Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2025
Visit Reason
A complaint investigation for complaints #2645352-C and #2651654-C was conducted from October 27, 2025 to October 29, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was conducted for two complaints identified as #2645352-C and #2651654-C. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2025
Visit Reason
A complaint investigation was conducted for multiple complaints (#1720595-C, #1720596-C, #1720856-C, #2560809-C, #2627689-C, and #2627697-C) from September 29, 2025 to October 2, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation involved six complaints identified by their numbers; the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 5
Jun 6, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for long term care facilities, including care planning, medication administration, nursing services, infection control, and resident care.
Findings
The facility was found not in substantial compliance with several requirements including incomplete and inaccurate care plans, untimely medication administration, inadequate perineal care, insufficient nursing staff leading to delayed call light responses, and failure to follow infection prevention and control protocols during an outbreak. Corrective actions and systemic measures were planned and implemented.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain a complete and accurate Care Plan for 1 of 3 residents reviewed (Resident #1). | SS=D |
| Failed to administer medications according to Physician's orders and in a timely manner for 4 of 4 residents reviewed. | SS=E |
| Failed to provide proper perineal care for 1 of 3 residents reviewed (Resident #4). | SS=D |
| Failed to answer resident call lights in a timely manner (within 15 minutes) for 2 of 7 residents reviewed. | SS=E |
| Failed to follow appropriate infection control practices during an outbreak and when residents were on barrier precautions. | SS=E |
Report Facts
Census: 84
Medication administration delays: 4
Residents with delayed call light response: 2
Residents on barrier precautions: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Signed plan of correction |
| Staff F | Certified Medication Aide | Named in medication administration delay finding |
| Staff E | Certified Medication Aide | Interviewed regarding medication administration delays |
| Staff D | Certified Nursing Assistant | Named in perineal care deficiency |
| Staff G | Certified Nursing Assistant | Named in perineal care deficiency |
| Staff H | Certified Medication Aide | Observed failing infection control practices |
| Staff C | Registered Nurse and Assistant Director of Nursing | Observed failing infection control practices and interviewed |
| Staff B | Certified Nursing Assistant | Interviewed regarding infection control and call light response |
| Staff A | Licensed Practical Nurse | Interviewed regarding call light response |
| Director of Nursing | Confirmed medication delays and infection control expectations | |
| Administrator | Confirmed awareness of call light and infection control issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 6, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective June 6, 2025.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 14, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance with health requirements.
Findings
The facility was found to be in substantial compliance with health requirements based on the accepted Plan of Correction, resulting in certification effective March 14, 2025.
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 9
Feb 17, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of multiple complaints and facility reported incidents between February 17, 2025 and February 20, 2025.
Findings
The facility was found deficient in several areas including care plan timing and revision, services meeting professional standards, ADL care for dependent residents, mobility and range of motion, accident hazards and supervision, bowel/bladder incontinence care, sufficient nursing staff, resident records, and infection prevention and control. Multiple residents' care plans and medication administration practices were found lacking, and staff performance issues were noted.
Complaint Details
Complaints #124527-C, #126212-C, #126746-C were substantiated. Facility reported incidents #126199-I, #126777-I were substantiated.
