Rehabilitation Center of Des Moines

Inspectors wroteBased on clinical record review, observation, resident interview, staff interviews, nurse practitioner interview, and facility policy. The facility failed to follow up on progress notes from the nurse practitioner with orders for premarin vaginal cream (a prescription medication that contains estrogen used to treat certain types of urinary incontinence) 1 of 3 residents. (Resident#1). The facility reported a census of 70. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact for Resident#1 (R1). The Care Plan initiated 12/10/25 instructed staff that R1 had incontinence and to check as required for incontinence. Change clothing as needed after incontinence episodes. The Progress Note dated 4/29/26 by the Nurse Practitioner documented R1 was seen for complaints of urinary incontinence. [...]

Inspectors wroteBased on clinical record review, observation, resident interview, staff interviews, and review of the facility policy. The facility failed to administer Levothyroxine and Acyclovir per physicians orders for (Resident #7) 1 of 3 Residents reviewed. The facility reported a census of 70. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The physician signed a written order for Acyclovir (an antiviral medicine used to manage and treat viral infections like cold sores, genital herpes, shingles, and chickenpox) 800 mg 1 tablet 5 times daily by mouth for 7 days on 6/1/26. On 6/2/26 at 7:25 AM, Resident #7 indicated she was having some pain and had something that was like chicken pox. [...]

Inspectors wroteBased on electronic record review (EHR), staff interviews, policy review, and guidance from the 2024 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for 5 of 18 resident. Residents #1, #3, #6, and #13 were not coded correctly regarding pneumococcal vaccinations and Resident #3 and #13 were not coded correctly regarding the use a Code Alert (wander guard) bracelet. The facility reported a census of 72.

Inspectors wroteBased on record review, staff interview and policy review the facility failed to vaccinate an eligible resident with the pneumococcal vaccine for 5 of 5 resident reviewed, (Residents #1, #3, #6, #8 and #13). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, resident and staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 5 of 5 resident reviewed for vaccines (#1, #3, #6, #8, and #13). The facility reported a census of 72 residents.

Inspectors wroteBased on electronic health record review (EHR), staff interviews, and policy review, the facility failed to complete and document resident neurological exams (neurochecks) as scheduled for 2 of 2 residents reviewed for falls (Residents #3 and #8.) The facility reported a census of 72.

Inspectors wroteBased on electronic health record review (EHR), staff interviews, and policy review, the facility failed to coordinate nutritional care with the dialysis unit for 1 of 2 residents reviewed for dialysis (Resident #2). The facility reported a census of 72.

Inspectors wroteBased on electronic health record review (EHR), observations, staff interview, and policy review, the facility failed to provided oxygen (O2) therapy as ordered by the physician for 1 of 1 residents reviewed for respiratory care (Resident #2). The facility reported a census of 72.

Inspectors wroteBased on record review, observation, staff interview, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices to prevent cross contamination by staff failing to perform appropriate hand hygiene during medication administration for 1 of 4 residents reviewed for medication administration (Resident #2). The facility reported a census of 72 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide privacy and dignity while providing care to 1 out of 3 residents reviewed (Resident #5). Staff provided care to Resident #5 while she was lying in bed. During the provision of care both upper and lower areas of Resident #5 were exposed to include her breasts, buttocks and genitals. The blinds on this resident's window were left open with a parking lot just outside of her window. The facility reported a census of 72 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to have clear direction for their staff regarding code status for 1 of 1 resident reviewed (Resident #2). The facility had a doctor's order for a full code which directed that in the event Resident #2's heart and respirations should stop, CPR (Cardiopulmonary Resuscitation)(Chest Percussions and rescue breathing) (Full Code) was to be performed. The IPOST (Iowa Physician's Orders for Scope of Treatment) for this resident directed that this resident was to be a DNR (Do Not Resuscitate) in the event Resident #2's heart and respirations should stop this resident was not to have chest percussions nor was he to have rescue breathing given to him. The facility reported a census of 72 residents.

Inspectors wroteBased on observation, interviews, and record and policy review, the facility failed to ensure safety risks were minimized for 1 of 1 resident observed (Resident #8). Resident #8 was observed being pushed in her wheelchair (w/c) by Staff F, Certified Nurse Aide (CNA) without her feet on w/c pedals. It was noted that the bottom of Resident #8's feet were skimming the floor while Staff F was pushing her. The facility reported a census of 72 residents.

