Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Falls Health Care Center during CMS and state inspections, most recent first.
Infection control failed when a resident with influenza A was not placed on droplet precautions right away, allowing the roommate to move throughout the facility before a mask was offered and later develop URI symptoms requiring antibiotics, prednisone, and nebulizers. Staff also failed to use a clean barrier during a blood sugar check and handled oral meds with dirty gloves and a visibly dirty tablet screen during med pass, showing multiple breaks in infection control practice.
Restorative program not available for residents needing mobility support. The facility did not have a restorative program in place for residents, and two residents who had stroke/hemiplegia-related limitations and needed assistance with ADLs and mobility had no restorative services documented in their records. One resident with intact cognition said he wanted to try restorative again, and another resident with severe cognitive impairment said he did not have a restorative program and would exercise only when he wanted to. The DON confirmed the program was not currently available.
Failure to post daily nurse staffing information. Surveyors observed that the nurse staffing posting was not updated on multiple days and at times reflected outdated dates. The ADM stated the night nurse was expected to complete the posting for the next day and update it as changes occurred, but it had not been completed that week. The facility policy required staffing information to be readily available and posted at the beginning of each shift.
A facility failed to obtain informed consent before starting or continuing psychotropic medications with black box warnings for multiple residents. Records showed residents with intact cognition and diagnoses such as anxiety, depression, schizophrenia, stroke, and insomnia received antipsychotic and antidepressant medications, but the charts lacked consent documentation or evidence that risks, benefits, and alternatives were discussed. The DON and Administrator acknowledged missing consent documentation for these medications.
Inaccurate PASRR Coding on MDS: A resident’s MDS was coded incorrectly for PASRR status, showing no PASRR Level II outcome even though the resident’s PASRR indicated a Level II determination. The MDS Coordinator later confirmed the error during interview, stating she had recorded the resident as PASRR Level I in her notes and that the facility followed the RAI manual rather than having a specific MDS policy.
Failure to assess a resident with influenza A after return from the ER. The resident had SOB, COPD exacerbation, severe cognitive loss, and orders for Duo-nebs, prednisone, Tamiflu, and pulse oximetry monitoring, but the EHR lacked a physical assessment for several days and staff reported the positive flu result was not communicated during the weekend. The DON expected full VS, lung sounds, and pulse ox each shift, but documentation was limited and intermittent.
A resident who received routine hemodialysis had missing pre- and post-dialysis assessments in the MAR for multiple treatments. The care plan directed staff to monitor the dialysis access site and document dialysis flow sheets, but the MAR lacked assessment documentation on most dialysis days, and the facility's hemodialysis policy required assessment before and after treatment and access site monitoring upon return from dialysis.
Failure to set blood sugar parameters and notify the provider of critical glucose readings occurred for a resident with DM who was dependent on insulin and also received dialysis. The MAR/TAR lacked glucose parameters, multiple blood sugars were documented above 450 mg/dL, and staff did not call the MD after those elevated readings. The resident later vomited, refused dialysis, went to the hospital, and was admitted with a blood sugar greater than 600 mg/dL and DKA.
A resident with an order for Lantus insulin had a medication administration error when an RN attempted to prime an insulin pen without attaching a needle and without confirming insulin was expressed from the pen. The RN also failed to verify the pen’s expiration before preparing the dose, and a second pen was later primed the same incorrect way. The DON stated the facility had a pharmacy guide and insulin expiration list, but the list could not be located at the nurses’ station.
A facility failed to maintain an effective QAPI program after prior citations for F760 medication errors and F880 infection control concerns. During a later survey, staff again were observed with insulin pen administration issues and dirty gloves touching oral meds, and the DON acknowledged the prior issues were not corrected and that audit documentation was not maintained.
Failure to notify the physician when a resident's ordered Gabapentin was not administered as prescribed. A resident with intact cognition and diagnoses including anxiety, depression, and insomnia had MAR omissions for the medication over multiple days, and the progress notes lacked documentation that the MD was notified. The DON and Administrator stated the CMA should have alerted the nurse, and the nurse should have contacted the MD; the facility policy did not address what to do if medication was not available.
A resident with intact cognition and diagnoses including anxiety, depression, and insomnia did not receive ordered Gabapentin as prescribed. The MAR showed the evening dose was omitted for an extended period, and review of MARs and pharmacy delivery records confirmed the resident’s last dose was given before the medication became unavailable. The DON and Administrator stated staff should have reported the missing medication to the nurse, who would then contact the physician and pharmacy, but the facility policy lacked direction for unavailable medication.
