findings of regulatory insufficiencies related to service plans and care interventions. The complaint was substantiated as evidenced by the cited deficiencies.
Deficiencies (1)
| Description |
|---|
| The program failed to individualize service plans to indicate identified needs and preferences for assistance for 3 of 5 tenants reviewed. |
Report Facts
Total census: 73
Number of tenants with cognitive disorder: 17
Number of tenants without cognitive disorder: 56
Number of tenants reviewed: 5
Number of tenants with deficient service plans: 3
Number of falls for Tenant #1: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Boehm | Senior Executive Director | Signed Plan of Correction letter |
Inspection Report
Renewal
Census: 57
Deficiencies: 4
Dec 15, 2015
Visit Reason
The inspection was a Final Recertification Monitoring Evaluation Report conducted to assess regulatory compliance for Prairie Hills at Des Moines, focusing on tenant evaluation, service plans, nurse review, and food service.
Findings
The report identified regulatory insufficiencies in tenant evaluation, service plans, nurse review, and food service, including failures to complete evaluations with changes in condition, update service plans, conduct nurse reviews, and provide food safety training.
Deficiencies (4)
| Description |
|---|
| Evaluations of tenants were not completed with a change of condition, including failure to assess and document health status changes and incidents such as falls and injuries. |
| Service plans were not updated to meet the specific service needs of individual tenants. |
| Nurse reviews were not completed with changes of condition to assess and document health status and monitor progress related to previous recommendations. |
| Personnel responsible for food service did not have orientation or annual in-service training on food safety and protection. |
Report Facts
Civil penalty amount: 1500
Reduced civil penalty amount: 975
Census: 57
Tenant counts: 46
Tenant counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact for questions regarding the report and plan of correction |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Scott L. Regenwether | Executive Director | Signed the Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 9
Apr 28, 2015
Visit Reason
Investigation of complaints #52734-C and #52391-C regarding tenant rights and fire drills at Prairie Hills Assisted Living.
Findings
The investigation found no substantiated tenant refusal of hospital care but identified regulatory insufficiencies in program policies, medication administration, staffing, tenant documents, service plans, nurse review, food service, and structural requirements.
Complaint Details
Complaint #52734-C regarding tenant rights to make care choices was not substantiated. Complaint #52391-C regarding fire drills was referred to the State Fire Marshall's office.
Deficiencies (9)
| Description |
|---|
| Program policies and procedures did not always follow required standards, including incident reporting and medication lists not sent with tenants to hospital. |
| Medications were not administered correctly according to the program's medication policy. |
| Staff failed to follow handwashing and glove use procedures during tenant care. |
| Tenant documents were not protected from unauthorized use; computer and service plan book were unsecured. |
| Service plans were not individualized and did not include planned activities for tenants with dementia. |
| Nurse reviews were not completed with changes in tenant condition or to monitor progress as required. |
| Food service did not meet health standards; food temperature and handling issues were noted. |
| Structural deficiencies included unsafe grounds and damaged fencing around the dementia unit. |
| Staffing was insufficient to meet tenant needs; reliance on emergency personnel for lifting assistance. |
Report Facts
Census: 45
Tenants without cognitive disorder: 35
Tenants with cognitive disorder: 10
Tenants with cognitive disorder: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the cover letter and contact for questions regarding the report |
| Scott Regenwether | Executive Director | Facility Executive Director addressed in the report |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding medication lists and hospital transfers |
| Staff B | Certified Medication Assistant (CMA) | Interviewed regarding medication lists and hospital transfers |
| Staff C | Certified Nursing Assistant (CNA) | Observed and interviewed regarding handwashing, medication administration, and tenant care |
| Staff D | Universal Worker (UW) | Observed assisting with nebulizer treatment and toileting |
| Staff E | Universal Worker (UW) | Observed assisting tenants and handling medication |
| Staff F | Universal Worker (UW) | Interviewed regarding access to tenant information on computer |
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and staff expectations | |
| Registered Nurse (RN) | Interviewed regarding medication administration and staff expectations |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Jul 7, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations including water leaking into apartments, staff yelling and swearing at tenants, and a tenant not being evaluated in a timely manner.
