Inspection Reports for Prairie Wind Independent Living at Western Home Communities
5313 Caraway Ln, Cedar Falls, IA 50613, United States, IA, 50613
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 7, 2025, found the facility in substantial compliance with no deficiencies. Earlier inspections showed a mixed pattern, with some deficiencies related primarily to documentation accuracy, timely completion of assessments, and adherence to professional care standards. Prior reports also noted issues with medication administration, infection control, food safety, and supervision, including one immediate jeopardy finding related to resident elopement in 2020. Complaint investigations were mostly unsubstantiated, with one substantiated incident involving medication error that caused harm. The facility appears to have addressed several prior concerns, but some documentation and care process issues have recurred over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
71 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 7, 2025
Visit Reason
A complaint investigation for facility reported incident #1651446 was conducted from October 06, 2025 to October 07, 2025.
Complaint Details
Complaint investigation related to incident #1651446; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance with health requirements.
Findings
The facility was found to be in substantial compliance with health requirements, leading to certification effective February 20, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 5
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey with an investigation #126368-I from February 3, 2025 to February 6, 2025.
Complaint Details
Facility reported incident #126368 was not substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with deficiencies related to the completion and accuracy of Minimum Data Set (MDS) assessments, hospice care documentation, accuracy of assessments, and compliance with professional standards of care. The facility failed to complete timely and accurate assessments for residents receiving hospice care and had documentation issues related to restraints and physician orders.
Deficiencies (5)
Failure to complete Significant Change Minimum Data Set (MDS) assessments within 14 days for residents on hospice services.
Failure to accurately reflect the resident's status in MDS assessments, including documentation of falls, hospice care, and use of restraints.
Failure to meet professional standards of quality in comprehensive care plans.
Failure to follow physician orders to place washcloths in the hands of a resident for range of motion exercises.
Policy lacked direction to nursing staff to sign physician orders if not completed.
Report Facts
Resident census: 71
Residents reviewed for hospice services: 2
Residents reviewed for MDS accuracy: 5
Falls documented for Resident #33: 2
BIMS score for Resident #53: 4
BIMS score for Resident #70: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Quality of Life Services/MDS Coordinator | Reported on MDS assessments and accuracy issues. |
| Director of Nursing | Administrator & Director of Nursing | Reported facility outsourcing MDS assessments and compliance with coding. |
| Staff F | Licensed Practical Nurse (LPN) | Documented incident notes and participated in MDS coding. |
| Staff G | Certified Medication Manager (CMA) | Reported on restraint use and medication management. |
| Staff H | Certified Nursing Assistant (CNA) | Reported on restraint use and resident care observations. |
| Staff J | Registered Nurse (RN) | Reported on restraint use and resident care observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation of intakes #123336-C and #124516-I from December 10 to December 11, 2024.
Complaint Details
Complaint #123336 was not substantiated. Facility reported incident #124516 was not substantiated.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaint #123336 was not substantiated, and the facility reported incident #124516 was also not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
A complaint investigation was conducted for Facility Reported Incident #122616-I on August 27-28, 2024.
Complaint Details
Complaint 122616-I was not substantiated.
Findings
The facility was found to be in substantial compliance and the complaint was not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective March 29, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for the facility, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective July 18, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during an investigation of complaint #113697-C and facility reported incident #112485-I conducted from June 22, 2023 to July 6, 2023.
Complaint Details
Complaint #113697-C was investigated and found not substantiated. Facility reported incident #112485-I was also not substantiated.
Findings
The facility was cited for failure to provide a supportive and safe environment free from abuse, neglect, exploitation, and failure to report alleged violations of abuse and neglect within the required timeframes. Specific findings involved verbal abuse by a Certified Nursing Assistant towards Resident #4 and failure to separate the accused staff from residents during investigation.
Deficiencies (2)
Failure to provide a supportive and safe environment free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to report all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but not later than 2 hours after the allegation is made.
Report Facts
Deficiencies cited: 2
Resident census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in verbal abuse allegation towards Resident #4 |
| Staff A | Certified Nursing Assistant | Assisted Staff B and reported observations related to abuse incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
On-site revisit completed to verify compliance and plan of correction.
Findings
The facility was certified in compliance effective February 24, 2023, based on the revisit and plan of correction.
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 4
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of reported incidents #102079 and #109497.
Complaint Details
Facility reported incident #102079 is substantiated. Facility reported incident #109497 is not substantiated.
Findings
The facility was found to have deficiencies related to timely submission of Minimum Data Set (MDS) assessments, medication administration errors resulting in harm to a resident, improper food safety and sanitary practices, and infection prevention and control issues including failure to follow CDC guidelines and PPE protocols. The facility implemented corrective actions including staff education, audits, and policy updates.
Deficiencies (4)
Failure to submit a required Minimum Data Set assessment in a timely manner for 1 of 22 residents reviewed (Resident #19).
Failure to ensure competent, trained staff passed medications to residents on the second floor, resulting in harm to Resident #129 requiring hospitalization.
Failure to maintain sanitary practices when storing, preparing, and serving food, including presence of undated and open food items and improper food handling.
Failure to establish and maintain an infection prevention and control program consistent with CDC guidelines, including improper use of PPE and failure to change masks and sanitize face shields appropriately.
