Inspection Reports for
The Summit of Coralville

Complaint #130037-C and Incident #130046-I

Multiple regulatory insufficiencies were cited including failure to follow incident report policies, inadequate and inappropriate care and services to tenants, medication administration errors, staffing failures including leaving a unit unattended resulting in tenant elopement, incomplete tenant evaluations and service plans, failure to document nurse's notes by exception, and failure to retain tenant records for three years after transfer or death.

The complaint investigation focused on the care provided to Tenant C2, who was found on the floor after a fall with delayed EMS notification and subsequent hospitalization leading to death. The investigation also reviewed service plans and nurse reviews for other tenants.

The facility failed to provide adequate and appropriate care to a discharged tenant who suffered an unwitnessed fall and subsequent complications leading to death. Additionally, deficiencies were found in individualized service plans and nurse reviews following significant changes in tenant health status or incidents such as falls.

The visit was complaint-related, investigating Incident #111481-I involving an elopement and other tenant safety concerns.

The program failed to follow policies and procedures related to door alarm response, missing tenant, and head injuries involving tenants who eloped or fell. Medication administration was not properly documented or performed by certified staff. Staff nurse delegation training and dependent adult abuse training were incomplete or late. Evaluations and service plans were not updated as needed for tenants with significant changes. Food service staff lacked required sanitation and food handling training. Dementia-specific education was not completed timely by some staff.

The program failed to follow its policies and procedures related to door alarm response, missing tenant, and head injuries. Tenant #1 eloped on 3/5/23 and staff did not thoroughly check outside the door that alarmed. The Executive Director was not notified until the next day, and no post-elopement evaluation was completed. The incident report lacked vital signs documentation and notifications to family and primary care provider were delayed.

The visit was complaint-related involving Incident #99882-I and Complaint #99962-C. The complaint investigation identified multiple regulatory insufficiencies including failure to complete incident reports, failure to provide discharge notice, incomplete evaluations, missing nurse's notes, and incomplete service plans.

The program failed to follow established policies for incident reporting, did not provide timely written discharge notice to a tenant, failed to complete evaluations and service plans as needed with significant changes, and did not maintain timely nurse's notes reflecting exceptions in care. Multiple incidents of tenant aggression, elopement, and injury were documented with inadequate follow-up documentation and care planning.

Complaints 93380-C and 94081-C were investigated as part of the visit.

The Program failed to ensure medications were administered by properly trained staff, failed to consistently administer medications as prescribed, failed to ensure staff received required dependent adult abuse training, failed to perform required criminal history and abuse record checks prior to employment, and failed to ensure staff received required dementia-specific continuing education.

Complaint #88150-C investigation revealed multiple regulatory insufficiencies related to medication incident reporting, resident incident reporting, narcotic counts, nurse training, medication administration, tenant evaluations, and service plans.

The investigation found multiple regulatory insufficiencies including failure to complete medication incident reports timely, incomplete resident incident reports, incomplete narcotic count documentation, inadequate nurse delegated training, failure to administer medications as prescribed, failure to complete tenant evaluations within required timeframes, and failure to update service plans within required timeframes.