Cedar Falls Health Care Center

In the surveyor’s words

From the most serious findings on record at Cedar Falls Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 21, 2022

  Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to ensure 1 of 9 residents reviewed (Resident #41) was free from physical abuse resulting in injury. The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents. This incident constituted immediate jeopardy (IJ) to the resident's health and safety. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 1:20 PM. The facility reported a census of 55 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admitted [DATE] from a psychiatric hospital. […]

• Immediate jeopardy, isolatedF684Dec 21, 2022

  Based on observations, clinical record reviews, resident, family, and staff interviews, the facility failed to assess and intervene for the necessary care and services, to maintain a resident's highest practical physical well-being. The clinical record review revealed the nursing staff failed to provide a timely thorough assessment for 1 of 13 residents reviewed (Resident #5). The facility's failure to provide a timely assessment and intervention resulted in an immediate jeopardy (IJ) to the residents of the facility. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 9:53 AM. The facility decreased the citation to a D level prior to exit of the survey. The facility reported a census of 55 residents. […]

• Immediate jeopardy, isolatedF689Dec 21, 2022

  Based on observation, resident and staff interviews, record review and policy review, the facility failed to provide appropriate supervision in order to prevent physical abuse of 1 of 9 residents reviewed (Resident #41) resulting in injury and one staff member, Staff G, Registered Nurse (RN). The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents and staff from abuse. Resident #22's admitted to the facility from a psychiatric hospital after assaulting another resident at a different facility. These incidents constituted Immediate Jeopardy to the resident's and staff's health and safety. The facility reported a census of 55 residents. […]

• Immediate jeopardy, isolatedF689May 13, 2021

  Based on observation, clinical record review, staff, resident and Physician interview, the facility failed to protect residents against burn hazards from the baseboard heating elements in their rooms by placing resident beds parallel to the heaters in their rooms for 2 of 8 residents reviewed (Resident #1 and #22). On 4/2/21 Resident #1 rolled out of low bed and was found by staff with body on top of the heater with the skin of the lower left leg, knee, and upper thigh touching the heater. A Physicians note dated 4/12/21 revealed that resident sustained [CONDITION(S)] that involved 10-19 % of his body surface with 0% to 9% 3rd degree [CONDITION(S)]. On 4/21/21, Staff confirmed that Resident # 22, a known fall risk, was found on the floor parallel to the bed. […]

• Actual harm, isolatedF880Jan 8, 2026

  Based 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. […]