Accura Healthcare of South Des Moines

Inspectors wroteBased on clinical record review, resident and staff interview, the facility failed to maintain complete and accurate documentation of an ENT (Ear, Nose and Throat) referral for 1 of 3 residents' records reviewed (Resident #1). The facility reported a census of 82 residents. Findings Include: Review of Resident #1 Minimum Data Set (MDS) dated [DATE], documented Brief Interview for Mental Status score (BIMS) of 4, indicating severe cognitive impairment. Documented diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, Bipolar Disorder, Obsessive Compulsive Disorder and behaviors including hallucinations and delusions. Review of an Emergency Department After Visit Summary dated 8/27/25 revealed Resident #1 was seen for a fall that resulted in a nasal fracture. [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to initiate nursing assessments of a surgical amputation site in a timely manner for 1 of 1 residents reviewed for surgical sites (Resident #39). The facility reported a census of 74.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review the facility failed to flush an enteral gastrostomy tube (g-tube)(tube surgically inserted into the stomach to provide nutrition and medication) per the physician order prior to administering medication thru the gastrostomy tube for 1 of 1 resident (Resident #7) reviewed. The facility reported a census of 74 residents.

Inspectors wroteBased on observation, record review, staff interviews and policy review, the facility failed to use appropriate infection control practices and Enhanced Barrier Practices (EBP) during urinary catheter care for 1 of 3 residents reviewed (Resident #66). The facility reported a census of 74residents. Findings Include:Resident #66's Quarterly Minimum Data Set (MDS) assessment, dated 5/29/25, reflected a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS listed Resident #66 had an indwelling urinary catheter. The MDS included diagnoses of other neurological conditions, benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and retention of urine. The Care Plan with a target date of 9/3/25 included the following Focuses and Interventions:a. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident to resident altercations (Resident #5, #6, #11, #13). On 7/20/24, Resident #4 scratched Resident #13. On 11/22/24, Resident #4 hit Resident #5 in the hand with an empty plastic pop bottle and shortly after hit Resident #6 in the back. On 2/4/25, Resident #4 hit Resident #11 on the head and shoulder and kicked her knees. The facility reported a census of 79 residents.

Inspectors wroteBased on observation, policy review, and staff interviews, the facility failed to maintain hot holding temperatures above 135 degrees Fahrenheit for 1 of 1 meal observed. The facility reported a census of 79 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to implement resident centered care plan interventions to protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident to resident altercations (Resident #5, #6, #11, #13). The facility continued to use the intervention of resident separation, and implimentation of 15-minute checks, with additional follow up intervention. On 7/20/24, Resident #4 scratched Resident #13. On 11/22/24, Resident #4 hit Resident #5 in the hand with an empty plastic pop bottle and shortly after hit Resident #6 in the back. On 2/4/25, Resident #4 hit Resident #11 on the head and shoulder and kicked her knees. The facility reported a census of 79 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to follow physician's orders for a genetic testing referral for 1 of 3 residents reviewed for a physician's orders(Resident #4). The facility reported a census of 79 residents.

Inspectors wroteBased on observation, clinical record review, resident, family, and staff interviews, the facility failed to respect each resident's dignity throughout all cares provided or talk to residents with dignity and respect. The facility reported a census of 71.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility identified a census of 71 residents.

Inspectors wroteBased on direct observation, family and staff interviews, the facility failed to appropriately supervise and have interventions in place to ensure the resident's individual safety in the Chronic confusion and dementing illnesses (CCDI) unit. The facility reported a census of 28 in the CCDI unit and a total census of 71.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review the facility failed to utilize infection control techniques in order to prevent cross contamination for 2 of 3 residents reviewed for catheter care, treatments, and dressing changes (Resident #6 and #28). The facility also failed to ensure staff changed gloves and performed hand hygiene when contaminated for two of three residents observed. The staff failed to utilize a barrier and disinfect contaminated equipment and surfaces after use for 1 of 3 units observed. The facility staff also failed to don personal protective equipment on a resident on enhanced barrier precautions prior to catheter care for 1 of 3 units observed. The facility also failed to provide peri-care in a manner to prevent cross-contamination and infection for 1 of 3 residents observed for peri-care. [...]

