Azria Health Park Place

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

supplier when supplies on the invoice were not delivered. The items got overnight shipped and she typically received those items the following day. In an interview 9/8/25 at 10:05 AM, Resident #10 reported staff almost ran out of briefs last week. She was sent the wrong size brief, it was a size smaller than what she wore. Staff had to lay one brief and then pieced another brief to it. The staff made it work, it held the urine.In

an interview 9/8/25 at 3:20 PM, Resident #14 reported she thought her room needed to be dusted more often then it was being done. The facility always ran out of supplies, then the facility tells the staff they are using too much or wasting it. In an interview on 9/10/25 at 3:40 AM, the Infection Preventionist (IP) reported

she would need to get back to the surveyor about who was responsible for cleaning the mattresses on the resident beds. She would also need to get back to the surveyor about who was responsible for cleaning resident equipment, such as fans. The IP reported Staff J ordered the supplies. Staff told Staff J what they needed. On 9/11/25 at 11:20 AM, the IP reported she checked on who cleaned the mattresses and equipment. Housekeeping routinely cleaned the mattresses and fans in the rooms. If a mattress is visually soiled then anyone could wipe down the mattresses. When asked what staff would clean mattresses with,

she said she would have to get back to the surveyor on what cleaning product is used to clean the mattresses. In an interview 9/11/25 at 11:40 AM, the DON reported Staff J ordered supplies. The DON stated she felt the staff always had adequate supplies and linens. The DON acknowledged there had been

a time when she got a call they were running low on some supplies but they never ran out. The DON stated

she couldn't recall when this occurred, she did not want to speak on the wrong date. The DON reported linens were stocked by housekeeping, and staff were to obtain supplies from the bigger supply room to stock the hall supply rooms. In an interview 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported she was in the shower rooms within the past two weeks. She had maintenance adjust the doors so they latched. The RDO reported she didn't notice any concerns or issues when she was in the shower rooms. The RDO reported she did not know how long the ceiling in the housekeeper office / activity supply room had been falling down or how long the water stained walls in the laundry room or housekeeper office had been there. She doesn't spend time in the basement. The RDO reported she was aware of mice

in the facility about two weeks ago, otherwise she was last aware of mice activity in 1/2025 or 2/2025. She believed the outside door (exit door by the kitchen) contributed to the mice coming into the kitchen. The RDO confirmed she had never seen a mouse at the facility, thank goodness. She does not do critters. A tour of the facility with the RDO on 9/11/25 at 12:50 PM to observe some environmental areas of concern with the AC units in resident rooms, missing wall base, and concerns in the shower rooms. The RDO confirmed the AC units in resident rooms needed to be cleaned.A Homelike Environment policy revised 2/2021 revealed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect

a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment, clean bed and bath linens that are in good condition, and pleasant, neutral scents. The facility staff and management minimized, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting, including institutional odors. A Standard Precautions policy revised 9/2022 revealed standard precautions presume that all blood, body fluids and excretions may contain transmissible infectious agents. Resident Care Equipment soiled with blood, body fluids, secretions and excretions are handled in a manner to prevent cross-contamination and transfer of microorganisms to other residents and environments. Environmental surfaces and beds are appropriately cleaned.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the resident up from the wheelchair. The mechanical lift leg bar remained together as the resident was raised up and transferred toward the bed. As Staff E pushed the mechanical lift under the bed, the lift hit the cords under the bed. Staff E instructed Staff F, CNA, to pull the cords back. Staff E pushed the lift under bed and lowered the resident into bed. In an interview on 9/10/25 at 10:45 AM, the Regional Nurse reported the spread bar needed to be out whenever a resident transferred in a mechanical lift from one surface to another. The Regional Nurse reported they were going to do survey preparation but had not done any kind of competency audits such as transfers with the staff. In an interview 9/11/25 at 11:40 AM, the Director of Nursing (DON) reported their policy did not have information on whether the bars on the mechanical lift should be in or out when a resident transferred in a mechanical lift. The DON reported she thought it depended on where the lift was used and where the resident was being transferred to. The resident rooms were small and the mechanical lift needed to fit in the space that the staff were going. The DON reported she expected staff to follow the manufacturer instructions for use of the mechanical lift. On 9/11/25 at 4:20 PM during exit conference, the [NAME] President of Operations reported the mechanical lifts they have at the facility did not require the legs to be out when transferred a resident, the spreader bar should be opened to get around furniture or a wheelchair. A Safe Lifting and Movement of Residents policy revised 7/2017 revealed staff responsible for direct resident care would be trained in the safe and proper use of mechanical lifting devices. An undated Resident Lift/Transfer Safety Observation Form revealed wheelchair/bed locked prior to transfer. The Form lacked the steps for using a mechanical liftThe Protekt(R) 600 Lift Operation Manual revealed the lift allowed a person to be lifted and transferred safely with minimum physical effort provided by the caregiver. During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. Do not roll casters over any object while the resident is in the sling.The Hoyer HPL500 revealed the lift used for safe lifting and transfer of an individual from one resting surface to another such as a bed to a wheelchair. The lift leg bar can be opened to enable access around armchairs, wheelchairs and other furniture. For transferring and negotiating narrow doorways and passages, the lift legs should be in the closed position.The Linak Medline-Careline Lift User Manual revealed do not open the closing device on the twindrive during operation. Assure free space for movement of the application in both directions to avoid a blockade.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

