Deficiencies (last 6 years)
Deficiencies (over 6 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
218% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
84 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Investigation was conducted for two complaints identified as #2645352-C and #2651654-C. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Investigation involved six complaints identified by their numbers; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to maintain a complete and accurate Care Plan for 1 of 3 residents reviewed (Resident #1).
Failed to administer medications according to Physician's orders and in a timely manner for 4 of 4 residents reviewed.
Failed to provide proper perineal care for 1 of 3 residents reviewed (Resident #4).
Failed to answer resident call lights in a timely manner (within 15 minutes) for 2 of 7 residents reviewed.
Failed to follow appropriate infection control practices during an outbreak and when residents were on barrier precautions.
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
Date: 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
Routine
Census: 84
Deficiencies: 5
Date: May 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, infection control, staffing, and call light response times at The Bridges at Ankeny nursing facility.
Findings
The facility was found deficient in multiple areas including incomplete care plans, untimely medication administration, inadequate perineal care, delayed response to resident call lights, and failure to follow infection prevention and control protocols during an outbreak. Several residents were affected with minimal harm or potential for harm.
Deficiencies (5)
Failed to maintain a complete and accurate care plan for a resident, including addressing stomatitis and refusal of oral rinses after inhaler use.
Failed to administer medications according to physician's orders and in a timely manner for 4 residents.
Failed to provide proper perineal care for a resident, including inadequate cleansing of vaginal area and reuse of soiled brief.
Failed to answer resident call lights in a timely manner (within 15 minutes) for 2 residents, resulting in resident distress and a fall without injury.
Failed to follow appropriate infection control practices during an outbreak and when residents were on barrier precautions, including failure to sanitize equipment and improper use of PPE.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 3
Call light response times: 17
Call light response times: 18
Call light response times: 21
Residents tested positive: 10
Staff tested positive: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Failed to provide proper perineal care and failed to sanitize name tag after dropping it on bathroom floor |
| Staff G | Certified Nursing Assistant (CNA) | Observed during perineal care and name tag incident |
| Staff F | Certified Medication Aide (CMA) | Administered medications late and confirmed running behind schedule |
| Staff E | Certified Medication Aide (CMA) | Interviewed about medication administration delays |
| Staff H | Certified Medication Aide (CMA) | Observed dropping thermometer and failing to sanitize equipment |
| Staff C | Registered Nurse (RN) and Assistant Director of Nursing (ADON) | Observed improper placement of medication items and call light device; confirmed outbreak and staff PPE issues |
| Staff B | Certified Nursing Assistant (CNA) | Confirmed entering rooms without proper PPE during outbreak and inability to answer call lights timely |
| Staff A | Licensed Practical Nurse (LPN) | Confirmed staffing issues causing delayed call light responses |
| Administrator | Confirmed awareness of call light and infection control problems | |
| Director of Nursing (DON) | Confirmed medication administration delays, infection control expectations, and outbreak details |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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: 6
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents at The Bridges at Ankeny.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care conferences involving residents or their representatives, inadequate oral hygiene care for residents, unsafe bed positioning increasing fall risk, incomplete incontinence care, insufficient nursing staff leading to delayed call light responses, and failure to maintain accurate and timely documentation of resident incidents such as falls.
Deficiencies (6)
Failure to involve resident and/or representative in quarterly care conferences for one of three residents reviewed.
Failure to provide oral hygiene care as directed in the care plan for 3 of 3 residents reviewed.
Failure to ensure a resident's bed was placed in a low position to ensure safety for one of five residents reviewed for transfers.
Failure to provide complete incontinence care for one of four residents observed.
Failure to provide sufficient nursing staff to ensure call lights were answered within a reasonable time, resulting in delays up to 64 minutes.
