Inspection Reports for Woodland Terrace
1922 Fifth Avenue NW, Waverly, IA, 506771903
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 22, 2025, found the facility in compliance with no deficiencies cited. Prior inspections showed a mixed record with deficiencies related mainly to resident safety, medication management, infection control, and documentation. Notable issues included substantiated abuse by a staff member in August 2025, medication errors and food safety concerns in May 2025, and failure to prevent a resident fall in April 2024. Complaint investigations were mostly unsubstantiated except for the August 2025 abuse case and a few substantiated incidents involving resident safety and staff conduct. The facility appears to have addressed some prior deficiencies through plans of correction, but recent findings suggest ongoing challenges in staff supervision and care practices.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
87 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction, the facility will be certified in compliance effective September 18, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted as an investigation of a facility reported incident #1721281-M involving alleged abuse by a Certified Nursing Assistant (CNA) who tapped a resident on the head.
Complaint Details
The complaint investigation was substantiated based on evidence including staff interviews, disciplinary notices, and resident observations. Staff C was found to have tapped Resident #1 on the head, which was deemed abuse. Staff C was terminated. The facility lacked proper documentation and timely reporting of the incident.
Findings
The facility failed to ensure residents were free from physical abuse when a CNA tapped a resident on the head. The investigation revealed multiple staff interviews, documentation deficiencies, and lack of thorough investigation and reporting. Staff C was terminated and corrective actions including staff training and monitoring were planned.
Deficiencies (2)
Facility failed to ensure residents were free from physical abuse when a CNA tapped a resident on the head.
Facility failed to investigate, prevent, and correct alleged abuse violations thoroughly and timely.
Report Facts
Census: 87
Residents affected: 24
Date of incident: Jul 2, 2025
Date of survey completion: Aug 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Named in abuse incident for tapping resident on the head and terminated from employment |
| Staff A | Reported abuse incident and involved in interviews and corrective actions | |
| Staff B | Director of Nursing (DON) | Informed about abuse allegation and involved in investigation |
| Staff F | Certified Nursing Assistant (CNA) | Assisted resident and interviewed during investigation |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed and reviewed documentation related to abuse incident |
| Staff J | Co-DON | Interviewed regarding investigation and staff communications |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification of compliance effective May 21, 2025.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 7
Date: May 8, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of reported incidents and complaints between May 5, 2025 and May 8, 2025.
Complaint Details
The inspection included investigation of complaints #128317-1 and #128321-C reported between May 5, 2025 and May 8, 2025.
Findings
The facility was found deficient in several areas including failure to provide proper notice of bed-hold policy and discharge procedures, inaccurate resident assessments, medication administration errors, improper storage of medications, food safety violations, and infection control deficiencies. Plans of correction were submitted to address these issues.
Deficiencies (7)
Failure to provide notice of Bed-Hold policy and return prior to 1 of 1 hospitalizations reviewed; facility reported census of 86 residents.
Failure to accurately code Minimum Data Set (MDS) assessment for an indwelling catheter for 1 of 1 residents reviewed; census 86.
Medication error rate of 7.69% affecting 2 of 8 residents sampled; failure to administer correct dosage of medication.
Failure to properly store medications and remove expired medications in 1 of 3 medication carts inspected; census 86.
Failure to follow acceptable standards for administration of drugs and biologicals; medication errors documented for residents #2 and #29.
Failure to maintain food safety and sanitation in kitchen and dining areas; poor hand hygiene and contaminated food handling observed.
Failure to establish and maintain an infection prevention and control program; failure to wear isolation gown and gloves during high-risk care for 1 of 3 residents on enhanced barrier precautions.