Findings
The investigation found no regulatory insufficiencies related to the complaints. Water leaks were fixed, no tenant reported swearing or yelling by staff, and the internal investigation found no substantiation of the alleged staff misconduct. Clinical records review showed no documentation of untimely evaluations.
Complaint Details
The complaints investigated included water leaking into apartments from mechanical rooms, allegations of staff yelling and swearing at tenants, and a tenant not being evaluated in a timely manner. The allegations involving staff yelling were not substantiated after interviews and internal investigation. The tenant evaluation complaint was also not substantiated.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 11
Total population of General Population Program: 43
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 2
Total population of Dementia-Specific Program: 2
Total census of Assisted Living Program: 45
Number of tenants present at tenant meeting: 18
Number of family members present at tenant meeting: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Beck | RN Director | Named as facility director and involved in complaint investigation |
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Author of cover letter for the investigation report |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Jul 30, 2013
Visit Reason
The inspection was conducted as an amended final recertification and complaint/incident investigation for Prairie Hills at Des Moines, triggered by complaints including allegations of improper charges and discharge procedures.
Findings
The report details multiple regulatory insufficiencies related to tenant rights, involuntary discharge, evaluation, service plans, nurse review, medications, and policies and procedures. Two tenants were given discharge notices for exceeding retention criteria. Medication administration and documentation deficiencies were noted. The program's policies and procedures did not fully meet regulatory requirements.
Complaint Details
The complaint investigation included allegations that a tenant was charged $100 for leaving the program early and that a tenant was discharged improperly with insufficient notice and assistance. The investigation found issues with discharge notices, medication administration, and tenant care. The complaint was substantiated with findings of regulatory insufficiencies.
Deficiencies (1)
| Description |
|---|
| Regulatory insufficiencies were found in tenant rights, involuntary discharge, evaluations, service plans, nurse review, medication administration, and policies and procedures. |
Report Facts
Census: 47
Tenants without cognitive disorder: 36
Tenants with cognitive disorder: 11
Discharge notice days: 30
Medication doses: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Beck | RN Director | Named as facility director and involved in findings related to tenant care and discharge |
| Lori Miner | RN BSN | Monitor during investigation |
| Margaret Kaltefleiter | RN MS | Monitor during investigation |
| Rose Boccella | Program Coordinator | Signed cover letter for report |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Jan 2, 2013
Visit Reason
The inspection was a complaint/incident investigation revisit conducted on January 2, 2013, to evaluate the facility's compliance following a previous complaint investigation.
Findings
No regulatory insufficiencies were identified during the revisit. The program was found to be in full compliance with administrative rules and was issued a Standard Certification effective January 4, 2013.
Complaint Details
The revisit was related to a complaint/incident investigation involving medication administration issues identified in a prior onsite investigation in July/August 2012. The program had previously received regulatory insufficiencies related to medications, staffing, and service plans but showed correction during this revisit.
Report Facts
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 14
Total Population of Program at time of on-site: 52
Date of Complaint/Incident Investigation: Jan 2, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Beck | RN Director | Named as facility director in relation to the complaint investigation |
| Lori Miner | RN BSN | Monitor during the complaint/incident investigation |
| Ann Martin | RN, Bureau Chief | Monitor during the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 6
Oct 29, 2012
Visit Reason
The inspection was conducted as a Final First Complaint and First Incident Revisit Report for Prairie Hills of Des Moines, Iowa, related to regulatory insufficiencies in medications and compliance following a complaint/incident investigation.
Findings
The program was found to have regulatory insufficiencies related to medication administration errors, failure to follow physician orders, incomplete nurse reviews, and inadequate staffing. A $1250 civil penalty was assessed and a Plan of Correction was submitted and reviewed.
Complaint Details
The complaint/incident investigation was initiated due to concerns about medication administration, nurse reviews, evaluations, service plans, tenant rights, and staffing. The complaint was substantiated with multiple regulatory insufficiencies identified during the onsite visit on October 29, 2012.