Failure to maintain complete and accurate documentation for one of 22 residents reviewed, including delayed and incomplete fall documentation.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 7
Call light wait times: 64
Census: 83
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Named in fall incident documentation deficiency and failure to timely document fall |
| Staff E | Certified Nursing Assistant (CNA) | Reported as only CNA on hall with 27 residents and involved in oral care deficiency |
| Staff F | Certified Nursing Assistant (CNA) | Reported oral cares done for Resident #63 |
| Staff P | Certified Nursing Assistant (CNA) | Reported responsibility for documenting oral hygiene and involvement in oral care deficiency |
| Staff D | Assistant Director of Nursing (ADON) | Observed and corrected bed positioning deficiency |
| Staff A | Certified Nursing Assistant (CNA) | Observed performing incomplete incontinence care |
| Staff B | Certified Nursing Assistant (CNA) | Observed assisting with incontinence care |
| Staff L | Licensed Practical Nurse (LPN) | Reported staffing shortages and call light delays |
| Staff Q | Licensed Practical Nurse (LPN) | Reported staffing difficulties on weekends |
| Staff R | Certified Nursing Assistant (CNA) | Reported staffing shortages and impact on care timeliness |
| Staff I | Certified Nursing Assistant (CNA) | Reported challenges with staffing and resident care timeliness |
| Staff J | Certified Nursing Assistant (CNA) | Responded to Resident #23 fall |
| Staff O | Licensed Practical Nurse (LPN) | Reported increased admissions and workload |
| Staff M | Certified Nursing Assistant (CNA) | Reported working multiple shifts due to staffing shortages |
| Staff N | Certified Nursing Assistant (CNA) | Asked about resident admission status |
| Staff L | Licensed Practical Nurse (LPN) | Reported staffing shortages and call light delays |
| Staff K | Licensed Practical Nurse (LPN) | Named in fall incident documentation deficiency |
| Staff I | Certified Medication Aide (CMA) | Reported nurse responsibility for incident documentation |
Inspection Report
Routine
Census: 83
Deficiencies: 9
Date: Feb 20, 2025
Visit Reason
Routine inspection of The Bridges at Ankeny nursing facility to assess compliance with care plan development, medication administration, oral hygiene, restorative services, resident safety, staffing adequacy, medical record documentation, and infection control.
Findings
The facility was found deficient in multiple areas including failure to hold quarterly care conferences involving residents or representatives, improper medication handling, incomplete oral hygiene care, inadequate restorative exercise implementation, unsafe bed positioning, insufficient staffing leading to delayed call light responses, incomplete fall documentation, and failure to adhere to enhanced barrier precautions for infection control.
Deficiencies (9)
Failed to involve resident or representative in quarterly care conferences for Resident #63.
Failed to follow professional standards regarding medication left in the open and improper medication administration for Resident #20 and #230.
Failed to provide oral hygiene care as directed in care plans for Residents #63 and #25.
Failed to carry out therapy recommendations and provide restorative exercises for Residents #36, #54, and #63.
Failed to ensure Resident #12's bed was placed in a low position to ensure safety.
Failed to provide complete incontinence care and proper catheter care for Resident #27.
Failed to provide sufficient nursing staff to ensure call lights were answered within a reasonable time, causing delays up to 64 minutes.
Failed to maintain complete and accurate documentation of a fall incident for Resident #23, including delayed and incomplete fall assessment documentation.
Failed to ensure staff utilized Enhanced Barrier Precautions (EBP's) including wearing gowns and gloves when providing care to Resident #27 with an indwelling catheter.
