Inspection Reports for
Pillar of Cedar Valley
1410 West Dunkerton Road, Waterloo, IA, 507039626
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
223% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
119% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 3
Date: Dec 23, 2025
Visit Reason
Investigation of facility reported incident #2695755-I conducted December 22-23, 2025, related to resident-to-resident abuse allegations involving Residents #1, #2, and #5.
Complaint Details
The investigation was triggered by a facility reported incident #2695755-I involving resident-to-resident abuse. The facility failed to report three incidents within required time frames and did not conduct thorough investigations or implement adequate interventions. Resident #2 exhibited frequent physical and verbal aggression toward Residents #1 and #5, including hitting and verbal threats.
Findings
The facility failed to protect residents from resident-to-resident abuse, specifically Resident #2 physically and verbally abusing Residents #1 and #5 on multiple occasions. The facility also failed to report alleged abuse incidents timely to the Iowa Department of Inspections, Appeals and Licensing (DIAL) and did not thoroughly investigate or implement adequate interventions following the incidents.
Deficiencies (3)
Failure to protect residents from resident-to-resident abuse involving Residents #1 and #5 by Resident #2.
Failure to report alleged violations of physical abuse within required time frames to the state agency for incidents on 11/14/25, 12/10/25, and 12/15/25.
Failure to thoroughly investigate resident-to-resident abuse incidents and implement interventions to prevent further incidents.
Report Facts
Resident census: 136
Number of incidents not reported timely: 3
BIMS score: 99
BIMS score: 13
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Witnessed Resident #2 hit Resident #1 and #5; reported abuse allegations to supervisor |
| Staff B | Licensed Practical Nurse (LPN) | Reported abuse allegations to ADON or DON; witnessed incidents involving Resident #2 |
| Staff C | Certified Nursing Assistant (CNA) | Reported familiarity with Resident #2's aggressive behaviors and abuse incidents |
| Staff D | Assistant Director of Nursing (ADON) | Acknowledged Resident #2's behaviors and reported supervision measures |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 3
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse and failure to report and investigate abuse incidents properly.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident abuse by Resident #2 against Residents #1 and #5. The facility failed to report three incidents timely to the state agency and failed to conduct thorough investigations for all incidents.
Findings
The facility failed to protect residents from resident-to-resident abuse involving Resident #2 hitting Residents #1 and #5 on multiple occasions. The facility also failed to timely report suspected abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) and did not thoroughly investigate or implement interventions following the incidents.
Deficiencies (3)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse by Resident #2 toward other residents. Multiple incidents of hitting, yelling, and aggressive behaviors were documented with minimal harm.
F 0609: The facility failed to timely report suspected abuse incidents on 11/14/25, 12/10/25, and 12/15/25 to the Iowa Department of Inspections, Appeals and Licensing as required by law.
F 0610: The facility failed to thoroughly investigate resident-to-resident abuse incidents involving Resident #2 hitting Residents #1 and #5, lacking staff interviews and complete incident investigations.
Report Facts
Resident census: 136
Number of abuse incidents not timely reported: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Reported familiarity with Resident #2 and witnessing abuse incidents |
| Staff B | Licensed Practical Nurse (LPN) | Acknowledged receiving abuse training and reporting abuse allegations |
| Staff C | Certified Nursing Assistant (CNA) | Reported training for dependent adult abuse and familiarity with Resident #2 |
| Staff D | Assistant Director of Nursing (ADON) | Reported training on dependent adult abuse and familiarity with Resident #2's behaviors |
| Director of Nursing (DON) | Director of Nursing | Acknowledged failure to report incidents timely and incomplete investigations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 9, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on December 9, 2025, related to the facility's compliance with health requirements.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance with health requirements effective December 1, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 7
Date: Nov 17, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints and facility-reported incidents from September 8, 2025 to November 17, 2025.
Complaint Details
The survey included investigation of complaints #1736322-C, #1736323-C, and facility reported incidents #1736043-I, #1736324-I, and #2605835-I.
Findings
The facility was found deficient in multiple areas including timely transmission of resident assessments, failure to follow comprehensive care plans, failure to provide appropriate mobility aids, unsafe storage of hazardous tools, failure to implement physician orders for oxygen therapy, administration of expired insulin, and failure to maintain patient care equipment in safe operating condition.
Deficiencies (7)
Failed to transmit Minimum Data Set (MDS) assessments timely for 2 of 3 residents reviewed.
Failed to follow a resident's Care Plan for wheelchair safety and pressure injury prevention for 1 of 2 residents reviewed.
Failed to provide a palm splint to reduce/prevent contracture for 1 of 1 resident reviewed.
