Inspection Reports for Grand Living At Tower Place

540 S 51st St, West Des Moines, IA 50265, United States, IA, 50265

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Deficiencies per Year

8 6 4 2 0
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

8 16 24 32 40 48 Apr '22 Mar '23 Dec '24 Feb '25 Jun '25 Nov '25
Inspection Report Complaint Investigation Census: 36 Deficiencies: 0 Nov 3, 2025
Visit Reason
Investigation of Incident #130571-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #130571-I.
Complaint Details
Investigation of Incident #130571-I with no regulatory insufficiencies found.
Inspection Report Complaint Investigation Census: 34 Deficiencies: 0 Jun 26, 2025
Visit Reason
Investigation of Complaint #128520-C at the assisted living facility serving people with dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #128520-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive impairment: 34 Number of tenants without cognitive impairment: 0 Total census: 34
Inspection Report Complaint Investigation Census: 36 Deficiencies: 0 Feb 6, 2025
Visit Reason
Investigation of Complaint #125613-C regarding the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #125613-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive impairment: 36 Number of tenants without cognitive impairment: 0 Total census: 36
Inspection Report Complaint Investigation Census: 34 Deficiencies: 3 Dec 3, 2024
Visit Reason
The inspection was conducted to investigate complaints 118877-C, 121223-C, 118029-C, 121854-C, Incident 121624-I, Complaint 118087-C, and to perform a recertification visit for an Assisted Living Program for People with Dementia.
Findings
The Program failed to consistently follow established policies regarding door alarms and medication security, failed to follow physician orders for medication administration, and did not consistently follow the Personal Emergency Response policy for tenants with cognitive impairment. Several tenants' service plans lacked directions for staff on how often to check on them to address emergency needs.
Complaint Details
The investigation included complaints 118877-C, 121223-C, 118029-C, 121854-C, Incident 121624-I, and Complaint 118087-C. No regulatory insufficiencies were cited for complaints 118877-C, 121223-C, 118029-C, or 121854-C. Deficiencies were cited related to Incident 121624-I and Complaint 118087-C.
Deficiencies (3)
Description
Failed to consistently follow established policies regarding door alarms and medications, including elopement and unsecured medications.
Failed to ensure physician orders were followed for medication administration for 1 of 3 former tenants reviewed.
Failed to consistently follow the Personal Emergency Response policy, lacking directions in service plans for staff to respond to emergency needs for multiple tenants.
Report Facts
Number of tenants without cognitive impairment: 1 Number of tenants with cognitive impairment: 33 Total census: 34 Missing weekly weight documentation: 3 Number of tenants with Personal Emergency Response deficiencies: 6
Employees Mentioned
NameTitleContext
Director of FacetsDirector of FacetsInterviewed regarding elopement incident involving Tenant #1
Staff AInterviewed regarding elopement incident and search for Tenant #1
Assistant Director of WellnessAssistant Director of Wellness (ADOHW)Interviewed regarding medication refusal and disposal for Tenant #5
Director of Health and WellnessDirector of Health and Wellness (DOHC)Confirmed medication disposal policy and involved in monitoring medication administration
Inspection Report Complaint Investigation Census: 24 Deficiencies: 5 Mar 21, 2023
Visit Reason
The inspection was conducted as part of an investigation of Complaints #107887-C and #108037-C regarding medication administration and other regulatory concerns at the assisted living program.
Findings
The Program failed to consistently administer medications as prescribed, ensure proper background checks for agency staff, maintain individualized service plans reflecting tenant needs, provide appropriate training for all personnel, and encourage tenant participation in activities. Multiple deficiencies were cited affecting medication administration, record checks, service plans, staffing, and activities.
Complaint Details
The investigation was triggered by complaints #107887-C and #108037-C. The medication administration deficiency affected 1 of 2 former tenants. Background check and training deficiencies potentially affected all 24 tenants. Activity deficiencies potentially affected 13 tenants in the Monarch area.
Deficiencies (5)
Description
Failed to consistently administer medications as ordered by the physician, affecting 1 of 2 former tenants.
Failed to consistently ensure staffing agencies completed criminal history and background checks prior to employment.
Failed to consistently ensure service plans included tenants' identified needs and preferences for assistance.
Failed to consistently ensure all personnel, including agency/contract staff, were appropriately trained to meet tenant needs.
Failed to provide and encourage tenants to participate in appropriate activities reflecting individual differences and needs.
Report Facts
Total census: 24 Tenants without cognitive impairment: 3 Tenants with cognitive impairment: 21 Missed medication dates for Donepezil 10 mg: 5 Missed medication dates for Memantine HC 28 mg: 11 Agency staff reviewed: 2 Tenants potentially affected by agency staff issues: 24 Tenants potentially affected by activity deficiencies: 13
Employees Mentioned
NameTitleContext
Staff JInitials recorded on medication administration record; involved in medication documentation discrepancy.
Staff IMentioned in interview regarding medication administration and documentation.
Health and Wellness CoordinatorProvided explanations regarding medication documentation and staff practices.
Health and Wellness DirectorConfirmed agency staff background check issues and training documentation gaps.
Director of FacetsActivities DirectorConfirmed staff should assist tenants with activities and acknowledged lack of engagement.
Staff FFailed to assist with tenant activities and refused supervisor requests.
Inspection Report Renewal Census: 15 Deficiencies: 0 Apr 27, 2022
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder: 2 Number of tenants with cognitive disorder: 13 Total census: 15

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