Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pillar Of Cedar Valley during CMS and state inspections, most recent first.
A resident with a history of mental illness repeatedly engaged in physical and verbal aggression toward other residents and staff, resulting in multiple altercations. Despite existing care plans and interventions, the facility did not consistently update documentation or adjust interventions after incidents, and staff interviews confirmed ongoing aggressive behaviors. The facility's failure to prevent and properly document these incidents led to emotional and physical distress among affected residents.
The facility did not report several incidents of physical aggression by a resident with mental health conditions toward other residents and staff to the state agency within the required timeframe. Although staff were trained and aware of reporting protocols, only one of multiple incidents was reported as required, and the care plan lacked clear direction for reporting and preventing further altercations.
A resident with a history of aggressive behaviors was involved in multiple altercations with other residents, but the facility did not thoroughly investigate the incidents or update care plans to include interventions to prevent recurrence. Required interviews and documentation were incomplete, and the facility's policy for investigating and reporting abuse was not consistently followed.
Late Transmission of MDS Assessments: The facility failed to transmit required MDS assessments on time for two residents. One Quarterly MDS was not submitted because the EHR indicated not to send it, and the MDS Coordinator did not know why it was coded that way. A Death MDS was also transmitted late after the resident died in the facility, and the MDS Coordinator stated she did not know the required timeframe.
A resident’s wheelchair care plan was not followed. The wheelchair was observed without front anti-tippers, a pressure-relieving cushion, or Dycem, despite care plan interventions for fall risk and pressure ulcer prevention. An RN said she did not know what the resident needed, a CNA said she had never seen the cushion or Dycem, and the DON stated staff were expected to follow the care plan interventions.
A resident with stroke-related hemiplegia, limited ROM, and dependence for ADLs had an OT and care plan order for a soft carrot splint to the left hand to prevent contracture. Surveyors observed the resident multiple times with the left wrist and fingers flexed inward and no splint in place, and staff did not consistently offer or apply the splint. Interviews and record review showed inconsistent documentation, reliance on ETAR sign-offs without visual verification, and no documentation that the resident recently refused the splint.
Hazardous tools and materials were left unattended in an open housekeeping closet on the 3rd floor west hallway, including a box cutter, pipe wrench, Fire Fighter Eliminator 1330, and an impact drill, while residents passed nearby without staff present. The same area was later observed again with the closet open and the cart of items unattended. In addition, the oxygen room key was left hanging in the door with a metal piece, chain links, and a wooden stick attached while staff and residents walked by. Interviews with maintenance, the ADON, and the Administrator confirmed the items should not have been left out.
A resident with COPD and respiratory failure had a physician order for oxygen at 3 LPM continuous after a hospitalization for acute on chronic respiratory failure with hypoxia and hypercapnia. Staff repeatedly provided oxygen at 2 LPM instead, and one observed transfer left the resident without oxygen for 13 minutes. ETARs did not document oxygen as continuous, and staff interviews showed confusion about the correct order, with an ADON confirming the current order had not been entered into the EHR.
Expired insulin was administered to two residents with diabetes after an RN failed to verify the vial expiration dates before giving scheduled doses. One resident received Humalog and the other received Novolog from vials that were observed to be past the allowed open period, and the DON stated nurses were expected to check expiration dates before administration.
A resident’s bed frame had plastic protective edging loose and sticking up at the foot of the bed, and the condition was observed repeatedly over several days. Staff described a repair-request process using email or verbal notification to maintenance, and the facility policy stated that routine inspections are completed to ensure equipment and furnishings are free from safety hazards.
The facility failed to conduct a comprehensive assessment for Legionella growth in its water system and lacked a water management plan. Additionally, a resident with a PEG tube did not receive proper infection control measures, as an LPN handled the gastrostomy tube without gloves or PPE, despite Enhanced Barrier Precautions being in place. Staff interviews revealed a lack of communication and adherence to infection control policies.
The facility did not post notice of the availability of the most recent survey reports, nor were these reports readily accessible to residents, family members, and legal representatives. Observations showed a survey book placed on a rolling rack inside a community room, with no public display indicating its presence. Staff interviews revealed a lack of awareness about the requirement to post survey reports and their location.