Failed to lock up hazardous tools when staff were not present in resident areas.
Failed to implement current physician orders for oxygen therapy for 1 of 1 resident reviewed.
Failed to ensure residents did not receive expired insulin for 2 of 2 residents sampled.
Failed to maintain patient care equipment in safe operating condition for 1 of 1 resident reviewed.
Report Facts
Census: 136
Deficiencies cited: 7
Oxygen flow rate: 3
Oxygen flow rate observed: 2
Insulin expiration date: 9
Insulin administration frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | MDS Coordinator | Reported failure to submit MDS assessments timely. |
| Staff A | Registered Nurse (RN) | Administered expired insulin to residents #401 and #9. |
| Staff E | Licensed Practical Nurse (LPN) | Documented oxygen administration for Resident #15 and reported on splint application. |
| Staff I | Assistant Director of Nursing (ADON) | Directed staff to apply splints and confirmed oxygen order for Resident #15. |
| Staff B | Assistant Director of Nursing (ADON) | Discussed insulin expiration and oxygen key management. |
| Staff L | Assistant Maintenance | Reported on sprinkler company and tool safety. |
| Staff N | Assistant Maintenance | Reported on maintenance repair process. |
| Administrator | Administrator | Provided statements on policies and expectations regarding MDS submissions, oxygen key, and maintenance. |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 7
Date: Nov 17, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to timely transmit Minimum Data Set (MDS) assessments, failure to follow resident care plans, failure to provide appropriate range of motion care, failure to secure hazardous tools, failure to implement physician orders for oxygen therapy, administration of expired insulin to diabetic residents, and failure to maintain patient care equipment in good repair.
Deficiencies (7)
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments timely for 2 of 3 residents reviewed. The facility reported a census of 136 residents.
F 0656: The facility failed to follow a resident's Care Plan for 1 of 2 residents reviewed. Resident #5's wheelchair lacked required anti-tippers, pressure relieving cushion, and non-slip material.
F 0688: The facility failed to provide a palm splint to reduce/prevent contracture for 1 of 1 resident reviewed (Resident #15) despite physician orders and care plan interventions.
F 0689: The facility failed to lock up hazardous tools when staff were not present in resident areas, posing a safety risk to residents.
F 0695: The facility failed to implement current physician orders for oxygen therapy for 1 of 1 resident reviewed (Resident #15), including failure to maintain continuous oxygen as ordered.
F 0760: The facility failed to ensure residents did not receive expired insulin for 2 of 2 diabetic residents sampled (Residents #401 and #9).
F 0908: The facility failed to have patient care equipment in good repair for 1 of 1 resident reviewed (Resident #37) due to loose and sticking up plastic protective edging on the bed frame.
Report Facts
Residents census: 136
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | MDS Coordinator | Reported electronic health record program directed not to submit MDS assessments |
| Staff A | Registered Nurse (RN) | Verbalized lack of knowledge about wheelchair care plan interventions and administered expired insulin |
| Staff K | Certified Nurse Aide (CNA) | Reported never seeing cushion or Dycem for Resident #5's wheelchair |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for staff to follow care plans and physician orders |
| Staff I | Assistant Director of Nursing (ADON) | Directed staff to apply palm splint and confirmed oxygen order |
| Staff E | Licensed Practical Nurse (LPN) | Documented oxygen administration and reported lack of visual checks for splint placement |
| Staff C | Certified Nursing Assistant (CNA) | Assisted Resident #15 and handled oxygen concentrator |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Resident #15 and handled oxygen concentrator |
| Staff A | Registered Nurse (RN) | Administered expired insulin to Resident #401 and Resident #9 |
| Staff L | Assistant Maintenance | Reported on sprinkler company and tool safety |
| Staff B | Assistant Director of Nursing (ADON) | Verbalized expectations for oxygen key security |
| Staff N | Assistant Maintenance | Reported on maintenance repair process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 29, 2025
Visit Reason
A complaint investigation for complaint #2635636-C was conducted on October 28, 2025 to October 29, 2025.
Complaint Details
Complaint #2635636-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was conducted following a complaint investigation of intakes #127344-C and #127135-I from March 24, 2025 to March 25, 2025.
Complaint Details
Complaint investigation of intakes #127344-C and #127135-I was conducted and the facility was found in compliance.
Findings
The Pillar of Cedar Valley Nursing Home was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Report Facts
Total census: 136
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 6, 2025
Visit Reason
The annual survey and investigations #125689-M, #126196-I, and #126299-C were conducted from 02/03/25 to 02/06/25 to assess compliance with 42 CFR 483 Subpart I for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID).
