Inspection Reports for Edencrest at Beaverdale
3410 Beaver Ave, Des Moines, IA 50310, United States, IA, 50310
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 17, 2025, found no deficiencies during the complaint investigation. Earlier inspections identified recurring issues with documentation accuracy, medication management, tenant supervision, and staff training, particularly related to dementia care and safety measures such as door alarms. Several complaint investigations were substantiated, including findings related to medication labeling and storage, tenant elopement, and incomplete service plans, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were either unsubstantiated or involved minor deficiencies without enforcement actions. The facility’s inspection history shows some ongoing challenges, but the absence of deficiencies in the latest report suggests some improvement in compliance.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
63 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Jun 17, 2025
Visit Reason
Investigation of Complaint #129336-C at Edencrest at Beaverdale assisted living program.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #129336-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 40
Number of tenants with cognitive impairment: 23
Total census: 63
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 1
Apr 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to tenant documentation and safety checks in an assisted living program for people with dementia.
Findings
The program failed to consistently maintain accurate documentation of personal and health-related care task sheets for tenants with cognitive impairment, specifically failing to document safety checks as required by tenants' service plans. This deficiency was confirmed through record reviews and interviews.
Deficiencies (1)
| Description |
|---|
| Failed to consistently maintain accurate documentation of personal and/or health-related care (task sheets) for tenants unable to advocate for themselves or with multiple service providers, including hospice care. |
Report Facts
Number of tenants without cognitive impairment: 40
Number of tenants with cognitive impairment: 27
Total census: 67
Safety checks required per shift: 8
Tenants reviewed with Global Deterioration Scale score of 4 and above: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alison Brothwell | BSN RN | Named on the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Oct 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation for Complaint #123900-C and a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The Program failed to consistently follow policies regarding medication labeling and storage, tenant service plan signatures, and ensuring operating door alarms on exit doors. Specific deficiencies included unlabeled insulin pens without date documentation, medications not stored in locked locations, unsigned tenant service plans, and non-functioning door alarms on exit doors.
Complaint Details
Complaint #123900-C was investigated with no regulatory insufficiencies cited from Incident 119799-I. The complaint investigation identified multiple regulatory insufficiencies related to medication labeling, storage, service plan signatures, and door alarms.
Deficiencies (4)
| Description |
|---|
| Failed to follow policy and consistently ensure medications were labeled appropriately, affecting 1 of 2 tenants who received insulin. |
| Failed to follow policy and consistently ensure medications were locked and secured, affecting 1 of 2 tenants who received insulin. |
| Failed to consistently ensure tenant service plans were signed and dated, pertaining to 1 of 2 sample tenants. |
| Failed to consistently ensure an operating door alarm on each exit door in a dementia-specific program, potentially affecting 21 tenants. |
Report Facts
Number of tenants without cognitive impairment: 47
Number of tenants with cognitive impairment: 21
Total census: 68
Tenants potentially affected by door alarm deficiency: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administered medications to Tenant #1 and reported storage of insulin pens. | |
| Staff B | Confirmed failure to date insulin pens and discussed insulin pen storage changes. | |
| Quality Assurance Nurse | Acknowledged the door alarm issues and stated the Program would address them immediately. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Mar 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints (#115644-C and #116396-C) and incidents concerning medication administration and tenant care.
Findings
The investigation found regulatory insufficiencies including failure to consistently ensure tenants received medications as prescribed and failure to ensure a tenant with unmanageable incontinence continued to meet criteria to remain in the assisted living program.
Complaint Details
The complaint investigation involved multiple complaints (#115644-C and #116396-C). No regulatory insufficiencies were found in other complaints and incidents (#115247-I, #115688-I, #115689-I, #113050-C, #115289-C, #116290-C).
Deficiencies (2)
| Description |
|---|
| Failure to consistently ensure tenants received medications as prescribed by the tenant's physician or authorized practitioner, evidenced by missing staff initials on medication administration records for Tenant #C2. |
| Failure to ensure a tenant with unmanageable incontinence continued to meet criteria to remain in the assisted living program, evidenced by unsanitary conditions and progressive worsening of the tenant's apartment. |
Report Facts
Number of tenants without cognitive disorder: 41
Number of tenants with cognitive disorder: 30
Total census: 71
Dates missing staff initials on medication administration records: 22
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Mar 1, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaint #110810-C regarding regulatory insufficiencies at the facility.
Findings
The program failed to consistently ensure all personnel, including contract/agency staff, were appropriately trained to meet tenant needs, specifically lacking dementia-specific training for three reviewed staff members, potentially affecting 35 tenants with cognitive impairment.
