Inspection Reports for
Mill Pond
1201 SE Mill Pond Ct, Ankeny, IA 50021, United States, IA, 50021
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
98% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
A complaint investigation for complaint #1778464-C and facility reported incident #2666895-I was conducted from November 12, 2025 to November 13, 2025.
Complaint Details
Complaint #1778464-C and facility reported incident #2666895-I were investigated and found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
A complaint investigation for complaint #2640934-C was conducted from 10/22/2025 to 10/23/2025.
Complaint Details
Complaint #2640934-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective March 26, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from March 3, 2025 to March 6, 2025.
Findings
The facility failed to meet food safety requirements by not obtaining final cooking temperatures on alternative menu items and failed to ensure proper documentation of insulin administration for a resident. Deficiencies were noted in food safety compliance and resident medication records.
Deficiencies (2)
Facility failed to obtain final cooking food temperatures on alternative menu items prepared in the satellite kitchen.
Facility failed to ensure documentation of insulin administration for one resident reviewed for medication regimen.
Report Facts
Census: 59
Medication administration documentation errors: 5
Inspection Report
Routine
Census: 59
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with food safety and medication administration regulations at the nursing home.
Findings
The facility failed to obtain final cooking temperatures on alternative menu items prepared in the satellite kitchen and failed to ensure documentation of insulin administration for one resident. Both issues were identified through observation, record review, and staff interviews.
Deficiencies (2)
F0800: The facility failed to obtain final cooking food temperatures on alternative menu items prepared in the satellite kitchen, risking food safety.
F0842: The facility failed to ensure documentation of insulin administration for one resident, with missing records for multiple months and no clarification in progress notes.
Report Facts
Residents present: 59
Insulin administration missing records: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
A complaint investigation was conducted for Complaint #124181-C and Facility Reported Incident #123158-I from November 13, 2024 to November 14, 2024.
Complaint Details
Investigation related to Complaint #124181-C and Facility Reported Incident #123158-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 1, 2024
Visit Reason
The document serves as a plan of correction following a prior inspection, with certification of compliance effective May 1, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction accepted by the surveyors.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 5
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints and facility reported incidents.
Complaint Details
Complaint #118336-C was substantiated. Facility reported incident #118531-I was substantiated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to report and investigate allegations of abuse timely, failure to provide adequate ADL care including oral and incontinent care, and failure to notify the provider of changes in pressure ulcer condition.
Deficiencies (5)
Failure to ensure staff treated residents with dignity and respect for 1 of 1 residents reviewed for dignity (Resident #45).
Failure to report an allegation of abuse in a timely manner to the State Agency for 1 of 2 residents reviewed for abuse (Resident #45).
Failure to initiate an abuse investigation and separate residents from alleged perpetrators in a timely manner for 1 of 2 residents reviewed for abuse (Resident #45).
Failure to provide oral care after meals as directed and incontinent care for 1 of 3 residents reviewed for Activities of Daily Living (Resident #51).
Failure to notify the provider after a change in condition in a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #37).
Report Facts
Census: 57
Deficiencies cited: 5
BIMS score: 15
BIMS score: 99
Pressure ulcer measurement: 0.3
Pressure ulcer measurement: 0.8
Pressure ulcer measurement: 0.5
Pressure ulcer measurement: 3.2
Pressure ulcer measurement: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nursing Assistant | Named in resident mistreatment and abuse allegation involving Resident #45 |
| Staff I | Certified Nursing Assistant | Named in resident mistreatment and abuse allegation involving Resident #45 |
| Staff K | Certified Nursing Assistant | Named in resident mistreatment and abuse allegation involving Resident #45 |
| Staff B | Licensed Practical Nurse | Named in verbal altercation and abuse allegation involving Resident #45 |
| Staff H | Certified Nursing Assistant | Received resident complaint about mistreatment for Resident #45 |
| Staff F | Certified Nursing Assistant | Provided incontinent care to Resident #51 without oral care |
| Staff E | Certified Nursing Assistant | Provided incontinent care to Resident #51 without oral care |
| Staff D | Certified Nursing Assistant | Provided care to Resident #51 but failed to provide oral care after meals |
| Staff G | Licensed Practical Nurse | Applied ointment to Resident #51's buttocks |
| Staff M | Certified Nursing Assistant | Provided incontinence care to Resident #51 without oral care |
| Staff L | Certified Nursing Assistant | Provided incontinence care to Resident #51 without oral care |
| Staff C | Clinical Administrator | Oversaw investigation and reporting of abuse and pressure ulcer care |
| Staff A | Hospice Nurse | Measured Resident #37's pressure ulcer on 4/10/24 |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 4
Date: Apr 15, 2024
Visit Reason
The inspection was conducted due to complaints regarding mistreatment and abuse of Resident #45 by agency CNAs, including rough handling and failure to report and investigate abuse allegations timely.