Inspectors wroteBased on observation, clinical record review, staff interview and family interview, and policy review, the facility failed to maintain infection control standards due to not wearing Personal E(PPE) of gown and gloves while providing high contact care activity for a resident required to be on Enhanced Barrier Precautions (EBP) (an infection control intervention requiring staff to wear designated PPE to reduce transmission of organisms for designated residents) for 3 (Resident #49, #119, and #219) of 3 residents reviewed and not completing proper hand hygiene with cares for 1 (Resident #52) of 1 reviewed. The facility reported a census of 66 residents.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure dignity was provided, resident pulled to shower room backwards down the hall covered with only a blanket for 1 of 3 residents reviewed for dignity (Resident #51). The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review, the facility failed to revise and update a comprehensive person-centered care plan for 2 of 21 residents reviewed (Residents #27 and #61). The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to obtain follow-up blood work in the timeframe ordered by the Primary Care Provider (PCP) laboratory (Resident #49) and the resident was eventually hospitalized with 1 of 3 residents reviewed. The facility reported a census of 66 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility policy the facility failed to ensure specialist referral for 1 of 3 residents reviewed for referrals. Resident #38 complained of worsening vision. The facility reported a census of 66 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview the facility failed to ensure an emergency tracheostomy kit was at the resident's bedside for 1 of 3 residents reviewed (Resident #57). The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure 1 of 1 residents reviewed for vehicle safety(Resident #8) was secured in a van during transport, causing the resident to fall out of her seat. The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to honor a resident's desire to be a Do Not Resuscitate(DNR) status by initiating cardiopulmonary resuscitation(CPR) for 1 of 4 residents(Resident #2) reviewed for advance directives(written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual was incapacitated). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to notify the resident's family of an increase in pain and the need for additional pain medication for 1 of 3 residents reviewed for a change in condition(Resident #1). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to report an allegation of abuse to the State Agency within 2 hours for 1 of 1 residents reviewed for an allegation of abuse(Resident's #3). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to separate an alleged perpetrator of abuse(Staff D) from other residents for 1 of 1 allegation of abuse reviewed(Resident's #3). The facility reported a census of 65 residents.

Inspectors wroteBased on observations, staff interview, clinical record review, and policy review the facility failed to implement appropriate infection control practices to prevent cross contamination. The facility reported a census of 68 residents.

Inspectors wrote4. A Minimum Data Set (MDS) dated [DATE] for Resident #6, included diagnoses of Non-Alzheimer's Dementia and heart failure. The MDS identified the resident required extensive assistance of one staff for dressing. A continuous observation on 10/02/23 starting at 8:36 AM, Resident # 6 was in the dining room with six other residents. Resident #6 was sitting in a wheel chair, dressed in a shirt and with a blanket covering above knees to feet, with her bare upper thighs exposed. At 8:47 AM, a staff member pulled the blanket up to resident's waist and the blanket slid back down with exposure of upper thighs again and remained exposed until resident was taken to her room at 9:05 AM. An observation on 10/03/23 at 8:40 AM, Resident # 6 was in the dining room with staff assisting with dining. Resident was dressed in shirt and pants, no socks with bare feet exposed. An observation on 10/04/23 at 8: [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to report the results of an investigation for an allegation of abuse within 5 working days of the incident to the State Survey Agency for one of three residents reviewed (Resident #170). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to refer 1 of 1 sampled resident with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who had a possible newly diagnosed serious Mental Disorder, Intellectual Disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination (Resident #17). The facility reported a census of 68 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive care plan for 2 of 2 residents reviewed (Residents #7 & #54). The facility reported a census of 68 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive care plan for 1 of 1 resident reviewed (Resident #17). The facility reported a census of 68 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to ensure two storage closets were locked when not in use. The facility reported a census of 68 residents.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure residents who were reliant on enteral nutrition received their tube feeding per physician orders for 2 of 3 residents reviewed for tube feedings (Resident #32 & Resident #63). The facility reported a census of 68 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to provide adequate pain management for 1 of 17 residents reviewed (#7). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis treatment (Resident #17). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide a complete, accurate, and detailed record for resident medication administration for 1 of 1 resident reviewed and failed to protect resident information from unauthorized access for 1 of 1 resident reviewed. The facility reported a census of 68 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to provide a call system for resident access for 2 of 19 residents sampled (Resident #9 & #32).

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify the long term care ombudsman for resident transfers to an acute care hospital for 1 of 3 residents reviewed for rehospitalization (Resident #12). The facility reported a census of 68 residents.