Deficiencies (6)
| Description |
|---|
| Failure to administer medications according to physician ordered parameters. |
| Failure to complete nurse reviews following significant changes in tenant conditions. |
| Failure to complete health, functional, and cognitive evaluations following significant changes. |
| Failure to include interventions meeting individualized needs in service plans. |
| Allowing tenant to lie on the floor for over five hours due to inadequate staffing. |
| Failure to notify physician as ordered regarding changes in medication parameters. |
Report Facts
Civil penalty amount: 1250
Reduced civil penalty amount: 812.5
Total census: 46
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 6
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Beck | RN Director | Named as facility director and involved in medication administration findings. |
| Rose Boccella | Program Coordinator | Contact person for appeal and compliance questions. |
| Maribeth Frejand | RN Monitor | Conducted complaint/incident investigation. |
| Joyce Kix | RN Monitor | Conducted complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 5
Jul 30, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding regulatory insufficiencies in areas including nurse review, evaluation, service plans, tenant rights, medications, and staffing at Prairie Hills at Des Moines.
Findings
The investigation found multiple regulatory insufficiencies including failure to provide timely nurse reviews, inadequate pain medication availability, insufficient staffing, incomplete service plans, and failure to meet tenant care needs. The program was assessed a $7,000 civil penalty and issued a Conditional Certificate with sanctions.
Complaint Details
Complaint investigation was substantiated with findings of regulatory insufficiencies in nurse review, medication administration, staffing, and tenant care. The program was assessed a $7,000 civil penalty and issued a Conditional Certificate effective August 14, 2012, with sanctions including no new admissions and required proof of nurse delegation within 30 days.
Deficiencies (5)
| Description |
|---|
| Failure to complete nurse review, service plans, and evaluations with significant changes in tenants' condition. |
| Pain medication was not available for a tenant for over 5 hours. |
| Staff were not fully delegated and on-call staff were not available. |
| Inadequate staffing to meet tenant needs and failure to respond to staffing issues. |
| Medication administration errors and documentation discrepancies. |
Report Facts
Civil penalty amount: 7000
Reduced penalty amount: 4550
Census: 54
Complaint/Incident Investigation Dates: July 30, 31 and August 6, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kit Steiber | Administrator | Named as administrator of Prairie Hills at Des Moines in relation to the complaint investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the amended demand letter and involved in the investigation. |
| Rose Boccella | Program Coordinator | Contact person for questions regarding the letter and involved in the investigation. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 7
Mar 20, 2012
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to medications, evaluation, and service plans at Prairie Hills Assisted Living.
Findings
The investigation found repeated regulatory insufficiencies in medications, evaluation, and service plans, including medication errors such as crushing medications without physician orders, failure to complete evaluations of tenants' health and cognitive status, and failure to update service plans to reflect tenant needs. Tenant #5 was found to be bed bound with significant health declines and inadequate care documentation.
Complaint Details
Complaint allegations #38113-C and 37367-CR involved tenants with cognitive deficits not being reminded to attend meals and activities. The complaint investigation found multiple regulatory insufficiencies related to medications, evaluations, and service plans, with no regulatory insufficiency noted for tenant rights or staffing.
Deficiencies (7)
| Description |
|---|
| Failure to sign medications when given, missing or incomplete physician orders, and failure to complete treatments as ordered for Tenant #1. |
| Administration of medications by unlicensed personnel not in accordance with nurse delegation requirements. |
| Staff lack of knowledge of Tenant #1's planned care tasks and hospice interventions. |
| Registered nurse's failure to complete evaluations when Tenant #1 exhibited significant changes in health and functional status. |
| Registered nurse's failure to update service plans for hospice tenants after significant changes in health and functional status. |
| Failure to develop and update individualized service plans based on evaluations and tenant needs. |
| Registered nurse's failure to complete nurse reviews when significant changes in condition occurred with Tenant #1. |
Report Facts
Civil penalty amount: 1500
Census count: 46
Tenants without cognitive disorder: 31
Tenants with cognitive disorder: 11
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kit Steiber | Administrator | Administrator of Prairie Hills at Des Moines, named in report header. |
| Joyce Kix | RN | Monitor during complaint/incident investigation. |
| Maribeth Freland | RN | Monitor during complaint/incident investigation. |
| Rose Boccella | Program Coordinator | Contact person for civil penalty demand letter. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Feb 17, 2012
Visit Reason
The inspection was conducted as a complaint investigation following allegations that the Prairie Hills Assisted Living Program failed to comply with regulatory requirements related to medication administration and staffing.
