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 Harmony Waterloo during CMS and state inspections, most recent first.
Incomplete and Outdated Nurse Staff Posting: The facility failed to keep the daily nurse staff posting current and failed to include the number of hours nursing staff worked. Surveyors observed outdated postings and missing hour information on multiple days, and the Administrator acknowledged the posting should be current every day and that several postings were incomplete or unavailable.
Pureed Food Portions Not Measured or Properly Explained by Cooks: Two cooks could not explain the puree process and did not measure pureed roast beef and butternut squash after blending to ensure equal portions for residents on a pureed diet. One cook said she had never been trained to measure pureed food, and both cooks stated they used the scoop size on the menu without a guide for serving size. The facility policy required equal portions or the appropriate scoop number so each resident receives the correct nutrient density.
Staff failed to follow the menu’s portion instructions during meal service. A cook used a #6 scoop instead of the #8 scoop directed for mashed potatoes and also served roast beef with a 6 oz. scoop instead of the 3 oz. portion listed on the menu. An observation showed most resident plates in the dining room had no mashed potatoes left, and facility leadership stated staff were expected to follow the menus.
Food and drink were not consistently served at a safe and appetizing temperature on room trays. Test trays showed hot items dropping below 135 F before service, including mashed potatoes, roast beef, and squash on multiple carts, even though steam table temperatures were acceptable before meal service. Several residents reported that hot food was not always hot enough, and one resident said she had cold tomato soup and that staff would reheat it if asked. Dietary staff also preheated hot plates in advance and left them on the counter, contrary to the Administrator, DON, and Infection Preventionist’s stated expectation that they be heated as used.
Failure to implement and document restorative programs for two residents. One resident with severe cognitive impairment and multiple chronic conditions had OT-recommended PROM for both UEs, but the care plan, Kardex, and EHR lacked the restorative program and staff reported it was not done consistently. Another resident with Parkinson’s disease and intact cognition had a care plan for walking and ROM restoratives, but documentation showed the walking program was completed only a few times over two months, with no refusals recorded; the resident wanted to walk more and the DON acknowledged the missing documentation.
An LPN improperly primed a Humalog insulin pen by dialing and pressing the plunger before attaching the needle, then set the pen to the ordered dose for a resident with diabetes and intact cognition. The LPN stated she thought she was getting the air out of the pen and did not know the needle had to be attached first. The DON said the needle should be placed on the pen before priming, and the facility policy referenced manufacturer instructions requiring the needle to be attached before the test dose is performed.
A resident dependent on staff for transfers and personal care was left soiled, uncovered, and without access to assistance after an argument with two CNAs during bedtime care. The resident's calls for help went unanswered for about an hour, leading to significant distress and increased anxiety. Staff interviews revealed failures in communication, lack of timely response, and inadequate adherence to abuse prevention and reporting protocols by both direct care staff and facility leadership.
A staff member exploited a resident by using her credit card to pay a personal cell phone bill after routinely accepting the card to purchase soda from a vending machine. The resident, who was dependent on staff for mobility and had multiple medical conditions, discovered the unauthorized charge after discharge, prompting a police investigation that linked the transaction to the staff member. Staff interviews revealed it was common for residents to give staff money or cards for vending machine purchases, despite facility policies prohibiting financial exploitation and personal cell phone use during work.
The facility failed to maintain a comfortable temperature in the shower room, as required by regulations, affecting two residents who reported the room was cold despite warm water. Maintenance confirmed the temperature was below the required range due to heating system issues. Although heat lamps were intended as a temporary solution, residents reported they were not used. The administrator acknowledged a delay in addressing the issue due to communication lapses.
The facility failed to accurately document MDS assessments for two residents. One resident's MDS omitted documentation of a diuretic medication, despite its administration being recorded in the MAR. Another resident's MDS incorrectly noted routine anti-psychotic medication use, which was not supported by MAR records. The DON confirmed these errors, and the facility lacked a specific MDS policy, relying on the RAI manual.