Findings
The facility was found to be in substantial compliance overall, with no deficiencies cited in investigations #126196-I and #126299-C. However, investigation #125689-M resulted in a deficiency cited at W153 related to staff failure to immediately report allegations of mistreatment, neglect, or abuse of Client #5.
Deficiencies (1)
The facility failed to ensure staff immediately reported allegations of abuse, neglect, and mistreatment of Client #5 as required by policy.
Report Facts
Investigations conducted: 3
Date of alleged abuse report: Dec 24, 2024
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and demonstrate substantial compliance for certification.
Findings
The facility was found to be in substantial compliance based on the acceptance of the credible allegation and Plan of Correction, resulting in certification effective October 31, 2024.
Inspection Report
Annual Inspection
Census: 132
Deficiencies: 11
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a reported incident #123574-I from September 30, 2024 to October 3, 2024.
Findings
The facility was found to have multiple deficiencies including failure to protect resident rights and dignity, inadequate privacy measures, failure to post survey results, incomplete fall assessments, inadequate infection control practices, and failure to ensure safe environment free of accident hazards. Several residents had care and safety issues related to privacy, fall risk, infection prevention, and call light responsiveness.
Deficiencies (11)
Failure to provide privacy curtain between residents #29 and #64, removing all privacy for Resident #29.
Failure to post notice of availability of most recent survey results to residents and family members.
Failure to apply continuous oxygen at 2 liters per minute as ordered for Resident #52.
Failure to complete resident fall assessment or neurological checks following an unwitnessed fall for Resident #53.
Failure to ensure resident environment free of accident hazards; Resident #79 fell in shower unattended.
Failure to apply gloves or additional PPE during administration of enteral tube feeding for Resident #52.
Failure to establish and maintain an infection prevention and control program including surveillance, reporting, and staff education.
Failure to provide adequate call light system for Resident #103.
Failure to ensure minimum 80 square feet of personal room space for Resident #29.
Failure to provide privacy curtain between Resident #29 and Resident #64.
Failure to ensure direct access to exit corridor for residents in a 4-person room.
Report Facts
Census: 132
Census: 103
Deficiencies cited: 11
MDS assessment dates: Multiple MDS assessment dates for residents #29, #27, #52, #53, #79, #103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kersten Kleinlein | Administrator | Signed plan of correction on 10/31/24 |
| Staff A | Assistant Director of Nursing (ADON) | Acknowledged no curtain between Resident #29 and #64; involved in privacy and room access findings |
| Staff G | Licensed Practical Nurse (LPN) | Observed and administered tube feeding to Resident #52; involved in infection control deficiency |
| Staff H | Registered Nurse (RN) | Involved in Resident #52 care and fall incident findings |
| Director of Nursing (DON) | Involved in multiple findings including privacy, fall prevention, and infection control | |
| Staff E | Certified Nursing Assistant (CNA) | Observed call light response issues for Resident #27 |
| Staff F | Certified Nursing Assistant (CNA) | Observed call light response issues for Resident #27 |
| Staff B | Scheduler | Interviewed regarding survey book location |
| Staff C | Licensed Practical Nurse | Reported Resident #103 call light issues |
| Staff D | Assistant Director of Nursing (ADON) | Involved in room access and privacy curtain findings |
| Staff I | Certified Nursing Assistant (CNA) | Interviewed about Resident #53 fall |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 2
Date: Oct 3, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to properly assess and supervise residents after falls and to ensure safety from accident hazards.
Complaint Details
The investigation was complaint-related, focusing on failure to assess and supervise residents after falls. The report documents substantiation of these issues for two residents.
Findings
The facility failed to complete fall assessments or neurological checks following a resident's unwitnessed fall and failed to provide adequate supervision to prevent a resident from falling in the shower. The facility reported a census of 132 residents.
Deficiencies (2)
F 0684: The facility failed to complete resident fall assessment or neurological checks following a resident reported, unwitnessed fall for 1 of 3 residents reviewed. The resident reported a fall but no incident report or fall assessment was completed.
F 0689: The facility failed to ensure residents were safe from accidents and hazards for 1 of 3 residents reviewed. Staff failed to supervise a resident in the shower, resulting in a fall.
Report Facts
Residents affected: 3
Census: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Assistant Director of Nursing | Notified of resident self-reported fall and applied Band-aid |
| Staff G | Licensed Practical Nurse | Reported information about resident fall to Director of Nursing |
| Staff I | Certified Nursing Assistant | Received resident fall report and informed LPN |
| Director of Nursing | Director of Nursing | Set expectation for nursing assessment and fall incident reporting |
Inspection Report
Routine
Census: 132
Deficiencies: 11
Date: Oct 3, 2024
Visit Reason
The inspection was an unannounced routine survey to assess compliance with regulatory requirements related to resident rights, dignity, safety, infection control, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inadequate call light availability, improper infection control practices during tube feeding, failure to follow oxygen therapy orders, incomplete fall assessments, inadequate supervision leading to resident falls, lack of water management plan for Legionella prevention, and insufficient resident room space and access.
