Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Falls Health Care Center during CMS and state inspections, most recent first.
A resident reported missing money, but the facility failed to report the allegation to DIAL within the required 24-hour timeframe. The Administrator believed the resident had a history of misplacing items and assumed the money would be found, leading to a delay in reporting. The facility's policy requires such allegations to be reported promptly.
A resident with severe cognitive impairment and a known behavior of packing food into her mouth experienced a choking incident. Despite staff awareness, the Care Plan lacked specific interventions for this behavior. The resident required the Heimlich maneuver and CPR before being transferred to the hospital. The facility's policy mandates regular updates to Care Plans, but the Assistant Director of Nursing was unaware of the resident's behavior, indicating a communication gap.
The facility failed to serve hot food at the required temperature of at least 135 degrees Fahrenheit. A test tray showed the casserole at 131 degrees Fahrenheit and the beans at 116.6 degrees Fahrenheit. Staff C from dietary was unaware of the expected temperature, and the Dietary Manager stated that food should be served at 154 degrees Fahrenheit. The facility's policy required maintaining hot food temperatures above 135 degrees Fahrenheit.
The facility failed to ensure compliance with its policy requiring all staff to wear hair nets in the kitchen. Two CNAs were observed entering the kitchen without proper hair containment. One CNA entered without a hair net, while another wore a hair net that did not fully cover her hair. The Dietary Manager confirmed the expectation for all staff to adhere to this policy.
A facility failed to maintain a medication error rate below five percent when administering insulin to two diabetic residents. An RN did not prime insulin pens before administration, contrary to manufacturer's instructions, leading to improper dosing. The facility's policy lacked specific guidance on insulin pen use, and there was no record of in-service education on the procedure.
Two incidents of infection control breaches were observed during medication administration. A CMA and an RN were seen handling medications with bare hands, contrary to facility policy. The CMA did not perform hand hygiene and handled multiple medications directly, while the RN split a tablet with bare hands. Staff interviews confirmed these actions were against the facility's infection control procedures.
The facility failed to ensure door and wander guard alarm checks were completed as documented, compromising resident safety. A resident with severe cognitive loss and low elopement risk, and another with high elopement risk, were involved. The Maintenance Supervisor, responsible for these checks, falsified records under pressure from the Administrator during his medical leave. The facility's compliance program prohibits such falsification, yet the Administrator and staff engaged in these practices, leading to a deficiency.
The facility failed to notify the family of a resident's hospital transfer and passing due to incorrect contact information, and did not inform a physician when another resident's medications were unavailable upon admission. These deficiencies highlight lapses in communication and protocol adherence.
A facility failed to administer medications as ordered for a newly admitted resident, resulting in significant medication errors. The resident, with intact cognition and multiple diagnoses, did not receive prescribed doses of Clonazepam, Famotidine, Metoprolol, Hydroxyzine, and Methocarbamol. An RN noted the absence of medications, and the DON confirmed no documentation of provider notification. The facility's policy on medication errors was not followed.
The facility failed to maintain a safe and comfortable environment due to ceiling leaks in the hallway and dining room. Observations showed water coming from the ceiling, with garbage cans and wet floor signs in place. Staff confirmed the leaks occurred during rain, and the Administrator mentioned indecision about roof replacement. Residents expressed dissatisfaction, and the facility lacked a policy for a clean environment.
A resident with PTSD, psychotic disorder, and chronic pain received medications outside scheduled times on multiple occasions without documented rationale. The facility's policy required timely administration, but this was not followed, and the DON expected staff to document any deviations, especially for high-risk medications.
A facility failed to provide showers twice a week for a resident and did not provide incontinence care for three residents. One resident, with a history of stroke and hemiplegia, was not offered showers during specific periods, despite expressing their importance. Documentation for June 2024 lacked evidence of toileting hygiene for this resident and two others, who had conditions like malnutrition, PTSD, diabetes, and sepsis. The DON confirmed the absence of a policy on bathing and incontinence care, expecting staff to follow industry standards.
