Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mill-pond during CMS and state inspections, most recent first.
Failure to attempt a GDR for a resident receiving lorazepam for anxiety. The resident had intact cognition, diagnoses of anxiety and depression, and an active order for lorazepam at bedtime with no discontinue date. The record showed no GDR since the prior dose reduction, and the annual psychotropic review documented that a GDR was not contraindicated. The DON acknowledged the facility missed the medication on the quarterly psychotropic review and had not attempted or discussed a GDR since 2024.
A resident with intact cognition and acne remained on daily doxycycline for prophylaxis after admission, but the record lacked a documented stop date, specialist follow-up, or PCP review supporting continued use. A pharmacist requested clarification on the antibiotic’s indication and ongoing need, but the resident declined dermatology follow-up and the chart did not show a completed PCP reassessment. The DON stated nursing did not make the referral and the IP was not notified or monitoring the resident’s continuous antibiotic use as required by facility policy.
Unlabeled and Unsealed Open Food Items in Pantry: Surveyors observed multiple opened dry pantry items, including croutons, cereal, pasta, and almonds, that were left unsealed and without labels showing the date received or opened. The CDM and Administrator both stated opened food stored in the pantry should be labeled and securely sealed, and the facility policy required food items to be dated, labeled, and properly covered after opening.
The facility failed to obtain final cooking temperatures for alternative menu items prepared in the satellite kitchen. During a lunch service, a cook and a server were observed preparing tomato soup and macaroni and cheese without checking the final cooking temperatures. The Nutrition and Culinary Supervisor and the Certified Dietary Manager acknowledged the oversight, emphasizing the importance of temperature checks for food safety. The facility's policy requires reheated foods to reach specific temperatures to ensure safety.
A facility failed to document insulin administration for a resident with diabetes and Parkinson's. The MAR showed missing entries for Glargine and Aspart over several months, and the electronic health record lacked documentation to confirm administration. The DON could not verify if the insulin was given or not documented, contrary to the facility's policy requiring immediate documentation after administration.
A resident with anxiety, heart failure, and post-polio syndrome reported rough and dismissive treatment by two agency CNAs, causing pain and emotional distress. The CNAs did not follow proper procedures for removing the resident's brace and shoes, and the resident's concerns were not promptly reported or addressed by the facility.
A resident with anxiety, heart failure, and post-polio syndrome reported that two agency CNAs were rough and disrespectful while removing his brace and shoes, causing pain and fear. Despite the resident's immediate complaints to staff, the incident was not reported to the State Agency until two days later. The facility's policy required allegations of abuse to be reported within two hours, but this was not followed.
A facility failed to promptly investigate and separate alleged perpetrators after a resident reported rough treatment and inappropriate comments by two agency CNAs. Despite the resident's clear communication, the facility did not act immediately, allowing the alleged perpetrators to return to work before any action was taken.
A resident with coronary artery disease, diabetes, and non-Alzheimer's dementia developed an unstageable pressure ulcer on the left heel. The facility failed to notify the provider of the wound's deterioration from 11/22/23 to 12/4/23, despite the resident's complaints of pain and worsening condition. The Clinical Administrator acknowledged the oversight, which occurred over the Thanksgiving holiday.
A resident with Alzheimer's and dysphagia did not receive required oral care after meals and inconsistent incontinent care, despite being dependent on staff for these activities. Observations and interviews revealed lapses in care, with staff failing to follow the care plan and speech therapy recommendations, leading to a deficiency in the resident's care.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed lorazepam, an antianxiety psychotropic medication, for anxiety. Resident #16 had a BIMS score of 14, indicating intact cognition, and the MDS documented diagnoses of heart failure, anxiety disorder, and depression. The care plan identified use of lorazepam for anxiety, and the EHR showed an order for lorazepam 0.5 mg at bedtime that had no discontinue date. The record also showed no attempt at a GDR since March 2024 for lorazepam. The annual psychotropic medication evaluation completed in August 2025 documented that the resident received lorazepam and that the last GDR had been from 0.75 mg nightly to 0.5 mg nightly on 3/18/24; it also documented that a GDR was not contraindicated. A quarterly psychotropic medication evaluation completed in February 2026 documented that the resident did not currently receive antianxiety medications, and the DON stated the facility missed lorazepam on that evaluation. During interview, the DON acknowledged the facility had not attempted or discussed a GDR for lorazepam since 2024 and stated there should have been a GDR recommendation in the last year or a rationale from the PCP for why a GDR should not be attempted.