Report Facts
Residents reviewed for MDS assessment: 22
Census: 74
Resident involved in medication error: 1
Residents involved in infection control observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse (RN), Nurse Mentor | Named in medication error finding and progress notes related to Resident #129 |
| Staff F | Registered Nurse (RN) | Named in medication error finding and progress notes related to Resident #129 |
| Staff D | Registered Nurse (RN) | Named in medication error finding and progress notes related to Resident #129 |
| Staff J | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration practices |
| Director of Nursing (DON) | Director of Nursing | Involved in medication error notification and infection prevention corrective actions |
| Staff H | Certified Medication Aide (CMA) | Interviewed regarding medication administration error |
| Staff I | Certified Medication Aide (CMA) | Interviewed regarding medication administration error |
| Staff G | Certified Nursing Aide (CNA) | Observed during food handling and infection control deficiencies |
| Staff L | Observed during food handling deficiencies | |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed regarding food handling practices |
| Staff A | Certified Nursing Assistant (CNA) | Observed during infection control deficiencies |
| Staff B | Certified Nursing Assistant (CNA) | Observed during infection control deficiencies |
| Staff C | Registered Nurse (RN) | Observed during infection control deficiencies |
| Staff N | Certified Nurse Aide (CNA) | Involved in catheter care and infection control observations |
| Staff O | Certified Nurse Aide (CNA) | Involved in catheter care and infection control observations |
| Staff P | Registered Nurse (RN) | Provided statements regarding catheter care and infection control |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 2
Date: Sep 1, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey to assess compliance with Medicare Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to promote resident dignity by standing over residents while providing meal assistance and failure to maintain proper food handling to prevent cross contamination and foodborne illness.
Deficiencies (2)
Failure to promote resident dignity by standing over residents while providing meal assistance for 3 residents observed.
Failure to maintain proper food handling to prevent cross contamination of food in 2 out of 3 dining rooms observed.
Report Facts
Total residents: 86
Number of dining educations planned: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tabitha C Tjaden | Administrator | Signed report and mentioned in interview regarding meal assistance protocol |
| Staff A | Lead Hospitality Coordinator | Observed failing proper food handling and interviewed about food safety practices |
| Staff B | Certified Nursing Assistant (CNA) | Observed failing proper glove use during meal service |
| Staff C | Licensed Practical Nurse (LPN) | Observed standing over resident during meal assistance |
| Staff D | Certified Nursing Assistant (CNA) | Observed standing over resident during meal assistance |
| Staff E | Certified Nursing Assistant (CNA) | Observed standing over resident during meal assistance |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations for meal assistance |
| System Quality Assurance Officer | System Quality Assurance Officer | Verified facility protocol for meal assistance |
| Household Coordinator | Household Coordinator | Observed standing over residents during meal assistance and interviewed about food handling |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 25, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted an investigation in accordance with Medicare Conditions of Participation to review facility reported incidents.
Complaint Details
Facility reported incidents #97397-I and #98063-I were reviewed and found not substantiated.
Findings
The facility was found to be in compliance. Two facility reported incidents (#97397-I and #98063-I) were reviewed and not substantiated.
Inspection Report
Abbreviated Survey
Census: 79
Deficiencies: 1
Date: Jan 19, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted a Focused COVID-19 Infection Control Survey, including review of facility reported incidents and complaints.
Complaint Details
Three complaints were reviewed: Complaint 88024 was substantiated without deficiency; Complaint 93885 was not substantiated; Complaint 95153 was substantiated.
Findings
The facility was found to be not in compliance with infection control requirements. A significant deficiency was identified related to inadequate supervision to prevent falls, specifically involving Resident #9 who experienced multiple falls resulting in a pelvic fracture.
Deficiencies (1)
Facility failed to provide adequate supervision to prevent a fall with injury in 1 of 3 residents reviewed (Resident #9), who had multiple falls resulting in a non-displaced fracture of the left superior pubic ramus.
Report Facts
Total residents: 79
Fall Risk Evaluation score: 12
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #9's condition and fall |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #9's behavior and fall risk |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed about Resident #9's fall history and supervision |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed about Resident #9's attempts to transfer and anxiety |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed about circumstances of Resident #9's fall on 10/28/20 |
| Director of Nursing | Interviewed about Resident #9's anxiety and interventions attempted |
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 11/22/20 to 11/24/20 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation regarding complaint #90407-C was conducted by representatives of the Department of Inspection and Appeals.
Complaint Details
Complaint #90407-C was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #90407-C was unsubstantiated.
Report Facts
Total residents: 79
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Date: May 28, 2020
Visit Reason
The inspection was conducted as a result of an investigation of a facility reported incident #99916-I, completed on May 14, 19, and 20-28, 2020, regarding a resident elopement incident.
Complaint Details
The facility reported incident #99916-I was substantiated. The investigation revealed that Resident #1 eloped from the facility on 5/8/20 without staff knowledge or permission. The resident was found outside the building by a tenant and returned safely. The facility failed to ensure staff knew the policy for testing exit doors and failed to properly test the door alarm, contributing to the elopement.
Findings
The facility failed to ensure adequate supervision to prevent elopement for one of three residents reviewed, resulting in immediate jeopardy to resident health and safety. The resident exited the building without staff knowledge, and staff were not fully aware of the facility's policy to test exit doors. The facility implemented corrective actions including staff education and updated procedures to ensure door alarms function properly and residents at risk are monitored.
Deficiencies (1)
Facility failed to ensure that each resident received adequate supervision to prevent the hazard of elopement; staff did not properly test door alarm prior to elopement incident.
Report Facts
Census: 69
Incident Dates: 3
Temperature: 55
Temperature: 32
Wind Speed: 29
Report
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