Failure to Timely Report Allegation of Missing Money
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the Iowa Department of Inspection and Appeals and Licensing (DIAL). The incident involved a resident who reported missing money on February 25, 2025. The Social Service Designee was informed by a Certified Nurses' Aide about the missing money and subsequently reported it to the Director of Nursing during a morning meeting. The Director of Nursing and the Administrator were made aware of the situation, and the Social Services Designee was instructed to search the resident's room for the missing money, which was not found. Despite being aware of the allegation, the Administrator did not report the incident to DIAL within the required 24-hour timeframe, as outlined in the facility's policy. The Administrator believed the resident had a history of misplacing items and assumed the money would be found. The Director of Nursing acknowledged that the allegation should have been reported within the required timeframe. The facility's policy mandates that allegations of abuse, including misappropriation, must be reported within 24 hours, even if they do not result in serious bodily injury.
Failure to Revise Care Plan for Resident with Known Choking Risk
Penalty
Summary
The facility failed to revise and implement interventions on the comprehensive Care Plan for a resident with a known behavior of packing food into her mouth. This deficiency was identified during a review of clinical records and interviews with staff, revealing that the Care Plan did not include specific interventions for this behavior. The resident, who had severe cognitive impairment and was edentulous, was on a regular diet with no documented swallowing disorders. Despite staff awareness of the resident's tendency to pack food, the Care Plan lacked directives to address this behavior. An incident occurred where the resident's tablemate alerted staff to a possible choking situation. A Certified Medication Aide (CMA) attempted the Heimlich maneuver, and the resident was subsequently lowered to the floor and CPR was initiated. The resident was transferred to the hospital after emergency responders arrived. Interviews with staff members confirmed that they were aware of the resident's behavior of packing food, yet the Care Plan did not reflect this known risk. The facility's policy required the Interdisciplinary Team (IDT) to develop and implement a comprehensive, person-centered Care Plan, which should be revised as the resident's condition changes. However, the Assistant Director of Nursing (ADON) was unaware of the resident's behavior, indicating a communication gap. The Director of Nursing (DON) acknowledged that concerns were reported by CNAs, but the Care Plan was not updated to include interventions for the resident's behavior of packing food into her mouth.
Failure to Serve Hot Food at Required Temperature
Penalty
Summary
The facility failed to serve hot food at the required temperature of at least 135 degrees Fahrenheit, as evidenced by a test tray provided on December 10, 2024. The casserole on the test tray measured 131 degrees Fahrenheit, and the beans measured 116.6 degrees Fahrenheit. Staff C from the dietary department confirmed that she took the temperatures in Celsius and was unaware of the expected temperature for the food. During an interview, the Dietary Manager stated that hot food should be served at a temperature of at least 154 degrees Fahrenheit. The facility's policy, last revised in October 2017, directed staff to maintain hot food temperatures above 135 degrees Fahrenheit. The facility reported a census of 38 residents at the time of the survey.