Inspectors wroteBased on clinical record review and staff interview the facility failed to provide the resident/resident representative notice of the bed hold policy at the time of transfer for hospitalization for two (Residents # 36 and #43) of three residents reviewed. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to develop and implement a Baseline Care Plan that included anticoagulant (blood thinner), antipsychotic, and antidepressant medications and monitoring for one (Resident #76) of three residents reviewed. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review, resident, family, and staff interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being. Clinical record review revealed the nursing staff failed to provide thorough assessment, did not contact the resident's physician in a timely manner or provide treatment for 1 of 18 residents reviewed. (Resident#61).

Inspectors wroteBased on clinical record review, observations, staff interview, competency checklist, and a mechanical lift manufacturer user instruction manual, the facility staff failed to utilize safe transfer technique when they used a mechanical lift (Hoyer) transfer device for 1 of 3 residents observed for transfers and required a mechanical lift for transfers (Resident #23). The facility also failed to ensure adequate ventilation and temperature controls in a room that contained servers and electronic devices. The facility also failed to ensure bathroom call lights accessible for residents and staff for 1 of 3 units observed. The facility reported a census 71 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and the facility policy review, the facility staff failed to provide complete incontinence care for one of three residents reviewed (Resident #23). The facility reported a census of 71 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 5 errors out of 37 opportunities for error resulting in an error rate of 13.51% (Residents #69). The facility identified a census of 71 residents

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to follow the physician's orders and administer medications as ordered. Facility staff administered medications through a gastrostomy tube instead of by mouth as ordered for 1 of 7 residents observed during medication administration. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure staff protected and prevented resident to resident abuse for 1 of 1 resident reviewed (Resident # 3), when Resident # 2 slapped Resident #1 while in the lounge area. Resident #2 had a known history of resident to resident altercations and history of hitting staff, and the facility failed to evaluate the effectiveness of the interventions implemented to prevent harm to other residents. The facility reported a census of 72 residents.

Inspectors wroteBased on observation, clinical record review, policy review, resident and staff interviews, the facility failed to carry out safety interventions to prevent the likelihood of further abuse perpetrated by Resident #2 for 2 of 2 residents reviewed for abuse (Resident #'s 1 and #3); the facility failed to carry out interventions to prevent a fall with a major injury for 1 of 3 residents reviewed for a fall (Resident #6). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, clinical record review, documentation from the facility self-report, staff interviews and facility policy the facility failed to provide an environment free from sexual abuse for 1 of 2 residents reviewed for sexual abuse. (Resident #1). Resident #2, the aggressor was well known for sexual behavior and comments toward other females. Resident #1 experienced unwanted sexual touching on 3/16/24. On 4/23/24, Resident #2 was observed sitting by Resident #4 who had poor cognitive status, and was unsupervised by staff for over two minutes. A serious adverse outcome was likely to occur as the facility failed to provide proper supervision of Resident#2, which put Resident#4 and any other vulnerable residents at risk for unwanted sexual advances. There was an immediate need for the facility to take steps to ensure all residents were protected from the risk of abuse. [...]

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to hold a medication as directed per the physicians orders for which caused a resident to reschedule an appointment for 1 or 3 residents reviewed. (Resident #1). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review and staff and resident interview, the facility failed to provide two baths a week as directed for 2 out of 4 residents reviewed (#1 and #4). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, and staff interview the facility failed to have 1 of 3 residents seen at least once every 60 days by the physician. (Resident #1) The facility census was 78 residents.

Inspectors wroteBased on resident and staff interviews, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 1 of 3 residents reviewed . (Resident #1). The facility identified a census of 78 residents.

Inspectors wroteBased on resident interviews, staff interviews, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time, under 15 minutes. Residents and staff reported having low staffing caused missed or delayed cares. The facility reported a census of 72 residents.

Inspectors wroteBased on resident interview, clinical record review, and staff interview, the facility failed to treat residents with dignity and respect throughout cares provided for 3 of 9 residents reviewed (Resident #2, Resident #12, and Resident #14). The facility reported a census of 72 residents.

Inspectors wroteBased on resident interview, staff interview, documentation review, and facility policy review, the facility failed to report an allegation of abuse within two (2) hours to the State Survey Agency related to mistreatment of 1 resident (Resident #12). The facility reported a census of 72 residents.

