Wesley Homes Des Moines Health Center

In the surveyor’s words

From the most serious findings on record at Wesley Homes Des Moines Health Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 21, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure one of two residents (Resident 2) reviewed for falls with fractures, received care and services according to professional standards. The failure to thoroughly assess and timely identify a hip fracture after a fall including a delay of emergency treatment and the omission of an ordered narcotic pain medication prior to medical transport to the emergency room resulted in harm to Resident 2 and diminished quality of life. […]

• Actual harm, isolatedF689Mar 21, 2023

  Based on observations, interviews, and record review the facility failed to provide adequate supervision, implement care interventions, and/or complete a thorough investigation of accidents for 2 of 2 residents (Residents 1 & 2) reviewed for falls with fractures. The failure to supervise and implement interventions for care needs resulted in harm to Resident 1 including a wrist fracture, severe pain, emotional distress, and diminished quality of life. The failure to ensure residents receive supervision to prevent accidents placed residents in the memory care unit at risk for falls and injury. The failure to identify the root cause of the resident falls detracted the facility from preventing future falls, placing residents at continued risk for falls and injury. […]

• Actual harm, isolatedF686May 5, 2022

  Based on observation, interview and record review the facility failed to ensure timely skin/wound assessments to monitor and evaluate residents skin and to implement interventions to prevent a coccyx pressure ulcer (PU) for 1 of 3 sampled residents (Resident 1) reviewed for pressure ulcer/injury. These failures resulted in the development of Resident 1's avoidable unstageable pressure ulcer. Findings included . Review of the 02/2022 facility policy titled Pressure Injury, Prevention and Management policy showed the assessment of pressure injuries would be performed by a licensed nurse (LN) and documented on the (fill in blank form designated form). […]

• Actual harm, isolatedF689Feb 5, 2021

  Based on observation, interview and record review, the facility failed to provide a safe environment for one (#1) of 11 residents reviewed for accidents. The facility failed to put measures in place to prevent Resident #1 from rolling out of bed and making contact with an adjacent base-board heater. This failure caused actual harm to the resident who incurred substantial burns, with subsequent pain and diminished quality of life. Findings included . A 01/14/2021 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident #1 was admitted to the facility on [DATE], had unclear speech, highly impaired vision and wore no corrective lenses, severely impaired cognitive skills for daily decision making, and required extensive assistance of two people for bed mobility and transfers. […]

• No harm, potential for more than minimal, widespreadF726Oct 29, 2024

  Based on interview and record review the facility failed to ensure nurse and nurse aide staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 7 of 7 staff (Staff H, I, J & K - Nurse Aids and Staff E, G, & R - Licensed Nurses) reviewed for competency. […]