Findings
The investigation found a regulatory insufficiency related to medication administration, specifically the failure to obtain the correct dosage of an Exelon patch for a tenant. No regulatory insufficiency was found related to staffing despite the registered nurse resignation.
Complaint Details
The complaint alleged that the Program ran out of medications for a tenant and the tenant was not given medications as ordered. The complaint was substantiated with findings related to medication administration but not staffing.
Deficiencies (1)
| Description |
|---|
| Failure to obtain the correct dosage of the Exelon patch as ordered by the physician for Tenant #1. |
Report Facts
Civil penalty amount: 500
Civil penalty reduction amount: 325
Tenant age: 81
Tenant population census: 44
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 10
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor for the complaint/incident investigation. |
| Kit Steiber | Administrator | Administrator of Prairie Hills Assisted Living. |
| Rose Boccella | Program Coordinator | Contact person for the Department of Inspections and Appeals regarding the report. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 7
Jan 5, 2012
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to tenant rights, evaluation, medications, staffing, service plans, and nurse review at Prairie Hills Assisted Living.
Findings
The investigation found repeated regulatory insufficiencies in staffing, tenant rights, medications, and service plans. Specific issues included failure to coordinate hospice care, incomplete medication administration records, lack of wound care documentation, and inadequate evaluations and service plans for tenants receiving hospice care.
Complaint Details
The complaint investigation was substantiated and involved allegations that a tenant receiving hospice care was not receiving adequate skilled care, including issues with medication administration, wound care, evaluations, and staffing. The investigation confirmed multiple regulatory insufficiencies.
Deficiencies (7)
| Description |
|---|
| Failure to coordinate hospice staff to provide appropriate care for tenants receiving hospice care. |
| Medications were not recorded as given, including multiple medication administration errors. |
| Oxygen saturation levels were not recorded and physician orders related to oxygen therapy were unclear or not followed. |
| Wound care treatments were not recorded and service plans did not establish interventions related to wound care. |
| A tenant’s physician was not contacted regarding aspiration or orders to restrict fluid intake to thickened liquids. |
| Service plans and evaluations were incomplete or not representative of tenant needs, especially for tenants receiving hospice care. |
| Staffing patterns were inadequate to meet tenant care needs, including insufficient direct care staff and lack of knowledge about hospice services. |
Report Facts
Civil penalty amount: 2500
Census count: 43
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH, Monitor | Named as monitor for the complaint/incident investigation. |
| Kit Steiber | Administrator | Administrator of Prairie Hills Assisted Living during investigation. |
| Rose Boccella | Program Coordinator | Contact person for civil penalty and plan of correction. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Dec 12, 2011
Visit Reason
The inspection was conducted as a complaint investigation following allegations of tenant abuse, medication errors, staffing issues, and tenant rights violations at Prairie Hills Assisted Living.
Findings
The report found regulatory insufficiencies in tenant rights, medication administration, and staffing. A tenant sustained a large bruise due to staff grabbing the tenant's arm, and medication was not administered as prescribed. Staffing was found to be inadequate at times, and tenant care was sometimes rough or inappropriate.
Complaint Details
The complaint was substantiated. Tenant #1 was bruised on the right hand and wrist after staff grabbed the tenant's arm to pull them out of bed. Police and hospital records confirmed the injury. Medication errors and staffing issues were also investigated and substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to comply with tenant rights, including abuse and neglect resulting in injury to a tenant. |
| Medication administration errors, including failure to administer medications as prescribed. |
| Staffing insufficiencies and inappropriate staff behavior toward tenants. |
Report Facts
Civil penalty amount: 1000
Census: 40
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor of the complaint/incident investigation. |
| Rose Boccella | Program Coordinator | Contact person for the demand letter and civil penalty. |
| Kit Steiber | Administrator | Administrator of Prairie Hills Assisted Living during investigation. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Nov 30, 2011
Visit Reason
The inspection was conducted in response to a complaint alleging mold and mildew on ceiling tiles and bathroom fans, holes in wall heating units, and black mold in toilet bowls at Prairie Hills at Des Moines.
Findings
The Construction/Design Engineer Senior conducted an investigation and found no evidence of mold or damage in inspected units. The complaint was determined to be unsubstantiated, and no regulatory insufficiencies were identified.