Report Facts
Census: 86
Medication error rate: 7.69
Medication carts inspected: 3
Residents sampled for medication errors: 8
Residents with medication errors: 2
Residents with MDS assessment error: 1
Hospitalizations reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Shea | Administrator | Signed the plan of correction on 5-21-25 |
| Staff J | Social Services | Reported failure to do a Bed Hold for Resident #39 transfers to hospital |
| Staff A | Certified Nursing Assistant (CNA) | Acknowledged Resident #38 had a Foley catheter |
| Staff B | Registered Nurse (RN) | Acknowledged Resident #38 had a Foley catheter |
| Staff C | Certified Nursing Assistant (CNA) | Acknowledged Resident #38 had a Foley catheter |
| Staff D | MDS Coordinator | Responsible for completing annual MDS assessment for Resident #38; acknowledged failure to code indwelling catheter |
| Staff N | Certified Medication Aide (CMA) | Failed to administer correct dosage of medication to Resident #2 |
| Staff O | Registered Nurse (RN) | Reported nurses follow five medication rights |
| Staff K | Co-Director of Nursing (CDON) | Explained medication administration procedures and audits |
| Staff P | Registered Nurse (RN) | Observed medication administration errors for Resident #29 |
| Staff H | Licensed Practical Nurse (LPN) | Reported medication cart audits and medication expiration date procedures |
| Staff F | Dietary Cook | Observed food handling and hygiene violations |
| Staff L | Dietary Staff | Observed food handling and hygiene violations |
| Staff M | Certified Nursing Assistant (CNA) | Observed transferring Resident #79 with urinary catheter |
| Staff E | Interviewed regarding catheter care and infection prevention | |
| Staff O | Registered Nurse (RN) | Reported staff use of isolation gowns and gloves during catheter care |
| Staff K | Co-Director of Nursing (CDON) | Reiterated enhanced barrier precautions requirements |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
A complaint investigation for complaint #126535-C and facility reported incident #125452-I was conducted from February 20, 2025 to February 24, 2025.
Complaint Details
Complaint #126535-C and facility reported incident #125452-I were investigated and found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
The document is a Plan of Correction submitted following a previous inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective June 18, 2024.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 4
Date: May 30, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from May 28, 2024 to May 30, 2024.
Findings
The facility was found non-compliant with federal regulations regarding treatment and services to prevent and heal pressure ulcers and quality assessment and assurance committee membership requirements. Deficiencies included failure to provide weekly assessments and interventions for pressure ulcers and failure to have required members at Quality Assessment and Assurance meetings. Infection prevention and control program deficiencies related to hand hygiene during medication administration were also noted.
Deficiencies (4)
Failure to provide weekly assessment and intervention for pressure ulcers for Resident #64.
Failure to have minimum required members at Quality Assessment and Assurance (QAA) meetings.
Failure to have Infection Preventionist attend required QAA meetings.
Failure to perform proper hand hygiene and follow personal protective equipment guidelines during medication administration for 2 of 6 residents reviewed.
Report Facts
Census: 85
Dates of survey: Survey conducted from May 28, 2024 to May 30, 2024.
Number of residents reviewed for medication administration: 6
Residents with medication administration issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Shea | Administrator | Signed the plan of correction on 6/18/24. |
| Megan Cerwinske | Co-Director of Nursing (co-DON) | Overseeing Infection Preventionist responsibilities and working toward CDC certification. |
| Staff A | Registered Nurse (RN) | Observed failing to perform proper hand hygiene during medication administration. |
| Staff B | Co-Director of Nursing (Co-DON) | Reported concerns about Staff A's hand hygiene during medication administration. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
A revisit of the survey ending April 4, 2024 was conducted on April 25, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective April 17, 2024.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaint #117360-C and facility reported incidents #117681-1 and #118105-1, focusing on allegations related to resident safety and supervision.
Complaint Details
Complaint #117360-C was not substantiated, while incidents #117681-1 and #118105-1 were substantiated.
Findings
The facility failed to follow safety interventions for one of three residents reviewed, resulting in an unwitnessed fall causing a fractured right femur. The investigation found that staff failed to position the resident's bed in the lowest position, contributing to the fall. The facility lacked a policy directing bed positioning when residents are unattended.
Deficiencies (1)
The facility failed to ensure the resident environment remains free of accident hazards by not positioning Resident #2's bed in the lowest position, leading to a fall and fracture.
Report Facts
Census: 86
Dates of incidents: Nov 11, 2023
Date of MDS assessment: Sep 14, 2023
Date of inspection: Apr 3, 2024
Date of plan of correction implementation: Apr 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Shea | Administrator | Signed the plan of correction and involved in investigation |
| Staff A | Registered Nurse | Documented the unwitnessed fall incident and interviewed during investigation |
| Staff B | Licensed Practical Nurse | Interviewed regarding care provided on the date of the fall |
| Staff C | Certified Nursing Assistant | Cared for Resident #2 during the incident and provided statements |
| Staff D | Certified Nursing Assistant | Interviewed and involved in camera footage review |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 17, 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 a credible allegation of compliance and plan of correction effective August 4, 2023.
