Inspection Reports for
Stirlingshire of Coralville

Complaint #130582-C and Incidents #130776-I, #130914-I, and #131096-I were investigated during this recertification visit.

Multiple regulatory insufficiencies were cited related to program policies and procedures, tenant rights, staffing, record checks, service plans, and life safety emergency policies. The facility failed to follow established policies and procedures related to door alarms and elopement, failed to provide adequate care and services, failed to maintain sufficient staffing, failed to conduct required background checks, failed to update service plans, and failed to maintain an operating door alarm system.

Investigations of complaints #130582-C, #130776-I, #130914-I, and #131096-I were conducted during the recertification visit.

The program failed to provide adequate and appropriate care to tenants, failed to maintain sufficient trained staffing to meet tenant needs, and failed to have an operating door alarm system in the dementia-specific program. Multiple incidents of tenant elopement and inappropriate tenant interactions were documented.

Investigation of Complaint #127646-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation of the complaint.

The visit was triggered by Complaint #121004-C. The complaint involved concerns about tenant care, including a choking incident resulting in death, medication administration errors, failure to complete evaluations and update service plans, and safety issues with exit door alarms.

The Program failed to provide adequate and appropriate care, including failure to follow diet orders leading to a choking incident and death, failure to administer medications as ordered for multiple tenants, failure to complete evaluations and update service plans as needed with significant changes, and failure to maintain operating door alarms on all exit doors in the memory care unit.

The program failed to ensure Tenant C1's diet order for cut-up food was followed, resulting in the tenant choking on uncut brussels sprouts. Staff were unaware of the tenant's Do Not Resuscitate (DNR) status at the time of the emergency, leading to CPR being performed despite the tenant's hospice and DNR status. Corrective actions included reorganization of tenant charts and re-education of staff on locating code status paperwork.

The visit was triggered by complaints and investigations identified by case numbers 118974-C, 117278-I, and 115633-I. The investigation found substantiated issues including insufficient staffing, retention of a dangerous tenant, and inadequate service plans.

The program failed to provide sufficient trained staff to meet tenant needs, retained a physically aggressive tenant despite interventions, and failed to include identified needs and preferences in service plans for some tenants. Housekeeping and safety concerns were noted, including inadequate assistance with toileting and housekeeping tasks, aggressive behaviors resulting in injuries, and inappropriate tenant interactions.

The program retained a tenant who was physically aggressive towards other tenants and staff despite multiple interventions and incidents documented over several months. The tenant caused injuries to other tenants and staff and required a 30-day discharge notice.

The investigation was triggered by complaints #111997-C, #113995-C and incidents #112609-I, #112824-I, #113143-I, and #111744-I. Regulatory insufficiencies were cited during this investigation.

The program failed to follow established policies and procedures related to door alarms, missing person/elopement incidents, and safety checks for tenants. Care and treatment were inadequate for several tenants, including failure to complete evaluations, service plans, and incident reports. Multiple tenants experienced falls, injuries, and elopements, with staff not following proper protocols. Documentation and monitoring were deficient, and staff education and corrective actions were planned.

Investigations 112712-I, 112824-I, 113143-I, 113995-C

The Program failed to provide adequate care and treatment to Tenant C1, including pain management, wound care, and oral care, resulting in hospitalization and death. The Program also failed to follow policies related to door alarms and elopement for tenants #3 and #4, did not complete an incident investigation report for Tenant #5's fall with injury, and had multiple omissions in required hourly safety checks affecting all memory care tenants.

Investigation into Incident #107646-I and Complaint #101578-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation.

The Program failed to provide adequate and appropriate services for one tenant who eloped from the facility, with issues including incomplete incident reporting and delayed evaluations. Additionally, deficiencies were found in staff training related to dependent adult abuse and food service sanitation and safety orientation.

Incident #100149-I

The program failed to provide adequate supervision and safety measures for Tenant #1, who eloped from the facility and was missing for approximately 29 minutes. The incident report was incomplete and unsigned, and evaluations related to the significant change in the tenant's condition were delayed. The door alarm was not properly monitored, and staff did not respond promptly to the alarm.