Complaint Details
Complaint alleged mold and mildew on ceiling tiles and bathroom fans, holes in wall heating units, and black mold in toilet bowls. The complaint was investigated and found to be unsubstantiated.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 32
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 2
TOTAL census of Assisted Living Program: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doran Pruisner | Construction/Design Engineer Senior | Conducted the complaint investigation and determined the complaint was unsubstantiated |
| Kit Steiber | Senior Living Consultant | Provided information during the investigation and was filling in as interim administrator |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Oct 5, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations about tenant door locks being broken, failure to report incidents, retention of a tenant with violent behaviors, and staffing and food service concerns at Prairie Hills Assisted Living Program.
Findings
The investigation found no regulatory insufficiencies related to tenant door locks, incident reporting, or violent behaviors. However, deficiencies were noted in staffing documentation and food service training, including lack of delegated nursing tasks documentation and missing orientation and annual training for food handlers.
Complaint Details
The complaint investigation was substantiated with findings related to staffing and food service deficiencies. Allegations about broken door locks, failure to report incidents, and retention of a tenant with violent behaviors were not substantiated.
Deficiencies (3)
| Description |
|---|
| Lack of documentation that task delegations by the Registered Nurse to staff #3, #4, and #6 were completed. |
| Insufficient number of trained staff to fully meet tenants' identified needs. |
| Personnel responsible for food preparation or service lacked orientation on sanitation and safe food handling and annual in-service training on food protection. |
Report Facts
Total census: 34
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 5
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor for the complaint/incident investigation |
| Dawn Larkin | Administrator | Named as facility administrator in relation to the investigation |
Inspection Report
Monitoring
Census: 29
Deficiencies: 1
Sep 14, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Prairie Hills at Des Moines to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.
Findings
The program did not receive any regulatory insufficiencies during this certification period. A review of staff files revealed one regulatory insufficiency related to incomplete background checks for child abuse. Tenant satisfaction was positive with no other concerns noted.
Deficiencies (1)
| Description |
|---|
| The program did not complete a background check for child abuse as required prior to employment. |
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 29
Tenants at community meeting: 31
Staff files reviewed: 5
Staff #5 hire date: Jan 20, 2011
Criminal background and dependent adult abuse checks completion date: Jan 13, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
May 16, 2011
Visit Reason
The inspection was conducted as a final incident investigation following reports of money missing from a tenant, with losses occurring in January and March 2011.
Findings
The investigation found no regulatory insufficiencies. The program reported five other losses of money since December 2010, initiated surveillance equipment, and had terminated three employees. The program staff consisted of 16 certified nurse aides with access to tenant rooms.
Complaint Details
The complaint involved allegations of money missing from a tenant. The losses occurred in January and March 2011. The investigation found no regulatory insufficiencies and noted the program had initiated surveillance equipment and terminated three employees.
Report Facts
Number of tenants with dementia between Stages 4 and 7: 5
Number of tenants without cognitive disorder: 20
Total population of program at time of on-site: 25
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 2
Number of tenants receiving specialized care in a dedicated setting: 3
Total population of program at time of on-site: 28
Program staff: 16
Terminated employees: 3
Losses of money reported since December 2010: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor for the incident investigation |
Inspection Report
Original Licensing
Census: 6
Deficiencies: 1
May 24, 2010
Visit Reason
The visit was conducted as a Final Initial Certification and Incident Monitoring Evaluation for Prairie Hills Assisted Living Des Moines, assessing regulatory compliance and incident investigation.
Findings
The report found no substantiated regulatory insufficiencies in tenant care, staffing, or structural requirements. However, there was a regulatory insufficiency related to incomplete record checks for two staff members, resulting in a $500 civil penalty.
Deficiencies (1)
| Description |
|---|
| Incomplete record checks and evaluations prior to hire for staff persons #3 and #4, including missing evaluations for clearance and mandatory training documentation. |
Report Facts
Civil penalty amount: 500
Current number of tenants without cognitive disorder: 5
Current number of tenants with cognitive disorder: 1
Total Population of GPP: 6
Total Census of ALP: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN Monitor | Conducted the monitoring visit and observations |
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