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 2
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #114050-C and facility reported incident #113136-I from July 10 to July 13, 2023.
Complaint Details
Complaint #114050-C was not substantiated. Facility reported incident #113136-I was not substantiated.
Findings
The facility failed to revise the care plan to accurately reflect physician orders for oxygen use for one resident. Documentation related to oxygen administration and saturation levels was incomplete or missing, and the facility did not follow physician orders for oxygen management.
Deficiencies (2)
Care Plan Timing and Revision - The facility failed to revise the care plan to accurately reflect physician orders for oxygen and use of oxygen for one resident.
Respiratory/Tracheostomy Care and Suctioning - The facility failed to follow physician orders and manage oxygen use for one resident, including lack of documentation and failure to monitor oxygen saturation levels as ordered.
Report Facts
Census: 91
Complaint Number: 114050
Incident Number: 113136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Shea | Administrator | Signed the plan of correction document |
| Staff A | Health Services Supervisor | Interviewed and acknowledged oxygen orders and care plan deficiencies for Resident #34 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
A complaint investigation for complaint #107481-C was conducted from April 19, 2023 to April 20, 2023.
Complaint Details
Complaint #107481-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
Re-Inspection
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
A revisit of the survey ending February 17, 2022 and investigation of complaint #103746-C was conducted from April 5, 2022 to April 19, 2022.
Complaint Details
Complaint #103746 was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility was in substantial compliance effective March 22, 2022. Complaint #103746 was not substantiated.
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 9
Date: Feb 17, 2022
Visit Reason
Recertification survey and investigation of facility reported incidents #101776 and #102420 conducted from 2/14/22 to 2/17/22.
Complaint Details
Facility reported incident #101776 was substantiated. Incident involved staff calling a resident a baby and pushing a resident to a seated position. The facility investigated and took corrective actions including terminating involved staff and contacting staffing agency.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, advance directive compliance, freedom from abuse and neglect, timely reporting of alleged violations, accurate resident assessments, medication administration, dietary services, and infection prevention and control.
Deficiencies (9)
Failure to ensure staff treated residents with dignity and respect for 1 of 24 residents reviewed (Resident #34).
Failure to change outside chart binder markings from full code to Do Not Resuscitate for 1 of 24 residents (Resident #179).
Failure to ensure residents remained free from abuse; CNA pushed Resident #129 repeatedly to a seated position by pushing on his shoulders.
Failure to report suspected abuse within required timeframe for 1 of 1 resident reviewed (Resident #129).
Failure to submit a quarterly Minimum Data Set (MDS) assessment timely for 1 of 2 residents (Resident #2).
Inaccurate coding of significant weight gain on MDS assessment for 1 of 2 residents (Resident #48).
Failure to administer Levothyroxine 50 mcg per physician order for 1 of 5 residents reviewed (Resident #4).
Failure to perform proper hand hygiene, wear hairnets properly, prevent cross contamination, and reheat food to required temperature during meal service.
Failure to utilize proper infection control techniques with medication administration, blood sugar monitoring, and urinary catheter maintenance for multiple residents.
Report Facts
Residents reviewed: 24
Residents reviewed: 25
Residents reviewed: 2
Residents reviewed: 5
Residents reviewed: 3
Resident census: 83
Weight measurements: 135.4
Weight measurements: 133
Weight measurements: 132.8
Weight measurements: 138.8
Medication dosage: 50
Temperature: 167
Temperature: 170
Temperature: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nurse Aide (CNA) | Named in abuse finding for calling resident a baby and barred from working in facility |
| Staff J | Certified Nurse Aide (CNA) | Named in abuse finding for pushing Resident #129 to seated position |
| Staff K | Witness who admitted failure to intervene in abuse incident | |
| Staff O | Activity Assistant | Witness to abuse incident and suspended for 3 days |
| Staff M | Assistant Director of Nursing (ADON) | Involved in code status and advance directive findings |
| Staff E | Registered Nurse (RN) / Staff Development | Involved in MDS assessment and medication administration findings |
| Staff F | Licensed Practical Nurse (LPN) | Involved in MDS assessment findings |
| Staff A | Licensed Practical Nurse (LPN) | Observed administering medication including Levothyroxine |
| Staff B | Licensed Practical Nurse (LPN) | Observed improper glucometer cleaning and medication handling |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed about glucometer cleaning and catheter tubing placement |
| Staff H | Dietary Aide | Observed failing to follow proper food handling, hygiene, and reheating procedures |
| Staff N | Infection Control/Assistant Director of Nursing (ADON) | Interviewed about medication administration and catheter tubing placement |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted an investigation in accordance with Medicare Conditions of Participation, reviewing facility reported incidents #95460-I and #95437-I.