Non-compliance with Hair Net Policy in Kitchen
Penalty
Summary
The facility failed to ensure that all staff entering the kitchen adhered to the policy of wearing hair nets, as observed in two separate instances. On December 9, a Certified Nurse Aide (CNA), identified as Staff A, entered the kitchen without a hair net, walked in front of the steam table, filled a cup at the coffee machine, and exited. On December 10, another CNA, identified as Staff B, entered the kitchen with a hair net that did not fully contain her hair, leaving the sides and back exposed. She proceeded to walk around the steam table, retrieve ice from the ice machine, open a refrigerator to take out a pitcher of iced tea, and set it on the prep table for the cook to cover with plastic wrap before exiting. The Dietary Manager confirmed the expectation for all staff to wear hair nets upon entering the kitchen, as per the facility's policy on employee hygiene and sanitary practice dated October 2017.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent when administering insulin to two diabetic residents. On the morning of December 10, 2024, a Registered Nurse (RN) administered insulin to Resident #8 without priming the insulin pens as per the manufacturer's instructions. The RN set the doses for Tresiba and Fiasp insulin pens but did not prime them with two units of insulin, which is necessary to ensure the resident receives the full prescribed dose. The Director of Nursing (DON) later confirmed that the nurses are expected to follow the manufacturer's directions, although there was no record of in-service education on insulin pen administration. The facility's Insulin Administration Policy, revised in September 2014, lacked specific instructions on priming and administering insulin via a pen. Similarly, another incident involved Resident #32, where the same RN failed to prime the Insulin Aspart Flex Pen before administration. The RN set the pen to the required dose according to the sliding scale insulin order but did not perform the necessary air shot to ensure proper dosing. The resident then self-administered the insulin without the pen being primed. The manufacturer's instructions for the Insulin Aspart Flex Pen clearly state the need to perform an air shot before each injection to avoid injecting air and ensure proper dosing. These actions led to a significant medication error rate, as the facility did not adhere to the proper insulin administration procedures.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed in two separate incidents involving nursing staff. In the first incident, a Certified Medication Aide (CMA) did not perform hand hygiene before setting up a resident's morning medications. The CMA handled medication cards and punched pills into her bare hands before placing them into a medication cup. Additionally, she touched multiple tablets from a stock bottle with her bare hands, placing one into the medication cup and returning the rest to the bottle. The CMA also broke a tablet in half with her bare hands at the resident's request. In the second incident, a Registered Nurse (RN) was observed handling a resident's medication with bare hands. The RN took a tablet from a medication cup, split it using a pill splitter, and placed it back into the cup with bare hands. The facility's policy, revised in 2012, directed staff to follow infection control procedures, including the use of gloves when handling medications. Interviews with staff confirmed that touching medications with bare hands was against the facility's expectations and policy.
Failure to Conduct and Document Alarm Checks
Penalty
Summary
The facility failed to ensure that door alarm checks and wander guard alarm checks were physically completed as documented, compromising the safety of residents. Two residents, one with severe cognitive loss and a low risk of elopement, and another with severe cognitive loss and a high risk of elopement, were involved. The facility's documentation indicated that door alarms were checked daily, but interviews and reviews revealed inconsistencies and falsifications in the records. Staff C, the Maintenance Supervisor, was responsible for conducting and documenting these checks. However, during his medical leave, the checks were not performed, and upon his return, he was instructed by the Administrator to backdate the documentation to cover the period he was absent. Staff C admitted to falsifying records under pressure from the Administrator, who later acknowledged that the checks had not been done and that the documentation was inaccurate. The facility's Corporate Compliance Program emphasizes the importance of accurate and complete record-keeping, prohibiting falsification of records. Despite this, the Administrator and Staff C engaged in practices that violated these standards, leading to a deficiency in maintaining a safe environment for residents. The lack of proper oversight and communication regarding the responsibility for alarm checks during Staff C's absence contributed to the deficiency.
Failure to Notify Family and Physician of Resident Changes
Penalty
Summary
The facility failed to properly notify the family and physician of two residents regarding significant changes in their conditions. For Resident #6, who had a history of traumatic subdural hematoma and seizure disorder, the facility did not successfully inform the family about the resident's transfer to the hospital and subsequent admission. Despite the resident having intact cognition and being independent in bed mobility, the facility had incorrect contact information on file, which led to the family not being notified. This oversight resulted in the family being unaware of the resident's hospitalization and eventual passing. In the case of Resident #5, who was admitted from a short-term hospital stay with diagnoses including orthopedic aftercare, hypertension, muscle weakness, and severe obesity, the facility failed to notify the physician when medications were unavailable upon admission. The resident's medication administration record indicated that several doses of prescribed medications were held due to unavailability, yet there was no documentation of physician notification. The Director of Nursing confirmed the lack of documentation and stated that staff were expected to notify the provider if medications could not be administered as ordered. The facility's failure to update contact information and notify relevant parties of significant changes in residents' conditions and medication availability highlights deficiencies in communication and adherence to established protocols. These lapses in procedure resulted in inadequate notification to family members and healthcare providers, which is critical in ensuring appropriate care and support for residents during significant health events.
