Resident #10 told federal inspectors on September 8 that staff "almost ran out of briefs last week." She received the wrong size brief, one size smaller than what she wore. "Staff had to lay one brief and then pieced another brief to it," she said. "The staff made it work, it held the urine."
The makeshift solution came during a broader pattern of supply shortages that frustrated both residents and staff at the Des Moines facility.
Resident #14 said the facility "always ran out of supplies, then the facility tells the staff they are using too much or wasting it." She also complained that her room needed dusting more often than it was being done.
The Director of Nursing acknowledged there had been times when she got calls about running low on supplies, though she claimed they never completely ran out. She couldn't recall when the shortages occurred and "did not want to speak on the wrong date."
Supply problems weren't the only concern inspectors found during their September complaint investigation.
Mice had invaded the facility. The Regional Director of Operations said she was aware of mice activity about two weeks before the inspection, and previously in January or February 2025. She believed an outside door by the kitchen contributed to mice entering the building.
The regional director had never actually seen a mouse herself. "She does not do critters," inspectors noted.
Environmental problems plagued multiple areas of the building. In the basement housekeeper office and activity supply room, the ceiling was falling down. Water stains marked walls in both the laundry room and housekeeper office.
The regional director admitted she didn't know how long the ceiling had been deteriorating or when the water damage occurred. "She doesn't spend time in the basement," the report stated.
Air conditioning units in resident rooms needed cleaning, which the regional director confirmed during a facility tour with inspectors on September 11.
Shower room doors weren't latching properly until maintenance recently adjusted them after the regional director noticed the problem during a visit within the previous two weeks.
Basic cleaning protocols appeared confused among staff. The Infection Preventionist couldn't immediately answer who was responsible for cleaning mattresses on resident beds or resident equipment like fans.
When pressed for details on September 11, she said housekeeping routinely cleaned mattresses and fans, and that anyone could wipe down visually soiled mattresses. But she couldn't specify what cleaning products staff used for mattresses, promising to get back to inspectors with that information.
The facility's own policies contradicted the conditions inspectors observed. A Homelike Environment policy from February 2021 promised residents "a safe, clean, comfortable and homelike environment" with "clean bed and bath linens that are in good condition" and "pleasant, neutral scents."
The policy specifically aimed to minimize "characteristics of the facility that reflect a depersonalized, institutional setting, including institutional odors."
A Standard Precautions policy from September 2022 required that resident care equipment soiled with body fluids "are handled in a manner to prevent cross-contamination." It mandated that "environmental surfaces and beds are appropriately cleaned."
Supply ordering fell to one staff member, identified as Staff J, according to both the Infection Preventionist and Director of Nursing. Staff were supposed to tell Staff J what they needed, and supplies would typically arrive the following day via overnight shipping when items on invoices weren't delivered.
The system apparently wasn't working reliably enough to prevent the brief shortage that left staff improvising solutions for residents' basic dignity needs.
Missing wall base and other maintenance issues rounded out the environmental concerns inspectors documented during their tour of the facility.
The inspection found violations affecting "many" residents, though inspectors classified the harm level as minimal or potential for actual harm. The complaints that triggered the federal review revealed a facility struggling with basic supply management while mice roamed areas near food service and building infrastructure deteriorated around residents who deserved better care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Azria Health Park Place from 2025-09-11 including all violations, facility responses, and corrective action plans.