Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Suites At Western Home Communities during CMS and state inspections, most recent first.
A resident with a left heel pressure injury was transferred by two CNAs without a gown, despite care plan and MD orders directing EBP for wound-related care. The room lacked an EBP sign and PPE outside the door, and staff and the Administrator gave conflicting statements about whether EBP was still required because the wound was scabbed, healed, or not draining. The facility policy stated EBP is indicated for residents with wounds.
The facility failed to complete the SCSA MDS within 14 days for two residents who elected hospice services. One resident's assessment was completed 20 days after hospice election, while another's was 6 days late. Staffing issues and reliance on outsourced MDS assessments contributed to the delays.
The facility failed to ensure accurate MDS assessments for four residents, leading to misrepresentations of their care status. A resident's fall with a pelvic fracture was not documented as a major injury, hospice care was omitted for another, and restraint use was incorrectly recorded. Additionally, a resident's discharge location was inaccurately noted as a hospital transfer. These errors were attributed to clerical mistakes and misunderstandings of regulations.
A resident with cognitive and physical impairments did not receive the prescribed rolled washcloths for hand contracture management, as ordered by a physician. Despite documentation indicating compliance, observations showed the resident without washcloths, and staff interviews revealed inconsistencies in care. The care plan was not updated to reflect the physician's order, and the facility's policy lacked guidance on handling incomplete orders.
Failure to Use EBP During Resident Transfer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during a routine transfer for a resident with a left heel pressure injury. The resident’s MDS identified an unstageable pressure injury presenting as a deep tissue injury that was not present on admission. The care plan directed staff to wear gloves and a gown for transfers related to wounds, and physician orders directed EBP due to the left heel wound. The EHR identified the pressure ulcer as in-house acquired on 8/3/25, and later wound documentation described the area as healed or closed with continued monitoring, while also showing measurements and a scabbed area to the left heel. During observation, the resident’s room did not have an EBP sign on the door or PPE available outside the room. Two CNAs transferred the resident from bed to wheelchair using a mechanical lift, and neither staff member wore a gown during the procedure. Staff interviews showed confusion about whether EBP was still required because the wound was healed or not draining. The RN nurse mentor stated that if the wound was covered and not draining, the resident would not typically be in EBP. The Administrator stated the resident had been removed from EBP the previous week because the wound did not drain, and later stated she would not call the wound healed. The facility policy stated that EBP is indicated for residents who have wounds, and the algorithm indicated EBP for residents with covered or contained open wounds.
Delayed Completion of SCSA MDS for Hospice Residents
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) within the required 14 days following the election of hospice services for two residents. Resident #45 was admitted to hospice care on 5/30/24, but the SCSA MDS was not completed until 6/19/24, which was 20 days after the hospice election. The MDS assessment documented various health conditions, including memory impairment and metabolic encephalopathy, but did not reflect the hospice care services. The delay was attributed to staffing issues, as the MDS Coordinator was out sick, and a different person from the service provider completed the MDS, leading to accuracy problems. Similarly, Resident #4 was admitted to hospice services on 1/3/25, but the SCSA MDS was completed 6 days late on 1/22/25. The facility's staff, including Staff B, acknowledged the delay and stated that they followed the RAI Manual for completing the MDS. The report highlights that the facility's process for completing the MDS assessments was not timely, as required by federal regulations, which mandate that the assessment accurately reflects the resident's status within 14 days of a significant change.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the care status of four residents. Resident #33 experienced a fall resulting in a pelvic fracture, which was not documented as a major injury in the MDS assessment. Despite the fracture being identified in hospital records, the MDS inaccurately recorded the incident as a fall without injury. The Director of Nursing (DON) and the MDS Coordinator acknowledged the inaccuracy, attributing it to a misunderstanding of state versus federal regulations and a lack of familiarity with the RAI manual. Resident #45 was admitted to hospice care, but the MDS assessment failed to document this significant change in status. Although the resident's care plan and progress notes indicated hospice enrollment, the MDS did not reflect this, leading to a misrepresentation of the resident's care needs. The MDS Coordinator admitted to the oversight, noting that hospice care should have been captured in a significant change MDS assessment. Resident #53's MDS inaccurately documented the use of restraints, despite multiple staff members confirming that no restraints were used. The error was attributed to a clerical mistake during the MDS coding process. Similarly, Resident #70's discharge location was incorrectly recorded in the MDS as a transfer to a hospital, while documentation and staff confirmed the resident was discharged to a private home with hospice care. The Administrator recognized this as a clerical error and planned to address the issue with the MDS vendor.
Failure to Follow Physician's Order for Hand Contracture Management
Penalty
Summary
The facility failed to follow a physician's order for a resident with significant cognitive and physical impairments, including metabolic encephalopathy, stroke, and dementia. The resident, who was under hospice care, had a physician's order to have rolled washcloths placed in their hands daily to manage contractures. However, observations on multiple occasions revealed that the resident was not provided with the washcloths as ordered. The care plan was not updated to reflect the physician's order, and staff interviews indicated a lack of consistent implementation of the order. Despite the physician's order being documented and signed off as completed in the Electronic Treatment Administration Record (ETAR), the resident was observed without the washcloths in their hands. Staff interviews revealed confusion and inconsistency regarding the use of washcloths versus palm protectors, with some staff reporting pain when attempting to use the protectors. The Director of Nursing acknowledged that if the order was signed off, it should have been completed, and any changes or refusals should have been communicated to the physician or hospice. The facility's policy lacked specific guidance on not signing off on incomplete orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Specialty Care | 0.3 mi | ★★★★★ | 6 | 0 |
| Newaldaya Lifescapes | 1.7 mi | ★★★★★ | 1 | 0 |
| Martin Health Center, Inc | 2.7 mi | ★★★★★ | 0 | 0 |
| Cedar Falls Health Care Center | 3.2 mi | ★★★★★ | 20 | 0 |
| Harmony House Health Care Center | 3.5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.