Deficiencies (11)
F 0550: The facility failed to treat residents with dignity and respect, including lack of privacy curtains between roommates and delayed response to call lights.
F 0577: The facility failed to post notice of availability of survey results and failed to have survey reports readily accessible to residents and families.
F 0658: The facility failed to apply continuous oxygen at 2 liters per minute as ordered for a resident, with inconsistent oxygen use observed.
F 0684: The facility failed to complete fall assessments or neurological checks following a resident-reported unwitnessed fall.
F 0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident falling in the shower unattended.
F 0693: The facility failed to apply gloves or additional PPE during administration of enteral tube feeding, risking infection.
F 0880: The facility failed to perform a water system assessment to identify and prevent Legionella growth and failed to use enhanced barrier precautions during tube feeding.
F 0912: The facility failed to provide a minimum of 80 square feet of personal room space for a resident with a roommate.
F 0913: The facility failed to ensure residents had direct access to an exit corridor from their designated room space in a shared room.
F 0914: The facility failed to provide a privacy curtain between two roommates, removing privacy for one resident.
F 0919: The facility failed to provide a call light for a resident's bathroom and bathing area.
Report Facts
Census: 132
Call light missing: 1
Room measurement: 55
Oxygen flow rate: 2
Tube feeding rate: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing (ADON) | Acknowledged lack of privacy curtain and room access issues |
| Staff G | Licensed Practical Nurse (LPN) | Observed administering tube feeding without gloves |
| Staff H | Registered Nurse (RN) and Assistant Director of Nursing (ADON) | Discussed oxygen therapy and infection control practices |
| Staff D | Assistant Director of Nursing (ADON) | Acknowledged lack of direct exit access and call light issues |
| Staff E | Certified Nursing Assistant (CNA) | Observed delayed response to call light for Resident #27 |
| Staff I | Certified Nursing Assistant (CNA) | Reported Resident #53 fall to nursing staff |
| Director of Nursing (DON) | Director of Nursing | Provided expectations on call light response, oxygen therapy, and fall assessments |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged room size and privacy curtain issues, and lack of Legionella water plan |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
Investigation of multiple complaints and a facility reported incident conducted from 7/22/24 to 7/23/24.
Complaint Details
Complaints #119804, #121601, #121438, #121405, #121305, #120969, and #120152 were not substantiated. Facility reported incident #121508 was not substantiated.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. None of the complaints or the facility reported incident were substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
The inspection was conducted following complaint investigation intakes #117028-I, #117349-I, and #120005-I from 4/11/24 to 4/16/24.
Complaint Details
Complaint investigation intakes #117028-I, #117349-I, and #120005-I were investigated and resulted in a finding of substantial compliance.
Findings
The Pillar of Cedar Valley Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
A complaint investigation for complaint #116543-C and a facility reported incident #116110-I was conducted on 11/1/23-11/2/23.
Complaint Details
Complaint investigation for complaint #116543-C and facility reported incident #116110-I; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
A complaint investigation was conducted for complaints #114893-C, #115083-C, #115128-C, #115252-C and facility reported incidents #113984-I, #114207-I, #115087-I from September 5, 2023 to September 7, 2023.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The document is a plan of correction submitted following a previous inspection, indicating the facility's acceptance of compliance and certification effective July 21, 2023.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction; no specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #113575-C and facility reported incident #113846-I from June 26, 2023 to June 29, 2023.
Complaint Details
Complaint #113575-C was investigated and found not substantiated. Facility reported incident #113846-I was also not substantiated.
Findings
The facility was found to have deficiencies related to failure to provide appropriate services to maintain or improve resident abilities in activities of daily living for one resident and failure to limit the timeframe for PRN psychotropic medication orders to 14 days for one resident. Complaint #113575-C and incident #113846-I were not substantiated.
Deficiencies (2)
Failure to provide appropriate care and services to maintain or improve resident abilities with mobility and dining-eating for one resident.
Failure to limit PRN orders for psychotropic drugs to 14 days or obtain appropriate documentation for extension for one resident.