A facility failed to submit a PASRR for a resident with new mental health diagnoses. The resident, with intact cognition, had existing diagnoses of diabetes, hypertension, alcohol abuse, and a history of stroke. Despite being on an anti-psychotic medication, the PASRR did not document any mental health conditions. Neuropsychiatry notes revealed diagnoses of anxiety and Bipolar depression, with the resident on an anti-psychotic and a new antidepressant. The facility's records lacked a new PASRR submission, and the Social Services Director was unaware of the new diagnosis. The Administrator noted the absence of a PASRR policy, relying on federal regulations.
A facility failed to follow up on abnormal blood sugar levels for a diabetic resident. The MAR required notifying the MD for levels outside specified parameters, but on two occasions, the resident's blood sugar exceeded the threshold without proper follow-up. The nurse was unable to contact the MD on the first occasion and placed the notification in the fax folder, while the second occasion lacked documentation. Facility policy required reporting abnormal levels to the physician and following active orders.
A facility failed to respect resident dignity and rights when an LPN reprimanded two residents for expressing concern about another resident's hospitalization. One resident, with intact cognition and multiple diagnoses, felt degraded by the LPN's actions. The Director of Nursing later stated that residents are not bound by HIPAA and saw no issue with the conversation.
A resident with dementia fell from her wheelchair, resulting in a forehead bruise. The fall was witnessed by an RN, but neurological checks were not initiated immediately, and the family was not promptly informed. The resident was later found to have a hematoma, prompting further assessment and hospital transfer. There was a lack of communication and documentation among staff regarding the incident.
The facility failed to treat residents with dignity, as several were left in the dining room for extended periods after meals. A resident with ALS reported waiting up to three hours for assistance, while another with Parkinson's disease felt alone and forgotten due to long waits. A CNA confirmed that residents often waited a long time for help back to their rooms, indicating a systemic issue in providing timely assistance.
A resident with ALS and anxiety disorder did not receive his prescribed diazepam due to the facility running out of the medication. The facility's process required staff to reorder medications when low, but this was not done. The pharmacist noted the lack of a reorder and a missing physician's signature on a new order, causing further delays. The DON acknowledged the oversight in ordering and issues with hospice orders.
The facility failed to provide a clean and homelike environment, with issues including urine spills, dried fecal matter, and improper handling of urinals. Additionally, meal trays were not removed in the dining room, detracting from the homelike atmosphere.
The facility failed to maintain dignity for two residents by not providing timely grooming care. A female resident was observed with lengthy chin hairs, and a male resident had multiple days of facial hair growth despite preferring to be clean-shaven.
A resident with COPD and other respiratory conditions was observed using oxygen therapy without a current physician order. The last order was discontinued, and the Care Plan team accidentally deleted the oxygen therapy order, leading to a deficiency in providing appropriate respiratory care.
The facility failed to store food according to professional standards, with several items found unsealed, undated, and unlabeled, including moldy bread. The Dietary Manager acknowledged the oversight, which violated the facility's Food Storage policy.
Incomplete and Outdated Nurse Staff Posting
Penalty
Summary
The facility failed to keep the daily nurse staff posting current and failed to post the number of hours nursing staff worked for multiple days during the survey. Surveyors observed that on 1/11/26 at 11:23 AM the Nurse Staff Posting displayed was dated 1/10/26 and did not include the number of hours staff worked. On 1/12/26 at 2:03 PM the Nurse Staff Posting still lacked the number of hours staff would work, and on 1/13/26 at 12:51 PM the posting again lacked the number of hours staff would work. On 1/14/26 at 9:14 AM surveyors observed the Nurse Staff Posting dated 1/13/26 still posted and it also lacked the number of hours staff worked. The facility reported a census of 71 residents. Later on 1/14/26 at 10:04 PM, the Administrator stated the night shift nurse completed the Nurse Staff Posting, explained it should be current every day, and acknowledged the staff did not complete the nurse hours worked section on 1/12/26 and 1/13/26; she also stated there was no completed posting for 1/11/26 and 1/14/26.
