Inspection Reports for Mill Valley Care Center
1201 Park Street, IA, 520311911
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 9, 2025, found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a mixed pattern with several citations related primarily to resident care practices, including transfer techniques, pressure ulcer assessments, and timely reporting of abuse allegations. Prior deficiencies also involved documentation issues, care plan implementation, medication administration, and infection control. Complaint investigations were mostly unsubstantiated, with a few substantiated cases involving injury from transfer techniques, pressure ulcer care, and failure to report abuse promptly. The facility’s recent inspections indicate improvement, as the latest surveys have not identified new deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
35 residents
Based on a July 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 9, 2025
Visit Reason
A complaint investigation for complaints #2634673-I was conducted from October 8, 2025 to October 9, 2025.
Complaint Details
Complaint investigation for complaint #2634673-I; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
An annual recertification survey and investigation of complaint #129396-C was conducted from June 16, 2025 to June 19, 2025.
Complaint Details
Complaint #129396-C was investigated and found not substantiated.
Findings
Complaint #129396-C was not substantiated. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
An investigation regarding complaint #123528-C was conducted.
Complaint Details
Investigation was complaint-related for complaint #123528-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on August 19, 2024, related to facility certification compliance.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, with certification effective August 12, 2024.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #119066-C and #121230-C from July 22, 2024 to July 25, 2024.
Complaint Details
Complaints #119066-C and #121230-C were substantiated without deficiency.
Findings
The facility was found not to meet the requirement for free of accident hazards and adequate supervision to prevent accidents, specifically related to transfer techniques resulting in injury to one resident. Complaints investigated were substantiated without deficiency.
Deficiencies (1)
The facility failed to follow appropriate transfer techniques resulting in injury for one resident.
Report Facts
Resident census: 35
Mental Status score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Physical Therapist | Signed Therapy Communication form indicating resident was an assist of two and total body lift |
| Staff B | Certified Occupational Therapy Assistant | Clarified full body lift meant a Hoyer lift during interview |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, certifying the facility's substantial compliance and compliance certification effective February 9, 2024.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective February 9, 2024. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The inspection was conducted as a result of Complaint #118630-C from February 5 to February 8, 2024, to investigate allegations related to quality of care at Mill Valley Care Center.
Complaint Details
Complaint #118630-C was substantiated.
Findings
The facility failed to document weekly pressure ulcer assessments for 2 of 3 residents reviewed, resulting in worsening pressure ulcers. The complaint was substantiated based on clinical record review, staff interviews, and policy review.
Deficiencies (1)
Failure to document Weekly Pressure Ulcer Assessments for 2 of 3 residents reviewed, leading to worsening pressure ulcers.
Report Facts
Resident census: 34
Pressure ulcer measurements: 0.7
Pressure ulcer measurements: 1.9
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.25
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated they were unable to find the weekly pressure ulcer assessments for Resident #2 and Resident #3 and acknowledged the assessments should have been done. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
The document serves as a plan of correction following a survey, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective June 8, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 7
Date: May 18, 2023
Visit Reason
The inspection was conducted as an Annual Recertification Survey to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to complete significant change assessments timely, failure to develop and revise comprehensive care plans appropriately, inadequate incontinence care, improper catheter bag positioning, and failure to answer call lights in a timely manner.
Deficiencies (7)
Failure to maintain dignity for residents, including delayed response to call lights and inappropriate staff behavior.
Failure to complete a significant change Minimum Data Set (MDS) within 14 days after significant weight loss was identified.
Failure to develop a comprehensive care plan addressing the indwelling catheter for a resident.
Failure to revise care plan timely to address significant weight loss interventions.
Failure to provide proper incontinence care to prevent potential urinary tract infections.
Failure to maintain Foley catheter bag off the floor to prevent potential urinary tract infections.
Failure to answer call lights in a timely manner for residents.