Severity Breakdown
D: 8
E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - Facility failed to involve resident and/or representative in care conferences and ensure quarterly care conferences for one resident. | D |
| Services Provided Meet Professional Standards - Facility failed to follow accepted professional standards regarding medication being left in the open. | D |
| ADL Care Provided for Dependent Residents - Facility failed to provide oral hygiene care as directed in care plans for 3 residents. | D |
| Increase/Prevent Decrease in ROM/Mobility - Facility failed to carry out therapy recommendations and restorative exercises for 3 residents. | D |
| Free of Accident Hazards/Supervision Devices - Facility failed to ensure resident bed was in a low position to prevent falls for one resident. | D |
| Bowel/Bladder Incontinence, Catheter, UTI - Facility failed to provide proper peri-care and catheter care for residents. | D |
| Sufficient Nursing Staff - Facility failed to provide sufficient nursing staff to answer call lights timely and provide needed care. | E |
| Resident Records - Facility failed to maintain complete and accurate documentation for 1 of 22 residents reviewed. | D |
| Infection Prevention & Control - Facility failed to ensure staff utilized Enhanced Barrier Precautions when caring for residents requiring them. | D |
Report Facts
Census: 83
Deficiencies cited: 9
Call light response times: 15
Residents reviewed for oral hygiene: 3
Residents reviewed for restorative services: 4
Residents reviewed for safety bed position: 5
Residents reviewed for catheter care: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Named in medication administration deficiency and terminated due to repeated performance infractions |
| Staff F | Certified Nursing Assistant (CNA) | Reported oral hygiene care and restorative activities |
| Staff I | Certified Medication Aide (CMA) | Reported restorative aide activities and medication administration |
| Staff D | Assistant Director of Nursing (ADON) | Checked resident room during fall assessment |
| Staff C | Assistant Director of Nursing (ADON) | Reported on evidence-based practice compliance |
| Director of Nursing | Provided multiple interviews and statements regarding medication errors, staffing, and fall assessments |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 31, 2024
Visit Reason
A revisit of the survey ending September 19, 2024 and investigation of Complaints #124277-C, #124362-C and Facility Reported Incidents #124355-I, #124358-I was conducted from October 29, 2024 through October 31, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 11, 2024.
Complaint Details
Investigation included Complaints #124277-C, #124362-C and Facility Reported Incidents #124355-I, #124358-I.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 11
Sep 16, 2024
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#123108-C, #123123-C, #123199-C, #123251-C) and facility reported incidents (#123258-I and #123455-I) from September 16 to September 19, 2024.
Findings
The facility was found to have multiple deficiencies including failure to provide toileting assistance and care to maintain resident dignity, failure to maintain a safe, clean, and homelike environment due to food debris and trash in the dining hall, failure to follow comprehensive care plans for residents, inadequate supervision and use of assistive devices leading to resident falls and injuries, insufficient nursing staff to meet resident needs, failure to administer respiratory treatments as ordered, inadequate response to call lights, and lapses in infection prevention and control practices.
Complaint Details
Complaints #123108-C, #123123-C, #123199-C, and #123251-C were substantiated. Facility Reported Incidents #123258-I and #123455-I were substantiated.
Deficiencies (11)
| Description |
|---|
| Failure to provide toileting assistance and care for a resident, compromising dignity. |
| Failure to maintain a safe, clean, and homelike environment due to food debris and trash in the dining hall. |
| Failure to follow comprehensive care plans for residents, including use of protective devices and fall prevention. |
| Failure to ensure adequate supervision and use of assistive devices, resulting in resident falls and injuries. |
| Insufficient nursing staff to meet resident needs and respond to call lights in a timely manner. |
| Failure to administer oxygen and respiratory treatments according to physician orders and care plans. |
| Failure to maintain infection prevention and control program, including hand hygiene and use of personal protective equipment. |
| Failure to adequately evaluate resident population and staffing needs through facility assessment. |
| Failure to provide sufficient nursing staff with appropriate competencies and skills. |
| Failure to ensure call lights are answered timely and residents' needs are met. |
| Failure to provide each resident with a nourishing, well-balanced diet according to preferences and care plans. |
Report Facts
Census: 87
Call light response times: 50
Call light response times: 81
Call light response times: 88
Call light response times: 95
Call light response times: 96
Call light response times: 82
Average census range: 45
Average census range: 59
Average Skilled Care residents per day: 15
Average Skilled Care residents per day: 25
Average long-term care residents per day: 60
Average long-term care residents per day: 75
Staff needed - Registered Nurses / Licensed Practical Nurses: 16
Staff needed - Registered Nurses / Licensed Practical Nurses: 21
Staff needed - Medication Aides / Nursing Assistants: 25
