Valley View Village: Resident Rights Violation - IA
The incident occurred at Valley View Village when staff found Resident #2 unresponsive in his room. The 79-bed facility had clear documentation of the resident's wishes: a signed Iowa Physician Orders for Scope of Treatment form indicating he wanted CPR attempted but specifically refused intubation or mechanical ventilation.
Staff initiated CPR and called 911. When paramedics arrived, they took over resuscitation efforts and intubated the resident. Nobody stopped them.
"Staff A, RN discussed Resident #2's code status verbally with EMS but did not present the IPOST," the Educational Nurse told inspectors. "Confirmed EMS did intubate Resident #2. No staff tried to stop EMS from intubating."
The resident had multiple serious health conditions including hypertension, Type 2 diabetes, cerebral infarction, heart failure and cardiomyopathy. His advance directive was clear about treatment limitations during end-of-life care.
Staff A, the registered nurse who started CPR, expressed concern about discussing the incident with inspectors because she no longer worked at the facility. She described the scene as chaotic: "They put on the AED and it did not advise shock as he was deceased. Emergency Medical Services arrived and took over CPR."
She acknowledged uncertainty about the resident's intubation status. "She does not remember if EMS intubated Resident #2 but they may have. She added that she did not remember if Resident #2 was a Do Not Intubate as it was very chaotic."
The Educational Nurse provided more definitive details. A certified nursing assistant had pulled her into the room after finding the resident unresponsive. "She assessed him he was still warm no pulse or respirations." The CNA who discovered the resident was "quite distressed," she said.
Valley View's Director of Nursing confirmed the resident's code status: full CPR with do-not-intubate orders. She acknowledged the violation of protocol.
"The DON reported typically, if sending someone out, they present the IPOST but this was very chaotic and both aids were extremely distressed, and that they don't usually do CPR," inspectors wrote. "The DON did state that the IPOST or wishes should have been presented to EMS."
The facility's own policy, updated this year, requires staff to check residents' code status and advance directive documents during crisis situations. The policy also mandates that original advance directive forms accompany residents during transfers or discharges to other facilities.
CPR continued until the resident's Power of Attorney was contacted and made the decision to discontinue resuscitation efforts.
The resident's care plan, initiated during his admission, lacked specific information about his end-of-life treatment preferences despite the existence of his signed advance directive. His medical record contained the properly executed IPOST form specifying his wishes for limited interventions.
Federal regulations require nursing homes to honor residents' advance directives and treatment preferences. The violation affected the resident's fundamental right to refuse specific medical interventions, even during emergency situations.
The chaos of the emergency response does not excuse the failure to follow established protocols for communicating residents' documented wishes to emergency medical personnel. Staff training and clear procedures exist specifically to ensure advance directives are respected during high-stress situations.
The resident's family had taken care to document his treatment preferences through the state's official advance directive process. Those wishes were ignored during his final moments because staff failed to present a single document that was readily available in his medical record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Village from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Valley View Village in Des Moines, IA was cited for violations during a health inspection on November 24, 2025.
The incident occurred at Valley View Village when staff found Resident #2 unresponsive in his room.
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.