Inspection Reports for
Birdee Cottage AL and MC
2221 Fairway Lane, Waterloo, IA, 50701
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
17 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation (#127410-C) regarding regulatory insufficiency at the assisted living facility.
Complaint Details
The deficiency was cited during the investigation of Complaint #127410-C. The Director confirmed the omission of alcohol consumption and titration plan in Tenant #1's service plan.
Findings
The facility failed to develop an individualized service plan for Tenant #1 that included her preferred use of alcohol and the physician's recommendation to titrate off the substance, despite cognitive impairment and provider input.
Deficiencies (1)
Failed to develop an individualized service plan based on identified preferences for Tenant #1, specifically regarding alcohol use and titration plan.
Report Facts
Census count: 17
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to investigate Complaint #121356-C and to perform a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
Complaint #121356-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 4
Number of tenants with cognitive impairment: 9
Total census: 13
Inspection Report
Original Licensing
Census: 11
Deficiencies: 9
Date: Sep 28, 2022
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate a complaint.
Complaint Details
The inspection was partially triggered by a complaint investigation #107552-C related to occupancy agreements and involuntary transfers.
Findings
The inspection identified multiple regulatory deficiencies including failure to include required information in occupancy agreements, inconsistent following of policies and procedures, incomplete incident reports, medication administration errors, incomplete wound care documentation, incomplete nurse delegation training, incomplete background checks, incomplete service plans, and failure to provide dementia-specific education for personnel.
Deficiencies (9)
Written occupancy agreement required; failed to include required information related to involuntary transfers and internal appeals process.
Program failed to consistently follow established policies and procedures; incident reports incomplete.
Medication administration records (MARs) incomplete; missing dates, times, reasons, results, and signatures.
Nurse delegation training not completed within 30 days for some staff.
Background checks not completed for all staff prior to employment.
Service plans not updated or signed timely; failed to reflect changes in tenant needs.
Food service menus did not meet recommended daily allowances; breakfast meal not included.
Dementia-specific education for personnel not completed within required timeframe.
Life safety code deficiency: operating alarm system not maintained; doors not secured at all times.
Report Facts
Census: 11
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 7
Number of deficiencies cited: 9
Number of tenants reviewed for policies and procedures: 3
Number of staff reviewed for nurse delegation training: 5
Number of tenants reviewed for medication administration: 3
Number of tenants reviewed for service plans: 3
Number of tenants reviewed for dementia-specific education: 5
Number of tenants with medication errors documented: 2
Number of tenants with incomplete nurse notes: 1
Number of tenants with incomplete service plans: 2
Number of tenants with incomplete occupancy agreements: 1
Number of tenants with incomplete incident reports: 2
Number of tenants with wound care documentation issues: 1
Number of tenants with medication administration documentation issues: 1
Number of tenants with incomplete narcotics policy: 11
Number of tenants with incomplete food service menus: 11
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