Report Facts
Resident census: 134
Weight measurements: 159.4
Weight measurements: 150.6
Weight measurements: 170.4
Therapy participation: 4
Therapy participation frequency: 6
PRN order duration limit: 14
BIMS score: 10
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding resident #132's rib pain and medication administration |
| Staff A | Certified Medication Assistant, CNA | Observed medication administration to resident #132 |
| Staff C | Interviewed about resident #132's activity and restorative program | |
| Staff D | Interviewed about restorative plan and resident #132's therapy refusals | |
| Administrator | Acknowledged resident #132's refusal to participate in restorative program and weight loss | |
| Lindy Arends | Laboratory Director | Signed the Statement of Deficiencies on 7-21-2023 |
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including maintenance of resident abilities and appropriate use of psychotropic medications.
Findings
The facility failed to provide appropriate services to maintain or improve resident abilities with mobility and dining for one resident, resulting in weight loss and reduced activity. Additionally, the facility failed to limit the timeframe for PRN psychotropic medication orders or obtain appropriate documentation for one resident.
Deficiencies (2)
F 0676: The facility failed to provide appropriate services to maintain or improve resident abilities with mobility and dining for Resident #132, who refused restorative exercises and had weight loss related to pain and inactivity.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days or obtain appropriate documentation from the provider for Resident #29, resulting in an indefinite PRN order without justification.
Report Facts
Resident census: 134
Weight measurements: 159.4
Weight measurements: 150.6
Weight measurements: 170.4
Refusals of restorative exercises: 4
PRN psychotropic medication dose: 0.5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 24, 2023
Visit Reason
A complaint investigation for complaints #112737-C and #113033-C was conducted from May 18, 2023 to May 24, 2023.
Complaint Details
Complaint investigation for complaints #112737-C and #113033-C; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective March 10, 2023.
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 1
Date: Feb 20, 2023
Visit Reason
A complaint investigation was conducted for multiple complaints between February 20, 2023 and February 22, 2023, including a substantiated complaint #110357-C.
Complaint Details
Complaint #110357-C was substantiated; complaints #111141-C, #110158-C, #109991-C, #108262-C, and #108178-C were not substantiated.
Findings
The facility was found not in compliance with environmental conditions related to cleanliness and sanitation. Observations revealed several areas with dark, dirty floors, dried urine, blood, and grime in resident rooms and common areas. Staffing shortages in housekeeping were noted.
Deficiencies (1)
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, evidenced by dirty floors, bed linens on floors, dried urine and blood, and grime in multiple resident rooms and common areas.
Report Facts
Census: 137
Housekeepers on day shift preferred: 8
Housekeepers on staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Housekeeping | Reported staffing and cleaning issues, provided daily cleaning checklist |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 12, 2022
Visit Reason
A complaint investigation was conducted for complaints #107009-C and #107435-C and a facility reported incident #108127-I from October 5, 2022 to October 12, 2022.
Complaint Details
Investigation related to complaints #107009-C and #107435-C and facility reported incident #108127-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 3, 2022
Visit Reason
A complaint investigation was conducted for complaints #105190-C, #105269-C, #105583-C, #106226-C, and #106531-C from July 27, 2022 to August 3, 2022.
Complaint Details
Investigation involved multiple complaints as listed; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Report Facts
Complaint numbers: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of a credible allegation of compliance and certification of the facility effective May 9, 2022.
Findings
The facility was found to be in compliance based on the accepted plan of correction and credible allegation of compliance, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 31, 2022
Visit Reason
The investigation was conducted in response to facility reported incident #104795-I and complaint #104724-C from May 17, 2022 to May 31, 2022.
Complaint Details
Investigation of complaint #104724-C and incident #104795-I resulted in no deficiencies.
Findings
The investigation resulted in no deficiencies being found.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 11, 2022
Visit Reason
An onsite revisit survey was conducted from 3/28/22 to 4/11/22 for the recertification survey conducted on 3/7/22 to 3/10/22.
Findings
The deficiencies cited during the annual recertification survey have been corrected effective 4/7/22.
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as a result of complaint investigations #1031170-C, #103611-C, and 103615-M between March 28, 2022 and April 11, 2022.
Complaint Details
Complaint #103177-C was not substantiated. Complaint #103611-C was substantiated. Findings for complaint #103615-M will be sent later under a separate cover letter.
Findings
The facility failed to ensure that all residents received adequate assistance with eating to maintain acceptable nutritional status, specifically for Resident #6 who experienced significant weight loss and inadequate meal assistance documentation.
Deficiencies (1)
Failure to ensure adequate assistance with eating to maintain acceptable nutritional status for Resident #6 with significant weight loss.