Complaint Details
The complaint involved Resident #45 reporting rough and disrespectful treatment by two agency CNAs on 1/17/24, including improper handling of his brace and shoes causing pain and fear. The resident reported the abuse to staff and via email. The facility failed to report the abuse timely to the State Agency, failed to investigate promptly, and failed to separate the alleged perpetrators from residents. Staff J and Staff K were agency CNAs involved and were asked to leave the facility after the incident. The facility also failed to notify the provider timely about a pressure ulcer condition change for Resident #37.
Findings
The facility failed to ensure residents were treated with dignity and respect, timely report and investigate allegations of abuse, and separate alleged perpetrators from residents. Additionally, the facility failed to notify the provider of a change in condition for a pressure ulcer in Resident #37.
Deficiencies (4)
F 0550: The facility failed to ensure staff treated Resident #45 with dignity and respect, resulting in rough and disrespectful care by agency CNAs.
F 0609: The facility failed to report an allegation of abuse in a timely manner to the State Agency for Resident #45.
F 0610: The facility failed to initiate an abuse investigation and separate alleged perpetrators from residents promptly after learning of abuse allegations involving Resident #45.
F 0686: The facility failed to notify the provider of a change in condition for a pressure ulcer on Resident #37's left heel from 11/22/23 to 12/4/23.
Report Facts
Residents census: 57
Pressure ulcer wound measurement: 0.3
Pressure ulcer wound measurement: 0.8
Pressure ulcer wound measurement: 0.5
Pressure ulcer wound measurement: 6.2
Pressure ulcer wound measurement: 1.8
Pressure ulcer wound measurement: 3.2
Pressure ulcer wound measurement: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nursing Assistant (CNA) | Named in abuse and mistreatment findings involving Resident #45 |
| Staff K | Certified Nursing Assistant (CNA) | Named in abuse and mistreatment findings involving Resident #45 |
| Staff B | Licensed Practical Nurse (LPN) | Involved in verbal altercation and reported by Staff J; mentioned in abuse investigation |
| Staff H | Certified Nursing Assistant (CNA) | Received report of abuse from Resident #45 and relayed information to nurse |
| Staff I | Certified Nursing Assistant (CNA) | Received abuse report from Resident #45 and took photo of Staff J for identification |
| Staff C | Clinical Administrator | Provided statements regarding abuse reporting and pressure ulcer notification |
| Staff A | Hospice Nurse | Measured pressure ulcer wound on Resident #37 |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 5
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, abuse prevention, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to timely report and investigate abuse allegations, failure to provide adequate oral and incontinent care, and failure to notify providers of changes in pressure ulcer conditions.
Deficiencies (5)
F 0550: The facility failed to ensure staff treated residents with dignity and respect for 1 of 1 residents reviewed for dignity (Resident #45).
F 0609: The facility failed to report an allegation of abuse in a timely manner to the State Agency for 1 of 2 residents reviewed for abuse (Resident #45).
F 0610: The facility failed to initiate an abuse investigation and failed to separate residents from alleged perpetrators in a timely manner for 1 of 2 residents reviewed for abuse (Resident #45).
F 0677: The facility failed to provide oral care after meals and incontinent care for 1 of 3 residents reviewed for activities of daily living (Resident #51).
F 0686: The facility failed to notify the provider after a change in condition in a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #37).
Report Facts
Residents present: 57
Pressure ulcer size: 6.2
Pressure ulcer size: 1.8
Pressure ulcer size: 0.3
Pressure ulcer size: 0.8
Pressure ulcer size: 0.5
Pressure ulcer size: 3.2
Pressure ulcer size: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nursing Assistant | Named in resident abuse and mistreatment allegations involving Resident #45 |
| Staff K | Certified Nursing Assistant | Named in resident abuse and mistreatment allegations involving Resident #45 |
| Staff B | Licensed Practical Nurse | Involved in verbal altercation and abuse allegation incident with Staff J |
| Staff H | Certified Nursing Assistant | Received resident report of mistreatment from Resident #45 |
| Staff I | Certified Nursing Assistant | Witnessed resident complaints and verbal altercation involving Staff J and Staff B |
| Staff F | Certified Nursing Assistant | Provided incontinent care but no oral care to Resident #51 |
| Staff E | Certified Nursing Assistant | Provided care to Resident #51 including catheter and incontinent care |
| Staff D | Certified Nursing Assistant | Provided bed bath and assisted with incontinent care for Resident #51 |
| Staff G | Licensed Practical Nurse | Provided skin check and ointment application for Resident #51 |
| Staff M | Certified Nursing Assistant | Provided incontinent care for Resident #51 |
| Staff L | Certified Nursing Assistant | Provided incontinent care for Resident #51 |
| Staff C | Clinical Administrator | Provided statements regarding abuse reporting and wound care notification |
| Staff A | Hospice Nurse | Measured wound on Resident #37's left heel |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
A complaint investigation for complaint #113365-C was conducted on December 12, 2023.