Report Facts
Census: 35
Weight loss percentage: 7.2
Weight loss percentage: 8.8
Weight loss percentage: 11.7
Weight loss percentage: 12.1
Call light response time: 10
Call light delay: 40
Call light delay: 60
Call light delay: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant | Reported call lights should be answered within 15 minutes |
| Staff E | Certified Nursing Assistant | Reported call lights should be answered within 10 to 15 minutes |
| Staff F | Licensed Practical Nurse | Reported call lights should be answered within 10 minutes |
| Director of Nursing | Reported expectation for call lights to be answered within 10 minutes and acknowledged Resident #12's complaint | |
| Staff H | Certified Nursing Assistant | Observed wiping resident's mouth with a spoon |
| Staff D | Certified Nursing Assistant | Observed not changing gloves after cleansing rectal area and improper basin emptying |
| Staff C | Certified Nursing Assistant | Observed ignoring catheter bag on floor |
| Staff A | Certified Nursing Assistant | Observed ignoring catheter bag on floor |
| Staff B | Certified Nursing Assistant | Observed ignoring catheter bag on floor |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 5, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective May 5, 2023.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of multiple complaints (#110833-C, #112047-C, #111158-I, and #111167-I) were conducted by the Department of Inspections and Appeals from April 6, 2023 to April 13, 2023.
Complaint Details
The complaint investigation found that staff failed to report abuse allegations timely for Resident #3, who was roughly pushed into his wheelchair by a registered nurse and subjected to verbal abuse. The facility policy required immediate reporting to the Charge Nurse and Administrator, which was not followed. The complaint was substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended COVID-19 practices. However, the facility failed to report allegations of abuse in a timely manner for one of two residents reviewed, specifically Resident #3 who was subjected to rough handling by staff and the incident was not reported immediately as required by policy.
Deficiencies (1)
Failure to report allegations of abuse in a timely manner for Resident #3, including rough handling by staff and use of profanity.
Report Facts
Total residents: 33
MDS Assessment date: Mar 9, 2023
Investigative Summary date: Feb 12, 2023
Plan of Correction completion date: May 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Reported witnessing abuse and failed to report incident immediately |
| Staff B | Registered Nurse | Alleged to have roughly pushed Resident #3 into wheelchair and used profanity |
| Staff C | Certified Nursing Assistant | Interviewed and stated facility never directed him to report abuse but he was aware to report as soon as possible |
| Staff D | Registered Nurse, Nurse Consultant | Reported expectation for immediate reporting and investigation of abuse |
| Administrator | Stated expectation for immediate reporting to supervisor and administrator |
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 9
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as part of the Recertification Survey and investigation of complaints and a facility self-reported incident.
Complaint Details
The inspection included investigation of Complaints #100223, #100684, and a Facility Self-Reported Incident #101567. Complaint #100684 and Incident #101567 were substantiated.
Findings
The facility was found deficient in multiple areas including failure to follow and implement comprehensive care plans for residents, failure to meet professional standards in medication administration, inadequate assistance with activities of daily living, failure to provide appropriate treatment for pressure ulcers, failure to implement restorative programs, failure to properly manage respiratory care, failure to post nurse staffing information timely, failure to implement infection prevention and control procedures, and failure to document COVID-19 vaccination declinations.
Deficiencies (9)
Failed to follow and implement comprehensive care plans for residents #4, #14, #21, and #22.
Failed to follow Physician Orders and administer as needed medications for Resident #26.
Failed to provide complete incontinence care and proper transfer assistance for Residents #4 and #22.
Failed to provide necessary treatment and services to promote healing of a Stage II pressure ulcer for Resident #22.
Failed to implement restorative program recommended by therapy for Resident #21.
Failed to date or document when oxygen tubing had been changed for Resident #16.
Failed to post daily nurse staffing information timely and in a prominent place.
Failed to implement appropriate infection control procedures including hand hygiene and disinfection of mechanical lifting equipment for Resident #14.
Failed to provide documentation of COVID-19 vaccination declination forms for 5 staff and 1 resident.
