Park View Rehab: Fall Alarm Failure Causes Harm - IA
Federal inspectors cited the facility for causing actual harm to a resident following the July 11, 2025 incident, findings documented during a complaint inspection completed September 4.
The alarm had been placed on the resident specifically so staff would know when he was getting up. It did not sound. A licensed practical nurse identified in the inspection report as Staff G told inspectors she found him across the hall from his room. The search, she said, didn't take long.
What she couldn't explain was why the alarm failed.
On September 3, Staff G told inspectors she didn't know why the alarm didn't go off that morning and that she never found out. A certified nursing assistant, identified as Staff H, said the same thing: she did not hear the alarm, and she did not know why it didn't sound.
By the following morning, Staff G had a theory. She told inspectors on September 4 that either staff hadn't turned the alarm on the night before, or the resident had figured out how to turn it off himself. "I thought he had learned how to turn it off," she said.
That detail sits at the center of what inspectors found troubling. The alarm existed because this resident needed monitoring when he stood. Staff G acknowledged she hadn't known he was capable of walking on his own. Yet the possibility that he had been disabling his own safety device, apparently more than once, had not been resolved or even fully investigated before the inspection.
By the time inspectors arrived, the facility had replaced the original alarm with a different type, one that sounds when the resident pulls away from it rather than relying on him leaving it switched on. Staff G described the new setup and said it was working. What she did not describe was any systematic review of how the original alarm had been managed, who was responsible for verifying it was active each shift, or what had changed in the facility's practices to prevent the same failure from happening again.
The inspection report references the facility's own Fall Occurrence policy, which states its purpose as ensuring residents are evaluated for fall risks and that interventions are put in place to minimize the risk of falls and injury. The policy is undated.
The gap between that stated purpose and what actually happened on July 11 is what federal inspectors flagged. An alarm that staff could not confirm was ever turned on, for a resident whose mobility staff did not fully understand, in a facility that could not determine after the fact what had gone wrong.
Inspectors classified the violation under F0689, the federal tag covering free from accident hazards, and rated the level of harm as actual harm, meaning the resident was hurt, not that harm was merely possible.
The inspection report does not describe the nature or extent of the resident's injuries. It does not name the resident. What it records is a nurse who went looking for someone she didn't expect to find on his feet, and found him across the hall, and still, months later, could not say with certainty why the alarm that was supposed to protect him had not made a sound.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Rehabilitation Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
Park View Rehabilitation Center in Sac City, IA was cited for violations during a health inspection on September 4, 2025.
The alarm had been placed on the resident specifically so staff would know when he was getting up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.