A resident reported missing money, but the facility failed to report the allegation to DIAL within the required 24-hour timeframe. The Administrator believed the resident had a history of misplacing items and assumed the money would be found, leading to a delay in reporting. The facility's policy requires such allegations to be reported promptly.
A resident with severe cognitive impairment and a known behavior of packing food into her mouth experienced a choking incident. Despite staff awareness, the Care Plan lacked specific interventions for this behavior. The resident required the Heimlich maneuver and CPR before being transferred to the hospital. The facility's policy mandates regular updates to Care Plans, but the Assistant Director of Nursing was unaware of the resident's behavior, indicating a communication gap.
The facility failed to serve hot food at the required temperature of at least 135 degrees Fahrenheit. A test tray showed the casserole at 131 degrees Fahrenheit and the beans at 116.6 degrees Fahrenheit. Staff C from dietary was unaware of the expected temperature, and the Dietary Manager stated that food should be served at 154 degrees Fahrenheit. The facility's policy required maintaining hot food temperatures above 135 degrees Fahrenheit.
The facility failed to ensure compliance with its policy requiring all staff to wear hair nets in the kitchen. Two CNAs were observed entering the kitchen without proper hair containment. One CNA entered without a hair net, while another wore a hair net that did not fully cover her hair. The Dietary Manager confirmed the expectation for all staff to adhere to this policy.
A facility failed to maintain a medication error rate below five percent when administering insulin to two diabetic residents. An RN did not prime insulin pens before administration, contrary to manufacturer's instructions, leading to improper dosing. The facility's policy lacked specific guidance on insulin pen use, and there was no record of in-service education on the procedure.
Two incidents of infection control breaches were observed during medication administration. A CMA and an RN were seen handling medications with bare hands, contrary to facility policy. The CMA did not perform hand hygiene and handled multiple medications directly, while the RN split a tablet with bare hands. Staff interviews confirmed these actions were against the facility's infection control procedures.
The facility failed to ensure door and wander guard alarm checks were completed as documented, compromising resident safety. A resident with severe cognitive loss and low elopement risk, and another with high elopement risk, were involved. The Maintenance Supervisor, responsible for these checks, falsified records under pressure from the Administrator during his medical leave. The facility's compliance program prohibits such falsification, yet the Administrator and staff engaged in these practices, leading to a deficiency.
The facility failed to notify the family of a resident's hospital transfer and passing due to incorrect contact information, and did not inform a physician when another resident's medications were unavailable upon admission. These deficiencies highlight lapses in communication and protocol adherence.
A facility failed to administer medications as ordered for a newly admitted resident, resulting in significant medication errors. The resident, with intact cognition and multiple diagnoses, did not receive prescribed doses of Clonazepam, Famotidine, Metoprolol, Hydroxyzine, and Methocarbamol. An RN noted the absence of medications, and the DON confirmed no documentation of provider notification. The facility's policy on medication errors was not followed.
The facility failed to maintain a safe and comfortable environment due to ceiling leaks in the hallway and dining room. Observations showed water coming from the ceiling, with garbage cans and wet floor signs in place. Staff confirmed the leaks occurred during rain, and the Administrator mentioned indecision about roof replacement. Residents expressed dissatisfaction, and the facility lacked a policy for a clean environment.
A resident with PTSD, psychotic disorder, and chronic pain received medications outside scheduled times on multiple occasions without documented rationale. The facility's policy required timely administration, but this was not followed, and the DON expected staff to document any deviations, especially for high-risk medications.
A facility failed to provide showers twice a week for a resident and did not provide incontinence care for three residents. One resident, with a history of stroke and hemiplegia, was not offered showers during specific periods, despite expressing their importance. Documentation for June 2024 lacked evidence of toileting hygiene for this resident and two others, who had conditions like malnutrition, PTSD, diabetes, and sepsis. The DON confirmed the absence of a policy on bathing and incontinence care, expecting staff to follow industry standards.
