Mill-pond

F-F812 Regulation-Food Safety Requirements, dated 2020, stated cooking food to the required temperature will either kill dangerous organisms or inactivate them enough so there is little risk to

the resident and food is safe to eat. Reheated cooked foods must be reheated to an internal temperature of 165 Fahrenheit. Ready-to-eat foods should be reheated to at least 135 Fahrenheit.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 2 165261 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165261 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mill-Pond 1201 SE Mill Pond Court Ankeny, IA 50021

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50500

Residents Affected - Few Based on electronic health record review, staff interview, and policy review, the facility failed to ensure documentation of insulin administration for 1 of 4 resident reviewed for medication regimen review (Resident #12). The facility reported a census of 59 residents.

Findings include:

The Minimum Data Set (MDS) Assessment, dated 1/16/25, listed Resident #12's medical diagnoses, which include diabetes and Parkinson's. The MDS noted the use of insulin.

The Order Summary Report, dated 3/6/25, listed an order for Glargine (long acting insulin), which is administered one time a day at night and an order for Lispro or Aspart (both fast-acting insulin), which is administered three times a day with meals.

The Medication Administration Record (MAR) revealed the following:

a. In September 2024, Glargine was not recorded as administered in 1 out of 30 days

b. In October 2024, Aspart was not recorded as administered at noon in 1 out of 31 days

c. In December 2024, Glargine was not recorded as administered in 1 of out of 31 days

d. In January 2025, Glargine was not recorded as administered in 1 out of 30 days

e. In February 2025, Glargine was not recorded as administered in 1 out of 28 days

The review of Progress Notes in the electronic health record lacked documentation to address if the insulin had or had not been given to Resident #12.

During an interview on 3/5/25, the Director of Nursing (DON) could not verify if the insulin had been administered and staff did not document or if the insulin was not administered at all. The DON would expect staff to document all medication administration. If the medication could not be given, additional documentation should be written to explain why it had not.

The policy Medication Administration Policy, modified May 2021, stated medications are documented immediately after administration by the nurse or medication aide. If the resident refuses, staff should indicated this in the electronic MAR as well as the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 165261