Harmony West Des Moines

In the surveyor’s words

From the most serious findings on record at Harmony West Des Moines, in the surveyor’s own words.

• Immediate jeopardy, widespreadF725Jun 8, 2023

  Based on observations, clinical record review, resident, family, and staff interviews, resident council notes, and policy review the facility failed to ensure sufficient and competent staff available to provide care to all residents as evidenced by residents with pressure ulcers and not being repositioned, lack of adequate staffing supervision of a resident observed near a hazard and a resident who tipped his motorized wheelchair when outdoor at the facility, and failure to administer treatments and medications timely. The facility staff also failed to ensure call lights within reach of residents and failed to ensure staff responded and answered residents' call lights within 15 minutes to meet residents' needs in a timely manner for 2 or 2 nursing units observed. […]

• Immediate jeopardy, widespreadF835Jun 8, 2023

  Based on observations, resident interviews, family interviews, staff interviews, clinical record review, facility assessment review, previous 2567 review, and employee file review, the facility's administration failed to effectively and efficiently maintain administrative responsibilities to ensure provision of ethical, high-quality health care services. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety affecting all residents. The facility reported a census of 86 residents. Findings include: The State Agency informed the facility of the IJ on 6/8/23 at 3:00 PM and provided the IJ template. The IJ began on 5/28/23 when the staff first reported issues with management not caring about their reported concerns. […]

• Immediate jeopardy, patternF684Jun 8, 2023

  Based on record review, staff interviews, and facility policy review the facility failed to assess and provide immediate interventions for Resident #39 who on [DATE] at 10:00 AM experienced a significant change in physical status and informed staff he didn't feel right and felt like he was dying. The resident presented with puss coming out of the urinary catheter insertion site, skin pale, statements of cold, sweating profusely, urine cloudy, and dull gray color, and blood sugar reading of 536 mg/dL. The staff failed to contact hospice or the primary care physician (PCP) for treatment orders and the resident passed away at approximately 2:30 PM. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety. […]

• Immediate jeopardy, patternF849Jun 8, 2023

  Based on record review, staff and family interviews, hospice documents, hospice agreement, and facility policy review the facility failed to notify 1 of 3 resident's hospice provider when he had an emergent change in condition (Resident #39). On [DATE] at 10:00 AM, the resident indicated the resident did not feel good and stated he felt like he was dying. The staff member noticed he was pale in color, cold to the touch, profusely sweating, and dull gray urine present. The Certified Medication Aide (CMA) checked his blood sugar and it was 536 mg/dL and gave him a pain medication for discomfort. The hospice provider on-call personnel that day indicated she was not notified of Resident #39's emergent change in condition. […]

• Immediate jeopardy, isolatedF684Mar 14, 2023

  Based on clinical record review, resident representatives and staff interviews, the facility failed to 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 did not perform a thorough assessment and follow-up assessments for 2 of 2 residents reviewed (Resident #87 and #150). Which resulted in an immediate jeopardy to residents' health and safety. The State Agency informed the facility of the Immediate Jeopardy (IJ) on March 8, 2023 at 10:15 A.M. and provided the IJ template. […]