Infection Control Failures During Influenza Exposure, Glucose Checks, and Medication Pass
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when Resident #17 tested positive for influenza A and the infection was not placed under droplet precautions right away. Resident #17 had a BIMS score of 6 and diagnoses that included altered mental state, acute respiratory failure, and adult failure to thrive. After the resident returned from the ED with influenza A, the room did not have an isolation sign or PPE available, and staff observed the resident lying in bed with the room door open while the roommate remained in the room and the privacy curtain was only partially drawn. Staff also observed the roommate leave the room and walk through the facility and dining room without being offered a medical mask until after traveling approximately 70 to 75 feet. Resident #17's roommate, Resident #38, later developed signs and symptoms of an upper respiratory infection with wheezing, chills, and malaise. The provider documented that Resident #38 appeared sick and ordered antibiotics, prednisone, and nebulizer treatments. Staff interviews showed that the influenza A result was not passed through report, the on-call nurse was not notified, and droplet precautions were not initiated until later. Staff and leadership stated that the resident should have been placed on precautions when the positive influenza result was known, and the room initially lacked the CDC droplet precaution sign and PPE setup. The facility also failed to follow infection control practices during other observed care. During a blood sugar check for a resident with diabetes and severe cognitive loss, staff placed glucose testing supplies on the resident's bedside table and bed without using a clean barrier, and the lid used for the supplies was not sanitized before being returned to the cart. During medication administration, staff handled oral medications with dirty gloves, touched a visibly dirty tablet screen while preparing medications, and contacted oral medications after touching other surfaces. These observations involved Residents #16, #19, #23, and #34 and showed inconsistent infection control practices during routine care.
Restorative program not available for residents needing mobility support
Penalty
Summary
The facility failed to have a restorative program available for all residents, and it did not implement a restorative plan for 2 residents who stated they would participate if therapy or restorative services were offered. Resident #36 had an MDS assessment showing a BIMS of 15 with no cognitive impairment and was dependent on staff for toileting, dressing, transfers, and personal hygiene. His diagnoses included stroke, anxiety, depression, and hemiplegia. Although his care plan documented participation in the Restorative Nursing Program with strengthening and stretches to prevent contractures and perform restorative exercises, the December 2025 and January 2026 Documentation Survey Reports lacked a restorative program. During interview, he said he had attended restorative in the past, would like to try it again, and might do it every day if he liked it. Resident #43 had an MDS assessment showing a BIMS of 6 with severe cognitive impairment and required moderate assistance for standing, transfers, and walking up to 50 feet. His diagnoses included depression, hypotension, and hemiplegia. The December 2025 and January 2026 Documentation Survey Reports also lacked a restorative program for him. During interview, he stated he did not have a restorative program and would do exercises when he wanted to. The Administrator confirmed the facility did not currently have a restorative program in place for residents and was working on implementing one, and stated both residents would probably benefit from a restorative program. The facility's Nursing Restorative Program manual instructed on implementation and maintenance of a restorative program.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information on 3 of 4 days of the annual survey for a census of 43 residents. On 1/5/26 at 10:17 AM, surveyors observed nurse staff posting information posted for 1/3/26. On 1/6/26 at 1:41 PM, the posting still reflected 1/5/25, and on 1/7/26 at 3:47 PM, the posting again reflected 1/5/25. During an interview on 1/8/26 at 11:24 AM, the Administrator stated she expected the night nurse to complete the nurse staff posting for the next day and post it on their shift, with staff updating it as changes occurred, and reported it had never been identified as an issue that it had not been updated before and she was unsure why it was not completed that week. Review of the Nurse Staffing Posting Information policy, revised in an unknown month in 2025, stated nurse staffing information is to be readily available in a readable format to residents, staff, and visitors at any given time and that the facility will post the nurse staffing at the beginning of each shift.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before starting psychotropic medications with black box warnings for 3 of 5 residents reviewed. The record review identified that Resident #36 had a BIMS score of 15 with diagnoses including stroke, hemiplegia, anxiety, and depression, and his records showed orders and administration of antipsychotic, antianxiety, and antidepressant medications, but his medical record lacked completion of an assessment regarding consent for the antianxiety and antidepressant medications since admission. Resident #40 had a BIMS score of 15 and diagnoses of anxiety, depression, and insomnia. His records showed orders for two antidepressant medications and administration of antianxiety and antidepressant medications since admission, but his medical record lacked completion of an assessment regarding consent for the antianxiety and antidepressant medications since admission. The DON reported the facility was working on obtaining informed consents for black box psychotropic medications during weekly behavior meetings and stated the consents should be documented in the Assessments portion of the medical record. Resident #8 had a BIMS score of 15, a PHQ-9 score of 6, verbal behaviors 4-6 days per week, rejection of care 1-3 days per week, and diagnoses including stroke, depression, and schizophrenia. His record showed ongoing administration of olanzapine, sertraline, and trazodone, including a new olanzapine order, but review of the EHR Progress Notes, Assessments, and Miscellaneous documentation lacked evidence that the facility informed him in advance of the risks and benefits of the medication, treatment alternatives, or other options. The Administrator reported no medication education or consent documentation was found for this resident and acknowledged missing consent forms for psychotropic medications.