Pureed Food Portions Not Measured or Properly Explained by Cooks
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services when 2 of 2 cooks could not explain the puree process and procedure. The facility had a census of 71 residents. During review of the Week 4 menu, the meal plan directed staff to serve 3 oz. of roast beef and 4 oz. of roasted butternut squash. During observation of the puree process for 4 residents, Staff E, a cook, pureed the roast beef and squash but did not measure the food after blending to ensure equal portions were provided. Staff E stated she did not use a measuring cup after pureeing and instead used the scoop size directed on the menu, and she reported she had never been trained to measure pureed food. Staff D, another cook who oversaw the kitchen while the Certified Dietary Manager was off, also stated that pureed food was not measured after blending and that the staff used the scoop size directed on the menu. Staff D and Staff E both stated they did not use a guide to instruct them on what serving size to use. After meal service, Staff D stated that one of the four residents who received a pureed diet was not at the facility, which explained why extra puree remained. Observation of the roast beef and butternut squash showed about one serving remaining. The Administrator, DON, and Infection Preventionist later stated that Staff D and Staff E had training on the puree process, but they did not know why the food was not measured during the meal observation. The facility’s Pureed Food Preparation policy stated that staff should serve with an appropriate scoop number or divide the food equally to provide equal portions, and that all pureed food must be used so the correct nutrient density is delivered to each resident.
Failure to Follow Menu Portion Instructions
Penalty
Summary
The facility failed to follow the menu instructions for portion sizes during meal service. The Week 4 menu directed staff to serve mashed potatoes with a #8 scoop and roast beef with a 3-ounce scoop, but the cook used a green scoop she believed was a #8 scoop that was actually a #6 scoop, and she used it for all residents served mashed potatoes. She also used a 6-ounce scoop for roast beef instead of the 3-ounce portion listed on the menu. An observation of the dining room showed 8 of 13 resident plates had no mashed potatoes left, indicating they had eaten them all, and the facility reported a census of 71 residents. The Administrator, DON, and Infection Preventionist stated they expected staff to follow the menus. The facility’s Menu Planning and Requirement policy stated menus are planned to provide nourishing, palatable, attractive meals that meet residents’ nutritional needs.
Food Trays Served at Inadequate Temperatures
Penalty
Summary
Food and drink were not consistently served at a safe and appetizing temperature for room trays. Based on observation, policy review, and staff and resident interviews, the facility failed to serve room trays at or above 135 degrees Fahrenheit for 3 of 3 test trays. On 1/13/26, the steam table held hot foods at acceptable temperatures before service, including mashed potatoes at 207 F, roast beef at 195.6 F, and squash at 177 F, but temperatures dropped below 135 F by the time the test trays were observed leaving the kitchen and during cart checks. The PARS cart showed mashed potatoes at 134.7 F and squash at 126.3 F, the Front and Center cart showed roast beef at 133.1 F and squash at 127.4 F, and the Back cart showed squash at 133 F. Resident interviews also reflected concerns that hot food was not always served hot enough. Resident #54, with a BIMS of 15, said she ate in her room and the food is not always the hottest. Resident #34, with a BIMS of 13, said sometimes the food is not hot enough. Resident #78, with a BIMS of 15, reported the hot food is not always hot enough. Resident #63, with a BIMS of 11, stated the food is not good and said she had cold tomato soup the other day, adding that staff will reheat it if asked. During room tray observation, dietary staff preheated hot plates before using them and left them sitting on the counter. The Administrator, DON, and Infection Preventionist stated they expected dietary staff to heat the hot plates as they use them and not in advance. The facility policy stated hot foods on room trays at the point of service are preferred to be at 120 F or greater to promote palatability.