A facility failed to maintain resident dignity and privacy, as observed in three cases. A resident with schizophrenia lacked a privacy curtain in his shared room, compromising his privacy. Another resident with anxiety disorder experienced a delay in assistance after activating her call light, despite being visibly uncomfortable. Additionally, a resident with schizophrenia and dysphagia received tube feeding in a common area against his wishes, affecting his dignity. These incidents highlight deficiencies in respecting resident rights and ensuring timely care.
A resident with COPD and respiratory failure was not consistently provided with oxygen therapy as ordered, receiving varying flow rates and at times no oxygen. Staff interviews revealed inconsistencies in following the physician's order for continuous oxygen at 2 liters per minute, and the facility lacked a policy on respiratory care.
A resident with a PEG tube for dysphagia was observed receiving enteral feeding in a dining room without proper infection control measures. An LPN administered the feeding without gloves or additional PPE, despite facility policy and an Enhanced Barrier Precautions sign indicating the need for such precautions. The resident required staff assistance for daily tasks and had a care plan to prevent infection at the gastrostomy tube site.
A resident with schizophrenia was found to have inadequate room space, measuring only 55 square feet instead of the required 80 square feet for shared rooms. The facility lacked a policy on room square footage, and the issue arose after adding bathrooms to rooms, reducing available space.
The facility failed to provide residents with direct access to an exit corridor from their designated room space, affecting four residents in a shared room. Two residents had to pass through others' spaces to exit, confirmed by the ADON and Maintenance Supervisor. The room's configuration changed after adding a bathroom, reducing space per resident. No policy on direct exit access was provided.
A facility failed to provide a privacy curtain between two residents, compromising the privacy of a resident with schizophrenia who was unable to make decisions about his own privacy. Staff acknowledged the absence of the curtain, which might have been removed for laundering or torn down by the other resident. The facility lacked a policy on privacy curtains.
A resident with intact cognition and multiple diagnoses was found without a call light in her room after moving to a new room. Observations and interviews confirmed the absence of the call light, and staff were unaware of the reason for its absence. Facility policy required call lights for residents changing rooms.
A resident with moderately impaired cognition and a history of falls reported an unwitnessed fall but did not receive a fall assessment or neurological checks as required by facility policy. Despite the resident's report and visible minor injury, staff failed to document the incident or conduct an investigation, contrary to the facility's fall prevention policy.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's Disease, was left unattended in the shower room, leading to a fall. The care plan required staff assistance during bathing, but the resident was found on the floor without supervision. The DON acknowledged that the resident should not have been left alone.
Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents involving physical and verbal aggression. One resident with a history of mental illness, including depression, anxiety, PTSD, and bipolar disorder, exhibited daily physical and verbal aggressive behaviors toward both staff and peers. Despite having care plans and interventions in place, such as behavior analysis, de-escalation techniques, and staff providing care in pairs, the resident continued to engage in aggressive acts, including hitting, yelling, and using inappropriate language toward other residents. Documentation revealed repeated altercations where this resident struck other residents in common areas, hallways, and during meal times, sometimes without provocation and sometimes following verbal exchanges. The facility's records showed that staff intervened by separating residents and redirecting the aggressive resident to her room, but these interventions did not prevent further incidents. There were also lapses in documentation, such as missing behavior charting and incident investigation summaries for some altercations. The care plans and individual program plans for the aggressive resident were not consistently updated following incidents, and there was a lack of timely evaluation and adjustment of interventions after repeated episodes of aggression. Staff interviews confirmed awareness of the resident's behaviors and the occurrence of multiple incidents involving physical aggression toward other residents and staff. Other residents involved in these incidents had diagnoses including anxiety, schizophrenia, and bipolar disorder, and some reported emotional distress following altercations. While some residents denied being afraid, they expressed concern about future incidents. The facility's policies required protection from abuse and outlined procedures for reporting and managing resident-to-resident altercations, but the repeated nature of the incidents and incomplete documentation indicated a failure to fully implement these protections and prevent abuse.