watch her before. The DON told her to relax, it was fine, she knew how to do the job. In an interview on 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported the Regional Staffing Coordinator determined the staffing levels at the facility and the facility also had a staffing coordinator on-site who was responsible for scheduling staff. The RDO reported she updated the facility assessment.

The RDO reported she expected the resident's call lights answered within 15 minutes. All staff were responsible to answer the call light. If the staff person could not address what was needed then the staff person needed to let the appropriate staff know they needed to help the resident. Review of the Past Calls Report dated 8/27/25 to 9/9/25 revealed call light response times greater than 15 minutes for the following rooms: N14 bed 2 - 3 times. The longest response time was 23 minutes, 24 seconds.N16 bed 2 - 4 times.

The longest response times was 23 minutes, 22 seconds.S5 bed 1 - 47 times. The longest response time was 1 hour and 51 minutes.S5 bed 2 - 3 times. The longest response time was 27 minutes. S6 - 44 times, with the longest response times of 1 hour and 23 minutes and 2 hours and 2 minutesS8 bed 1 - 17 times.

The longest response time was 1 hour and 25 minutes. S8 bed 2 - 9 times. The longest response times was 1 hour and 27 minutes. C2 bed 2 - 23 times. The longest response time was 1 hour and 34 minutes and 2 hours and 8 minutes. Resident Council Notes revealed under New Business an issue of concern to continue with call light audit. The section directed that for each concern raised, ask for a show of hands and how many residents shared the same concern. The following was recorded as the concern and the number of residents who shared the concern for call light audit: 12/26/24: 8 of 8 1/23/25: 7 of 8 2/27/25: 11 of 11 3/26/25: 11 of 114/24/25: 11 of 115/22/25: 10 of 10 The Resident Grievance/Complaint Log dated 1/1/25 9/2/25 revealed call light concerns 1/21/25 and 5/27/25. The facility assessment updated 5/29/25 revealed a facility assessment utilized to determine theresources necessary to care for the resident population served

during day to day operations. The facility assessment included the average daily census of 47-50 residents,

the care required by the population in consideration of the types of diseases, conditions, physical and cognitive abilities, and overall acuity of the residents. The facility assessment also revealed staff competency necessary to provide the level and types of cares needed for the population. The Facility Assessment revealed the number of residents who required assistance with ADL's and needed the assistance of 1-2 staff: Dressing - 31Bathing- 46Transfers- 29Eating -6Toileting -31The Facility Assessment also revealed the number of residents who had dependence on staff for ADL's: Dressing - 9Bathing4Transfers-3Eating -1Toileting -9The Facility Assessment revealed staffing plans are based off resident volume. to evaluate the overall number of facility staff needed to ensure enough qualified staff are available to meet each resident's needs 7 days a week and 24 hours per day. The Facility Assessment listed the total number of staff needed in a 24-hour period, including 3-4 licensed nurses providing direct care, 13-16 CNA/CMA's, and 2-4 housekeeping/laundry/maintenance staff. The resident matrix provided by the facility