Inaccurate PASRR Coding on MDS
Penalty
Summary
The facility failed to accurately code 1 of 2 residents with a PASRR outcome on the MDS assessment. Resident #7’s PASRR dated 1/13/23 showed a PASRR Level II outcome, but the resident’s MDS assessment dated [DATE] documented that she did not have a PASRR Level II outcome. The report identified this as an inaccurate MDS coding issue involving the resident’s PASRR status. During an interview on 1/8/26 at 10:17 AM, the MDS Coordinator stated she used a notebook to track notes for the MDS assessments she completed. In her notebook, she had recorded Resident #7 as having a PASRR Level I on the 12/11/25 MDS. After reviewing Resident #7’s PASRR dated 1/13/23, she confirmed the resident had a PASRR Level II outcome and stated the MDS dated [DATE] was coded inaccurately. She explained that her process normally worked but she must have looked at the PASRR too quickly. She also stated the facility did not have a specific policy for completing MDS assessments and instead followed the RAI manual for instruction.
Failure to Assess Resident With Influenza A
Penalty
Summary
The facility failed to assess a resident who tested positive for influenza A after returning from the hospital emergency room with shortness of breath and a diagnosis of influenza A and COPD exacerbation. The resident had severe cognitive loss, altered mental state, acute respiratory failure, and adult failure to thrive. The hospital discharge instructions included monitoring for worsening breathing, fever, chest pain, confusion, and other symptoms, and the physician orders on return included Duo-nebulizer treatments every 6 hours while awake for 7 days, prednisone, pulse oximetry monitoring with return to the ER if oxygen saturation was less than 90%, and Tamiflu when it arrived from the pharmacy, with the first dose given in the ER. A review of the EHR showed no physical assessment documented from the resident’s return through several days afterward, despite the change in condition and the positive influenza A result. Vital signs were documented only intermittently, with oxygen saturations recorded as low as 91% and 92%, but the DON stated she expected a full set of vital signs, lung sounds, and pulse oximetry every shift with documentation in progress notes. Staff interviews indicated the weekend RN did not enter the resident’s room, and the night nurse/ADON reported she was not informed the resident had tested positive for influenza A and did not receive notification. The facility’s policy on change in condition defined significant change but did not direct when to complete a nursing assessment or what to include in it.
Missing Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete pre- and post-dialysis assessments for a resident who received hemodialysis while living at the facility. Resident #40 had diagnoses including anxiety, depression, and insomnia, and his MDS documented that he received dialysis treatment. The care plan revised 12/9/25 identified that he required dialysis therapy and directed staff to complete the dialysis flow sheet daily to observe the shunt access site for complications and report abnormalities to the physician. Record review showed that Resident #40 received routine dialysis treatments at the dialysis center on multiple dates in December 2025 and early January 2026. His December 2025 MAR lacked a pre- or post-dialysis assessment directive except on 12/23/25, 12/29/25, and 12/31/25, and there was no documentation for assessments on the other dialysis days in December 2025. Review of the January 2026 MAR also showed no pre-dialysis assessment completed for 1/2/26. The facility's Hemodialysis policy required assessment of the resident's condition before and after dialysis and monitoring/documentation of the access site upon return from dialysis for bleeding or other complications.