Report Facts
Census: 128
Weight loss percentage: 15
Meal documentation missing: 31
Meals without physical assistance: 8
Meals lacking assistance documentation: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported that weekly weights were a Dietitian recommendation and not a physician's order, and described weight measurement methods for Resident #6. |
Inspection Report
Annual Inspection
Census: 130
Deficiencies: 14
Date: Mar 10, 2022
Visit Reason
The inspection was conducted as a licensure, recertification survey and investigation including complaint #102952 which was substantiated.
Complaint Details
Complaint #102952 was substantiated related to dignity and privacy issues with urinary drainage bags.
Findings
The facility was found deficient in multiple areas including dignity and privacy related to urinary drainage bags, reasonable accommodations for call light use, background checks, transfer and discharge documentation, bed hold notices, comprehensive assessments after significant changes, MDS transmission and accuracy, PASRR coordination, care plan development and revision, food safety, infection prevention and control, and COVID-19 immunization documentation.
Deficiencies (14)
Failed to promote dignity by covering a urinary drainage bag for 1 of 17 residents.
Failed to provide reasonable accommodations for use of a call light for 1 of 8 dependent residents.
Failed to complete a background employment check within 30 days of hire for 1 of 5 employees.
Failed to document transfer form and provide required information for 1 of 2 residents transferred to hospital.
Failed to notify resident or representative of bed hold policy during hospitalization for 2 of 2 residents.
Failed to complete significant change in status MDS assessment within 14 days for 2 of 4 residents reviewed for hospice services.
Failed to transmit MDS assessments timely to CMS for 5 of 5 residents reviewed.
Failed to accurately reflect PASRR level II status and pressure ulcer presence on MDS for residents.
Failed to implement PASRR specialized services and resubmit 60 day convalescent PASRR for residents.
Failed to develop a comprehensive care plan for a resident with an unstageable pressure injury.
Failed to revise care plan timely after significant change in status MDS and failed to revise care plan for suprapubic catheter use.
Failed to monitor and assess skin condition and document wound care appropriately for 1 resident.
Failed to perform hand hygiene and use clean gloves properly when emptying urinary drainage bags and failed to change soiled linens for 2 residents.
Failed to provide and document education, signed refusal forms, or medical contraindications for COVID-19 vaccine for 2 of 5 residents.
Report Facts
Residents in census: 130
Deficiencies with severity SS=D: 11
Deficiencies with severity SS=B: 4
Number of residents reviewed for dignity: 17
Number of dependent residents reviewed for call light: 8
Number of employees reviewed for background checks: 5
Number of residents reviewed for hospice services: 4
Number of residents reviewed for MDS transmission: 5
Number of residents reviewed for PASRR: 2
Number of residents reviewed for pressure ulcers: 4
Number of residents reviewed for infection control: 2
Number of residents reviewed for COVID-19 immunization: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in infection control deficiency for improper catheter bag emptying and hand hygiene |
| Staff G | Certified Nursing Assistant | Named in infection control deficiency for catheter bag emptying procedures |
| Staff H | Licensed Practical Nurse | Named in infection control deficiency for catheter bag emptying procedures |
| Staff K | Dietary Cook | Named in food safety deficiency for improper glove use and hand hygiene during puree meal preparation |
| Staff J | Registered Nurse/MDS Coordinator | Named in MDS transmission deficiency for failure to timely submit MDS assessments |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies related to care plan, infection control, MDS, PASRR, and COVID-19 immunization |
| Provisional Administrator | Provisional Administrator | Named in PASRR and infection control deficiencies |
| Staff A | Licensed Social Worker | Named in PASRR deficiency for failure to update PASRR |
| Staff C | Certified Nursing Assistant/Restorative Aide | Named in infection control deficiency for linens and catheter bag emptying |
| Staff F | Restorative Aide | Named in infection control deficiency for linens and catheter bag emptying |
| Staff E | Office Manager | Named in background check deficiency |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 5
Date: Jan 6, 2022
Visit Reason
A Focused COVID-19 Infection Control Survey and an investigation of Complaints #99318, #99881, #100321, and #101015 and a Facility Self-Reported Incident #100386 were conducted by the Department of Inspections and Appeals from 12/15/21 to 1/6/22.
Complaint Details
The complaints and the facility self-reported incident were investigated and found not substantiated.
Findings
The facility was not found in substantial compliance with CMS and CDC recommended practices to prepare for COVID-19. Multiple deficiencies were identified related to housekeeping, incontinence care, nutrition and hydration, food safety, and infection prevention and control. The complaints and incident were not substantiated.
Deficiencies (5)
Facility failed to maintain resident bathrooms in a clean, orderly manner and failed to provide clean linens and clean chairs in the dining room.