Failure to Implement and Document Restorative Programs
Penalty
Summary
The facility failed to implement and maintain a restorative program for 2 residents reviewed. Resident #17 had severely impaired cognition, required maximal assistance to roll in bed, and was dependent for bed-to-chair transfers. Her MDS listed multiple diagnoses including encephalopathy, leukemia, hypertension, chronic kidney disease, hyperlipidemia, dementia, convulsions, anxiety, depression, irregular heartbeat, and reduced mobility. OT discharge documentation stated the prognosis to maintain current level of function was excellent with consistent staff support and included a restorative program for gentle PROM to both upper extremities 1 to 2 times daily to maintain comfort and joint mobility, but the summary did not identify who would provide the program. Resident #17’s care plan and Kardex/tasks did not include the OT-recommended restorative program. The resident’s representative stated the staff did not do the restorative program consistently. A CNA stated Resident #17 did not have a restorative program, while another CNA explained that if exercises were needed they would be in the EHR. The DON and Administrator stated that when therapy discharges a resident with a program, the Director of Rehab notifies them, the program is documented in the EHR, and they expected therapy recommendations to be started and done correctly. The Director of Rehab later described Resident #17’s restorative program as more for the husband to do. Resident #26 had a BIMS score of 15 and required supervision or touching assistance for toileting, transfers, walking, and lower body dressing. Her care plan included restorative AROM to upper and lower extremities or group exercise, and the goal was to improve or maintain walking ability of 200 feet with a front wheeled walker and one assist. PT recommended that she walk with nursing staff 4 times daily in the halls and be encouraged to do active exercises. Review of restorative documentation showed walking was completed only 1 time out of 13 days in January 2026 and 2 times out of 31 days in December 2025, with no refusal documented. The resident stated she wanted to walk more and participate in a restorative program. The Administrator said staff should complete the walking restoratives, and the DON acknowledged the staff had not documented Resident #26’s walking restoratives as expected.
Improper Insulin Pen Priming
Penalty
Summary
The facility failed to properly prime an insulin pen before administering Humalog to a resident with diabetes. During observation, an LPN attempted to prime the pen by turning the dial to 2 units and pressing the plunger before the needle was attached. After placing the needle on the pen, she then set the pen to 10 units and stated she was ready to administer the insulin. The resident had a BIMS score of 14, indicating intact cognition, and the clinical record showed orders for Humalog 4 units subcutaneously three times daily and an additional sliding-scale Humalog order for blood sugar of 251-300. When questioned, the LPN stated she thought she was prepping the pen to get the air out and did not know the pen needed to have the needle in place to clear the air. The DON stated she expected the nurse to place the needle on the insulin pen prior to priming and said staff education had already begun. The facility policy instructed staff to prime insulin per manufacturer guidelines, and the manufacturer’s instructions required the needle to be attached before dialing a test dose and pressing the injection button to confirm insulin flow.
Resident Left Unattended and Deprived of Care Following Staff Argument
Penalty
Summary
A resident with diagnoses including congestive heart failure, diabetes mellitus, morbid obesity, anxiety, and depression, who was cognitively intact and dependent on two or more staff for transfers and personal care, was deprived of care and left in a vulnerable state. On the evening in question, the resident requested assistance with her usual nighttime routine, which involved transfer from a recliner to bed, cleaning, and changing into clean clothes. Two CNAs responded, but an argument ensued regarding the resident's care preferences. The resident asked one CNA not to return, after which both CNAs left her on the bed, soiled with urine, without a blanket, and with her call light and personal items out of reach. The resident's repeated calls for help went unanswered for approximately an hour, during which she became increasingly distressed, cold, and anxious. Multiple staff interviews confirmed that the resident was left unattended and that her requests for assistance were ignored. The resident was found later by another CNA, who provided care and comfort. The resident reported ongoing fear and anxiety, especially as the staff involved continued to work in the facility and pass by her room. The incident was not documented in the progress notes for that day, and the resident's anxiety and requests for medication increased following the event. Staff interviews revealed a lack of training, confusion about protocols, and failure to respond appropriately to the resident's distress and allegations of abuse. Leadership in the facility, including the DON and charge nurse, failed to address the resident's immediate concerns or investigate the incident in a timely manner. The DON was made aware of the situation but did not intervene or follow up with the resident, and staff were directed to ignore the resident's calls for help. The facility's abuse prevention policy required immediate reporting and investigation of abuse allegations, but these procedures were not followed. The resident's care plan, which included specific instructions for communication and reassurance, was not adhered to during the incident.
