Cedar Falls Health Care Center

Inspectors wroteBased on document review, time card review and staff interviews, the facility failed to ensure a Registered Nurse (RN) was in the facility for eight consecutive hours seven days a week. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide timely toileting assistance and incontinence care to prevent Resident #6 from remaining in a wet brief and sitting on a urine-soaked wheelchair cushion for 1 of 1 resident (Resident #6) reviewed for incontinence care. The facility reported a census of 49.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff properly prepared and distributed medications for residents on leave from the facility when Staff G, Registered Nurse (RN), sent full medication cards belonging to another resident (Resident #16) home with Resident #1 during a leave of absence for 2 of 2 resident reviewed (Residents #1 and #16). The facility identified a census of 49 residents.

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to ensure staff administered medications safely as prescribed without crushing non-crushable medications for 1 of 5 residents (Resident #10) reviewed for medication administration. The facility identified a census of 49 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff scheduled and provided transportation for medical appointments for 1 of 3 resident (Resident #1) reviewed for medical services. This failure resulted in Resident #1 missing specialty medical appointments. The facility identified a census of 49 residents.

Inspectors wroteBased on observation, clinical record review, Center for Disease Control and Prevention (CDC) Guidelines, Policy review and staff interviews, the facility failed to prevent the spread of infection for 2 of 2 residents who tested positive for influenza A (Residents #17 and #38). In addition, the facility failed to implement droplet precautions, sanitize the barrier used during a blood sugar check for 1 of 2 residents observed (Resident #23), and failed to adhere to infection control practices during medication administration when dirty gloves contacted oral medication for 3 of 7 resident observed (Residents #16, #19 and #34). On 1/2/26, the facility failed to follow infection control protocols after Resident #17 tested positive for influenza A. [...]

Inspectors wroteBased on record review, policy review, resident, and staff interviews, the facility failed to have a restorative program available for all residents at the facility. The facility failed to implement a restorative plan for 2 of 2 residents that reported if they had an option to do therapy, they would (Residents #36 and #43). The facility reported a census of 43 residents.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to post daily nurse staffing on 3 of 4 days of the annual survey. The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to obtain informed consent prior to starting psychotropic medications that have black box warnings (the most serious safety warning the Food and Drug Administration (FDA) uses and requires the healthcare provider to have a comprehensive discussion with the resident about the risks, benefits, and alternatives for use) for 3 for 5 residents reviewed for psychotropic medications. (Resident #36, #40, and #8). The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to accurately code 1 of 2 residents with a Preadmission Screening and Resident Review (PASRR) (a federal assessment that is a requirement for Medicaid-certified nursing facilities to screen all applicants for serious mental illness, intellectual disabilities, or developmental disabilities to ensure they are placed in the most appropriate, least restrictive setting and receive needed services, preventing inappropriate institutionalization and promoting community-based care) (Resident #7) on the Minimum Data Set (MDS) assessment. The facility reported a census of 43 residents.

Inspectors wroteBased on observation, clinical record review, policy review and staff interview, the facility failed to assess 1 of 1 residents positive for influenza A (Resident #17). The facility identified a census of 43 residents.

Inspectors wroteBased on record review, staff, resident and Nurse Practitioner interviews, and policy review the facility failed to complete pre and post dialysis (an external method to remove the wastes and toxins from the body with poor functioning kidneys) assessments (assessments involving checking the residents blood pressure, temperature, pulse, and weight; and inspection of the dialysis access site on the body) for 1 of 1 residents that received dialysis (Resident #40). The facility reported a census of 43 residents.

Inspectors wroteBased on record review, policy review, staff, resident, and Nurse Practitioner interview, the facility failed to have set blood sugar parameters (a numerical range the blood sugar should remain in) in place for 1 of 3 residents reviewed (Resident #40). In addition, the facility failed to notify a resident's doctor after the completion of elevated blood sugar assessments to ask if additional medication or treatment is needed for 1 of 3 residents reviewed for insulin medication usage (Resident #40). The facility reported a census of 43 residents.

Inspectors wroteBased on observation, clinical record review, policy review, manufacturer's guide for use and staff interview, the facility failed to properly prime an insulin pen and prevent expired insulin from being administered for 1 of 1 residents observed (Resident #39). The facility identified a census of 43 residents.

Inspectors wroteBased on policy review, document review and staff interviews, the facility failed to ensure an effective Quality Assurance Performance Program (QAPI) to address previously identified quality deficiencies, resulting in repeated identified concerns during the current survey. The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review, facility policy, and staff interviews, the facility failed to notify the physician when the facility failed to administer medications as prescribed for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43.

Inspectors wroteBased on clinical record review, facility policy, and staff interviews, the facility failed to administer medication as prescribed by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43.