Failure to Timely Report Alleged Physical Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of physical abuse within the required timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for three out of four reviewed incidents. Clinical record review, facility records, policy review, and interviews revealed that incidents involving aggressive and physically abusive behaviors by a resident toward other residents and staff were not reported as mandated. The incidents occurred on multiple dates and included physical altercations such as hitting, striking, and other aggressive behaviors. One resident, with a history of mental illness including depression, anxiety, PTSD, and bipolar disorder, exhibited frequent physical and verbal aggression toward staff and peers. The resident's care plan identified these behaviors and included interventions for staff to manage and document such incidents. Despite these interventions, the care plan lacked specific direction for reporting resident-to-resident altercations and for implementing interventions to prevent further incidents after they occurred. Documentation showed that staff were aware of the reporting requirements and had received training on dependent adult abuse. However, the facility's self-reported incident list showed that only one of the four incidents was reported to DIAL, with the remaining three not reported as required. Interviews with staff and facility leadership confirmed that these incidents should have been reported, and facility policy required prompt reporting of such events to state authorities.
Failure to Investigate and Intervene After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions following multiple resident-to-resident abuse incidents involving a resident with a history of aggressive behaviors. Clinical record review showed that this resident exhibited daily physical and verbal aggression, as well as daily rejection of care, and had diagnoses including depression, anxiety, PTSD, and bipolar disorder. Despite documented altercations with other residents on several occasions, the facility did not conduct comprehensive resident and staff interviews for the dates of the incidents to determine the extent of the allegations or whether other residents were affected. Additionally, the care plan lacked specific direction for staff to report and address resident-to-resident altercations after these incidents occurred. Facility documentation revealed that while some incidents were recorded and immediate actions such as separating residents and monitoring were taken, there was a lack of a complete investigation for at least one incident, and the care plan was not updated to include interventions to prevent further occurrences. The facility's policy required thorough investigation and reporting of all alleged violations, but this was not consistently followed, as evidenced by missing investigation summaries and incomplete follow-up after the incidents.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit MDS assessments to the State within the required timeframe for 2 of 3 residents reviewed, including Resident #29 and Resident #139. Resident #29’s Quarterly MDS had a completed date documented in the record, but there was no transmitted status. The MDS Coordinator stated the EHR program directed her not to submit the MDS, so she did not submit the assessment, and she did not know why it was coded that way. The Administrator reported the facility did not have a policy and used the RAI Manual, which directed that the Quarterly MDS be transmitted no later than 14 days after completion. Resident #139’s Death MDS was completed after the resident died in the facility, but the record showed it was not transmitted until later. The MDS Coordinator stated she did not know the Death MDS needed to be transmitted within a certain timeframe. The RAI Manual directed that the Death MDS be transmitted no later than 14 days after the resident’s date of death.
Failure to Follow Wheelchair Care Plan Interventions
Penalty
Summary
The facility failed to follow Resident 5’s Care Plan for wheelchair safety and pressure relief needs. On 9/9/25, Resident 5’s wheelchair was observed without front anti-tippers, a pressure relieving cushion, or non-slip material (Dycem). The Care Plan dated 9/25/19 identified a fall risk and directed front anti-tippers, and a 9/15/22 intervention directed Dycem for the wheelchair. The Care Plan also identified a potential for pressure ulcers and directed placement of a pressure reduction cushion in the wheelchair on 9/3/20. On 9/10/25, Resident 5 was again observed sitting in a wheelchair in the hallway without the cushion, anti-tippers, or Dycem. Staff A, RN, stated she did not know what Resident 5 needed for the wheelchair, and Staff K, CNA, reported she had never seen a cushion or Dycem for the wheelchair. The DON stated she expected staff to follow the Care Plan interventions, and the facility policy directed staff to review and update the Care Plan at least quarterly.