Staff Member Exploits Resident's Credit Card for Personal Use
Penalty
Summary
A staff member at the facility exploited a resident financially by using the resident's credit card to pay a personal cell phone bill. The resident, who was dependent on staff for mobility and required full assistance, frequently gave staff her credit or debit card to purchase soda from the vending machine, as she was unable to access it herself. After the resident was discharged, her bank notified her of an overdraft charge related to a cellular phone bill, which she did not authorize. A police investigation determined that the account holder for the cellular phone bill was a staff member who had worked at the facility during the resident's stay. Multiple staff interviews confirmed that it was common practice for residents, especially those who were bedbound, to give staff money or cards to purchase items from vending machines. Several staff members admitted to accepting residents' cards or cash to buy soda, while others stated they refused to take cards but acknowledged the practice was widespread. The facility's policies and employee handbook prohibited financial exploitation and the use of personal cell phones during work, but staff reported that cell phones were often present at the nurses' station and sometimes carried in pockets. The policy lacked specific direction regarding the handling of residents' credit, debit, or cash app cards. The resident involved had significant medical needs, including paraplegia, stage four pressure ulcers, osteomyelitis, diabetes, anxiety, and depression, and was cognitively intact. The incident was discovered after the resident's discharge, when she noticed the unauthorized charge and contacted the police. Staff schedules and timecards confirmed that the implicated staff member worked in the area where the resident lived during the relevant period. The facility did not identify other residents who reported misuse of their cards, but staff acknowledged that the practice of taking residents' cards for vending machine purchases had been ongoing.
Facility Fails to Maintain Comfortable Shower Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable temperature in the shower room, as required by regulations, which should be between 71 to 81 degrees. This deficiency was identified through observations and interviews with residents and staff. Resident #38, who has intact cognition and requires supervision for bathing, reported that the shower room was cold, despite the water being warm. This issue had been raised in resident council meetings since November, but no effective action was taken. Maintenance confirmed the shower room temperature was 66.7 degrees and acknowledged ongoing issues with the heating system, affecting multiple areas including the PARS lounge and physical therapy room. Although heat lamps were supposed to be used as a temporary measure, Resident #38 reported that staff did not utilize them. Similarly, Resident #65, who also has intact cognition and requires substantial assistance with bathing, reported experiencing a cold shower room during her shower. She confirmed that staff did not use the heat lamp, which was intended to mitigate the cold temperature. The facility's administrator was aware of the issue but noted a delay in addressing the concern due to a lapse in communication from the activities department. The concern form regarding the cold shower rooms was not assigned until late December, despite being received earlier, indicating a breakdown in the facility's internal communication and response processes.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document and submit the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For Resident #36, the MDS dated 11/16/23 did not include documentation of the resident being on a diuretic, despite the Medication Administration Record (MAR) showing that Lasix was administered during the 7-day look-back period. The Director of Nursing (DON) confirmed that the MDS was incorrect and should have included the diuretic medication. The facility lacked a specific policy for MDS, relying instead on the Resident Assessment Instrument (RAI) manual, which requires documentation of high-risk medications like diuretics during the look-back period. For Resident #65, the MDS dated 12/19/24 incorrectly documented the resident as receiving an anti-psychotic medication on a routine basis. However, a review of the MAR for November 2024, December 2024, and January 2025 showed no record of such medication being administered. The DON acknowledged the error, stating that the MDS was coded incorrectly and the resident was not on an anti-psychotic medication. These inaccuracies in the MDS assessments highlight a failure in the facility's documentation process, impacting the accuracy of resident care records.
Failure to Submit PASRR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was submitted for a resident who had new diagnoses documented in her medical record. The resident, identified with a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition, had diagnoses of diabetes, hypertension, alcohol abuse, and a history of stroke. The resident's PASRR dated 10/09/24 documented no mental health conditions and did not require a level II to be completed, despite the resident being on an anti-psychotic medication without a given diagnosis. Provider Intake Notes from Neuropsychiatry indicated the resident had a diagnosis of anxiety and Bipolar depression, for which she was on an anti-psychotic medication and started on a new antidepressant. The facility's Electronic Health Records lacked a new PASRR submission reflecting these new diagnoses and medications. The Social Services Director was unaware of the new diagnosis, and the Administrator reported the facility does not have a PASRR policy, instead following federal regulations.