Failure to Set Blood Sugar Parameters and Notify Provider of Critical Glucose Readings
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident with diabetes who received insulin and dialysis. Resident #40’s record showed a BIMS score of 15, diagnoses including anxiety, depression, insomnia, and diabetes mellitus, and that he was dependent on insulin. His MAR and TAR did not contain blood sugar parameters, and the facility’s records documented multiple blood sugar readings above 450 mg/dL, including 461, 551, 493, and 557 mg/dL. The DON stated she did not know the resident’s blood sugar parameters and expected nursing staff to call the doctor if blood sugar was below 70 or above 350 because there were no sliding scale orders outside that range. The facility also did not notify the resident’s doctor after the elevated blood sugar assessments were completed to ask whether additional medication or treatment was needed. Progress notes showed no doctor notification for the four elevated blood sugar readings. Later, the resident vomited, refused dialysis because he did not feel well, and requested to go to the hospital. The hospital documented a blood sugar greater than 600 mg/dL and admitted him for diabetic ketoacidosis. The Nurse Practitioner stated the resident’s blood sugars changed rapidly and that staff were expected to notify her or the doctor of blood sugars below 40 mg/dL and above 450 mg/dL.
Improper Insulin Pen Priming and Expired Insulin Check Failure
Penalty
Summary
The facility failed to ensure that insulin was administered correctly for Resident #39, who had an order for Lantus Solostar Insulin Pen 100 units/mL to inject 10 units subcutaneously. During a medication task observation, Staff B reviewed the resident’s EMAR and attempted to prime the insulin pen by dialing it to 2 units and pressing the plunger without first placing a needle on the pen. No insulin was visibly expressed from the pen, yet Staff B then set the pen to 10 units and placed the needle on it to administer the dose. Staff B did not check the insulin pen expiration date until after the surveyor asked for it, and then stated it was not okay to give the insulin. A new insulin pen was later obtained, but Staff B again primed it without placing a needle on the pen and again no insulin was visibly expressed. The DON stated that the facility had a pharmacist-provided procedure hanging in the medication room and that nurses used a guide listing insulin expiration dates kept at the nurses’ stations. However, Staff B could not locate the insulin list in the nurses’ station, and the DON reported calling the pharmacy for new copies of the expiration list. The pharmacy guide for using an insulin pen instructed staff to attach the needle before priming and to verify that insulin comes out of the needle, repeating the test if needed. The facility’s insulin administration policy lacked step-by-step direction or guidance on priming an insulin pen or administering insulin via pen, and the facility pharmacy appendix stated that an opened Lantus pen not refrigerated remained good for 28 days.
Repeated Medication Administration and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI program to address previously identified quality deficiencies, and repeated concerns were found during the annual recertification survey. The prior 12/12/24 Statement of Deficiencies and Plan of Correction cited F760 for significant medication errors involving insulin pen administration and F880 for infection control concerns related to staff touching medications with bare hands during medication administration. The facility’s plan of correction stated that staff involved were educated, other residents using insulin pens were identified, and the DON or designee would complete audits and forward results to the QAPI committee, with compliance documented on 1/9/25. During the 1/5/26 to 1/8/26 survey, observations, record review, document review, and policy review again identified F760 concerns with insulin pen priming and administration and F880 concerns with dirty gloves touching oral medication before administration. In interview, the Administrator and DON acknowledged the facility did not correct the issues from the prior survey. The DON stated she observed medication passes after 1/9/25 but did not document any audits, did not know why nurses started using gloves, and said nurses should not handle oral medications with dirty gloves or touch medications after touching the tablet screen. The DON also reported the consulting pharmacist completed monthly medication inspections and that a nursing skills fair had been planned but not completed before the survey.
Failure to Notify Physician of Omitted Gabapentin
Penalty
Summary
The facility failed to notify the physician when Gabapentin, ordered three times daily for Resident #1, was not administered as prescribed. Resident #1 had a BIMS score of 15, indicating intact cognition, and diagnoses included anxiety, depression, other psychoactive substance use disorder with mood disorder, and psychophysiologic insomnia. The MAR for September and October 2025 documented Gabapentin as omitted from 9/18/25 through 10/7/25, and the progress notes did not document that the physician was notified of the omission. During interviews, the DON stated the CMA should have contacted the nurse when the medication was not available, and the nurse should have contacted the physician; the Administrator stated the CMA should have notified the nurse and then the nurse should have notified the physician. The facility policy titled Acute Change in Condition Policy did not provide direction for staff if medication was not available.