Failure to Apply Ordered Left-Hand Splint
Penalty
Summary
The facility failed to provide a palm splint to Resident #15’s left hand to reduce or prevent contracture. Resident #15’s MDS showed intact cognition with a BIMS score of 13/15, a functional limitation in range of motion to one upper extremity, and dependence on staff for multiple ADLs. His diagnoses included non-traumatic brain dysfunction, stroke, and hemiplegia/hemiparesis. OT’s home therapy program directed staff to apply a soft carrot splint to the left hand with the larger end toward the 5th digit in the morning and leave it on as tolerated during the day, and the care plan also directed staff to apply the carrot splint to prevent contracture and pressure to the palm. During multiple observations, Resident #15 was seen sitting in a wheelchair with his left wrist flexed inward and the fore, middle, ring, and pinky fingers curled inward toward the palm, and no carrot splint was present in the left hand. On one occasion, after he was transferred back to bed and repositioned, staff exited the room without offering to place the palm carrot in his left hand. Resident #15 stated he would wear the palm carrot if staff offered it, but that it did not happen often. Staff later reported that he should be asked every day if he wanted to wear the carrot splint, and if he refused, the refusal should be documented and the nurse notified. Staff interviews and record review showed inconsistent implementation and documentation of the splint order. One CNA reported the resident had a padded glove at night but nothing used in the left hand during the daytime, and another said staff sometimes offered a rolled washcloth instead. An LPN stated he signed the ETAR indicating the splint was placed, but he did not visually verify it and relied on the resident care sheet. The resident care sheet reviewed by surveyors lacked direction that the carrot splint needed to be placed in the left hand, and the Administrator stated there was no documentation supporting that Resident #15 recently refused the splint.
Unattended hazardous tools and oxygen room key left accessible to residents
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and adequately supervised when hazardous tools and materials were left unattended in resident-accessible areas. On 9/8/25 at 1:38 PM, the 3rd floor west side hallway housekeeping closet was observed open and unattended with a wheeled cart blocking the doorway. The cart contained a box cutter, pipe wrench, Fire Fighter Eliminator 1330 non-toxic antifreeze solution for fire sprinklers, and an impact drill, while three residents passed the area with no staff present. At 1:42 PM, contracted sprinkler company staff arrived, worked with the cart items, shut the housekeeping closet, and left shortly after with the cart of tools and antifreeze. On 9/9/25 at 8:54 AM, the same hallway housekeeping closet was again observed open and unattended with the wheeled cart and the same hazardous items present. A resident was continuously walking around the area and several residents were in nearby rooms. At 9:07 AM, contracted sprinkler company staff came to the housekeeping door, began working with the Fire Fighter Eliminator, then took the cart and shut the door when finished. Also on 9/9/25 at 8:54 AM, the 3rd floor west side hallway oxygen room key was observed hanging in the keyhole with a metal piece, six heavy chain links, and a long wooden stick attached; several staff and residents walked by before a CNA removed the key at 9:44 AM. Staff interviews and policy review indicated maintenance expected the sprinkler company to keep hazardous items behind locked doors, the ADON stated the oxygen key should be returned to the nurses’ station and not left in the door, and the Administrator stated maintenance should be with the sprinkler company and the oxygen key should not be left out.
Failure to Follow Oxygen Order
Penalty
Summary
The facility failed to implement the current physician order for oxygen therapy for Resident #15, who had a history of COPD and respiratory failure and whose MDS documented shortness of breath with exertion, at rest, and while lying flat. The care plan directed staff to give oxygen as ordered and to check the flow rate routinely because the resident chose to change settings without consulting the nurse. After a hospitalization for acute on chronic respiratory failure with hypoxia and hypercapnia, the hospital summary listed an order for oxygen at 3 liters per minute continuous. Observations showed Resident #15 receiving oxygen at 2 liters per minute by nasal cannula on multiple occasions, including while seated in a wheelchair and while in bed. The oxygen concentrator was sometimes positioned out of the resident’s reach, and staff did not observe him attempting to change the setting during those observations. During one observed transfer, staff removed the nasal cannula and wheeled the resident to his room without oxygen, then assisted him to bed and did not reconnect the oxygen until 13 minutes later. The ETARs documented oxygen use at 3 liters per minute to keep saturations above 89%, but they did not document the oxygen as continuous per the physician order. Staff interviews showed multiple employees believed the resident was to receive 2 liters per minute, and the ADON stated the resident received 2 liters because he "blows himself out" and gives himself COPD exacerbations. The ADON later confirmed the current order was 3 liters continuous and acknowledged it had not been entered into the EHR. The DON stated staff were expected to follow the physician’s order.