Complaint Details
The investigation was triggered by Complaint #110810-C. The complaint was substantiated by findings that contract staff did not have required dementia-specific education.
Deficiencies (1)
| Description |
|---|
| Failed to consistently ensure all personnel, including contract/agency staff, were appropriately trained to meet tenant needs, lacking dementia-specific training for Staff A, Staff B, and Staff C. |
Report Facts
Number of tenants without cognitive impairment: 40
Number of tenants with cognitive impairment: 35
Total census: 75
Staff reviewed: 3
Tenants potentially affected: 35
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Nov 15, 2022
Visit Reason
The inspection was conducted as a result of investigations into Incident #108535-I and Complaint #108537-C at Edencrest at Beaverdale, an assisted living program for people with dementia.
Findings
The program failed to follow established policies and procedures regarding elopement for one tenant, including failure to develop a service plan prior to occupancy and failure to respond appropriately to door alarms. Staff did not conduct required head counts or properly monitor the tenant who eloped.
Complaint Details
The investigation was triggered by Incident #108535-I and Complaint #108537-C. No regulatory insufficiencies were cited during investigations of Complaints #108492-C or #108781-C. The complaint was substantiated with findings related to elopement and service plan deficiencies.
Deficiencies (2)
| Description |
|---|
| Failure to follow established policies and procedures regarding elopement for Tenant #1. |
| Failure to develop a service plan prior to occupancy for Tenant #1. |
Report Facts
Number of tenants without cognitive disorder in General Population Program: 45
Number of tenants with cognitive disorder in General Population Program: 1
Number of tenants without cognitive disorder in Memory Care Unit: 1
Number of tenants with cognitive disorder in Memory Care Unit: 34
Total census of Assisted Living Program for People with Dementia: 80
Global Deterioration Scale score for Tenant #1: 6
Door alarm initial activation time: 1435
Door alarm cleared time: 1449
Door alert times on Healthcare Coordinator's phone: 1444
Door alert times on Healthcare Coordinator's phone: 1448
Temperature at time of incident: 81
Wind speed at time of incident: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed failure to notice Tenant #1 eloping and not hearing iPad alert | |
| Healthcare Coordinator | Received door alerts but reported no training for on-call duties | |
| Staff B | Failed to initiate head count after door alarm | |
| Staff C | Stated door alarm should not be reset until all tenants accounted for | |
| Staff D | Registered Nurse | Confirmed findings on 10/27/22 at 9:27 a.m. |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 3
Jun 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation into Incident #104977-I and a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
The program failed to consistently ensure service plans included tenants' identified needs affecting 3 of 9 tenants reviewed. The program also failed to properly supervise tenants according to their service plans, specifically one tenant who eloped from the facility. Additionally, the program failed to have an operating alarm system on the front door, potentially affecting all tenants.
Complaint Details
The investigation into Complaint #103179-C found no regulatory insufficiencies. The complaint investigation related to Incident #104977-I identified deficiencies in service plans, supervision, and alarm system functionality.
Deficiencies (3)
| Description |
|---|
| Service plans did not consistently include tenants' identified needs and preferences for assistance, affecting 3 of 9 tenants reviewed (Tenant #2, #3, #4). |
| Failed to properly supervise tenants according to their service plans, resulting in Tenant #1 eloping from the facility and being missing for over three hours. |
| Failed to have an operating alarm system on the front door to the building, affecting 1 of 1 tenant identified and potentially all tenants. |
Report Facts
Census: 83
Tenants without cognitive disorder: 41
Tenants with cognitive disorder: 42
Tenants reviewed: 9
Tenants affected by service plan deficiency: 3
Safety checks per shift: 8
Duration tenant missing: 184
Distance tenant found from facility: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Last saw Tenant #1 wearing wanderguard at 8:20 PM; given written warning for falsifying documentation | |
| Staff B | Worked 3rd shift on night of Tenant #1 elopement; did not complete safety checks until tenant returned | |
| Staff C | Reported Tenant #3's sexual behaviors to Director | |
| Staff D | Reported Tenant #2's aggressive behaviors and lack of wanderguard check knowledge | |
| Staff E | Reported Tenant #2's physical and verbal aggression | |
| Staff F | Reported Tenant #3's sexual acting out | |
| Staff G | Reported Tenant #3's sexual behaviors as told by female co-workers | |
| Staff H | Reported Tenant #4 was not receiving finger foods at meal times | |
| Staff I | Reported Tenant #4 did not receive finger foods at meal times | |
| Staff J | Worked memory care and assisted living on night of Tenant #1 elopement; did not hear alarm | |
| Registered Nurse | RN | Confirmed Tenant #2's behaviors and lack of service plan updates; checked active exit-seeker box for Tenant #1 |
| Director | Confirmed alarm system failure and lack of monitoring; checked alarm system monthly | |
| Portfolio Leader | Confirmed awareness of Tenant #3's sexual behaviors and service plan deficiencies |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Nov 17, 2021
Visit Reason
The inspection was conducted to investigate complaints #98769 and 99631, an infection control review, and an incident investigation #100073 related to a tenant eloping from the assisted living memory care program.