Unnecessary Long-Term Antibiotic Use Without Adequate Review or Monitoring
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when Resident #47 remained on a daily doxycycline regimen for chronic acne without adequate review, monitoring, or documentation of continued need. The resident had a BIMS score of 15 and diagnoses that included medically complex conditions and acne. The record showed doxycycline hyclate 100 mg daily was started on admission for prophylaxis related to acne, then changed to doxycycline hyclate 50 mg daily with no discontinue date listed. A consulting pharmacist completed a medication regimen review and asked the facility to provide the antibiotic diagnosis, clinical rationale for continued use, whether the antibiotic was prescribed by a specialist, how often the resident saw the specialist, whether there had been a failed trial off therapy, and a re-evaluation date. The facility responded that the diagnosis was acne and that the resident would follow up with dermatology, but there was no documented re-evaluation date. The resident later declined dermatology follow-up and wanted her doctor to manage the skin condition, and staff noted the PCP would be updated, but the record lacked documentation that the PCP followed up on the antibiotic review. The DON stated there were no medical records or notes from the dermatologist who initially prescribed the antibiotic and no documentation since October 2025 from the PCP regarding the acne or need for the daily antibiotic. The DON also stated nursing staff did not make the referral to the PCP after the resident declined dermatology follow-up and that the resident’s continuous antibiotic was not referred to the Infection Preventionist for monitoring. The IP stated she did not receive notice when the resident was admitted on an antibiotic, had not been monitoring the resident’s antibiotic use, and the resident was not on her antibiotic log until the day of the interview. Facility policy required nursing documentation at the start and end of antibiotic therapy, review of response and lab results, and up-to-date infection control tracking of new antibiotic orders.
Unlabeled and Unsealed Open Food Items in Pantry
Penalty
Summary
The facility failed to date, seal, and label open food items stored in the main kitchen dry pantry. During observation of the pantry with the Certified Dietary Manager present, surveyors found 1 opened bag of dried croutons, 1 opened bag of dried cereal, 3 opened bags of dried pasta, and 1 opened bag of almonds that were all unsealed and without labels showing the date received or opened. The Certified Dietary Manager stated that opened bags of food should have a label when opened and be securely sealed when stored in the pantry. The Administrator also stated that opened bags of food stored in the pantry should have a label with the date opened and be securely sealed. The facility policy Safe Food Storage, updated May 2019, states that employees who receive and store food will maintain storage areas and make sure all goods are dated with received dates and that all food items are labeled, dated, and properly covered upon opening of the package.
Failure to Obtain Final Cooking Temperatures in Satellite Kitchen
Penalty
Summary
The facility failed to obtain final cooking food temperatures on alternative menu items prepared in the satellite kitchen, as observed during a lunch service. Staff A, a cook, and Staff B, a server, were seen preparing tomato soup for two separate residents without checking the final cooking temperature after microwaving. Additionally, Staff B prepared a microwaveable cup of macaroni and cheese without obtaining a final cooking temperature. During interviews, Staff C, the Nutrition and Culinary Supervisor, and the Certified Dietary Manager (CDM) acknowledged the oversight. The CDM emphasized the importance of obtaining final cooking temperatures for food safety and resident safety, especially with the variety of foods available on the alternative menu. The facility's policy, dated 2020, requires reheated cooked foods to reach an internal temperature of 165°F and ready-to-eat foods to be reheated to at least 135°F to ensure food safety.
Failure to Document Insulin Administration
Penalty
Summary
The facility failed to ensure proper documentation of insulin administration for a resident with diabetes and Parkinson's disease. The resident's Minimum Data Set (MDS) Assessment indicated the use of insulin, including Glargine and Lispro or Aspart. However, the Medication Administration Record (MAR) showed that Glargine was not recorded as administered on one day in September 2024, December 2024, January 2025, and February 2025. Additionally, Aspart was not recorded as administered at noon on one day in October 2024. The electronic health record's Progress Notes lacked documentation to confirm whether the insulin was administered or not. During an interview, the Director of Nursing (DON) was unable to verify if the insulin had been administered or if it was simply not documented. The facility's Medication Administration Policy, last modified in May 2021, requires that medications be documented immediately after administration. If a resident refuses medication, this should be indicated in the electronic MAR and the medical record. The DON expected staff to document all medication administration and provide additional documentation if the medication could not be given.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated a resident with dignity and respect. The resident, who had diagnoses including anxiety, heart failure, and post-polio syndrome, required significant assistance with daily activities. Despite having intact cognition, the resident reported that two agency CNAs were rough and dismissive while providing care, causing him pain and distress. The CNAs did not follow proper procedures for removing the resident's brace and shoes, leading to physical discomfort and emotional distress for the resident. The resident reported the incident via email, stating that the CNAs did not listen to his instructions and made inappropriate comments about his leg. The resident felt scared and hurt by their actions. The incident was corroborated by staff interviews, which revealed that the resident had reported the rough treatment to multiple staff members, but the information was not promptly acted upon. One of the CNAs involved was later identified by the resident through a photograph taken by another staff member. The facility's Clinical Administrator confirmed that the resident's allegations should have been reported immediately and that staff are expected to treat residents with kindness. The report highlights a failure in communication and timely reporting of the resident's concerns, as well as a lack of adherence to the facility's policy on treating residents with dignity and respect.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency for a resident with anxiety, heart failure, and post-polio syndrome. The resident, who had intact cognition, reported that two agency CNAs were rough while removing his brace and shoes, causing him pain and fear. Despite the resident's immediate complaints to staff members, the incident was not reported to the State Agency until two days later. The resident described the CNAs as being hurried and disrespectful, with one making an inappropriate comment about his leg. The resident reported the incident to a CNA the following day, who did not escalate the complaint. Another CNA connected the resident's complaint to one of the CNAs involved after a separate altercation occurred, but still did not report the incident immediately. The Clinical Administrator confirmed that the facility's policy required allegations of abuse to be reported within two hours and that alleged perpetrators should be separated from residents immediately. However, the facility lacked documentation of reporting the incident to the State Agency before the resident's email on the third day after the incident.