Inspectors wroteBased on the clinical record reviews, resident and staff interviews, the facility failed to provide residents with the assistance of Activities of Daily Living (ADLs) for 4 out of 6 residents reviewed for baths/showers (Residents #31, #49, #56, and #61). The facility reported a census of 78 residents.

Inspectors wroteBased on observation, staff and resident interviews, the facility failed to provide sufficient number of staff to provide Activities of Daily Living (ADL) assistance for 4 out of 5 residents reviewed (Resident #31, #49, #56 and #61). The facility reported a census of 78 residents.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities in order to address problem-prone areas and create a plan for improvement. The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility failed to provide quarterly financial statements for 3 of 3 residents reviewed for personal funds. (Residents #15, #35, and #36). The facility reported a census of 78 residents.

Inspectors wroteBased on employee file review, policy review, and staff interview, the facility failed to complete a criminal background check to include a record check evaluation for 1 of 3 staff members reviewed (Staff A). The facility reported a census of 78 residents.

Inspectors wroteBased on electronic record reviews, staff interview, and resident interview, the facility failed to develop a comprehensive, person-centered Care Plan for 2 out of 3 residents reviewed (Resident #19 and #61). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility failed to conduct quarterly care conferences which included the resident and/or the resident's representative and the interdisciplinary team for 3 of 3 residents reviewed (Residents #66, #67, and #68). The facility reported a census of 78 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, and staff interview, the facility failed to carry out a physician ordered intervention by failing to ensure the application of compression socks (used to prevent blood clots and aid in circulation) for 1 of 3 residents reviewed for assessment and intervention (Resident #56). The facility reported a census of 78 residents.

Inspectors wroteBased on observation, record review, resident, staff interviews, and facility policy review the facility failed to implement safety measures and interventions to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. On 11/26/23 during the lunch meal Resident #2 pushed a table into Resident #3 who responded by throwing cooled coffee on Resident #2. Later that same shift Resident #2 verbally threatened Resident #3 that she was going to get her. The facility separated the residents but failed to implement any measures to prevent further aggression. At approximately 7:00 p.m. that same day, a staff person responded to a commotion in Resident #3's room. Resident #2 and #3 were both in the room. [...]

Inspectors wroteBased on observation, record review, resident, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. The facility identified 31 other residents reside on the CCDI unit. Additionally, the facility failed to provide a safe mechanical lift transfer for 1 of 3 residents reviewed (Resident #1). The facility further failed to provide a safe environment on the CCDI unit allowing residents to exit the unit to a secured outdoor area without staff knowledge or consent due to the door alarm being deactivated.

Inspectors wroteBased on observation, record review, resident, staff interviews, and facility policy review the facility failed to have sufficient staff to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. Staff left the residents unattended and went to the nurse's station located in the middle of the unit to get help because there was no call light available in the room to summon help, no nurse was on the unit, and the CMA and the other CNA were in the enclosed nurses station and couldn't hear her calling for help. The facility identified 31 other residents reside on the CCDI unit. Additionally, the facility failed to have sufficient staff to provide a safe mechanical lift transfer for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, staff and resident interviews, staff posting sheets, nursing staff schedules, and the Facility Assessment, the facility failed to have a sufficient number of nursing staff on duty on a 24 hour basis to adequately and safely meet the residents' needs.

Inspectors wroteBased on employee interviews and facility documentation, the facility failed to have full time Registered Nurse Director of Nursing. The facility reported a census of 81 residents.

Inspectors wroteBased on resident interviews, staff interviews, resident council notes, and facility policy review, the facility failed to address issues brought forward from the Resident Council. The facility reported a census of 81 residents.

Inspectors wroteBased on resident interview, staff interviews, and resident [NAME] of Rights, the facility failed to facilitate the residents receiving unopened mail delivered to the facility. The facility reported a census of 81 residents.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to provide a safe and homelike environment by failing to exercise reasonable care for the protection of the resident's property from loss or theft for 4 of 4 residents reviewed for missing belongings (Resident #49, #15, #31, & #284) and failed to maintain a safe, clean, comfortable, and homelike environment during remodeling of the facility. The facility reported a census of 81 residents.