Findings
No regulatory insufficiencies were found during the complaint investigations and infection control review. However, a deficiency was cited for failing to ensure a safe environment when a tenant eloped from the program. The facility had issues with gate codes and gate malfunctions that allowed the tenant to leave unsupervised.
Complaint Details
The investigation of complaints #98769 and 99631 found no regulatory insufficiencies. The incident investigation #100073 found a deficiency related to tenant elopement.
Deficiencies (1)
| Description |
|---|
| The program failed to ensure a safe environment when a tenant eloped from the program due to gate code access and gate malfunctions. |
Report Facts
Number of tenants: 75
Temperature: 68
Incident time: 1930
Exit door alarm time: 1935
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Beach | Director | Named in plan of correction and interview regarding gate codes and elopement incident |
| RA D | Resident Assistant | Reported tenant #1 returned by neighbors and answered door during incident |
| RA F | Resident Assistant | Assigned to tenant #1 during incident and interviewed about elopement |
| Director of Nursing | Director of Nursing | Interviewed about tenant assessment and alarm activation during incident |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Jan 12, 2021
Visit Reason
The inspection was conducted during the investigation of complaints 93271-C, 93965-C, 94460-C and included an infection control survey.
Findings
No regulatory insufficiencies were cited during the investigation and infection control survey.
Complaint Details
Investigation involved complaints 93271-C, 93965-C, and 94460-C; no deficiencies were found.
Report Facts
Number of tenants without cognitive disorder in General Population: 29
Number of tenants with cognitive disorder in General Population: 2
Number of tenants without cognitive disorder in Memory Care Unit: 3
Number of tenants with cognitive disorder in Memory Care Unit: 22
Total Census of Assisted Living Program for People with Dementia: 56
Inspection Report
Renewal
Census: 60
Deficiencies: 0
Feb 5, 2020
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification inspection.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 8, 2019
Visit Reason
The inspection was conducted as an investigation of complaints identified by Incident numbers #83981-I, 84266-C, and 84141-C.
Findings
No regulatory insufficiencies were cited during the investigation of the specified incidents.
Complaint Details
Investigation of Incident #83981-I, 84266-C, and 84141-C with no regulatory insufficiencies cited.
Report Facts
Number of tenants without cognitive disorder in General Population: 40
Number of tenants with cognitive disorder in General Population: 2
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 17
Total Census of Assisted Living Program for People with Dementia: 59
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Feb 21, 2019
Visit Reason
Investigation of Incident #81329-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #81329-I.
Complaint Details
Investigation of Incident #81329-I; no regulatory insufficiencies were found.
Report Facts
Number of tenants without cognitive disorder in general population: 39
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 18
Total census: 59
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Jan 8, 2019
Visit Reason
Investigation of Complaint #79915 at the assisted living facility Edencrest at Beaverdale.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #79915 was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 1
Total population: 24
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 1
Total population: 17
TOTAL census: 41
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Aug 22, 2018
Visit Reason
Investigation of Incident #77261-C at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #77261-C; no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive disorder in general population: 31
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 14
Total census of assisted living program for people with dementia: 45
Inspection Report
Original Licensing
Census: 15
Deficiencies: 1
Jan 23, 2018
Visit Reason
The inspection was conducted as the initial certification to determine compliance with certification requirements for an Assisted Living Program for People with Dementia.
Findings
The program failed to complete required criminal history, dependent adult abuse, and child abuse record checks prior to employment for one of three staff reviewed. This deficiency was identified during the initial certification process.
Deficiencies (1)
| Description |
|---|
| Failure to complete criminal history, dependent adult abuse, and child abuse record checks prior to employment for one staff member. |
Report Facts
Number of tenants without cognitive disorder (General Population): 13
Number of tenants with cognitive disorder (General Population): 0
Number of tenants without cognitive disorder (Memory Care Unit): 0
Number of tenants with cognitive disorder (Memory Care Unit): 2
Total Census of Assisted Living Program for People with Dementia: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in finding for failure to complete required background checks prior to employment | |
| Sam Patterson | Manager | Author of Plan of Correction related to deficiency A118 |
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