Inspection Reports for Cedarhurst of Waterloo
526 Legacy Drive, Waterloo, IL, 62298
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 5, 2025, identified deficiencies related to the facility’s failure to conduct required bi-monthly disaster/fire drills, including night drills, and incomplete physician assessment certifications for residents with significant changes in condition. Earlier inspections and complaint investigations found similar issues, including a substantiated complaint for failure to report a resident’s fall resulting in a fractured wrist to the Illinois Department of Public Health. The main themes across reports involved disaster preparedness and regulatory reporting requirements. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of deficiencies suggests ongoing challenges with documentation and compliance, with no clear indication of improvement.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 2
Date: May 5, 2025
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with state regulations including disaster preparedness and physician assessments.
Findings
The facility failed to conduct required bi-monthly disaster/fire drills including night drills, failed to document resident participation and assistance during drills, and did not complete physician assessment certifications for residents with significant changes in condition, particularly those admitted to hospice care.
Deficiencies (2)
Failure to conduct disaster/fire drills on a bi-monthly basis including two night drills, and failure to document resident participation and assistance during drills.
Failure to complete physician assessment certification for residents identified with significant change of condition.
Report Facts
Residents: 76
Fire drills conducted: 2
Residents on hospice: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Maintenance Director | Stated facility had not been documenting resident participation in drills and could not provide night shift drills |
| E2 | Director of Wellness | Reported six residents on hospice without physician assessment certification after significant change of condition |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 2
Date: May 5, 2025
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with state regulations including disaster preparedness and physician assessments.
Findings
The facility failed to conduct required bi-monthly disaster/fire drills including two night drills, failed to document resident participation and assistance during drills, and did not complete physician assessment certifications for residents with significant changes in condition, particularly those admitted to hospice.
Deficiencies (2)
Failure to conduct disaster/fire drills on a bi-monthly basis including two night drills, and failure to document resident participation and assistance during drills.
Failure to ensure physician assessment certification was completed for residents identified with significant change of condition.
Report Facts
Residents present: 76
Fire drills conducted: 2
Residents on hospice: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Maintenance Director | Stated facility had not been documenting resident participation in drills and could not provide evidence of night shift drills. |
| E2 | Director of Wellness | Admitted no physician assessment certification was done for residents with significant change of condition admitted to hospice. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#2542162/IL187954) regarding the facility's failure to report a serious incident involving a resident's fall resulting in a fractured wrist.
Complaint Details
Complaint Investigation #2542162/IL187954 regarding failure to report a serious incident involving a resident's fall with fracture. The complaint was substantiated based on interview and record review.
Findings
The facility failed to report a resident's fall on 11/21/24 that resulted in an emergency room visit for a fractured right wrist to the Illinois Department of Public Health, as required by regulation.
Deficiencies (1)
Failure to report a fall resulting in an emergency room visit for a fractured right wrist to the Illinois Department of Public Health.
Report Facts
Incident date: Nov 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Confirmed that the resident's fall with fracture on 11/21/24 was not reported to IDPH |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#2542162/IL187954) regarding the facility's failure to report a serious incident involving a resident's fall resulting in a fractured wrist.
Complaint Details
Complaint Investigation #2542162/IL187954 regarding failure to report a serious incident involving a resident's fall with fracture; substantiation confirmed by interview with E1 on 3/17/25.
Findings
The facility failed to report a resident's fall on 11/21/24 that resulted in an emergency room visit for a fractured right wrist to the Illinois Department of Public Health, violating Section 295.2050 Incident and Accident Reporting regulations.
Deficiencies (1)
Failure to report a fall resulting in an emergency room visit for a fractured right wrist to the Illinois Department of Public Health.
Report Facts
Incident date: Nov 21, 2024
Report confirmation date: Mar 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director (ED) | Confirmed failure to report incident; no longer employed as of 3/24/25 |
| Regional Director of Nursing | Will provide re-education on communication and incident reporting to interim ED, Director of Nursing, and Assistant Director of Nursing |
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