Inspectors wroteBased on employee file review, communication from facility staff, and facility policy review, the facility failed to ensure 1 of 6 staff members (Staff E) completed the two hour Dependent Adult Abuse training within 6 months of hire date. The facility further failed to complete a Single Contact Repository (SING) background check prior to hire for 1 of 6 staff members (Staff C). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to develop comprehensive Care Plans for 5 of 19 residents reviewed (Resident #19, #31, #49, #52 and #77). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, resident and staff interview, and policy review, the facility failed to ensure residents received adequate frequency of baths/showers per the residents preference for 5 of 6 residents reviewed for baths/showers (Residents #15, #35, #49, #87, and #284). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to secure medications in a locked medication cart for two of four medication carts. The facility reported a census of 81 residents.

Inspectors wroteBased on observation, staff interviews, and the facility policy review, the facility failed to provide functional furniture appropriate to the residents needs for 11 out of 32 rooms reviewed. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, family and staff interviews, the facility failed to adequately equip residents with a communication system to call for assistance from a bedside and from toilet and bathing facility for 32 residents in the facility. The facility reported a census of 81 residents.

Inspectors wroteBased on resident observations, record review, staff interview, and policy review, the facility failed to provide residents with facial cleaning after meals for 1 of 8 residents reviewed for dignity (Resident #1). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to maintain Medicaid funded Resident Trust Fund (RTF) amounts exceeding $50 in an interest-bearing account. The facility also failed to secure RTF money held at the facility for 19 residents. The facility reported a census of 81 residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide individual financial records through quarterly statements for 3 of 3 residents (Residents #15, #35, and #36). The facility identified a census of 81 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 19 resident's reviewed in the sample (Residents #52). The facility reported a census of 81 residents.

Inspectors wroteBased on record review, family and staff interviews, and policy review, the facility failed to involve the resident and resident's representative in care conferences, and in making decisions about his or her plan of care and care plan development for 1 of 4 residents reviewed for care conferences (Resident #31).

Inspectors wroteBased on record review, policy review, and staff interviews the facility failed to properly discharge a resident by failing to provide a 30-day discharge notice and necessary discharge paperwork for 1 of 1 resident reviewed (#49). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, speech therapy recommendations, and staff interviews, the facility failed to follow speech therapy recommendations for a resident who had dysphagia for 1 of 7 residents reviewed (Resident #44). The facility also failed to obtain daily weights and notify the physician as ordered when a resident had a weight gain greater than 3 pounds in a day or 5 pounds in a week for 1 of 7 residents reviewed, and also failed to complete follow up skin assessments for 1 of 7 residents reviewed for a skin condition (Resident #87). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and policy review the facility failed to provide proper incontinence care to minimize the risk of cross-contamination and prevent the risk and occurrence of a urinary tract infection for 3 and 3 residents observed for incontinence care (Resident #31, #52, and #1).

Inspectors wroteBased on clinical record review, observation, staff interviews, and facility policy review, the facility staff failed to ensure a physician's order for oxygen use and failed to ensure oxygen equipment maintained for one of two residents reviewed for oxygen use (Resident #52). The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review, the facility failed to assure a medication error rate of less than 5%. The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to assure residents in the facility to be free of significant medication errors. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, observations, resident and staff interview, and facility policy review, the facility staff failed to change gloves and sanitize hands during cares, and failed to provide a sanitary environment and maintain infection control practices to prevent the potential spread of infection or disease for 3 of 19 residents sampled (Resident #52, #6, #35). The facility also failed to properly disinfect a glucometer after resident use for 1 of 2 observations. The facility reported a census of 81 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staffing information was posted daily with current date, resident census, and staffing hours. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide notice to the resident and/or representative of the facility's bed-hold policy prior to and upon transfer to the hospital for 4 of 4 residents reviewed for transfers to the hospital or another facility (Resident #87, #15, #24, and #49). The facility reported a census of 81 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure 1 of 1 Minimum Data Set (MDS) assessments reviewed for not being submitted to the Centers of Medicare and Medicaid Services (CMS) in 120 days (Resident #43). The facility reported a census of 81 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) assessment was completed and transmitted within 14 days of the Assessment Reference Date (ARD) for 1 of 2 residents reviewed (Resident #9). The facility reported a census of 81 residents.