Report Facts
Census: 83
Call light response time: 64
Restorative exercises performed: 1
Restorative exercises performed: 2
Oral hygiene completed: 7
Oral hygiene completed: 0
Restorative AROM lower extremity: 5
Restorative AROM upper extremity: 5
Ambulation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Involved in medication administration incident and fall documentation for Resident #23 |
| Staff A | Certified Nursing Assistant (CNA) | Performed incomplete incontinence care and catheter care for Resident #27 |
| Staff B | Certified Nursing Assistant (CNA) | Assisted with incontinence care and catheter care for Resident #27 |
| Staff E | Certified Nursing Assistant (CNA) | Reported oral hygiene care practices and staffing concerns |
| Staff F | Certified Nursing Assistant (CNA) | Reported restorative aide duties and staffing concerns |
| Staff H | Physical Therapist (PT) | Provided restorative program recommendations |
| Staff I | Certified Medication Aide (CMA) and restorative aide | Reported restorative program staffing issues |
| Staff L | Licensed Practical Nurse (LPN) | Reported staffing shortages and call light delays |
| Staff M | Certified Nursing Assistant (CNA) | Reported staffing shortages and admission challenges |
| Staff O | Licensed Practical Nurse (LPN) | Reported admission workload and fall incident response |
| Staff P | Certified Nursing Assistant (CNA) | Reported oral hygiene documentation and call light delays |
| Staff Q | Licensed Practical Nurse (LPN) | Reported staffing challenges on weekends and census workload |
| Staff R | Certified Nursing Assistant (CNA) | Reported staffing shortages and call light delays |
| Staff J | Certified Nursing Assistant (CNA) | Responded to Resident #23 fall incident |
| Staff L | Licensed Practical Nurse (LPN) | Confirmed nurse responsibility for incident documentation |
| Staff C | Assistant Director of Nursing (ADON) | Reported Enhanced Barrier Precautions policy and expectations |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for call light response, documentation, and infection control |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 9
Date: 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.
Complaint Details
Complaints #124527-C, #126212-C, #126746-C were substantiated. Facility reported incidents #126199-I, #126777-I were substantiated.
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.
Deficiencies (9)
Care Plan Timing and Revision - Facility failed to involve resident and/or representative in care conferences and ensure quarterly care conferences for one resident.
Services Provided Meet Professional Standards - Facility failed to follow accepted professional standards regarding medication being left in the open.
ADL Care Provided for Dependent Residents - Facility failed to provide oral hygiene care as directed in care plans for 3 residents.
Increase/Prevent Decrease in ROM/Mobility - Facility failed to carry out therapy recommendations and restorative exercises for 3 residents.
Free of Accident Hazards/Supervision Devices - Facility failed to ensure resident bed was in a low position to prevent falls for one resident.
Bowel/Bladder Incontinence, Catheter, UTI - Facility failed to provide proper peri-care and catheter care for residents.
Sufficient Nursing Staff - Facility failed to provide sufficient nursing staff to answer call lights timely and provide needed care.
Resident Records - Facility failed to maintain complete and accurate documentation for 1 of 22 residents reviewed.
Infection Prevention & Control - Facility failed to ensure staff utilized Enhanced Barrier Precautions when caring for residents requiring them.
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
Date: 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.
Complaint Details
Investigation included Complaints #124277-C, #124362-C and Facility Reported Incidents #124355-I, #124358-I.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 11, 2024.
Inspection Report
Routine
Census: 87
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide dignified toileting assistance, maintain a clean environment, follow care plans, ensure safe resident transfers, administer respiratory care properly, answer call lights timely, provide adequate staffing, serve nourishing diets, conduct adequate facility-wide assessments, and implement infection control practices.
Deficiencies (10)
Failed to provide toileting assistance and care in a dignified manner for Resident #7.
Failed to maintain a safe, clean, and homelike environment due to food left on the dining hall floor for multiple days.
Failed to follow care plans for Resident #3 including use of Geri-Sleeves and fall mats.
Failed to ensure safe mechanical lift transfers and use of stability legs, resulting in a resident fall with injury.
Failed to ensure safe transfers and use of gait belts for residents requiring assistance.
Failed to provide continuous oxygen therapy as ordered and respond to resident calls for help related to oxygen needs.
Failed to answer call lights in a timely manner and ensure adequate staffing to meet resident needs.
Failed to serve nourishing, well-balanced diets that consider resident preferences, including failure to provide room trays to residents who refused dining hall meals.
Failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources and staffing for resident care.
