Arbor Springs of West Des Moines L L C

In the surveyor’s words

From the most serious findings on record at Arbor Springs of West Des Moines L L C, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 30, 2026

  Based on clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to assess and respond to residents change in bowel status and failed to perform physician ordered weekly weight checks for 1 of 1 resident's reviewed for bowel and bladder and weight loss or gain (Resident #4). This resulted in harm to the resident when she was hospitalized for constipation and required manual disimpaction of stool. The facility reported a census of 46. Findings include; The Minimum Data set (MDS) for Resident #4, dated 04/22/2026, documented the following diagnoses: hypertension (high blood pressure), diabetes Mellitus (diabetes), Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, asthma or chronic obstructive pulmonary disorder (COPD). […]

• Actual harm, isolatedF689Jun 30, 2026

  Based 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. […]

• Actual harm, isolatedF684Mar 12, 2025

  Based 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 [DATE] 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 [DATE] 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 [DATE] revealed a displaced hip fracture that required surgical intervention. […]

• Actual harm, isolatedF692Mar 9, 2023

  Based 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. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 identified the presence of short and long-term memory impairment. The MDS revealed the resident required supervision with setup help from staff to eat. […]

• No harm, potential for more than minimal, widespreadF727Jun 30, 2026

  Based on clinical record review, staff interviews, and facility policy review the facility failed to maintain a Registered Nurse (RN) in the building for eight (8) consecutive hours a day. The facility reported a census of 46. Findings include: Review of a file titled Nursing Schedule Past 30 days, provided by the facility to surveyors on 06/23/2026 documented on 06/20/2026 five Licensed Practical Nurses (LPN) were in the building providing nursing coverage for the day, but no mention of RN coverage was present. In an interview on 06/25/2026 at 10:02 AM with the Director of Nursing (DON), she confirmed there was no RN present in the building on the 20th. She acknowledged this was a requirement. […]