Woodland Terrace

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

have any lingering effects. Staff A was just outside the room, so she went to the doorway of Resident #1's room and called Staff A in. Staff C voiced Staff A assisted her to stand the resident. Staff C washed Resident #1 up and put a new brief on her. Then Staff A assisted the resident back into bed. Staff C finished doing rounds on three more residents in the dementia unit. After she completed rounds and emptied the garbage, she went to Staff A and said, yo, I tapped Resident #1 on the head. She had spaced off reporting it earlier. Staff C stated she had tapped Resident #1 on the head without thinking about it. She was scared that if someone swung at her, she might swing back in a reaction. She got scared. It was just a reaction that happened. The Dependent Adult Abuse Prevention Policy, revised 11/03/23, included the following definitions:a. Staff: includes employees.b. Abuse: is the willful inflection of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal, physical and mental abuse. c. Willful: means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. d. Physical injury to, or injury which is at a variance with

the history given of the injury, unreasonable punishment, or assault of a dependent adult which involves a break of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances. The Policy directed the Resident Rights would be posted and resident's or resident representative would be given a copy of the resident right statement and an explanation of their right on admission and annually thereafter.

The Facility Resident [NAME] of Rights documented as a resident of the facility, you have the right to a dignified existence. This facility must treat you with respect and dignity and care for you in a manner and in

an environment that promotes maintenance or enhance of your quality of life. You have the right to be treated with dignity and respect.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Terrace

1922 Fifth Avenue NW Waverly, IA 50677

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

that morning. Staff A verbalized she did not go do a physical head to toe assessment on any other residents after the incident with Resident #1. Staff A further explained they verbally designate a certain wing for each CNA in the unit when they come on shift for rounds, but if there is a call light or a need the aide may work other hallways/rooms. Staff C worked the A hallway that night. Staff A voiced there were no residents that have the mental capacity to report if something happened to them in the unit. None of the residents have a high enough BIMS (Brief Interview for Mental Status, is a screening tool used in long-term care facilities to assess a resident's cognitive function. The score helps staff to detect early symptoms of cognitive decline) score for that. During an interview on 8/26/25 at 11:31 AM Staff J, DON reported she and Staff B, DON interviewed Staff A and other staff after the incident with Resident #1. When questioned why

the facility investigation did not have any documentation of any other staff interviews, Staff J responded

they had done a lot of investigations lately, so maybe they didn't talk to the staff. If they would have talked to other staff, then it would have been documented in the investigation. Staff J further reported no other residents were assessed that night/day after the incident with Resident #1. Staff J reviewed the resident roster for the dementia unit and stated possibly Resident #6 may be able to remember, but that would be giving a lot of the benefit of the doubt, after further review, Staff J stated there weren't really any residents that would be able to recall if something had been done to them. In the moment they all felt it was an isolated incident, so no head to toe assessments were done on residents (in the dementia unit). They never did any resident interview for other areas that Staff C had worked to ask about resident treatment. Interview completed on 8/26/25 at 11:50 AM Staff B voiced she didn't believe that any other residents back on the unit were assessed after resident #1's incident. Staff C admitted she tapped Resident #1 on the head. They didn't believe they had any reason to think any other residents were affected. Staff B reviewed the list of residents residing in the dementia unit. She responded, probably not, when asked if any of the residents could report if they had been mistreated. Staff B verbalized they had not done any other resident interviews

in other areas that Staff C had worked to see if any other residents had been affected. An interview on 8/27/25 at 11:12 AM Staff J explained when there is suspected abuse, she expects the nurse to assess the resident involved, complete an incident report, notify the physician and the family. When they do investigations, they just do them off the top of their head. They do not have any investigation checklist or tools to use. It would be nice to be able to ensure they are covering everything and that all departments are doing what they need to do for an investigation. During an interview on 8/27/25 at 11:34 AM the Administrator voiced the DON's do the investigations and it gets to be a lot so they have one person take lead on the investigation. She considers the investigation for Resident #1 closed at this time. She would have expected the nurse to look at other residents. In hindsight, it would have been good to go back and look at the residents that Staff C had contact with, especially residents that required one assist as Staff would have been the only resident in the room with them. The investigation was lacking because Staff C admitted what happened and the DON's thought it was an isolated situation. They are reviewing and will be making changes going forward. The Dependent Adult Abuse Prevention Policy, revised 11/03/23, included

the following definitions:a. Staff: includes employees.b. Abuse: is the willful inflection of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal, physical and mental abuse. c. Willful: means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. The Dependent Adult Abuse Prevention Policy, under Procedure directed, a thorough investigation would be implemented.

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Facility ID:

If continuation sheet