Inspection Reports for The Summit of Coralville

The inspection was conducted related to the investigation of Complaint #126085-C concerning the adequacy and appropriateness of care, treatment, and services provided to tenants at the assisted living program.

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 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 inspection was conducted during the investigation of Incident #111481-I and the recertification visit to determine compliance with certification of a Dedicated Dementia Specific Assisted Living Program.

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

The investigation of Incident #99882-I and Complaint #99962-C was completed to identify regulatory insufficiencies related to incident reporting, tenant discharge notification, evaluations, nurse's notes, and service plans at the assisted living program.

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.

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.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. An onsite infection control survey and complaint investigations were also completed.

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.

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

The inspection was conducted as a result of Complaint #88150-C regarding regulatory insufficiencies related to medication incident reporting, resident incident reporting, narcotic count documentation, nurse delegated training, medication administration, tenant evaluations, and service plan updates.

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.

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 inspection was conducted as part of an investigation of Complaints #84315-C and #84640-C regarding regulatory insufficiencies in the Assisted Living Program for People with Dementia.

The program failed to complete incident reports for medication errors and failed to ensure all medications administered were properly documented on the Medication Administration Record (MAR). Specific medication errors and documentation gaps were identified for Tenant #1.

The visit was triggered by complaints #84315-C and #84640-C. The findings substantiated medication errors and documentation deficiencies related to Tenant #1.

The investigation of Complaint #81231-C was conducted to evaluate regulatory insufficiencies related to program policies and procedures, tenant rights, staffing, and service plans at Grand Living at Bridgewater ALP.

The inspection found multiple deficiencies including failure to follow policies and procedures for incident reports, inadequate care and treatment for tenants, insufficient staff training within required timeframes, and failure to develop appropriate service plans reflecting tenant needs.

Complaint #81231-C was investigated and found substantiated with multiple regulatory insufficiencies identified related to incident reporting, tenant care, staffing training, and service plans.

Initial certification inspection conducted to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).

No regulatory insufficiencies were cited during the initial certification inspection.