Failed to implement infection prevention and control program including failure to wear gloves and follow enhanced barrier precautions during catheter care.
Report Facts
Census: 87
Call light response times > 15 minutes: 50
Call light response times > 15 minutes: 81
Call light response times > 15 minutes: 88
Call light response times > 15 minutes: 95
Call light response times > 15 minutes: 96
Call light response times > 15 minutes: 82
Oxygen saturation readings on room air: 98
Lowest oxygen saturation on room air: 84
Scheduled CNAs on day shift: 10
Scheduled CNAs on evening shift: 9
Scheduled CNAs on night shift: 5
Scheduled Nurses on day shift: 6
Scheduled Nurses on night shift: 3
Facility average census: 87
Facility average census (YTD): 92.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in toileting assistance and infection control findings |
| Staff D | Assistant Director of Nursing (ADON) | Named in toileting assistance and infection control findings |
| Staff M | Certified Nurses Aide (CNA) | Named in care plan noncompliance finding for Resident #3 |
| Staff K | Certified Nurses Aide (CNA) | Named in mechanical lift transfer deficiency |
| Staff L | Certified Nurses Aide (CNA) | Named in mechanical lift transfer deficiency |
| Staff B | Registered Nurse (RN) | Named in resident fall and weight chair incident |
| Staff A | Certified Nursing Assistant (CNA) | Named in resident fall and weight chair incident |
| Staff C | Certified Medication Aide (CMA) | Named in oxygen therapy and staffing findings |
| Staff I | Certified Nurses Aide (CNA) | Named in staffing findings |
| Staff H | Certified Nurses Aide (CNA) | Named in staffing findings |
| Staff E | Licensed Practical Nurse (LPN) | Named in staffing findings |
| Staff J | Registered Nurse (RN) | Named in staffing and dietary findings |
| Staff N | Certified Nurses Aide (CNA) | Named in staffing findings |
| Staff O | Certified Medication Aide (CMA) | Named in staffing findings |
| Staff P | Certified Nurses Aide (CNA) | Named in staffing findings |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 11
Date: 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.
Complaint Details
Complaints #123108-C, #123123-C, #123199-C, and #123251-C were substantiated. Facility Reported Incidents #123258-I and #123455-I were substantiated.
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.
Deficiencies (11)
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
Date: 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: 1
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as an annual Minimum Data Set (MDS) assessment to ensure accurate resident assessments and compliance with PASRR requirements.
Findings
The facility failed to accurately complete the MDS assessment for one of eighteen residents reviewed, specifically Resident #19, who had a Level II PASRR determination. The facility lacked a PASRR policy and planned to update and resubmit the MDS assessment information to CMS.
Deficiencies (1)
Failure to accurately complete a Minimum Data Set (MDS) assessment for one resident.
Report Facts
Census: 82
Residents reviewed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Social Services (SW) | Reported PASRR completion and psychiatric referral process for Resident #19 |
| Staff D | Assistant Director of Nursing (ADON) | Completed the MDS assessments prior to 3/2024 and planned to update and resubmit MDS information |
| Director of Nursing | Reported Staff D completed the MDS assessments before 3/2024 |
Inspection Report
Routine
Census: 82
Deficiencies: 9
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfers, notifications, assessments, care planning, medication administration, and infection control at The Bridges at Ankeny nursing facility.
Findings
The facility failed to provide adequate transfer documentation and notification to the LTC Ombudsman, did not accurately complete or update Minimum Data Set (MDS) assessments and care plans for several residents, had medication administration errors related to insulin pen use, and failed to follow infection prevention and control protocols including proper use of personal protective equipment and peri-care procedures.
Deficiencies (9)
Failed to provide discharge and medical information to the receiving health care institution at the time of discharge for one resident.
Failed to notify the Long Term Care Ombudsman of a resident transfer as required.
Failed to accurately complete a Minimum Data Set (MDS) assessment for one resident.
