Inspection Reports for The Rose of East Des Moines
1331 Idaho St, Des Moines, IA 50316, United States, IA, 50316
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 21, 2025, found no deficiencies during the complaint investigation. Earlier inspections generally showed compliance with certification rules and no regulatory insufficiencies in complaint investigations. Prior deficiencies primarily involved tenant rights, documentation and communication regarding tenant health status, and service plan development. Complaint investigations were mostly unsubstantiated, with no fines, immediate jeopardy findings, or license actions listed in the available reports. The inspection history indicates improvement over time, with recent inspections free of cited deficiencies.
Deficiencies (last 18 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2025 inspection.
Census over time
| Description |
|---|
| Staff failed to treat tenants with dignity and respect, potentially affecting all 54 residents. |
| Failure to notify the Long-Term Care Ombudsman regarding an involuntary transfer for Client #8. |
| Description |
|---|
| Failure to provide care, treatment, and services which were adequate and appropriate for Tenant #1, including lack of discharge planning and education regarding physical therapy refusal. |
| Description |
|---|
| Failed to ensure written communication regarding a change in a tenant's health status was available. |
| Name | Title | Context |
|---|---|---|
| Staff A | Staff involved in incident with Tenant #1 and failure to properly document and respond | |
| Registered Nurse B | Registered Nurse | Confirmed Tenant #1's injury and lack of documentation |
| Description |
|---|
| Failure to ensure written communication regarding a change in a tenant's health status, including documentation of a tenant fall incident and subsequent injury. |
| Name | Title | Context |
|---|---|---|
| Staff A | Staff involved in tenant fall incident and communication issues | |
| Registered Nurse (RN) B | Registered Nurse | Confirmed documentation issues regarding the incident |
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the complaint investigation report |
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the report and provided contact information |
| Description |
|---|
| The program failed to notify the tenant advocate and treating physician by certified mail immediately when an involuntary transfer was contested for one of two tenants. |
| The program failed to develop service plans that reflected the identified needs and preferences for assistance for five of six tenant files reviewed. |
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
| Description |
|---|
| The buildings and grounds shall be well-maintained, clean, safe and sanitary. (IAC r. 481-69.35(1)(b)) |
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor conducting the complaint/incident investigation |
| Felicia Owens | Administrator | Administrator of the facility named in the report |
| Rose Boccella | Program Coordinator | Author of the cover letter for the amended final complaint/incident investigation report |
| Description |
|---|
| Regulatory Insufficiency: The buildings and grounds shall be well-maintained, clean, safe and sanitary. (IAC r. 481-69.35(1)(b)) |
| Name | Title | Context |
|---|---|---|
| Felicia Owens | Administrator | Administrator of Rose of East Des Moines, named in report heading |
| Maribeth Freland | RN | Monitor for the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Signed cover letter for amended final complaint/incident investigation report |
| Staff #1 | Dietary Manager | Reported mouse droppings found in kitchen cupboards and pest control activities |
| Staff #2 | Previous maintenance personnel | Reported significant mice problems in maintenance garage and pest control efforts |
| Staff #3 | Previous Administrator | Reported rodent issues and tenant complaints, verified rodent trap placements |
| Staff #4 | Registered nurse/case manager | Reported tenant fear and mouse sightings, contacted previous Administrator about incident |
| Description |
|---|
| Failure to accurately evaluate tenants' cognitive and functional status using the Global Deterioration Scale (GDS) and Mini Mental Assessment, with incomplete documentation and inconsistent assessments. |
| Service plans did not reflect tenants' identified needs, including lack of assistance with toileting and incontinence management. |
| Name | Title | Context |
|---|---|---|
| Scott Berger | Administrator | Administrator of Rose of East Des Moines Assisted Living Program |
| Maribeth Freland | RN | Monitor during the inspection visit |
| Joyce Kix | RN | Monitor during the inspection visit |
| Rose Boccella | Program Coordinator mentioned in relation to penalty and appeals | |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Description |
|---|
| A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed; the evaluation was incomplete for Tenant #4. |
| A service plan shall be developed for each tenant based on evaluations and updated at least annually and when changes occur; deficiencies were found in service plans lacking specific interventions and signatures. |
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor involved in complaint/incident investigation |
| Joyce Kix | RN | Monitor involved in complaint/incident investigation |
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the incident investigation |
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Rose Bocella | Program Coordinator | Author of cover letter |
| Description |
|---|
| Service plan did not direct staff to monitor for signs and symptoms of Hypoglycemia and Hyperglycemia despite tenant receiving accu-checks and insulin injections. |
| Staff personnel files indicated training on accu-checks but lacked nurse delegated training and competency demonstration on signs and symptoms of Hypoglycemia and Hyperglycemia. |
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the Final Recertification Monitoring Evaluation |
| Vicki Truby | Administrator | Administrator of The Rose of East Des Moines named in the report |
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor who conducted the complaint investigation |
| Connie Schaffer | Certification Coordinator - Central Iowa | Author of the final incident investigation report cover letter |
| Description |
|---|
| Evaluations were not completed prior to, within 30 days of admission or with a change of condition and the cognitive evaluation utilized was not based as an objective tool. |
| Service plans were not based on updated cognitive, health and functional evaluations. |
| Nurse reviews were not complete. |
| Six fire drills are to be completed bimonthly, with two conducted during the night when tenants can reasonably be expected to be sleeping; program did not complete at least two fire drills during the night. |
| The program did not complete functional, cognitive and health evaluations within 30 days of admission for multiple tenants. |
| The program did not evaluate each proposed tenant's functional, cognitive and health status prior to signing the occupancy agreement and taking occupancy. |
| The program did not develop or update service plans within required timeframes for multiple tenants. |
| The program did not complete a nurse review with changes in health status on 9-2-09 and when tenant refused to go to hospital after being light headed and having trouble breathing on 9-13-09. |
| The program did not conduct emergency egress and relocation drills not less than six times per year on a bimonthly basis, with not less than two drills conducted during the night when tenants are sleeping. |
| Name | Title | Context |
|---|---|---|
| Vicki Truby | Administrator | Administrator of Rose of East Des Moines Assisted Living named in report |
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed demand letter assessing civil penalty |
| Description |
|---|
| The program did not consistently complete functional evaluations prior to tenant admission to determine eligibility and needed services. |
| The program did not consistently complete functional and cognitive evaluations within 30 days and with changes in health status to determine continued eligibility and service modifications. |
| The program did not consistently develop individualized service plans based on evaluations and did not update service plans within 30 days or as needed to meet tenant needs. |
| The program did not complete applicable employee record checks, including criminal background and dependent adult abuse checks, prior to hire as required. |
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