Report Facts
Resident census: 27
Deficiencies cited: 9
Braden Scale scores: 22
Braden Scale scores: 20
Braden Scale scores: 19
Pressure ulcer size: 4
Pressure ulcer size: 5
Pressure ulcer size: 2.5
Pressure ulcer size: 2
Pressure ulcer size: 1.5
Pressure ulcer size: 1.4
Oxygen liters: 3
BIMS score: 15
BIMS score: 11
BIMS score: 3
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aide (CNA) | Named in findings related to incontinence care for Resident #4 |
| Staff B | Certified Nurses Aide (CNA) | Named in findings related to incontinence care for Resident #4 |
| Staff C | Certified Nurses Aide (CNA) | Named in findings related to toileting and oxygen care |
| Staff D | Licensed Practical Nurse (LPN) | Named in findings related to toileting and oxygen care |
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to infection control and lifting equipment disinfection |
| Staff G | Certified Nursing Assistant (CNA) | Named in findings related to infection control and lifting equipment disinfection |
| Staff K | Registered Nurse (RN) MDS and Care Plan Coordinator | Named in findings related to care plan development |
| Staff L | Nurse Consultant | Named in findings related to restorative nursing documentation |
| Staff M | Occupational Therapy (OT) | Named in findings related to restorative program recommendations |
| Staff N | Certified Nursing Assistant (CNA) | Named in findings related to transfer assistance |
| Staff O | Certified Nursing Assistant (CNA) | Named in findings related to incontinence care and transfer assistance |
| Staff P | Certified Nursing Assistant (CNA) | Named in findings related to incontinence care |
| Staff Q | Licensed Practical Nurse (LPN) | Named in findings related to agency staff training |
| Staff E | Registered Nurse (RN) | Named in findings related to oxygen tubing change and COVID-19 vaccination education |
| Administrator | Named in findings related to COVID-19 vaccination education and declination forms |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 4
Date: Apr 14, 2021
Visit Reason
The inspection was conducted as an investigation of Complaints #86278 and #96286 from 3/10/21 to 4/14/21, both of which were substantiated.
Complaint Details
The investigation was triggered by Complaints #86278 and #96286 from 3/10/21 to 4/14/21, both substantiated.
Findings
The facility failed to obtain required written physician authorizations for prescription medication orders and medication administration, resulting in potential severe drug interactions for 2 of 5 residents reviewed. Additionally, the facility failed to provide comprehensive cardiac assessments and timely notification of condition changes for residents, and failed to maintain a supply of narcotic medications without errors for 3 of 12 residents reviewed. The facility reported a census of 30 residents.
Deficiencies (4)
Failed to obtain required written physician authorization for prescription medication orders and medication administration, including authorization for potential severe drug interactions for 2 of 5 residents reviewed.
Failed to provide comprehensive cardiac assessments, clarify cardiac medication orders, and notify cardiologist of acute cardiac condition changes for 1 of 12 residents reviewed.
Failed to ensure staff maintained a supply of narcotic medications, administered medications as ordered, and ensured 3 of 12 resident records were free from medication errors.
Failed to ensure each employee had a physical examination at least every four years as required by law for 4 of 5 employee records reviewed.
Report Facts
Resident census: 30
Residents reviewed for medication authorization deficiency: 5
Residents reviewed for cardiac assessment deficiency: 12
Residents reviewed for medication error deficiency: 12
Employees reviewed for physical examination deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Initiated and transcribed medication orders; involved in medication authorization deficiency |
| Staff G | Registered Nurse (RN) and Assistant Director of Nursing (ADON) | Involved in medication authorization deficiency and medication error findings |
| Staff Y | Registered Pharmacist (RPh) | Provided testimony regarding lack of physician authorization for medications |
| Staff Z | Corporate Nurse | Testified about lack of standing orders and physician authorization |
| Staff H | Registered Nurse (RN) | Provided testimony regarding standing orders and medication administration |
Inspection Report
Routine
Census: 38
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess 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
Routine
Census: 38
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Total residents: 38
Report
Jun 19, 2025
Report
Jul 25, 2024
Report
Feb 8, 2024
Report
May 18, 2023
Report
Apr 13, 2023
Report
Apr 13, 2023
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