Failed to develop and update the comprehensive Care Plan with PASRR Level II service recommendations for one resident.
Failed to develop and implement a comprehensive person-centered care plan for three residents.
Failed to review and revise a resident's Care Plan to meet needs for catheter care.
Medication error rate exceeded 5% due to improper insulin pen administration.
Failed to administer two insulin flexpens properly to ensure the proper amount of insulin administered.
Failed to ensure staff followed infection control practices to prevent cross contamination and infection, including improper peri-care technique and failure to remove PPE before exiting isolation room.
Report Facts
Census: 82
Medication error rate: 6.25
Fall risk score: 23
Insulin dose: 30
Insulin dose: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Administered insulin improperly to Resident #11 |
| Staff D | Assistant Director of Nursing (ADON) | Observed insulin administration and reported expectations for insulin pen use; acknowledged care plan deficiencies |
| Director of Nursing (DON) | Reported expectations for insulin pen administration and care plan revisions | |
| Staff C | Social Services (SW) | Reported PASRR completion and psychiatric referral process for Resident #19 |
| Staff G | Licensed Practical Nurse (LPN) | Reported on Resident #48's denture use and oral care |
| Staff H | Social Worker | Acknowledged care plan omissions for Resident #48 |
| Staff J | Certified Nursing Assistant (CNA) | Performed peri-care with infection control breaches |
| Staff K | Assistant Director of Nursing (ADON) | Acknowledged infection control concerns during peri-care observation |
| Staff A | Certified Nursing Assistant (CNA) | Provided peri-care and transferred Resident #11 while observed |
| Staff E | Certified Medical Assistant | Observed removing isolation gown and gloves improperly |
| Corporate Nurse | Reported expectations for insulin pen administration |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 8
Date: 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.
Deficiencies (8)
Failed to provide discharge and medical information to the receiving health care institution at the time of discharge for one resident.
Failed to notify the Long Term Care Ombudsman of a resident transfer as required.
Failed to accurately complete a Minimum Data Set (MDS) assessment for one resident.
Failed to develop and update the comprehensive Care Plan with PASRR Level II service recommendations for one resident.
Failed to develop and implement a comprehensive person-centered care plan for three residents.
Failed to review and revise a resident's Care Plan to meet the resident's needs for catheter care.
Medication error rate exceeded 5% due to improper insulin pen administration for one resident.
Failed to ensure infection prevention and control practices including proper use of PPE, disinfection of equipment, and peri-care technique.
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
Date: 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
Date: Feb 1, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding pressure ulcer care, infection control practices, and peri care for Resident #4 at The Bridges at Ankeny nursing home.
Complaint Details
The investigation was complaint-related, focusing on pressure ulcer care and infection control practices for Resident #4. The complaint was substantiated based on observations, staff interviews, and clinical record review.
Findings
The facility failed to properly assess and stage pressure ulcers, specifically a Stage 2 pressure ulcer on Resident #4's coccyx, and failed to provide appropriate infection control during peri care, including improper glove use by staff. The facility also lacked clear processes for pressure ulcer identification and staging.
Deficiencies (2)
Failed to provide assessment and intervention to identify pressure ulcer development for Resident #4, including failure to stage pressure ulcers.
Failed to provide perineal care using accepted infection control practices, including failure to remove gloves between clean and dirty sites and using the same gloves to apply cream to an open area.
Report Facts
Census: 96
Pressure ulcer measurement: 1.2
Pressure ulcer measurement: 0.3
Brief Interview for Mental Status score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Observed providing peri care without changing gloves and applying cream to an open wound. |
| Staff B | Registered Nurse (RN) | Applied Dermaseptin cream to Resident #4's coccyx but did not properly assess the wound. |
| Assistant Director of Nursing (ADON) | Reported nurses were not staging pressure ulcers and expressed uncertainty about wound classification. | |
| Director of Clinical Services | Acknowledged concerns about pressure ulcer staging and infection control, and stated nurses can stage ulcers. | |
| Director of Nursing (DON) | Acknowledged concerns about infection control and pressure ulcers and stated they would investigate further. | |
| Nurse Practitioner (ARNP) | Wound Nurse | Assessed Resident #4's wound, discussed pressure versus shearing, and planned to update wound documentation. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: 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.