on 9/3/25 at 12:04 PM revealed the following:28 residents on the North Hall25 residents on the South Hall6 residents on the Center Hall4 residents had pressure ulcers5 residents were on hospice care1 resident required enteral tube feedings4 residents had a catheterAn Answering the Call Light policy revised 9/2022 revealed ensure timely response to resident's requests and needs. Ensure the call light is accessible to the resident. Answer the call system timely. If you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812

On 9/3/25 at 11:35 AM, the RDO sent an email with the cleaning logs attached. The most recent [NAME] Cleaning Log was dated 5/31/25 and the Dietary Aide Cleaning Log was last completed on 4/29/25.

Level of Harm - Immediate jeopardy to resident health or safety

In an interview 9/4/25 at 12:24 PM, Resident #6 reported he had projectile vomiting for three weeks.

Residents Affected - Many

In an interview on 9/8/25 at 3:20 PM, Resident #14 reported the food at the facility was not that great. She could not eat the tomato soup at the facility because it made her have diarrhea. She ate tomato soup at home without having diarrhea but that was not the case at the facility.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 5:02 PM, Resident #19 reported housekeeping did not come into her room as often as she thinks they should. She had been at other facilities where the rooms were cleaned more often, but her room got cleaned once a week at this facility. The facility also had a lot of flies because the door to the outside was left open for residents to go out to smoke. Resident #19 reported the facility ran short on diapers (briefs) toward the end of the week. She stated she thought it all came down to the money and why the facility did not have adequate supplies. On 9/10/25 at 3:40PM the Housekeeping Supervisor (HS) reported her room had the broken and leaking ceiling for over a year, and she started reporting it before the last survey 11/2024, the leak has gotten worse since then. The HS stated the corporate had come out and viewed the leaks because she reported it to them, and they say it's terrible but nothing gets done. HS further reported

the laundry room is the same it hasn't been repaired yet, it's leaking directly down to a drain. The HS confirmed seeing mice downstairs, and knows there had been mice droppings on laundry as well. The HS reported seeing mice in resident rooms as well a few months ago, and the residents were asked to put their snacks in plastic containers. The Housekeeping Supervisor, stated had seen mice personally while cleaning at least two resident rooms in their dressers in the recent past. In an initial interview with the Acting Administrator and Regional Director of Operations on 09/03/2025 at 3:53 PM, she stated she had only just been informed of rodent activity and her staff are reporting it has been ongoing for at least two weeks. She was aware of previous rodent activity in March of 2025, but had not heard about it since. She stated they had contacted pest control about rodents at that time. On 9/11/25 at 12:35PM the Regional Director of Operations (RD0) reported she was unaware that there was no kitchen sanitation documentation completed, until the survey team requested it. The RDO further stated she was told there had been an issue with mice in the kitchen dating back to the last survey, but staff had not been reporting things to her.

She also reported not being aware of mice in resident rooms, the Maintenance Director should have reported that to her. In an interview 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported she did not know how long the ceiling in the housekeeper office/activity supply room had been falling down or how long the water stained walls in the laundry room or housekeeper office had been there.

She doesn't spend time in the basement. The RDO reported she was aware of mice in the facility about two weeks ago, otherwise she was last aware of mice activity in 1/2025 or 2/2025. She believed the outside door (exit door by the kitchen) contributed to the mice coming into the kitchen. The RDO confirmed she had never seen a mouse at the facility. In an interview on 09/11/2025 at 1:12 PM the Regional Director of Operations (RDO), acknowledged the previous facility leadership had not followed through with the QAPI plan created due to the results of the last standard survey

