Harmony Waterloo

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 30, 2025

  Based on observations, record review, resident and staff interviews and policy review, the facility deprived a resident of care by failing to communicate in a respectful manner during bedtime care, abandoned the resident in a vulnerable state and failed to respond to the resident's requests for necessary care resulting in the resident's ongoing fear and anxiety. Resident #4 stated on 10/13/25 one of the two nursing staff was arguing with her about her preference of care. Both nursing staff knowingly left Resident #4 on her bed, soiled with urine, without a cover and no staff answered the light for approximately an hour. […]

• Actual harm, isolatedF689Sep 15, 2022

  Based on clinical record review, staff and resident interviews and observations the facility failed to provide adequate supervision to ensure the safety of 2 of 4 residents reviewed (Resident #12 and #4). The facility reported a census of 78. Findings include: 1. According to the discharge Minimum Data Set (MDS) dated [DATE], Resident #12 had diagnoses which included stroke, pain and [CONDITION(S)]. The MDS indicated the resident had intact memory and cognitive function and did not exhibit behaviors. The resident required extensive assistance with transfers, dressing and hygiene needs. The resident had occasional bowel and bladder incontinence. […]

• No harm, potential for more than minimal, patternF761Jun 11, 2026

  Based on observations, staff interviews, and record and policy reviews, the facility failed to ensure that staff securely stored all medications for 2 of 2 residents reviewed (R#2 and R#8). The facility also failed to maintain a safe environment because staff left the medication carts and treatment carts unlocked and unsupervised. The facility reported a resident population of 68. Findings include: 1. Resident R#2's Minimum Data Set (MDS) admission assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF732Jan 14, 2026

  Based on observations, and staff interview the facility failed to keep the daily nurse staff posting current for 2 of 4 days during the survey. In addition, the facility failed to post the number of hours nursing staff worked for 4 of 4 days during the survey. The facility reported a census of 71 residents. Findings include: On 1/11/26 at 11:23 AM witnessed the facility's Nurse Staff Posting dated 1/10/26 (the day before) posting up. In addition, it lacked the number of hours staff worked. On 1/12/26 at 2:03 PM observed the facility's Nurse Staff Posting lacked the number of hours staff will work. On 1/13/26 at 12:51 PM witnessed the facility's Nurse Staff Posting lacked the number of hours staff will work. […]

• No harm, potential for more than minimal, patternF802Jan 14, 2026

  Based on observation, staff interviews, and policy review the facility failed to have 2 of 2 cooks able to explain the puree process and procedure. The facility reported a census of 71 residents. Findings include: The review of the Week 4, Week at a Glance with Portion (facility menu) instructed to serve 3 ounces (oz.) of roast beef and 4 oz. of roasted butternut squash. On 1/13/26 at 10:59 AM observation of the puree process for 4 residents revealed Staff E, Cook, didn't measure the roast beef or squash after pureeing in the blender to ensure they provided equal portions. On 1/13/26 at 11:12 AM Staff E reported she didn't use a measuring cup after pureeing the food. She instead uses the scoop size as directed on the menu and never got trained to measure the pureed food. […]