Expired insulin administered to two residents
Penalty
Summary
The facility failed to ensure that expired insulin was not administered to two residents with diabetes who received insulin multiple times each day. Resident #401 had a diagnosis of diabetes mellitus, a BIMS score of 15/15, and orders for Humalog insulin twice daily and on a sliding scale. During observation, Staff A removed a vial of Humalog insulin, drew up 4 units, and administered it to Resident #401 without checking the expiration date. The vial was observed to have an open date and an expiration date, and Staff A stated she should have checked the expiration date before giving the insulin. Staff B stated insulin is good for 28 days after opening and expected nurses to check the expiration date before administration. Resident #9 also had diabetes mellitus, a BIMS score of 12/15, and orders for Novolog insulin twice daily and on a sliding scale. During observation, Resident #9's Novolog vial was found with an open date and an expiration date, and Staff A confirmed she gave the scheduled AM dose from that expired vial without verifying the expiration date. The DON stated the facility did not have an insulin policy, but expected nurses to check medication expiration dates before administration, and noted it was not the first time expired insulin had been found in the medication cart. The facility's medication administration policy required verification of the medication, dose, time, and method of administration, but did not include checking expiration dates.
Equipment Not Kept in Good Repair
Penalty
Summary
The facility failed to keep patient care equipment in good repair for Resident 37 when the bed frame had plastic protective edging loose and sticking up at the foot of the bed. This condition was observed on 9/8/25 at 11:20 AM, remained unchanged on 9/9/25 at 9:53 AM, and was still present on 9/10/25 at 7:15 AM. During interviews on 9/11/25, the Assistant Maintenance staff stated that staff could email or verbally call maintenance if something needed to be fixed and that residents could also let them know verbally. The Administrator stated that repair requests were handled by email to maintenance, and the emails were printed out to identify what needed repair. The facility policy titled Physical Environment - Maintenance Repair Request, revised 7/15/25, stated that inspections are completed on a routine basis to ensure equipment and furnishings are free from safety hazards.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to perform a comprehensive assessment to identify potential growth areas for Legionella and other opportunistic waterborne pathogens within its water system. Despite having a Legionella Policy, the Maintenance Supervisor admitted to not having a water mapping or management plan in place. The facility relied on the constant use of its water systems, such as showers and kitchens, to prevent stagnation, but did not conduct a formal assessment or develop a plan to monitor and prevent Legionella growth. The Administrator, who had experience with Legionella assessments, acknowledged the need for a water management plan, but no such plan was in place at the time of the survey. Additionally, the facility failed to implement proper infection control practices for a resident with a Percutaneous Enteral Gastrostomy (PEG) tube. The resident, who had a history of schizophrenia, dysphagia, and flaccid hemiplegia, required assistance with daily tasks and had an Enhanced Barrier Precautions sign posted on their door. However, an LPN was observed handling the resident's gastrostomy tube without wearing gloves or additional PPE, contrary to the facility's policy and the posted precautions. The LPN cleaned the g-tube port with an alcohol wipe and reattached the feeding tube in a communal dining area without following the required infection control measures. Interviews with facility staff revealed a lack of communication and understanding regarding the Enhanced Barrier Precautions and the necessary infection control practices. The Assistant Director of Nursing and the Director of Nursing both confirmed the expectation for staff to use appropriate PPE when handling gastrostomy tubes, but this was not adhered to in practice. The facility's failure to enforce its infection control policies and ensure staff compliance with Enhanced Barrier Precautions contributed to the deficiency in infection prevention and control.
Failure to Post and Make Survey Reports Accessible
Penalty
Summary
The facility failed to post notice of the availability of the most recent survey reports and did not have these reports readily accessible to residents, family members, and legal representatives. Observations on two consecutive days revealed that a three-ring binder labeled 'Department of Inspection and Appeals (DIA) Survey Book 1/6/22 to present' was placed flat on a rolling rack inside a set of double doors labeled as the community room. This area was a hallway leading to the facility conference room and the therapy room, and there was no public display or posting indicating that the facility survey results were available for review or where to find the survey book. Further observations showed that the binder remained in the same location, and no residents were seen accessing the area. Interviews with staff, including a scheduler and the Director of Nursing, revealed a lack of awareness regarding the requirement to post survey reports and their location. The Director of Nursing mentioned that the cart with the survey book had been moved due to recent repainting, but acknowledged that the facility had not posted information about the availability and location of the survey reports.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of its residents, as evidenced by several observations during an unannounced visit. Resident #29, who has schizophrenia and limited communication abilities, was found in a room without a privacy curtain separating his space from his roommate, Resident #64. This lack of privacy was acknowledged by the Assistant Director of Nursing and the Maintenance Supervisor, who were unaware of the reason for the missing curtain. Additionally, Resident #64 had to pass through Resident #29's space to enter or exit the room, further compromising privacy. Resident #27, diagnosed with anxiety disorder and schizoaffective disorder, experienced a delay in receiving assistance after activating her call light. Despite being visibly uncomfortable and sweating, she was left waiting for approximately 20 minutes before staff returned with the necessary equipment to assist her. The Director of Nursing later stated that call lights should be answered within 15 minutes, and staff should attempt to alleviate immediate discomfort even if they cannot fully meet the resident's needs immediately. Resident #52, who has schizophrenia, dysphagia, and flaccid hemiplegia, was observed receiving tube feeding in a common area, which was against his expressed wishes. The resident had been depressed since the placement of the gastrostomy tube and preferred to have feedings done in private. Despite this, a Licensed Practical Nurse connected the feeding tube in the dining room, exposing the resident's gastrostomy tube in front of others. The Director of Nursing acknowledged that this practice was a concern for resident dignity.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to adhere to the physician's order for continuous oxygen therapy at 2 liters per minute for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with hypoxia. Observations revealed that the resident was receiving oxygen at varying flow rates, significantly higher than the prescribed 2 liters per minute, and at times, the resident was without oxygen therapy altogether. The resident was observed in the dining room with oxygen set at 6 liters per minute and later at 5 liters per minute while in bed. On another occasion, the resident was seen without oxygen in the dining room, while the oxygen concentrator in the room was running at 4.5 liters per minute. Interviews with staff indicated a lack of consistent adherence to the physician's order, with one LPN stating that the resident mainly wore oxygen when in bed and received it as needed in common areas. The Assistant Director of Nursing confirmed the order for continuous oxygen but noted that the resident sometimes refused to wear it outside the room. The Director of Nursing emphasized the expectation for staff to follow physician orders, yet the Facility Administrator admitted to not having a policy related to respiratory care or oxygen therapy, highlighting a gap in the facility's protocol management.
Infection Control Lapse During Enteral Feeding
Penalty
Summary
The facility failed to adhere to proper infection prevention protocols during the administration of enteral tube feeding for a resident. The resident, who had a Percutaneous Enteral Gastrostomy (PEG) tube due to dysphagia, was observed in the dining room without gloves or additional Personal Protective Equipment (PPE) being used by the staff member administering the feeding. The staff member, an LPN, cleaned the gastrostomy tube port with an alcohol wipe and attached the feeding tube without wearing gloves, despite the presence of an Enhanced Barrier Precautions sign on the resident's door indicating the need for additional PPE. The resident, who had diagnoses including schizophrenia, dysphagia, and flaccid hemiplegia, required staff assistance for daily tasks and had a care plan in place to prevent infection at the gastrostomy tube site. The facility's policy required staff to wash hands and don gloves before handling gastrostomy tubes to reduce infection risk. However, the LPN did not follow these protocols, and the Director of Nursing acknowledged the concern for resident dignity and the expectation for appropriate infection control practices.
Inadequate Room Space for Resident
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of personal room space for residents with roommates, as evidenced by the case of a resident diagnosed with schizophrenia. This resident, who was rarely or never understood according to a Brief Interview for Mental Status, was observed to have a room space measuring only 82 inches by 98 inches, which is approximately 55 square feet. The resident's care plan indicated that he chose to sleep in a recliner and did not have a bed, which may have contributed to the oversight in room space allocation. The Maintenance Supervisor confirmed the inadequate room size and acknowledged that the room was previously certified for four residents. It was suggested that the addition of a bathroom to each resident's room might have reduced the available square footage per resident. The facility did not have a policy addressing the required square footage in resident rooms, which contributed to the deficiency. Discussions were underway to potentially move the resident to a different room to comply with space requirements.