Complaint Details
Complaint #113365-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 20, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective March 20, 2023.
Inspection Report
Routine
Census: 52
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including nutritional status and nursing staff responsiveness.
Findings
The facility failed to maintain acceptable nutritional status for one resident, including failure to properly weigh and notify physicians of significant weight loss. Additionally, the facility failed to answer call lights promptly for three residents, with documented wait times exceeding 15 minutes.
Deficiencies (2)
F 0692: The facility failed to maintain acceptable nutritional status for Resident #2, who experienced a 15-pound weight loss in two weeks without documented physician notification. Weekly weights were not consistently obtained or properly documented as required by physician orders.
F 0725: The facility failed to answer call lights within 15 minutes for 3 of 6 residents reviewed, with documented wait times up to 34 minutes. The facility's call light policy lacked instructions to staff on timely response.
Report Facts
Residents affected: 1
Residents affected: 3
Census: 52
Weight loss: 15
Call light wait time: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding weight monitoring and documentation for Resident #2 |
| Staff B | Certified Nursing Aid (CNA) | Interviewed regarding weight documentation and reweighing Resident #2 |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding weight measurement procedures and notification requirements |
| Director of Nursing (DON) | Interviewed regarding staff responsibilities for weight monitoring and physician notification | |
| Administrator | Interviewed regarding expectations for call light response times |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of complaint #109836-C from February 20, 2023 to February 23, 2023.
Complaint Details
The inspection included an investigation of complaint #109836-C.
Findings
The facility was found deficient in maintaining acceptable nutritional status for one resident who experienced significant weight loss without proper physician notification. Additionally, the facility failed to answer call lights promptly for three residents, with wait times up to 34 minutes, despite administrative expectations for response within 15 minutes.
Deficiencies (2)
Failure to maintain acceptable parameters of nutritional status for Resident #2, including lack of timely weight documentation and physician notification of significant weight loss.
Failure to provide sufficient nursing staff response to call lights within 15 minutes for 3 residents (Residents #255, #254, and #10).
Report Facts
Resident weight loss: 15
Facility census: 52
Call light wait time: 34
Call light wait time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding Resident #2's weight monitoring and documentation. |
| Staff B | Certified Nursing Aid (CNA) | Interviewed regarding weight documentation and reweighing Resident #2. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding weight reporting and physician notification procedures. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff responsibilities for weight monitoring and physician notification. |
| Administrator | Administrator | Interviewed regarding expectations for call light response times. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
The complaint investigation was conducted for complaints #106701-C and facility reported incidents #106465-I and #106461-I from November 14 to November 15, 2022.
Complaint Details
Complaint #106791 was substantiated without a deficiency.
Findings
Complaint #106791 was substantiated without a deficiency. No other deficiencies or findings are explicitly stated in the report.
Inspection Report
Renewal
Census: 53
Deficiencies: 1
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as part of a recertification survey and investigation of incident #92307 completed September 20-28, 2021.
Findings
The facility failed to provide a safe method of transfer for one resident, resulting in fractures due to improper use of a mechanical lift. The incident was substantiated, and the facility implemented staff retraining and corrective actions to ensure compliance with care plans and safety protocols.
Deficiencies (1)
Facility failed to provide a safe method of transfer for one resident, resulting in fractures of the left shoulder and right hip when staff failed to use a full mechanical lift.
Report Facts
Total residents: 53
Incident investigation dates: 8
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/10/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 45
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 1
Date: Jan 15, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey to assess compliance with federal regulations, specifically regarding therapeutic diet prescriptions.
Findings
The facility failed to provide the correct pureed diet to one of two residents on a pureed diet, resulting in a resident receiving ground steak instead of pureed steak. The facility implemented corrective actions including staff coaching, education, and ongoing audits to ensure compliance with therapeutic diet orders.
Deficiencies (1)
Failed to provide the correct diet for one of two residents on a pureed diet, serving ground steak instead of pureed steak.
Report Facts
Facility census: 54
Date of compliance: Jan 24, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Cook | Named in the finding for serving incorrect diet and received coaching and education |
| Staff B | Certified Nurse Aide | Reported on diet menu slips and diet verification process |
| Staff C | Certified Nurse Aide | Reported on pocket care plan and diet verification |
| Dietary Manager | Reported on diet preferences and staff training | |
| Medical Director | Clarified diet order for Resident #24 |
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