Medication Not Administered as Ordered
Penalty
Summary
The facility failed to administer Gabapentin as prescribed for one resident whose MDS showed a BIMS score of 15 and diagnoses including anxiety, depression, other psychoactive substance use, unspecified with mood disorder, and psychophysiologic insomnia. The resident’s MAR for September and October 2025 documented the evening dose of Gabapentin as omitted from 9/18/25 through 10/7/25, and review of the MARs showed the resident’s last dose was given on 9/18/25 at noon. Pharmacy delivery records showed Gabapentin was delivered on 8/1/25, 8/14/25, and again late on 10/6/25, but the medication was not available for administration during the gap in doses. The DON reviewed the pharmacy delivery records and MARs and confirmed the resident did not receive Gabapentin after the last dose on 9/18/25 at noon. The DON reported the facility had trouble with CMAs not reporting when medications were unavailable, and later stated CMAs should notify the nurse when medication is unavailable, with the nurse then contacting the physician, pharmacy, and responsible party. The Administrator stated staff should notify the nurse of unavailable medication, and the nurse should notify the physician and pharmacy as soon as possible. The facility policy titled Acute Change in Condition Policy lacked direction for staff if medication was not available.
Failure to Timely Report Allegation of Missing Money
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the Iowa Department of Inspection and Appeals and Licensing (DIAL). The incident involved a resident who reported missing money on February 25, 2025. The Social Service Designee was informed by a Certified Nurses' Aide about the missing money and subsequently reported it to the Director of Nursing during a morning meeting. The Director of Nursing and the Administrator were made aware of the situation, and the Social Services Designee was instructed to search the resident's room for the missing money, which was not found. Despite being aware of the allegation, the Administrator did not report the incident to DIAL within the required 24-hour timeframe, as outlined in the facility's policy. The Administrator believed the resident had a history of misplacing items and assumed the money would be found. The Director of Nursing acknowledged that the allegation should have been reported within the required timeframe. The facility's policy mandates that allegations of abuse, including misappropriation, must be reported within 24 hours, even if they do not result in serious bodily injury.
Failure to Revise Care Plan for Resident with Known Choking Risk
Penalty
Summary
The facility failed to revise and implement interventions on the comprehensive Care Plan for a resident with a known behavior of packing food into her mouth. This deficiency was identified during a review of clinical records and interviews with staff, revealing that the Care Plan did not include specific interventions for this behavior. The resident, who had severe cognitive impairment and was edentulous, was on a regular diet with no documented swallowing disorders. Despite staff awareness of the resident's tendency to pack food, the Care Plan lacked directives to address this behavior. An incident occurred where the resident's tablemate alerted staff to a possible choking situation. A Certified Medication Aide (CMA) attempted the Heimlich maneuver, and the resident was subsequently lowered to the floor and CPR was initiated. The resident was transferred to the hospital after emergency responders arrived. Interviews with staff members confirmed that they were aware of the resident's behavior of packing food, yet the Care Plan did not reflect this known risk. The facility's policy required the Interdisciplinary Team (IDT) to develop and implement a comprehensive, person-centered Care Plan, which should be revised as the resident's condition changes. However, the Assistant Director of Nursing (ADON) was unaware of the resident's behavior, indicating a communication gap. The Director of Nursing (DON) acknowledged that concerns were reported by CNAs, but the Care Plan was not updated to include interventions for the resident's behavior of packing food into her mouth.
Failure to Serve Hot Food at Required Temperature
Penalty
Summary
The facility failed to serve hot food at the required temperature of at least 135 degrees Fahrenheit, as evidenced by a test tray provided on December 10, 2024. The casserole on the test tray measured 131 degrees Fahrenheit, and the beans measured 116.6 degrees Fahrenheit. Staff C from the dietary department confirmed that she took the temperatures in Celsius and was unaware of the expected temperature for the food. During an interview, the Dietary Manager stated that hot food should be served at a temperature of at least 154 degrees Fahrenheit. The facility's policy, last revised in October 2017, directed staff to maintain hot food temperatures above 135 degrees Fahrenheit. The facility reported a census of 38 residents at the time of the survey.