Staff needed - Medication Aides / Nursing Assistants: 31
Per Patient Days (PPD): 4
PPD on 9/16/24: 3.8
Oxygen saturation assessments: 98
Lowest oxygen saturation: 84
Pulse oxygen level: 79
Staffing numbers on day shift: 10
Staffing numbers on evening shift: 9
Staffing numbers on night shift: 5
Staffing numbers on night shift: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Assistant Director of Nursing (ADON) | Reported expectations for gait belt use and staff assistance during resident transfers. |
| Staff F | Certified Nursing Assistant (CNA) | Observed interactions with Resident #7 and catheter care. |
| Staff C | Certified Medication Aide (CMA) | Reported on medication administration and resident assistance. |
| Staff B | Registered Nurse (RN) | Responded to resident fall and evaluated injuries. |
| Staff A | Certified Nursing Assistant (CNA) | Observed resident not wearing protective sleeves and assisted with care. |
| Staff M | Certified Nursing Assistant (CNA) | Observed resident not wearing protective sleeves and assisted with care. |
| Staff I | Certified Nursing Assistant (CNA) | Reported gait belt use and resident familiarity. |
| Staff K | Certified Nursing Assistant (CNA) | Reported gait belt use and resident familiarity. |
| Staff E | Licensed Practical Nurse (LPN) | Reported staffing concerns and nurse availability. |
| Staff N | Certified Nursing Assistant (CNA) | Reported insufficient staffing to complete tasks. |
| Staff J | Registered Nurse (RN) | Reported kitchen staff forgetting to serve room trays. |
| Staff O | Certified Medication Aide (CMA) | Reported staffing shortages affecting resident care. |
| Director of Nursing (DON) | Director of Nursing | Reported expectations for care plan adherence and staffing. |
| Executive Director (ED) | Executive Director | Reported staffing levels and facility census. |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Reported on meal tray requests and kitchen service. |
| Maintenance Director | Maintenance Director | Reported on equipment maintenance and weight chair repairs. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 2, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance effective May 2, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction accepted by the surveyors, resulting in certification of compliance.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 8
Apr 4, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from April 1, 2024 to April 4, 2024.
Findings
The facility was found deficient in multiple areas including failure to provide proper discharge documentation and notification to the Long Term Care Ombudsman, inaccurate and incomplete Minimum Data Set (MDS) assessments and care plans, medication administration errors, and infection control practices that risk cross-contamination and infection spread.
Severity Breakdown
SS=D: 6
SS=B: 1
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide discharge and medical information to the receiving health care institution at the time of discharge for one resident. | SS=D |
| Failed to notify the Long Term Care Ombudsman of a resident transfer as required. | SS=D |
| Failed to accurately complete a Minimum Data Set (MDS) assessment for one resident. | SS=B |
| Failed to develop and update the comprehensive Care Plan with PASRR Level II service recommendations for one resident. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for three residents. | SS=D |
| Failed to review and revise a resident's Care Plan to meet the resident's needs for catheter care. | SS=D |
| Medication error rate exceeded 5% due to improper insulin pen administration for one resident. | SS=D |
| Failed to ensure infection prevention and control practices including proper use of PPE, disinfection of equipment, and peri-care technique. | SS=E |
Report Facts
Census: 82
Medication error rate: 6.25
MDS assessments reviewed: 18
Residents with care plan deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in medication error finding related to improper insulin pen administration |
| Staff D | Assistant Director of Nursing (ADON) | Observed medication administration and acknowledged care plan deficiencies |
| Staff C | Social Services (SW) | Reported PASRR completion and psychiatric referral process |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing peri-care with infection control deficiencies |
| Staff J | Certified Nursing Assistant (CNA) | Observed performing peri-care with improper technique |
| Staff K | Assistant Director of Nursing (ADON) | Observed peri-care and acknowledged infection control concerns |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding care plan, medication administration, and infection control expectations |
| Administrator | Administrator | Reported no policy for resident transfers to hospital and ombudsman notification |
| Corporate Nurse | Corporate Nurse | Reported expectations for insulin pen administration |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 23, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective February 23, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Feb 1, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations (#116574-C, 116726-C, 118393-C, and 118482-C) regarding pressure ulcers and infection control at The Bridges at Ankeny.
Findings
The facility failed to provide proper assessment and treatment for pressure ulcers, specifically for Resident #4 who developed a Stage 2 pressure ulcer. Additionally, infection prevention and control practices were deficient, including improper perineal care and failure to follow infection control protocols.