Facility staff failed to provide timely incontinence care for residents #4, #8, and #9.
Facility failed to provide the breakfast meal, promote nutrition, and monitor food consumption for residents #4, #8, and #9.
Facility failed to store food in a safe and sanitary manner, including thawed pork chops without date labels and undated food items in coolers.
Facility failed to properly wear Personal Protective Equipment (PPE) during resident care and failed to conduct adequate infection prevention and control training and monitoring.
Report Facts
Facility census: 131
Number of dining room chairs observed: 35
Number of meals with undocumented consumption: 43
Number of thawed pork chops without date labels: 10
Number of random PPE audits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings related to failure to provide timely incontinence care and breakfast to residents. |
| Staff B | Registered Nurse (RN) | Named in findings related to resident care and assistance. |
| Staff C | Certified Medication Aide (CMA) | Named in findings related to resident care and meal documentation. |
| Staff D | Licensed Practical Nurse (LPN) | Named in findings related to charge nurse responsibilities and resident care. |
| Staff F | Food Service Supervisor (FSS) | Named in findings related to food safety violations and PPE noncompliance. |
| Staff E | Certified Nursing Assistant (CNA) | Named in findings related to improper PPE use during resident transfer. |
| Staff G | Food Service Supervisor | Named in interview regarding dietary documentation issues. |
| Staff I | Registered Dietician | Named in interview regarding dietary department sanitation issues. |
| Staff J | Plant Supervisor | Named in interview regarding cleaning responsibilities for dining room chairs. |
| Co-Director of Nurses | Named in resident care observations. |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 6
Date: Aug 2, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident at the facility. The visit aimed to investigate these allegations and ensure compliance with regulatory requirements.
Complaint Details
The complaint investigation was triggered by allegations of abuse, neglect, and mistreatment of a resident who was agitated and attempted to leave the facility. The resident was reported to have been restrained improperly and denied adequate care. The investigation included interviews with staff, review of medical records, and observation of care practices. The allegations were substantiated based on findings.
Findings
The investigation found that the facility failed to prevent mistreatment and adequately protect a resident from abuse and neglect. Deficiencies were noted in resident care, staff training, and documentation. The facility was required to implement corrective actions to address these issues.
Deficiencies (6)
Failure to ensure all alleged violations involving mistreatment, neglect or abuse were reported immediately to the administrator and other officials.
Failure to provide adequate supervision and protection to a resident with dementia who was agitated and attempted to leave the facility.
Failure to provide sufficient staff training on abuse prevention, communication, and behavioral health management.
Failure to maintain accurate and complete resident records including weight monitoring and dietary orders.
Failure to ensure adequate food safety and sanitation in the kitchen and dining areas.
Failure to provide sufficient dietary staff and ensure proper food preparation and menu planning.
Report Facts
Total residents: 123
Dates of onsite visit: Inspection conducted from 2021-06-10 to 2021-08-02
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted an investigation in accordance with Medicare Conditions of Participation, reviewing complaints #97108-C and #97179-C.
Complaint Details
Complaint #97108-C was not substantiated. Complaint #97179-C was substantiated without deficiency.
Findings
The facility was found to be in compliance. Complaint #97108-C was not substantiated, and complaint #97179-C was substantiated without deficiency.
Report Facts
Total residents: 168
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Feb 22, 2021
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey conducted in conjunction with an investigation of facility reported incidents and complaints.
Complaint Details
Complaint #95154-C was substantiated; other complaints (#95137-I, #94534-C, #95138-C, #94930-C, #94102-C) were not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19, but a deficiency was identified related to ensuring a safe and secure environment for residents. Specifically, the facility failed to ensure staff maintained adequate supervision and completed required rounds every two hours for residents, impacting 2 of 13 residents reviewed.
Deficiencies (1)
The facility failed to ensure staff maintained a safe and secure environment for 2 of 13 residents reviewed, including failure to complete rounds every two hours during overnight shifts.
Report Facts
Total residents: 116
Residents reviewed: 13
Residents with deficient supervision: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Reported overnight shift issues and inability to complete rounds |
| Staff B | CMA/CNA | Stated expectation for staff to complete rounds every 2 hours |
| Staff C | CNA | Stated expectation for staff to complete rounds every 2 hours |
| Director of Nursing | Interviewed regarding staff rounds and supervision |
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 1
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by the Department of Inspection and Appeals on 12/14/20 - 12/15/20 to assess compliance with CMS and CDC recommended practices for a COVID-19 outbreak.
Findings
The facility was found to be in non-compliance with infection prevention and control requirements, including failure to ensure staff performed hand hygiene, properly donned and doffed PPE, disinfected equipment, and followed isolation precautions for residents on isolation. Multiple observations and interviews documented lapses in infection control practices.