Non-compliance with Hair Net Policy in Kitchen
Penalty
Summary
The facility failed to ensure that all staff entering the kitchen adhered to the policy of wearing hair nets, as observed in two separate instances. On December 9, a Certified Nurse Aide (CNA), identified as Staff A, entered the kitchen without a hair net, walked in front of the steam table, filled a cup at the coffee machine, and exited. On December 10, another CNA, identified as Staff B, entered the kitchen with a hair net that did not fully contain her hair, leaving the sides and back exposed. She proceeded to walk around the steam table, retrieve ice from the ice machine, open a refrigerator to take out a pitcher of iced tea, and set it on the prep table for the cook to cover with plastic wrap before exiting. The Dietary Manager confirmed the expectation for all staff to wear hair nets upon entering the kitchen, as per the facility's policy on employee hygiene and sanitary practice dated October 2017.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent when administering insulin to two diabetic residents. On the morning of December 10, 2024, a Registered Nurse (RN) administered insulin to Resident #8 without priming the insulin pens as per the manufacturer's instructions. The RN set the doses for Tresiba and Fiasp insulin pens but did not prime them with two units of insulin, which is necessary to ensure the resident receives the full prescribed dose. The Director of Nursing (DON) later confirmed that the nurses are expected to follow the manufacturer's directions, although there was no record of in-service education on insulin pen administration. The facility's Insulin Administration Policy, revised in September 2014, lacked specific instructions on priming and administering insulin via a pen. Similarly, another incident involved Resident #32, where the same RN failed to prime the Insulin Aspart Flex Pen before administration. The RN set the pen to the required dose according to the sliding scale insulin order but did not perform the necessary air shot to ensure proper dosing. The resident then self-administered the insulin without the pen being primed. The manufacturer's instructions for the Insulin Aspart Flex Pen clearly state the need to perform an air shot before each injection to avoid injecting air and ensure proper dosing. These actions led to a significant medication error rate, as the facility did not adhere to the proper insulin administration procedures.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed in two separate incidents involving nursing staff. In the first incident, a Certified Medication Aide (CMA) did not perform hand hygiene before setting up a resident's morning medications. The CMA handled medication cards and punched pills into her bare hands before placing them into a medication cup. Additionally, she touched multiple tablets from a stock bottle with her bare hands, placing one into the medication cup and returning the rest to the bottle. The CMA also broke a tablet in half with her bare hands at the resident's request. In the second incident, a Registered Nurse (RN) was observed handling a resident's medication with bare hands. The RN took a tablet from a medication cup, split it using a pill splitter, and placed it back into the cup with bare hands. The facility's policy, revised in 2012, directed staff to follow infection control procedures, including the use of gloves when handling medications. Interviews with staff confirmed that touching medications with bare hands was against the facility's expectations and policy.
Failure to Conduct and Document Alarm Checks
Penalty
Summary
The facility failed to ensure that door alarm checks and wander guard alarm checks were physically completed as documented, compromising the safety of residents. Two residents, one with severe cognitive loss and a low risk of elopement, and another with severe cognitive loss and a high risk of elopement, were involved. The facility's documentation indicated that door alarms were checked daily, but interviews and reviews revealed inconsistencies and falsifications in the records. Staff C, the Maintenance Supervisor, was responsible for conducting and documenting these checks. However, during his medical leave, the checks were not performed, and upon his return, he was instructed by the Administrator to backdate the documentation to cover the period he was absent. Staff C admitted to falsifying records under pressure from the Administrator, who later acknowledged that the checks had not been done and that the documentation was inaccurate. The facility's Corporate Compliance Program emphasizes the importance of accurate and complete record-keeping, prohibiting falsification of records. Despite this, the Administrator and Staff C engaged in practices that violated these standards, leading to a deficiency in maintaining a safe environment for residents. The lack of proper oversight and communication regarding the responsibility for alarm checks during Staff C's absence contributed to the deficiency.
Failure to Notify Family and Physician of Resident Changes
Penalty
Summary
The facility failed to properly notify the family and physician of two residents regarding significant changes in their conditions. For Resident #6, who had a history of traumatic subdural hematoma and seizure disorder, the facility did not successfully inform the family about the resident's transfer to the hospital and subsequent admission. Despite the resident having intact cognition and being independent in bed mobility, the facility had incorrect contact information on file, which led to the family not being notified. This oversight resulted in the family being unaware of the resident's hospitalization and eventual passing. In the case of Resident #5, who was admitted from a short-term hospital stay with diagnoses including orthopedic aftercare, hypertension, muscle weakness, and severe obesity, the facility failed to notify the physician when medications were unavailable upon admission. The resident's medication administration record indicated that several doses of prescribed medications were held due to unavailability, yet there was no documentation of physician notification. The Director of Nursing confirmed the lack of documentation and stated that staff were expected to notify the provider if medications could not be administered as ordered. The facility's failure to update contact information and notify relevant parties of significant changes in residents' conditions and medication availability highlights deficiencies in communication and adherence to established protocols. These lapses in procedure resulted in inadequate notification to family members and healthcare providers, which is critical in ensuring appropriate care and support for residents during significant health events.