Inspectors wroteBased on record review, policy review, and staff interviews the facility failed to report within the required time frame an allegation of abuse to Iowa Department of Inspection and Appeals and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, facility medical record, family, volunteer, resident, and staff interviews the facility failed to revise and implement interventions on the comprehensive Care Plan to include redirection for a resident with a known behavior of packing food into her mouth for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 39. Findings Include: Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of traumatic brain dysfunction (brain damage caused by an outside force), heart failure, hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin). The MDS documented no swallowing disorders. [...]

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to serve hot food at a temperature of at least 135 degrees Fahrenheit (F) for 1 of 1 test tray requested. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to ensure all staff entering the kitchen had their hair contained in a hair net for 2 of 2 observations. The facility reported a census of 38 residents:

Inspectors wroteBased on observation, clinical record review, policy review, manufacturer's instructions for use and staff interviews, the facility failed to ensure a medication error rate of less than five percent when administering insulin to a diabetic resident via insulin pen for 2 of 2 residents sampled (Residents #8 and #32). The Facility reported a census of 38 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview the facility failed to adhere to infection control practices while administering medication. Observations of the nursing staff revealed they touched medication with their bare hands during medication administration for 2 of 4 residents observed for oral medication pass. The facility identified a census of 38 residents.

Inspectors wroteBased on document review, policy review, and staff interviews, the facility failed to ensure door alarm checks and wander guard alarm checks were physically completed as documented to ensure the safety of facility residents including 2 of 2 residents sampled (Residents #3 & #7). The Facility identified a census of 35 residents.

Inspectors wroteBased on record review, staff and family interview on 7/15/24 the facility failed to make the required notifications for residents for 2 of 5 residents reviewed (Residents #5 and #6). The facility failed have an updated condition report list to accurately notify the family/resident representative of an acute transfer and hospital admission for Resident #6. In addition, the facility failed to notify the physician when the facility didn't have medications to give Resident #5 the night of her admission to the facility. The facility identified a census of 35 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to following medication administration protocols for a new admission resident to the facility. The facility failed to provide medications as ordered on admission for 1 of 4 residents reviewed (Resident #5). The facility reported a census of 35 residents.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe and comfortable environment due to leaks in the ceiling in the hallway entering the main dining room and in the main dining room. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to provide services that met professional standards regarding the administration of medications administered outside the scheduled time frames for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 39 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide or offer a shower twice a week for 1 of 3 residents reviewed (Resident #3). In addition, the facility failed to provide incontinence care for 3 of 3 residents reviewed (Residents #3, #4, #6). The facility reported a census of 39 residents.

Inspectors wroteBased on record review, resident and staff interviews, and policy review the facility failed to assist 1 of 1 residents reviewed with requested discharge planning to an assisted level of care (Resident #28). The facility reported a census of 35 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to notify the resident or their representative of the policy for Bed Holds for 1 of 3 resident reviewed (Resident #3). Resident #3 went out to the hospital on 2 separate occasion and no notification of the Bed Hold policy was issued for Resident #3. The facility reported a census of 35 residents.

Inspectors wroteBased on record review and interview, the facility failed to do a PASARR (pre-admission screening and resident review) Level 2 for 1 of 3 residents reviewed (Resident #19). The facility failed to do a PASARR Level 2 when a mental health diagnosis was added for Resident #19. The facility reported a census of 35 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for reevaluation when 1 of 2 residents reviewed (Resident #8) demonstrated increased behavioral, psychiatric, or mood-related symptoms and the facility received an order to send to the emergency room (ER) for Psychiatric evaluation and treatment. The facility reported a census of 35 residents.

Inspectors wroteBased on record review, resident, staff, and Provider interviews, and policy review the facility failed to provide adequate assessment and intervention to 1 of 2 residents reviewed for hospitalizations (Resident #16). The facility reported a census of 35 residents.

Inspectors wroteBased on record review, resident, staff, and Provider interview, and policy review the facility failed to maintain records and complete routine assessments for 2 of 3 residents documented with pressure ulcers (Resident #17 and #24). The facility reported a census of 35 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to maintain records for 1 of 5 residents reviewed (Resident #35) on education and offering of Pneumococcal and Influenza vaccination. The facility reported a census of 35 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to maintain records for 1 of 5 residents reviewed (Resident #35) on education and offering of COVID-19 vaccination. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, record review, family and staff interview, and facility policy review the facility failed to provide adequate assessment and timely intervention for 1 of 3 residents reviewed (Resident #3). On 8/14/23 Resident #3 had a witnessed fall, was lowered to the floor by staff. Facility staff failed to assess the resident prior to assisting to stand, failed to report the fall to the charge nurse, and failed to provide ongoing monitoring and assessment following the fall. On 8/18/23 the resident was noted to have swelling, and yellow-green bruising to the left knee, required transfer and admission to the local hospital for a fractured left femur. The facility reported a census of 39 residents.