Complaint Details
Facility reported incidents #95460-I and #95437-I were reviewed and found not substantiated.
Findings
The facility was found to be in compliance with no deficiencies cited. Both reported incidents were not substantiated.
Report Facts
Facility reported incidents reviewed: 2
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #94067-C.
Complaint Details
Complaint #94067-C was investigated and found not substantiated.
Findings
The complaint #94067-C was not substantiated during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 23 - 24, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 3, 2020
Visit Reason
Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 2 - 3, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 1
Date: Oct 1, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and in response to Complaint #93590-C and Facility Reported Incident #93531.
Complaint Details
Complaint #93590-C was not substantiated. Facility Reported Incident #93531 was substantiated.
Findings
The facility failed to provide adequate supervision for Resident #1 who eloped from the facility, resulting in a substantiated incident. The facility lacked a policy for 15-minute safety checks and failed to monitor the resident appropriately during the night shift.
Deficiencies (1)
Failure to provide adequate supervision for Resident #1 to prevent elopement and ensure safety.
Report Facts
Census: 94
MDS assessment score: 15
Wandering Risk Assessment score: 6
15-minute safety checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Shea | Administrator | Signed the plan of correction. |
| Staff A | Registered Nurse | Provided statements regarding 15-minute safety checks and resident supervision. |
| Staff B | Nurse Aide | Observed Resident #1 during the night shift and reported on resident behavior. |
| Staff C | Registered Nurse | Completed Incident Report and reported resident's return to facility. |
| Director of Nursing | Director of Nursing | Acknowledged lack of policy for 15-minute safety checks and resident monitoring. |
Inspection Report
Routine
Census: 91
Deficiencies: 2
Date: Aug 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 8/3/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified related to accident hazards and sufficient nursing staff, including failure to ensure adequate supervision to prevent accidents and failure to respond timely to resident call lights.
Deficiencies (2)
The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident sustaining a major injury after falling in the bathroom.
The facility failed to ensure sufficient nursing staff to respond to resident call lights in a timely manner, with 6 out of 7 residents' call lights not answered promptly.
Report Facts
Total residents: 91
Residents with call light response issues: 6
Call light events: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Dobbs | Director of Nursing | Provided interview regarding call light response expectations and staffing |
Inspection Report
Abbreviated Survey
Census: 94
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/22/20 to assess the facility's 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
Annual Inspection
Census: 101
Deficiencies: 4
Date: Feb 13, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey to assess compliance with federal regulations related to resident care, assessments, and medication administration.
Findings
The facility was found deficient in coordinating PASARR reassessments, applying adaptive devices as ordered, providing appropriate peri-care for incontinent residents, and properly administering insulin injections using an insulin pen. The facility submitted plans of correction including staff education, audits, and competency checks.
Deficiencies (4)
Failed to re-assess one resident for PASARR evaluation as required.
Failed to apply a splint according to physician order and therapy recommendations for one resident.
Failed to provide appropriate peri-care for two residents, missing cleansing of all areas touched by briefs.
Failed to properly administer insulin using an insulin pen, including failure to prime the pen before injection.
Report Facts
Facility census: 101
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Named in peri-care deficiency and splint application observation |
| Staff C | Certified Nurse Aide (CNA) | Named in peri-care deficiency observation |
| Staff D | Licensed Practical Nurse (LPN) | Named in splint application and insulin administration deficiencies |
| Staff E | Assistant Director of Nursing | Provided expectations on peri-care standards |
| Staff F | Reported PASARR submission requirements | |
| Staff A | Registered Nurse (RN) | Provided training information on insulin pen administration |
| Director of Nursing | Director of Nursing (DON) | Provided expectations on splint application, peri-care, and insulin administration |
| Staff Development Coordinator | Responsible for staff training and competency checks |
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