Failure to Investigate and Separate Alleged Perpetrators of Abuse
Penalty
Summary
The facility failed to initiate an abuse investigation and separate residents from alleged perpetrators in a timely manner after a resident reported maltreatment. Resident #45, who had diagnoses including anxiety, heart failure, and post-polio syndrome, reported that two agency CNAs were rough while removing his brace and shoes, causing him pain. Despite the resident's intact cognition and clear communication of his distress, the facility did not act immediately to investigate or separate the alleged perpetrators from the resident. On the morning following the incident, the resident informed Staff I CNA about the rough treatment and inappropriate comments made by the CNAs. However, Staff I did not report this information immediately. Later that day, an altercation occurred between one of the alleged CNAs and another staff member, which led to the CNA being asked to leave the facility. It was only after this incident that Staff I connected the dots and confirmed the identity of one of the alleged perpetrators with the resident. The facility's Clinical Administrator stated that allegations of abuse should be reported within 2 hours and that alleged perpetrators should be separated from residents immediately. However, the facility lacked documentation of an immediate investigation following the resident's initial report to Staff I. Additionally, the alleged perpetrators were allowed to return to work before any action was taken, further compromising the resident's safety and well-being.
Failure to Notify Provider of Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to notify the provider after a change in condition in a pressure ulcer for one resident. The resident, who had coronary artery disease, diabetes, and non-Alzheimer's dementia, was at risk for developing pressure ulcers but initially had no unhealed pressure ulcers. The resident required varying levels of assistance for daily activities and had inattention and disorganized thinking. On 11/15/23, a provider noted a corn on the resident's left heel and ordered a corn pad. Subsequent body audits on 11/22/23 and 11/29/23 noted a dark red scab on the left heel, which later developed into an unstageable pressure ulcer by 12/4/23. The facility lacked documentation of provider notification of the change in the resident's heel condition from 11/22/23 to 12/4/23. On 12/4/23, the resident complained of pain in the left heel, and a skin and wound evaluation revealed an unstageable pressure ulcer. The wound measured 0.3 cm x 0.8 cm x 0.5 cm and was tender to touch. A care plan entry on the same day directed staff to elevate the heel off the bed surface. However, by 4/10/24, the wound had worsened, measuring 3.2 cm x 2.8 cm with brown eschar and redness. The Clinical Administrator acknowledged that staff missed notifying the provider about the wound's deterioration over the Thanksgiving holiday, and no provider notification was found until 12/4/23. The facility's policy required staff to notify the physician if any evidence of deterioration was noted, which was not followed in this case.
Failure to Provide Adequate Oral and Incontinent Care
Penalty
Summary
The facility failed to provide adequate oral and incontinent care for a resident diagnosed with Alzheimer's disease, dementia, gastroesophageal reflux disease, and dysphagia. The resident was totally dependent on staff for eating, oral care, and required assistance from two staff members for toileting and personal care. Observations and interviews revealed that the resident did not receive oral care after meals as directed by the care plan and speech therapy recommendations. Additionally, the resident was not consistently checked and changed for incontinence as required, with family members and staff interviews indicating lapses in care. On multiple occasions, staff members, including CNAs and an LPN, were observed providing care to the resident without performing the necessary oral care. The facility's documentation and interviews with staff confirmed the lack of oral care after meals, despite the care plan and clinical resident profile specifying this requirement. The speech therapy evaluation highlighted the resident's risk for aspiration due to physical impairments, underscoring the importance of following the prescribed oral care regimen. The facility's failure to adhere to these care directives resulted in a deficiency in the resident's care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ankeny
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny View Care Center | 2.2 mi | ★★★★★ | 24 | 0 |
| The Bridges At Ankeny | 2.2 mi | ★★★★★ | 16 | 0 |
| On With Life | 2.3 mi | ★★★★★ | 0 | 0 |
| Trinity Center At Luther Park | 7.1 mi | ★★★★★ | 17 | 1 |
| Bishop Drumm Retirement Center | 7.2 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.