Inspection Reports for Edencrest at Siena Hills
455 SW Ankeny Rd, Ankeny, IA 50023, United States, IA, 50023
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 24, 2025, identified several deficiencies related to timely response to personal emergency response system pendants, staff training and documentation, background checks, and dementia-specific continuing education. Earlier inspections showed a pattern of issues primarily involving medication administration, timely care and services, and staff training, with some substantiated complaints about medication errors and delayed responses. Complaint investigations occasionally found no deficiencies, but substantiated cases included medication errors causing adverse effects and failure to follow medication protocols. Enforcement actions included written warnings and retraining related to medication management, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with medication administration and staff training, with no clear improvement trend in recent years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
56 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Date: Sep 24, 2025
Visit Reason
The inspection was conducted as part of an investigation of complaints and incidents related to the facility's care and services.
Complaint Details
The deficiencies were cited during the investigation of Complaints #129981-C, #130213-C, #130334-C and Incidents #130029-I and #130028-I.
Findings
The investigation found multiple deficiencies including failure to respond timely to personal emergency response system (PERS) pendants, inadequate documentation of nurse delegation and training, failure to provide dependent adult abuse training within required timeframes, incomplete background checks prior to employment, insufficient staff training on medication administration, and failure to ensure dementia-specific continuing education for personnel.
Deficiencies (6)
Failure to ensure tenants received adequate care, treatment and services by responding to personal emergency response system (PERS) pendants in a timely manner.
Failure to maintain documentation of current nurse delegated procedures for staff.
Failure to ensure staff received dependent adult abuse training within six months of employment.
Failure to consistently perform background checks prior to employment.
Failure to ensure all personnel including agency/contract staff were appropriately trained to meet tenant needs, including medication administration.
Failure to ensure all staff received eight hours of dementia-specific continuing education annually.
Report Facts
Total census: 56
Tenants without cognitive impairment: 50
Tenants with cognitive impairment: 6
PERS response times: 109
PERS response times: 26
PERS response times: 28
PERS response times: 14
PERS response times: 25
PERS response times: 23
PERS response times: 53
PERS response times: 5
PERS response times: 74
PERS response times: 3
PERS response times: 24
PERS response times: 17
Staff reviewed for nurse delegation documentation: 3
Staff reviewed for background checks: 3
Agency/contract staff reviewed: 5
Staff reviewed for dependent adult abuse training: 3
Staff reviewed for dementia-specific education: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Michaud | Executive Director | Signed report and involved in corrective action plans |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #125266-I and Complaint #1266855-C at the assisted living facility.
Complaint Details
Investigation of Incident #125266-I and Complaint #1266855-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaint.
Report Facts
Number of tenants without cognitive impairment: 38
Number of tenants with cognitive impairment: 17
Total census: 55
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints regarding tenant care and services at Edencrest at Siena Hills.
Complaint Details
The investigation was triggered by complaints #118680-C, #120107-C, #121124-C, and #121808-C. No regulatory insufficiencies were cited for complaint #123001-C. The complaints involved concerns about tenant rights, medication administration, and service plan adequacy.
Findings
The investigation found that the program failed to provide timely care and services to tenants, including delayed response times to calls for assistance and medication administration errors. Additionally, the service plans did not adequately identify tenant needs, including hygiene and housekeeping issues.
Deficiencies (3)
Failed to ensure care and services were consistently provided in a timely manner to tenants, evidenced by delayed response times to calls for assistance for Tenant #3, Tenant #9, and an unidentified tenant.
Failed to ensure medications were administered as prescribed to Tenant C3, including administration of discontinued medications and failure to communicate medication changes.
Failed to ensure the service plan identified the needs of Tenant #2, including incontinence of bowel and housekeeping issues.
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 24
Total census: 66
Response times in minutes for Tenant #9: Response times ranged from 16 to 59 minutes on various dates in August 2024
Response times in minutes for Tenant #3: Response times ranged from 18 to 36 minutes on various dates in August 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported staff were to respond to tenants within 5 minutes when they push a pendant for assistance. | |
| Staff B | Stated she is able to respond to most pendants within 5 minutes and was asked about medication delivery timing. | |
| Staff C | Interviewed regarding Tenant #3's medication timing and call for assistance. | |
| Regional Director of Clinical | Reported expectation that staff respond to tenants' pendant calls within 15 minutes and confirmed medication administration findings. | |
| RN | Registered Nurse | Completed pre-admission assessment for Tenant C3 and was involved in medication administration issues. |
| Director of Wellness | Notified about medication order confusion and confirmed service plan findings. | |
| Tenant C3's hospice nurse | Reported Tenant C3 was unable to swallow scheduled hydrocodone and was in pain. | |
| Executive Director | Conducted tour and identified odor and cleanliness issues in Tenant #2's apartment. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 4
Date: Jan 16, 2024
Visit Reason
The inspection was conducted to investigate Complaints #116065-C and #116167-C and to conduct a recertification visit for compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The visit was triggered by complaints #116065-C and #116167-C. No regulatory insufficiencies were cited during investigations of complaints #117059-C and incidents #114095-I, #116643-I, and #113646-I.
Findings
The inspection found regulatory insufficiencies related to medication administration delays, failure to obtain required signatures on service plan updates, lack of dependent adult abuse training for some staff, and failure to provide annual dementia-specific continuing education for personnel.