Failure to Administer Medications as Ordered for New Admission
Penalty
Summary
The facility failed to follow medication administration protocols for a newly admitted resident, resulting in significant medication errors. Resident #5, who was admitted from a short-term hospital stay, had a Minimum Data Set (MDS) assessment indicating intact cognition and diagnoses including orthopedic aftercare, hypertension, muscle weakness, and severe obesity. The resident's Medication Administration Record (MAR) for June 2024 included orders for several medications, including Clonazepam, Famotidine, Metoprolol, Hydroxyzine, and Methocarbamol. However, the facility did not administer the prescribed doses on 6/27/24 and 6/28/24, as documented in the MAR. An electronic progress note by a Registered Nurse (RN) on 6/27/24 indicated that the facility did not have the resident's medications available at that time. Furthermore, the Director of Nursing (DON) confirmed that there was no documentation of notifying the provider about the missed medications. The facility's Medication Variance Guideline policy outlines steps to follow when a medication error occurs, including recognizing the error, evaluating the patient's condition, reporting to a supervisor, notifying the physician, and documenting the physician's response. However, these steps were not followed, leading to the deficiency.
Ceiling Leaks in Dining Area Compromise Resident Environment
Penalty
Summary
The facility failed to provide a safe and comfortable environment due to leaks in the ceiling in the hallway entering the main dining room and in the main dining room. Observations revealed multiple garbage cans with turn sheets underneath them, caution wet floor signs, and water coming from the ceiling. The ceiling appeared discolored with tears in both the hallway and the dining room. Staff interviews confirmed that the leaks occurred when it rained, and the facility had been dealing with this issue for some time. The Administrator disclosed that the company was undecided about replacing the entire roof as they were considering purchasing the building. A tarp had been placed on the roof for about a month to minimize leakage, and bids had been requested to fix the roof. Despite receiving quotes to fix the roof months earlier, the issue remained unresolved. Interviews with residents indicated dissatisfaction with the situation, describing the leaks as bothersome. Additionally, the facility lacked a policy regarding maintaining a clean and comfortable environment.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to provide services that met professional standards regarding the administration of medications for one resident. The clinical record review revealed that medications for this resident were administered outside the scheduled time frames on multiple occasions without documented rationale. The resident, who had intact cognition as indicated by a BIMS score of 15, had diagnoses including PTSD, psychotic disorder, and chronic pain. The facility's Medication Administration policy required medications to be administered at the right time, yet this was not adhered to. The undated facility form titled 'Medication Administration Times' specified time frames for medication administration, which were not followed. The Director of Nursing (DON) stated that staff were expected to administer medications within these time frames and document any deviations, especially for high-risk medications. However, the records showed that medications were given late on several dates, with no documentation explaining the delays or any notification to the physician, indicating a failure to meet professional standards of quality care.
Failure to Provide Adequate Hygiene and Incontinence Care
Penalty
Summary
The facility failed to provide or offer showers twice a week for a resident and did not provide incontinence care for three residents. Resident #3, who had a history of cerebral vascular accident and hemiplegia, was identified as occasionally incontinent and expressed that showers were very important to them. However, the facility's records showed that Resident #3 was not offered or provided a shower during specific periods in April and May 2024. Additionally, documentation for June 2024 lacked evidence of toileting hygiene being provided on multiple occasions. Resident #4, frequently incontinent and diagnosed with malnutrition and PTSD, had a care plan indicating a potential for impaired skin integrity. Despite this, the June 2024 documentation showed missing records of toileting hygiene on several dates. Similarly, Resident #6, who was occasionally incontinent and had diagnoses of diabetes mellitus and sepsis, also had missing documentation for toileting hygiene in June 2024. The Director of Nursing acknowledged the absence of a policy on bathing and incontinence care, stating that the staff was expected to follow industry standards for these services.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 152 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martin Health Center, Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Newaldaya Lifescapes | 1.5 mi | ★★★★★ | 1 | 0 |
| The Suites At Western Home Communities | 3.2 mi | ★★★★★ | 1 | 0 |
| Pinnacle Specialty Care | 3.3 mi | ★★★★★ | 6 | 0 |
| Pillar Of Cedar Valley | 5.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.