Complaint Details
Complaints #116574-C, 116726-C, and 118393-C were substantiated based on observations, staff interviews, clinical record review, and facility policy review.
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.
Deficiencies (2)
Failure to provide assessment and intervention to prevent pressure ulcer development for Resident #4.
Failure to provide perineal care using accepted infection control practices for Resident #4.
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
Date: 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.
Complaint Details
Investigation involved complaints #112064-C and #112644-C and facility reported incident #111819-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Census: 69
Deficiencies: 3
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident notification of transfers/discharges, accuracy of Minimum Data Set (MDS) assessments, and food safety and handling practices within the facility.
Findings
The facility failed to notify the Long Term Care Ombudsman of resident discharges/transfers for 2 of 3 residents reviewed, failed to accurately complete MDS assessments for 3 of 17 residents, and did not follow professional standards for food storage, preparation, and service, including improper labeling, cleaning, and glove use.
Deficiencies (3)
Failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 2 of 3 residents reviewed.
Failed to accurately complete a Minimum Data Set (MDS) assessment for three of seventeen residents reviewed.
Failed to store, prepare, distribute and serve food in accordance with professional standards, including unlabeled food items, improper cleaning, and improper glove use.
Report Facts
Residents reviewed for MDS accuracy: 17
Residents affected by MDS deficiency: 3
Residents affected by notification deficiency: 2
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Provided information about Resident #56's ambulation status |
| Staff D | Certified Nursing Assistant (CNA) | Provided information about Resident #56's ambulation status |
| Staff B | Dietary Aide | Reported on cleaning responsibilities of unit refrigerators and kitchen areas |
| Staff A | Registered Nurse | Reported dietary staff responsibilities for cleaning unit kitchenettes |
| Staff E | Dietary Aide | Observed preparing and serving food with improper glove use and sanitation |
| Dietary Manager | Dietary Manager | Provided information on food safety protocols, freezer conditions, and staff responsibilities |
| Business Office Manager | Business Office Manager (BOM) | Explained facility's notification process to Long Term Care Ombudsman |
| MDS Coordinator | MDS Coordinator | Reported on MDS assessment completion and planned corrections |
| Director of Nursing | Director of Nursing | Identified dietary staff responsibilities for cleaning and handling food in unit kitchenettes |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 3
Date: 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.
Complaint Details
Complaints 106981-C, 108181-C, and 108632-C were investigated and found to be unsubstantiated.
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.
Deficiencies (3)
Failed to notify the Long Term Care Ombudsman of discharge/transfer for 2 of 3 residents reviewed.
Failed to accurately complete Minimum Data Set (MDS) assessments for three residents.
Failed to store, prepare, and serve food in accordance with professional standards for food service safety.
Report Facts
Residents reviewed: 3
Census: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
The inspection was conducted to investigate Complaint #100911 from March 31, 2022 to April 6, 2022.
Complaint Details
Complaint #100911 was investigated and found to be in substantial compliance. Complaint #100901-C was not substantiated.
Findings
The facility was found to be in substantial compliance with no substantiation for Complaint #100901-C.
Inspection Report
Renewal
Census: 53
Deficiencies: 1
Date: 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)
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
Date: 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.
Complaint Details
Complaint 95236-C was investigated and found not substantiated.
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.
Report Facts
Total Residents: 48
Inspection Report
Abbreviated Survey
Census: 43
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #87263-C was not substantiated. Facility reported incident #87266-I was not substantiated.
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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.
Complaint Details
Investigation of complaint #91262-C was not substantiated.
Findings
The COVID-19 focused infection control survey resulted in no concerns identified, and the complaint investigation was not substantiated.
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