Failure to Administer Medications as Ordered for New Admission
Penalty
Summary
The facility failed to follow medication administration protocols for a newly admitted resident, resulting in significant medication errors. Resident #5, who was admitted from a short-term hospital stay, had a Minimum Data Set (MDS) assessment indicating intact cognition and diagnoses including orthopedic aftercare, hypertension, muscle weakness, and severe obesity. The resident's Medication Administration Record (MAR) for June 2024 included orders for several medications, including Clonazepam, Famotidine, Metoprolol, Hydroxyzine, and Methocarbamol. However, the facility did not administer the prescribed doses on 6/27/24 and 6/28/24, as documented in the MAR. An electronic progress note by a Registered Nurse (RN) on 6/27/24 indicated that the facility did not have the resident's medications available at that time. Furthermore, the Director of Nursing (DON) confirmed that there was no documentation of notifying the provider about the missed medications. The facility's Medication Variance Guideline policy outlines steps to follow when a medication error occurs, including recognizing the error, evaluating the patient's condition, reporting to a supervisor, notifying the physician, and documenting the physician's response. However, these steps were not followed, leading to the deficiency.
Ceiling Leaks in Dining Area Compromise Resident Environment
Penalty
Summary
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. Observations revealed multiple garbage cans with turn sheets underneath them, caution wet floor signs, and water coming from the ceiling. The ceiling appeared discolored with tears in both the hallway and the dining room. Staff interviews confirmed that the leaks occurred when it rained, and the facility had been dealing with this issue for some time. The Administrator disclosed that the company was undecided about replacing the entire roof as they were considering purchasing the building. A tarp had been placed on the roof for about a month to minimize leakage, and bids had been requested to fix the roof. Despite receiving quotes to fix the roof months earlier, the issue remained unresolved. Interviews with residents indicated dissatisfaction with the situation, describing the leaks as bothersome. Additionally, the facility lacked a policy regarding maintaining a clean and comfortable environment.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to provide services that met professional standards regarding the administration of medications for one resident. The clinical record review revealed that medications for this resident were administered outside the scheduled time frames on multiple occasions without documented rationale. The resident, who had intact cognition as indicated by a BIMS score of 15, had diagnoses including PTSD, psychotic disorder, and chronic pain. The facility's Medication Administration policy required medications to be administered at the right time, yet this was not adhered to. The undated facility form titled 'Medication Administration Times' specified time frames for medication administration, which were not followed. The Director of Nursing (DON) stated that staff were expected to administer medications within these time frames and document any deviations, especially for high-risk medications. However, the records showed that medications were given late on several dates, with no documentation explaining the delays or any notification to the physician, indicating a failure to meet professional standards of quality care.
Failure to Provide Adequate Hygiene and Incontinence Care
Penalty
Summary
The facility failed to provide or offer showers twice a week for a resident and did not provide incontinence care for three residents. Resident #3, who had a history of cerebral vascular accident and hemiplegia, was identified as occasionally incontinent and expressed that showers were very important to them. However, the facility's records showed that Resident #3 was not offered or provided a shower during specific periods in April and May 2024. Additionally, documentation for June 2024 lacked evidence of toileting hygiene being provided on multiple occasions. Resident #4, frequently incontinent and diagnosed with malnutrition and PTSD, had a care plan indicating a potential for impaired skin integrity. Despite this, the June 2024 documentation showed missing records of toileting hygiene on several dates. Similarly, Resident #6, who was occasionally incontinent and had diagnoses of diabetes mellitus and sepsis, also had missing documentation for toileting hygiene in June 2024. The Director of Nursing acknowledged the absence of a policy on bathing and incontinence care, stating that the staff was expected to follow industry standards for these services.
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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) |
|---|---|---|---|---|
| Martin Health Center, Inc | 1.2 mi | — | 0 | 0 |
| Newaldaya Lifescapes | 1.5 mi | — | 1 | 0 |
| The Suites At Western Home Communities | 3.2 mi | — | 1 | 0 |
| Pinnacle Specialty Care | 3.3 mi | — | 6 | 0 |
| Pillar Of Cedar Valley | 5.8 mi | — | 13 | 0 |
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