Failure to Follow Up on Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to follow up on blood sugar levels that were outside of physician-defined parameters for a diabetic resident. The Medication Administration Record (MAR) for the resident included an order for fingerstick blood sugar checks four times a day, with instructions to notify the Medical Doctor (MD) for levels less than 70 or greater than 300. On two occasions, the resident's blood sugar levels were recorded as 364 and 375, both exceeding the threshold. On the first occasion, the nurse attempted to contact the MD but was unsuccessful and placed the notification in the fax folder. There was no documentation of follow-up for the second occasion. The facility's policy required staff to report any abnormal blood sugar levels to the physician and to follow active orders as written. The Director of Nursing stated that she expected the MD to be notified of such levels and to be informed if there were issues reaching the MD, with a progress note documenting the abnormal level, MD notification, and any new orders received.
Failure to Respect Resident Dignity and Rights
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by the interactions involving two residents and a staff member. Resident #65, who has intact cognition and diagnoses including congestive heart failure, hypertension, diabetes, and anxiety, reported feeling degraded by an LPN, Staff A. The incident occurred when Resident #65 and another resident, Resident #8, expressed concern for Resident #11, who was in the hospital. Staff A reprimanded them for discussing another resident, which made Resident #65 feel bad, despite Resident #11 not being upset by the conversation. The Director of Nursing later stated that residents are encouraged not to discuss others, but they are not bound by HIPAA, and there was no concern with the conversation that took place. Resident #8, who frequently visits other residents as they are her only family, corroborated the account, stating that she and Resident #65 expressed genuine concern for Resident #11's well-being. Staff A's intervention, telling them they couldn't talk about other residents, left Resident #8 feeling upset. Staff A admitted she did not directly hear the conversation but was informed by another staff member, whose identity she could not recall. The Director of Nursing did not see any issue with the conversation and felt there was no need to address it with Resident #65.
Failure to Conduct Timely Assessment and Notification After Resident Fall
Penalty
Summary
The facility failed to complete a full assessment, including neurological assessments, and did not notify the family and provider in a timely manner for a resident who fell out of her wheelchair. The resident, who had a history of non-Alzheimer's dementia, unspecified dementia with behavioral disturbances, and repeated falls, was dependent on staff for transfers. On the evening of the incident, the resident fell and hit her forehead, resulting in a 5 cm bruise. Despite the fall being witnessed by a registered nurse, neurological checks were not initiated immediately, and the family was not promptly informed. The incident occurred when the resident attempted to retrieve a baby doll that had fallen from her wheelchair. Staff A, who witnessed the fall, did not start neurological checks or document the incident immediately, citing being occupied with medication pass and believing the resident was acting fine. Staff A also failed to notify the on-call nurse about the fall, which was against the facility's policy. The resident was later found to have a hematoma on her forehead, and her condition prompted further assessment and eventual transfer to the hospital. There was a lack of communication and documentation among the staff regarding the fall. Staff C, who came on duty later, was not informed about the fall until days later and noticed the hematoma during her assessment. The resident's daughter was not informed of the fall until much later, and there was confusion among staff about the timing and details of the incident. The facility's policy required immediate assessment and notification following a fall, which was not adhered to in this case.
Failure to Uphold Resident Dignity in Dining Room
Penalty
Summary
The facility failed to treat four residents with dignity, as observed by surveyors. Residents were left in the dining room for extended periods after meals, with some waiting up to three hours for assistance to return to their rooms. Resident #2, with moderately impaired cognition and dependent on staff for mobility due to ALS, reported waiting long periods after meals. Resident #6, with intact cognition and Parkinson's disease, also experienced long waits in the dining room after meals, feeling alone and forgotten. Resident #7, who could self-propel in a wheelchair, noted that other residents who couldn't self-propel had to wait a long time for assistance. Resident #8, with intact cognition and hemiplegia from a stroke, was observed asleep at the dining table after breakfast, indicating prolonged waiting times. Staff interviews confirmed the issue, with a CNA acknowledging that residents who couldn't return to their rooms independently often waited a long time due to staff being busy. The facility's policy on Resident Rights, Dignity, and Respect emphasizes the right to considerate and respectful care, yet the observations and interviews indicate a failure to uphold these standards. The facility reported a census of 84 residents, highlighting the potential for systemic issues in providing timely assistance to residents dependent on staff for mobility.