Deficiencies (1)
Failure to ensure staff performed hand hygiene prior to gloving for residents on isolation precautions, disinfected face shields and masks, and properly donned and doffed PPE.
Report Facts
Total residents: 120
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Anderson | Contacted via email on 12/30/2020 to schedule a root cause analysis |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
The Iowa Department of Inspection and Appeals conducted a complaint investigation in accordance with Medicare Conditions of Participation.
Complaint Details
Complaints #94585-C and #94401-C were investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with no substantiated complaints.
Inspection Report
Routine
Census: 119
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 18 - 19, 2020 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
Complaint Investigation
Census: 116
Deficiencies: 6
Date: Oct 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of complaints 93089-C, 91028-C, 93752-C, 92773-C, and 89267-C, and facility reported incident 89501-I. The visit was to investigate complaints and assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The investigation was triggered by complaints 93089-C, 91028-C, 93752-C, 92773-C, and 89267-C, and facility reported incident 89501-I. All complaints were substantiated.
Findings
The facility was found not in compliance with CMS and CDC recommended practices for COVID-19. Deficiencies included failure to administer intravenous medication and physician ordered labs for one resident, failure to ensure adequate supervision during meals for residents on altered diets, failure to maintain a qualified full-time dietitian, and failure to consistently practice proper food handling safety measures. The facility also failed to meet requirements for quality assessment and assurance committee meetings and COVID-19 reporting.
Deficiencies (6)
Failure to administer intravenous Vancomycin medication and physician ordered labs for Resident #1 as ordered.
Failure to ensure residents received nursing supervision while consuming altered textured diet and failed to protect residents against hazards in the environment, resulting in choking incident for Resident #4.
Failure to employ a qualified full-time dietitian or certified dietitian nutrition professional.
Failure to consistently practice proper food handling safety measures, including handling food without gloves and improper hand hygiene by staff.
Failure to ensure quality assessment and assurance committee met minimum quarterly meeting requirements.
Failure to meet COVID-19 reporting requirements including timely notification to residents, representatives, and families of confirmed COVID-19 cases and mitigation actions.
Report Facts
Total residents: 116
Deficiencies cited: 6
Vancomycin trough lab dates missed: 3
Resident #4 choking incident date: Sep 30, 2020
Compliance dates: Jan 7, 2021
Compliance dates: Oct 15, 2020
Compliance dates: Nov 2, 2020
Compliance dates: Jan 7, 2021
Compliance dates: Dec 7, 2021
Compliance dates: Jan 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Provided timeline and interviews related to medication administration deficiency |
| Staff M | Registered Nurse | Interviewed regarding routine care and medication administration |
| Staff A | Licensed Practical Nurse | Reported performing Heimlich maneuver during choking incident |
| Staff B | Certified Nurse Aide | Witnessed choking incident and tray delivery |
| Staff F | Dietary Director | Reported on diet orders, tray delivery, and food safety education |
| Staff J | Contract Dietitian | Provided information on diet management and resident assessments |
| Staff L | Cook | Observed handling food without gloves and improper hand hygiene |
| Staff O | Dietary Aide | Tested positive for COVID-19 |
| Staff P | Aspen Nurse | Tested positive for COVID-19 |
| Staff Q | Laundry Assistant | Tested positive for COVID-19 |
| Staff R | Registered Nurse | Tested positive for COVID-19 |
| Staff S | Dietary Aide | Tested positive for COVID-19 |
| Staff T | Laundry | Tested positive for COVID-19 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 22, 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 for COVID-19 preparation.
Findings
The facility failed to utilize all appropriate personal protective equipment, specifically gowns, when caring for a resident on isolation precautions, indicating non-compliance with infection prevention and control requirements.
Deficiencies (1)
Facility failed to utilize all appropriate personal protective equipment when caring for residents on isolation precautions for 1 of 3 residents reviewed (Resident #1).
Report Facts
Date of survey: Jun 22, 2020
Number of residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Facility Director of Nursing acknowledged the PPE deficiency and directed corrective actions | |
| Staff A (CNA) | Observed not wearing gown during care of resident on isolation precautions | |
| Staff B (CNA) | Observed not wearing gown during care of resident on isolation precautions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 29, 2020
Visit Reason
The inspection was conducted to investigate multiple complaints identified by numbers #88311, 88338, #87570, #87668, and #88533.
Complaint Details
Complaints #88311, 88338, #87570, #87668, and #88533 were investigated and determined to be not substantiated.
Findings
All complaints investigated during this visit were found to be not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
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