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. The facility reported a census of 59 residents.Findings Include:The CASPER Report for the facility identified the facility had previously received an Infection control deficiency in 2023 and 2024. A Safe, clean, and homelike environment deficiency in 2023 and 2024. At the conclusion of the complaints survey on 09/11/2025 the facility was cited again for Infection control and Homelike environment. The Facility's QAPI Plan, revised 2/05/2025, identified a monitoring process which included multiple sources of data. The QAPI Plan failed to identify a process to address previously identified quality deficiencies.Review of the QAPI minutes since 11/27/2024 identified repeat deficiencies and deficient practices from the last standard survey, but did not document follow through and showed numerous repeated issues addressed during QAPI meetings. In an interview on 09/11/2025 at 01:12 PM with the Director of Nursing (DON), the acting QAPI designee, she could not explain why there are repeated issues documented in the QAPI meetings, and could not explain where the follow through was documented. She stated her expectation is for the follow through to be documented and for issues to not be repeated. In that same interview, the Regional Director of Operations (RDO), she acknowledged the previous facility leadership had not followed through with the QAPI plan created due to the results of the last standard survey.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azria Health Park Place

2401 East Eighth Street Des Moines, IA 50316

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

the upper buttock toward the leg. Staff F touched and opened the drawers on a bedside table, then opened

a cabinet door and obtained a clean brief. Staff F then changed her gloves and sanitized her hands. Staff F rolled the resident onto her left side. Staff E removed the soiled brief and sling, then took disposable wipes and cleansed the resident's lower back and buttocks. A large amount of liquid stool was present. Staff E continued to cleanse the resident's buttocks with disposable wipes. Staff E placed the soiled linens into a plastic bag, then placed the bag of soiled linens on top of a trashcan. Staff rolled the resident onto her right side then onto her back and attached the tabs on the brief. Staff F removed gloves and sanitized his hands.

At 12:08 PM Staff E bagged up the trash and wheeled the mechanical lift to the common area by the nurse's station. 3.The MDS assessment dated [DATE REDACTED] revealed Resident #1 had diagnoses of dementia, a fractured right lower leg and morbid obesity. The MDS recorded the resident had incontinence.

The Care Plan revised 8/21/25 revealed the resident had incontinence and required assistance of two staff for toileting.

During observation on 9/8/25 at 2:18 PM, Staff E, CNA, removed Resident #1's brief and sprayed cleansing foam onto the resident's abdominal fold and periarea. Staff E provided pericare, then rolled the resident onto her left side. Staff E removed the sling and soiled brief under the resident. Staff E took the bottle of foam cleanser and sprayed the cleanser to the resident's buttocks area. Staff E took disposable wipes and cleansed the buttocks area. Staff G, CNA, rolled the resident, placed a clean brief on the resident then removed her gloves. Staff E did not change gloves or sanitize hands during cares.

In an interview 9/10/25 at 10:45 AM, the Regional Nurse reported she expected staff to change gloves whenever the gloves were dirty.

In an interview 9/10/25 at 3:40 PM, with the Infection Preventionist (IP), the Regional Nurse sat in the room as the surveyor interviewed the IP and stated she was present to observe. The IP reported gloves needed to be changed in-between contact with residents, whenever staff did a check and change, and during cares.

The IP stated gloves needed changed especially if the gloves were soiled. She expected staff to sanitize their hands every time gloves were taken off and staff could use hand sanitizer up to 3-5 times then hands needed to be washed. The IP reported staff should disinfect equipment in-between each use.

In an interview 9/11/25 at 11:40 AM, the Director of Nursing reported she expected gloves changed if soiled or in-between going from a dirty to clean area or task.

The facility's Infection Control Policies and Practices revised 7/2014 revealed the infection control policies were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

A Standard Precautions policy revised 9/2022 revealed standard precautions presume that all blood, body fluids and excretions may contain transmissible infectious agents. Hand hygiene performed with alcohol-based hand rub or soap and water before and after contact with a resident, before moving from work on a soiled body site to a clean body site on the same resident, and after removing gloves. Gloves changed as necessary during the care of a resident to prevent cross-contamination from one body site to another such as when moving from a dirty site to a clean site. Resident care equipment are handled in a manner to prevent transfer of microorganisms to other residents and the environment.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet