Pillar Of Cedar Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterloo, Iowa.
- Location
- 1410 West Dunkerton Road, Waterloo, Iowa 50703
- CMS Provider Number
- 165307
- Inspections on file
- 30
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 13
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.
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.
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.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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