Inspection Reports for Stirlingshire of Coralville
1140 Kennedy Pkwy, Coralville, IA 52241, IA, 52241
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a pattern of deficiencies related primarily to tenant care, medication administration, service plan updates, and safety measures such as door alarms in the memory care unit. Prior reports also noted issues with staffing levels, management of aggressive tenants, and incomplete documentation, with one inspection citing a choking incident that resulted in a tenant’s death. Complaint investigations were mostly substantiated in earlier years, though the most recent investigation found no regulatory insufficiencies. The trend suggests some improvement in compliance, as recent inspections have not identified new deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
20 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to investigate Complaint #127646-C at the assisted living facility.
Complaint Details
Investigation of Complaint #127646-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive impairment: 2
Number of tenants with cognitive impairment: 18
Total census: 20
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 5
Date: Oct 31, 2024
Visit Reason
The inspection was conducted related to the investigation of Complaint #121004-C concerning regulatory insufficiencies in care and services at an assisted living program for people with dementia.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to provide care, treatment and services that were adequate and appropriate, including failure to follow diet orders leading to a choking incident and death of Tenant C1.
Failure to administer medications as prescribed for 7 current tenants and 4 discharged tenants, including insulin sliding scale errors and missed medication doses.
Failure to complete tenant evaluations as needed with significant change for 4 current tenants and 1 discharged tenant.
Failure to update service plans as needed for 5 current tenants and 2 discharged tenants to reflect changes in tenant status and behaviors.
Failure to have an operating alarm system connected to each exit door in the dementia-specific program, including unalarmed patio door and non-audible alarms on other doors.
Report Facts
Total census: 19
Number of tenants without cognitive impairment: 3
Number of tenants with cognitive impairment: 16
Number of falls for Tenant #1 after last evaluation: 10
Number of medication administration errors for Tenant #1: 50
Number of times medications were not administered or documented for various tenants: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Kubik- Hasley | Executive Director | Signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 3
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to investigate complaints and conduct a recertification visit to determine compliance with certification rules for a Dementia-Specific Assisted Living Program.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to provide a sufficient number of trained staff to meet the needs of tenants, including assistance with housekeeping and toileting.
Retained a tenant who was physically aggressive towards tenants and staff despite interventions, resulting in injuries and emergency room visits.
Failed to include identified needs and preferences for services in the service plans for tenants, including addressing inappropriate behaviors and family concerns.
Report Facts
Total census: 14
Number of tenants with cognitive impairment: 14
Number of tenants without cognitive impairment: 0
30-day discharge notice date: Feb 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Kubik-Hasley | Executive Director | Signed the Plan of Correction and confirmed findings with the DON. |
| Director of Nursing (DON) | Confirmed findings, involved in interventions and care planning for tenants. |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 7
Date: Jul 31, 2023
Visit Reason
The inspection was conducted as part of an investigation into multiple complaints and incidents related to regulatory insufficiencies at the Assisted Living Program for People with Dementia at Stirlingshire of Coralville MC.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Program failed to follow established policies and procedures related to door alarms and missing person/elopement for 2 tenants, incomplete incident reports for a tenant with a fall and fracture, and safety checks affecting all tenants in memory care.
Program failed to provide adequate care, services, and treatment for 6 of 6 current tenants and 1 discharged tenant, including pain management and dressing of wounds.
Program failed to complete evaluations as needed with significant change for 1 tenant with weight loss.
Program failed to follow admission and retention criteria for 1 tenant who required two-person assistance with transfers.
Program failed to maintain documentation for incident reports involving tenants, including medication errors, accidents, falls, and elopements for 1 of 2 discharged tenants.
Program failed to update service plans as needed for 5 current tenants and 2 discharged tenants to reflect individual care needs.
Program failed to conduct nurse reviews for significant changes in condition and to ensure medication orders were current and administered properly for 1 current tenant and 1 discharged tenant.
Report Facts
Number of tenants with cognitive disorder: 19
Number of tenants without cognitive disorder: 0
Number of tenants reviewed with deficiencies: 6
Number of tenants reviewed with incomplete evaluations: 1
Number of tenants requiring two-person assistance: 1
Number of tenants with incomplete incident reports: 1
Number of tenants with incomplete service plans: 5
Number of discharged tenants with incomplete service plans: 2
Number of tenants with incomplete nurse reviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to follow policy and procedure for door alarms and elopement incidents | |
| Executive Director | Interviewed regarding tenant elopements and staff compliance with door alarm policy | |
| Staff B | Interviewed regarding stairwell door alarm and tenant care | |
| Staff D | Interviewed regarding stairwell door alarm and tenant care | |
| Staff E | Interviewed regarding stairwell door alarm and tenant care | |
| Staff F | Interviewed regarding stairwell door alarm and tenant care | |
| Staff G | Interviewed regarding tenant care and condition | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding tenant care, hospice, and staff education |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
Investigation into Incident #107646-I and Complaint #101578-C at the assisted living program for people with dementia.
Complaint Details
Investigation into Incident #107646-I and Complaint #101578-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 5
Total census: 5
Inspection Report
Original Licensing
Census: 2
Deficiencies: 3
Date: Nov 1, 2021
Visit Reason
The inspection was conducted as an initial certification to determine compliance with certification for a Dementia-Specific Assisted Living Program and to investigate Incident #100419-I and Incident #100370-I.
Findings
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.
Deficiencies (3)
Failure to provide adequate and appropriate services for one tenant, including incomplete incident report and delayed evaluations after elopement.
Two of six staff did not complete required dependent adult abuse training within six months of employment.
Six staff responsible for food service did not receive required orientation on sanitation and safe food handling prior to handling food.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 1
Total census: 2
Staff reviewed for dependent adult abuse training: 6
Staff not compliant with dependent adult abuse training: 2
Staff reviewed for food service orientation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings for failure to complete dependent adult abuse training and food service orientation; involved in tenant elopement incident. | |
| Staff C | Named in findings for failure to complete dependent adult abuse training and food service orientation. | |
| Staff B | Mentioned in relation to tenant elopement incident and staff response. | |
| Staff I | Mentioned in relation to tenant elopement incident and staff response. | |
| Staff J | Mentioned in relation to tenant elopement incident and staff response. | |
| Staff D | Named in findings for failure to complete food service orientation. | |
| Staff E | Named in findings for failure to complete food service orientation and involved in tenant assessment after elopement. | |
| Staff F | Named in findings for failure to complete food service orientation. | |
| Staff H | Named in findings for failure to complete food service orientation. | |
| Executive Director | Executive Director | Provided statements and confirmed findings; named in Plan of Correction. |
| Clinical RN | Clinical Registered Nurse | Involved in tenant elopement incident and assessment. |
| Maintenance Director | Maintenance Director | Checked door alarm functionality after tenant elopement. |
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