Arbor Springs of West Des Moines L L C

Inspectors wroteBased on observation, clinical record review, resident, family and staff interview and policy review, the facility failed to provide appropriate supervision for 1 of 3 residents reviewed for falls (Resident #3). The facility failed to provide a complete assessment and investigation to determine the root cause and failed to monitor and modify interventions in order to prevent further accidents for Resident #3. The facility also failed to utilize assistive devices per care plans to prevent bruising injuries for 2 of 2 residents (Resident #4 & #6). During the survey process, staff were observed to transfer residents by gripping forearms and hands. After alerting the facility, to prevent further injury, the staff were observed to place the gait belt then continue to grip the residents by the arms and not by the gait belt during transfers. The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, staff interview and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a significant change in status assessment (SCSA) that should have been completed within 14 days after it was determined the resident's status from baseline had occurred for 2 of 12 residents reviewed (Resident #3 & #1). The facility failed to complete a SCSA when Resident #3 experienced a decline in activities of daily living physical function after the return from hospital care for fractured hip repairs on 3/10/26 and on 5/6/26. The facility also failed to complete a timely significant change for Resident #1 when enrolled into Hospice care. The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 1 of 3 residents (Resident #2) who were sampled for care plan review. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, family interview and staff interviews, the facility failed to appropriately supervise and maintain an environment free of potential hazards for 1 of 1 residents reviewed (Resident #2) after a resident made suicidal statements and self harmed. The facility reported a census of 49 residents.

Inspectors wroteBased on employee file review, staff interview, and policy review, the facility failed to ensure completion of dependent adult abuse training within six months of hire for 1 of 5 employee files reviewed. The facility reported a census of 53 residents.

Inspectors wroteBased on record review, observation, resident and staff interview, and policy review the facility failed to document follow up skin assessments for 1 of 3 residents reviewed for skin concerns (Resident #2). The facility reported a census of 53 residents.

Inspectors wroteBased on direct observation, staff interview, and clinical record review, the facility failed to protect residents from potential accidents and hazards for 1 of 16 residents reviewed (Resident #46). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, pharmacy interview, manufacturer recommendations, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 30 opportunities for error resulting in an error rate of 6.67 % (Residents #1 and #21). The facility identified a census of 53 residents.

Inspectors wroteBased on direct observation, clinical record review, staff interview, and policy review, the facility failed to provide residents with prescribed therapeutic diets for 1 of 3 residents reviewed (Resident #30). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) practices for a resident with an open pressure injury for 1 of 3 resident reviewed for pressure ulcer/injury (Residents #14). The facility reported a census of 53 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, facility staff correspondence and policy review, the facility failed to provide a thorough assessment and timely intervention for 1 of 4 residents reviewed. (Resident #1). On 2/23/25 Resident #1 was lowered to the floor. Staff E, Certified Nurse Assistant (CNA) notified Staff A, Licensed Practical Nurse (LPN) who failed to complete a thorough assessment. The Assistant Director of Nursing (ADON) was notified at 9:15 AM on 2/24/25 that Resident #1 was in pain, the ADON failed to do an assessment until 3:15 PM and the Director of Nursing (DON) obtained an order for pain medication yet failed to ensure that it was administered. An x-ray on 2/25/25 revealed a displaced hip fracture that required surgical intervention. The facility reported a census of 53 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to provide post-fall assessments and interventions for 3 of 3 residents reviewed (Residents #1, #2, and #3). The facility reported a census of 55 residents.

Inspectors wroteBased on Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) data, facility document review, and staff interviews, the facility failed to maintain a Register Nurse (RN) for at least 8 consecutive hours a day. The Facility reported a census of 51. Review of the CMS Payroll Based Journal data revealed the facility did not report an RN in the facility for a 48-hour period starting on 11/04/23 until the end of day on 11/05/23. Review of the staffing schedule provided by the Administrator on 06/05/24 at 08:19 AM confirmed the Payroll Based Journal data. There was not an RN in the facility for a 48-hour period starting on 11/04/23 and ending end of day 11/05/23. Review of the facility assessment last updated in 12/23 did not state the daily staffing requirements. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility failed notify the long term care ombudsman for a resident transfer to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident #36).

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to document skin assessments for one of two residents reviewed for skin conditions (Resident # 9). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to ensure staff provided incontinence care to minimize the risk of cross-contamination and minimize the risk of urinary tract infections for one of four residents observed for incontinence care (Residents #26), and failed to utilize infection control techniques and changed gloves when contaminated while providing incontinence cares. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 2 of 2 residents (Resident #26 and Resident #37) reviewed for nutrition. This failure resulted in harm due to Resident #26 experiencing a weight loss of over 17% in 6 months and Resident #37 experiencing a weight loss of over 10% in 6 months. The facility reported a census of 53 residents.

Inspectors wroteBased on observations, clinical record review, and staff interview, the facility failed to implement intervention to prevent a resident who did not have a pressure ulcers from developing one for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 53.

Inspectors wroteBased on clinical record review, beneficiary notices of noncoverage review, and staff interview, the facility failed to provide the required forms for Medicare Liability Notices and Beneficiary Appeals within 48 hours of when skilled services ending for 2 of 3 residents reviewed (Residents # 17 and #100). In addition the facility failed to adequately inform residents of their right to appeal the decision for discontinuation of skilled services for 1 of 3 residents reviewed (Residents #100). The facility reported a census of 53 residents.