Failure to Administer Anxiety Medication
Penalty
Summary
The facility failed to ensure the administration of anxiety medications for a resident with moderately impaired cognition, diagnosed with ALS, anxiety disorder, and depression. The resident reported not receiving his anxiety medication, diazepam, because the facility ran out. The Medication Administration Record showed multiple doses coded as unavailable, indicating the medication was not administered. The facility's process required nursing staff to notify the pharmacy when medication was low, but there was no record of the diazepam being reordered before it was depleted. The pharmacist confirmed that no reorder was received for the resident's diazepam, and the new order to increase the dose lacked a physician's signature. This led to delays as the pharmacy had to contact the hospice-affiliated physician. The Director of Nursing acknowledged the oversight in ordering the medication timely and the issue with hospice orders lacking physician signatures, which contributed to the resident missing several doses of his medication.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable, clean, and homelike environment for its residents. Resident #21 had difficulty managing his urinal, frequently spilling it, which resulted in a strong urine odor in his room and the hallway outside. Despite the resident's complaints and visible evidence of urine spills, the issue persisted over several days. Staff interviews confirmed that the facility was aware of the problem but had not yet found a suitable solution for the resident's urinal management. Additionally, housekeeping staff acknowledged the presence of urine odors and spills but did not adequately address the issue in a timely manner. Resident #51's room had dried fecal matter on the floor that remained for over 24 hours. Observations over multiple days showed that the fecal matter was not cleaned, despite the facility's policy of daily room cleaning. Interviews with housekeeping staff and the facility administrator confirmed that the fecal matter was present and had not been addressed promptly. This indicates a failure in the facility's cleaning protocols and communication between staff members. Resident #60's room had a hand urinal that was not emptied and was placed on the floor and later on a heating unit, both of which had visible urine stains. The resident expressed concerns about the staff not emptying the urinal in a timely manner. Staff interviews revealed that the facility's policy required urinals to be emptied every two hours and surfaces to be sanitized, but these procedures were not followed. Additionally, during meal times, residents in the dining room received their meals on trays, which were not removed and placed on the tables, further detracting from a homelike environment.
Failure to Maintain Resident Dignity Through Proper Grooming
Penalty
Summary
The facility failed to maintain dignity for two residents by not providing appropriate grooming care. Resident #6, a female, was observed on multiple occasions with lengthy chin hairs, which were only removed after several days. Resident #65, a male, was seen with multiple days of facial hair growth despite expressing a preference to be clean-shaven. These observations were made over several days, indicating a lack of timely grooming assistance for these residents.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for the use of oxygen therapy for a resident. Resident #19, who had diagnoses of asthma, chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome, and chronic bronchitis, was observed wearing oxygen set at 2 Liters (L) without a current physician order. The last documented order for oxygen was discontinued on 4/15/24, and the resident's Minimum Data Set (MDS) and clinical records lacked documentation of oxygen use between 12/26/23 and 5/17/24. Interviews with the resident and staff revealed that the resident had been using oxygen therapy and a CPAP machine since admission. However, the Care Plan team had accidentally deleted the oxygen therapy order. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the error during an interview. The facility's failure to maintain a current physician order for oxygen therapy for Resident #19 constitutes a deficiency in providing appropriate respiratory care.
Food Storage Deficiency
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. Several food items in the kitchen's storage and freezers were found opened, unsealed, undated, and unlabeled, including a frozen bag of strawberries, frozen premade omelets, frozen cookie dough, a package of hot dog buns, and a package of bread with visible mold. During an interview, the Dietary Manager acknowledged the failure to seal, label, and date the items when opened, as required by the facility's Food Storage policy dated 2020. This policy mandates that all food items be labeled with the name of the food and the date received, and once opened, packages should be re-dated with the date opened and used according to safe food storage guidelines or the manufacturer's expiration date.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Retirement | 0.5 mi | ★★★★★ | 4 | 0 |
| Ravenwood Specialty Care | 0.9 mi | ★★★★★ | 17 | 0 |
| Harmony House Health Care Center | 3.5 mi | ★★★★★ | 14 | 0 |
| Northcrest Specialty Care | 3.7 mi | ★★★★★ | 7 | 0 |
| Pinnacle Specialty Care | 4.1 mi | ★★★★★ | 6 | 0 |
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