Accolade Healthcare of Waterloo

In the surveyor’s words

From the most serious findings on record at Accolade Healthcare of Waterloo, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 25, 2025

  Based on observation, interview and record review, the facility failed to follow physician's orders for STAT labs and x rays for 2 (R4, R103) of 4 residents reviewed for following physician's orders in a sample of 49. This failure resulted in delayed treatment for symptomatic pneumonia. Findings include: 1. R4's Undated Face Sheet, documents initially admitted on [DATE] with diagnoses including acute respiratory disease and chronic cough.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documents she was alert.R4's Progress Note, dated 1/9/2025 at 1:15 PM New orders: STAT (immediately/without delay) STAT CXR (chest x ray) and STAT KUB (abdominal x ray) orders placed. R4's POS (Physician's Order Sheet), dated 1/9/2025 documents STAT chest x ray and STAT KUB. […]

• Actual harm, isolatedF689Aug 23, 2024

  Based on interview and record review the Facility failed to ensure resident was being properly supervised and in a clutter-free environment that was free of hazards for 1 of 5 residents (R80) reviewed for falls in the sample of 56. This failure resulted in R80 who had a history of falls tripping over a chair or bedside table in the sunroom, requiring seven stitches. Findings include: R80's Physician Order Sheet for August 2024 documents a diagnosis of Alzheimer disease, atrial fibrillation, overweight retention of urine, generalized anxiety disorder, myocardial infarction, major depressional disorder, type 2 diabetes mellitus without complications. R80's Minimum Data Set, dated dated dated [DATE] documents R80 was severely impaired for cognition for activities of daily living. […]

• Actual harm, isolatedF689Sep 16, 2022

  Based on interview, record review, and observation the facility failed to provide safe transfers to prevent falls for 1 of 17 residents (R117) reviewed for falls in the sample of 49. This failure resulted in R117's falling and sustaining a right elbow fracture. Findings Include: R117's Minimum Data Set (MDS) dated [DATE] documents R117 is cognitively intact and requires Extensive Assistance with 2 person physical assist in transfer; moving from seated to standing position-not steady, only able to stabilize with staff assistance; surface-to-surface transfer-not steady, only able to stabilize with staff assistance. R117's Face Sheet undated documents R117 diagnoses as [CONDITION(S)], unspecified affecting right dominant side, Muscle weakness, [CONDITION(S)] following cerebral infarction. […]

• Actual harm, isolatedF686Jul 30, 2021

  Based on observation, record review and interview the facility failed to timely identify, assess, and monitor the formation of a pressure ulcer for 1 of 4 residents (R114) reviewed for pressure ulcers in the sample of 65. This failure resulted in R114 developing an unstageable pressure ulcer on her elbow. Findings Include: R114's Minimum Data Set (MDS) dated [DATE] documents R114 has moderate cognitive impairment. R114's Electronic Health Record (EHR) Progress Note dated 6/24/21 documents, report was received from a regional hospital. […]

• No harm, potential for more than minimal, widespreadF609Aug 23, 2024

  Based on interview and record review the facility failed to identify and immediately report allegations of physical and sexual abuse for 4 (R5, R124, R430, R103) residents reviewed for abuse. This failure has the potential to affect all residents in the facility. Findings include: 1. R5's face sheet, dated 8/14/24, documented R5 has diagnoses of dementia, depression, generalized anxiety disorder, and hypertension. R5's MDS (Minimum Data Set), dated 5/22/24, documented R5 is severely cognitively impaired. R5's incident report, dated 8/9/24 at 5:30 pm, documented R5 has a 2 cm by 2 cm raised dark purple bruise noted to the left side of forehead. On 8/13/24 at 9:05 am R5 was observed with an approximately 2 cm by 2 cm yellow and purple bruise to the left side of her forehead. […]