Complaint Details
Complaints #116574-C, 116726-C, and 118393-C were substantiated based on observations, staff interviews, clinical record review, and facility policy review.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide assessment and intervention to prevent pressure ulcer development for Resident #4. | SS=D |
| Failure to provide perineal care using accepted infection control practices for Resident #4. | SS=D |
Report Facts
Census: 96
Deficiency count: 2
MDS score: 5
Pressure ulcer measurement: 1.2
Pressure ulcer measurement: 0.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Provided peri care to Resident #4 and acknowledged open area and bleeding. |
| Staff B | Registered Nurse (RN) | Applied Dermaseptin ointment to Resident #4's coccyx and assessed the wound. |
| Assistant Director of Nursing (ADON) | Interviewed regarding pressure ulcer staging and nursing practices. | |
| Director of Nursing (DON) | Informed about infection control and pressure ulcer concerns. | |
| Director of Clinical Services | Acknowledged concerns and planned to work on solutions. | |
| Nurse Practitioner (ARNP) | Assessed Resident #4's wound and provided clinical guidance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2023
Visit Reason
A complaint investigation for complaints #112064-C, #112644-C, and a facility reported incident #111819-I was conducted from May 1, 2023 to May 3, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation involved complaints #112064-C and #112644-C and facility reported incident #111819-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 3, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction, effective 02/03/23.
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 3
Dec 15, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints 106981-C, 108181-C, and 108632-C.
Findings
The facility was found deficient in notifying the Long Term Care Ombudsman of resident transfers or discharges for 2 of 3 residents reviewed, and in accurately completing Minimum Data Set (MDS) assessments for three residents. Additionally, food safety deficiencies were identified related to food storage, preparation, and sanitation practices.
Complaint Details
Complaints 106981-C, 108181-C, and 108632-C were investigated and found to be unsubstantiated.
Severity Breakdown
Level B: 1
Level D: 1
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the Long Term Care Ombudsman of discharge/transfer for 2 of 3 residents reviewed. | Level B |
| Failed to accurately complete Minimum Data Set (MDS) assessments for three residents. | Level D |
| Failed to store, prepare, and serve food in accordance with professional standards for food service safety. | Level E |
Report Facts
Residents reviewed: 3
Census: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 6, 2022
Visit Reason
The inspection was conducted to investigate Complaint #100911 from March 31, 2022 to April 6, 2022.
Findings
The facility was found to be in substantial compliance with no substantiation for Complaint #100901-C.
Complaint Details
Complaint #100911 was investigated and found to be in substantial compliance. Complaint #100901-C was not substantiated.
Inspection Report
Renewal
Census: 53
Deficiencies: 1
May 3, 2021
Visit Reason
The inspection was a health recertification survey conducted from May 3, 2021 to May 6, 2021 to assess compliance with federal regulations related to food procurement, storage, preparation, and service safety.
Findings
The facility was found to have multiple food items opened and not dated, unlabeled and undated food containers, and improper storage practices that could lead to cross contamination. The Dietary Manager reported efforts to organize and label kitchen shelves to address these issues.
Deficiencies (1)
| Description |
|---|
| Facility failed to label and date multiple food items and did not refrain from storing thawing meat over ready to eat food items or produce, violating food safety requirements. |
Report Facts
Total residents: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Reported starting to organize the kitchen and label shelves |
Inspection Report
Abbreviated Survey
Census: 48
Deficiencies: 0
Mar 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 2/18 to 3/3/21 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. The investigation of a facility self-reported incident and a complaint were not substantiated and did not result in deficiencies.
Complaint Details
Complaint 95236-C was investigated and found not substantiated.
Report Facts
Total Residents: 48
Inspection Report
Abbreviated Survey
Census: 43
Deficiencies: 0
Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 12/28/20 through 12/29/20 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint #87263-C and facility reported incident #87266-I were conducted by the Department of Inspection and Appeals on September 8 - 10, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #87263-C and facility reported incident #87266-I were not substantiated.
Complaint Details
Complaint #87263-C was not substantiated. Facility reported incident #87266-I was not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 4, 2020
Visit Reason
The visit was a COVID-19 focused infection control survey conducted from June 1 to June 3, 2020, and included an investigation of complaint #91262-C.
Findings
The COVID-19 focused infection control survey resulted in no concerns identified, and the complaint investigation was not substantiated.
Complaint Details
Investigation of complaint #91262-C was not substantiated.
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