Deficiencies (4)
Failure to obtain medications timely and administer according to doctors orders for 1 current tenant and 1 discharged tenant.
Failure to provide two hours of dependent adult abuse training within six months of employment for 2 of 4 staff reviewed.
Failure to obtain signatures following updates to the service plan for 1 discharged tenant with a change in medication administration.
Failure to provide annual dementia-specific continuing education for 1 staff employed longer than one year.
Report Facts
Number of tenants without cognitive impairment: 35
Number of tenants with cognitive impairment: 26
Total census: 61
Staff reviewed for dependent adult abuse training: 4
Staff lacking dependent adult abuse training within six months: 2
Staff employed longer than one year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Employed longer than one year; lacked annual dementia-specific continuing education | |
| Staff B | Failed to complete dependent adult abuse training within six months of employment | |
| Staff C | Failed to complete dependent adult abuse training within six months of employment | |
| Registered Nurse | Reported medication refusal and leftover medications for Tenant C1 | |
| Healthcare Coordinator | Reported delay in sending medication orders due to fax machine failure | |
| Director | Director | Confirmed findings regarding staff training deficiencies |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
Investigation of complaints #103345-C, #104047-C, and #109477-C at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaints #103345-C, #104047-C, and #109477-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigations.
Report Facts
Number of tenants without cognitive disorder: 36
Number of tenants with cognitive disorder: 24
Total census: 60
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 0
Date: Dec 21, 2021
Visit Reason
The document is a plan of correction following an onsite review of an assisted living program for people with dementia, including investigations #101180-C and #101181-C and an infection control review.
Findings
No regulatory insufficiencies were cited during the investigations or the infection control review.
Report Facts
Number of tenants without cognitive disorders: 30
Number of tenants with cognitive disorders: 36
Total tenants: 66
Inspection Report
Renewal
Census: 64
Deficiencies: 0
Date: Oct 5, 2021
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. An onsite infection control survey and Complaint #99666-C were also completed.
Complaint Details
Complaint #99666-C was investigated during the visit; no regulatory insufficiencies were cited.
Findings
No regulatory insufficiencies were cited during the recertification visit and infection control survey.
Report Facts
Number of tenants without cognitive disorder - General Population: 30
Number of tenants with cognitive disorder - General Population: 9
Number of tenants without cognitive disorder - Memory Care Unit: 2
Number of tenants with cognitive disorder - Memory Care Unit: 23
Total Census of Assisted Living Program for People with Dementia: 64
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Mar 16, 2021
Visit Reason
The inspection was conducted during the investigation of complaints 92206-A and 93066-I and included an infection control survey.
Complaint Details
Investigation of complaints 92206-A and 93066-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the complaint investigation and infection control survey.
Report Facts
Number of tenants without cognitive disorder (General Population): 21
Number of tenants with cognitive disorder (General Population): 5
Number of tenants without cognitive disorder (Memory Care Unit): 3
Number of tenants with cognitive disorder (Memory Care Unit): 16
Total Census of Assisted Living Program for People with Dementia: 45
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jun 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #83095-C to assess regulatory insufficiencies at Edencrest at Siena Hills.
Complaint Details
Complaint #83095-C was investigated. The complaint was substantiated as the program failed to consistently ensure medications were administered as prescribed, affecting 1 of 2 tenants reviewed who received insulin injections.
Findings
The program failed to implement the plan of correction dated 12/12/18, specifically regarding medication administration as prescribed by physicians. One tenant was affected by inconsistent administration of insulin injections due to lack of supplies such as needles.
Deficiencies (2)
Failure to implement the plan of correction for medication administration.
Tenant not receiving medication as ordered by the physician due to lack of supplies (needles).
Report Facts
Census of Assisted Living Program for People with Dementia: 33
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 13
Tenant #1 blood sugar readings: 6
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Dec 11, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #79828 related to medication administration errors at Edencrest at Siena Hills.
Complaint Details
Complaint #79828 was investigated and substantiated. The medication error involved Tenant #1 receiving another tenant's medications, leading to nausea, vomiting, elevated blood pressure, and an ER visit. Staff received written warnings and medication management retraining.
Findings
The investigation revealed that the program failed to administer medications as prescribed by a physician, resulting in a medication error where a tenant received another tenant's medications, causing adverse symptoms and requiring an ER visit. The program lacked proper medication delivery policies and staff failed to follow medication administration protocols.
Deficiencies (1)
Program failed to administer tenants' medications as prescribed by a physician, resulting in medication errors including administration of wrong medications to a tenant.
Report Facts
Total census: 25
Residents without cognitive disorder: 14
Residents with cognitive disorder: 11
Residents in Dementia-Specific Program: 10
Tenants affected by medication error: 1
Date of compliance: Dec 12, 2018
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Oct 11, 2018
Visit Reason
Investigation of Incident #78520-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #78520-I; no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 15
Number of tenants with cognitive disorder in General Population: 0
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total Census of Assisted Living Program for People with Dementia: 24
Inspection Report
Plan of Correction
Census: 12
Deficiencies: 0
Date: Mar 14, 2018
Visit Reason
Initial certification and complaint investigation conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the initial certification and complaint investigation.
Report Facts
Census: 12
Number of tenants without cognitive disorder: 7
Number of tenants with cognitive disorder: 5
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