Lack of Direct Exit Access for Residents
Penalty
Summary
The facility failed to ensure that residents had direct access to an exit corridor from their designated room space. This deficiency affected four residents who were residing in a room shared by four individuals. Specifically, two residents in the back of the room had to pass through the designated spaces of other residents to exit the room and access the hallway. Observations and interviews with the Assistant Director of Nursing and the Maintenance Supervisor confirmed that there was no direct way for these residents to enter or exit their allotted space without traversing through another resident's area. The Maintenance Supervisor acknowledged that the room was previously certified for four residents, but the addition of a bathroom to each room reduced the square footage per resident, contributing to the issue. The facility did not provide a policy regarding direct access to an exit corridor.
Lack of Privacy Curtain Between Residents
Penalty
Summary
The facility failed to provide a privacy curtain between two residents, resulting in a lack of privacy for one of the residents who was unable to make decisions regarding his own privacy. Observations revealed that there was no curtain between the designated room spaces of the two residents, despite a track being present on the ceiling for a curtain. The resident who was unable to respond had a diagnosis of schizophrenia and was rarely or never understood, indicating a need for privacy that he could not advocate for himself. Interviews with staff, including the Assistant Director of Nursing and the Maintenance Supervisor, confirmed the absence of the curtain and suggested it might have been removed for laundering or torn down by the other resident. The facility did not have a policy addressing privacy curtains, contributing to the oversight.
Deficiency in Call Light Availability for a Resident
Penalty
Summary
The facility failed to provide a working call light system for a resident, leading to a deficiency. The resident, who had intact cognition with a BIMS score of 13, was diagnosed with seizure disorder, benign paroxysmal vertigo, malnutrition, bipolar disorder, and schizophrenia. She moved to her current room on January 11, 2022, but was observed on September 30, 2024, and again on October 2, 2024, without a call light in her room. During interviews, the resident reported not having a call light and was unaware that all rooms should have one. Staff members, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed that the resident should have a call light but were unsure why it was missing or how long it had been absent. The facility's policy, dated January 1, 2019, stated that staff should ensure residents who change rooms have a call light available.
Failure to Conduct Fall Assessment for Self-Reported Fall
Penalty
Summary
The facility failed to complete a fall assessment or neurological checks following a resident's self-reported, unwitnessed fall. Resident #53, who has moderately impaired cognition and a history of falls, reported falling in her room but could not recall the details. Despite this report, there was no fall incident report or assessment documented in the resident's records. The resident was found crawling on the floor and later reported to staff that she had fallen, but no immediate assessment or investigation was conducted by the nursing staff. The facility's policy requires an investigation into the circumstances of a fall, completion of a fall assessment, and documentation in the electronic health record. However, these steps were not followed after Resident #53's report. Staff members, including a CNA and the ADON, were informed of the fall but did not perform the necessary assessments or complete an incident report. The DON confirmed that the expectation is for nursing staff to assess any resident who reports a fall, whether witnessed or not, and to complete the necessary documentation and assessments.
Resident Left Unattended in Shower Room Resulting in Fall
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #79, who was left unattended in the shower room, resulting in a fall. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 03, was diagnosed with hypertension, dementia, Parkinson's Disease, anxiety, and depression. The care plan for the resident, revised on 9/26/24, specified that the resident required assistance from one staff member during bathing. However, on 7/19/24, a nursing progress note documented that the resident was found on the floor in the shower room without any staff supervision, although no injuries were noted. The Director of Nursing confirmed that the resident should not have been left unattended in the shower.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 137 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northcrest Specialty Care | 4.5 mi | ★★★★★ | 7 | 0 |
| Martin Health Center, Inc | 4.8 mi | ★★★★★ | 0 | 0 |
| Cedar Falls Health Care Center | 5.8 mi | ★★★★★ | 20 | 0 |
| Newaldaya Lifescapes | 5.8 mi | ★★★★★ | 1 | 0 |
| Pinnacle Specialty Care | 6.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pillar Of Cedar Valley.
100% money-back within 48 hours.
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.