Inspection Reports for The Summit of Coralville
3 Russell Slade Blvd, Coralville, IA 52241, United States, IA, 52241
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 15, 2025, identified deficiencies related to inadequate care following an unwitnessed fall, incomplete individualized service plans, and missing nurse reviews after significant tenant health changes. Earlier inspections showed a pattern of issues with medication administration, staff training, incident reporting, service plan updates, and tenant safety, including elopements and falls. Deficiencies commonly involved medication management, staff training, and failure to update or complete service plans and evaluations. Several complaint investigations were substantiated, including cases involving tenant harm and lapses in care, but enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with care and documentation, with no clear improvement trend over time.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
34 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: May 15, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to provide care, treatment and services that were adequate and appropriate to Tenant C2, who had an unwitnessed fall and delayed EMS response.
Failure to develop a service plan reflecting the identified needs and preferences of Tenant #3, including use of assistive devices.
Failure to complete nurse reviews as needed for Tenant #1 and Tenant C1 after significant health changes and incidents.
Report Facts
Total census: 34
Tenants without cognitive impairment: 3
Tenants with cognitive impairment: 31
Incident time delay: 60
Calcium level: 11.3
Nurse review completion date: Jun 10, 2025
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 12
Date: Oct 5, 2023
Visit Reason
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.
Complaint Details
The visit was complaint-related, investigating Incident #111481-I involving an elopement and other tenant safety concerns.
Findings
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.
Deficiencies (12)
Failure to follow door alarm response and missing tenant policies resulting in an elopement without proper notification and evaluation.
Failure to complete timely nurse review and neurological checks after tenants sustained head injuries from falls.
Staff administering medications lacked a state-approved medication manager certificate at the time of medication pass.
Failure to document sliding scale insulin administration for a tenant.
Failure to provide nurse delegation training within 60 days of nurse employment for staff administering medications.
Failure to ensure dependent adult abuse training was completed within six months of employment for some staff.
Failure to request DHS evaluation prior to employment for a staff member with a criminal history record.
Failure to complete tenant evaluations as needed with significant change for multiple tenants.
Failure to document nurse's notes by exception in a timely manner for tenants with known illnesses or incidents.
Failure to update tenant service plans as needed to reflect significant changes, behaviors, and interventions.
Failure to provide orientation and annual in-service training on sanitation and safe food handling for food service staff.
Failure to provide eight hours of dementia-specific education within 30 days of employment for some direct care staff.
Report Facts
Total census: 29
Number of tenants without cognitive impairment: 6
Number of tenants with cognitive impairment: 23
Date of inspection: Oct 5, 2023
Number of tenants reviewed: 6
Number of staff reviewed for training: 6
Number of staff reviewed for medication delegation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Medication Aide | Observed administering medications without proper certification and training. |
| Staff A | Staff with criminal history record employed without DHS evaluation prior to hire. | |
| Staff B | Staff lacking dependent adult abuse training and dementia-specific education within required timeframes. | |
| Staff C | Staff lacking dementia-specific education within required timeframe. | |
| Staff D | Staff lacking annual food safety training. | |
| Staff E | Staff lacking dependent adult abuse training. | |
| Staff H | Staff involved in elopement incident and retrained on door alarm and missing resident policies. | |
| Staff I | Staff involved in elopement incident and retrained on door alarm and missing resident policies. | |
| Staff J | Staff involved in elopement incident; no longer employed. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 5
Date: Aug 24, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to follow established policy and procedure related to the completion of incident reports for current and discharged tenants.
Failed to provide a written notice for a tenant discharge as required by the occupancy agreement.
Failed to complete evaluations as needed with significant change for current and discharged tenants.
Failed to document nurse's notes timely and accurately for current and discharged tenants.
Failed to update service plans as needed with significant change for current and discharged tenants.
Report Facts
Number of tenants without cognitive disorder: 10
Number of tenants with cognitive disorder: 17
Total census: 27
Incident date: Aug 5, 2022
Incident date: Aug 14, 2022
Incident date: Sep 11, 2021
Discharge date: Sep 13, 2021
Weight loss percentage: 9.62
Incident date: Jun 22, 2022
Incident date: Aug 3, 2022
Incident date: Sep 24, 2021
Incident date: Oct 5, 2021
Inspection Report
Renewal
Census: 25
Deficiencies: 5
Date: Aug 19, 2021
Visit Reason
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.
Complaint Details
Complaints 93380-C and 94081-C were investigated as part of the visit.
Findings
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.
Deficiencies (5)
Failed to consistently ensure medications were administered by staff who successfully completed a department-approved medication aide/manager course.
Failed to consistently ensure tenants received medications as prescribed, including an incident where a tenant was given more insulin than ordered.
Failed to consistently ensure staff received training as required in identification and reporting of dependent adult abuse.
Failed to consistently perform criminal history and child/dependent adult abuse record checks prior to employment.
Failed to ensure staff received a minimum of eight hours of dementia-specific continuing education annually.
Report Facts
Census tenants with cognitive disorder: 25
Staff reviewed for medication training: 6
Tenants affected by medication training deficiency: 25
Tenants reviewed for medication administration: 4
Units of insulin overdose: 8
Staff reviewed for dependent adult abuse training: 3
Staff affected by dependent adult abuse training deficiency: 1
Staff reviewed for criminal and abuse record checks: 3
Staff affected by record check deficiency: 1
Staff reviewed for dementia-specific education: 3
Staff affected by dementia education deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to complete department-approved medication aide/manager course, failed to complete dependent adult abuse training, failed to complete required dementia-specific continuing education, and lacked criminal history and abuse record checks prior to employment. | |
| Staff B | Lacked documentation of dependent adult abuse training. | |
| Director | Confirmed staff had not completed medication administration requirements and acknowledged medication administration failures during exit interview. | |
| Executive Director | Confirmed lack of dependent adult abuse training documentation and record checks for staff. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 7
Date: Mar 2, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Program failed to complete a medication incident report when medication error was noted.
Program failed to complete a resident incident report when direct care staff had knowledge of fall occurring.
Program failed to complete Shift Narcotic Count documents in accordance with nurse delegation document regarding narcotic count.
Program failed to provide nurse delegated training that included all tasks including the administration of liquid and powder medications.
Program failed to administer medications as prescribed by a tenant's physician.
Program failed to complete assessments/evaluations within 30 days and annually.
Program failed to update service plans within 30 days of taking occupancy, as needed with significant change or annually.
Report Facts
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 7
Total census: 20
Date survey completed: Mar 2, 2020
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 3
Date: Sep 23, 2019
Visit Reason
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.
Complaint Details
The visit was triggered by complaints #84315-C and #84640-C. The findings substantiated medication errors and documentation deficiencies related to Tenant #1.
Findings
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.
Deficiencies (3)
Program failed to complete an incident report for 1 of 3 residents reviewed on two separate medication errors.
Program failed to ensure all medications administered were documented on the Medication Administration Record (MAR).
Program failed to ensure medications for 1 out of 3 tenants reviewed were administered as ordered by the physician.
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 14
Total census: 17
Medication errors reviewed: 3
Medication administration record gaps: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Contacted hospice regarding medication doses and involved in incident report discussions |
| Director of Nursing | DON | Reviewed medication administration records and confirmed medication errors and documentation gaps |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 4
Date: Mar 6, 2019
Visit Reason
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.
Complaint Details
Complaint #81231-C was investigated and found substantiated with multiple regulatory insufficiencies identified related to incident reporting, tenant care, staffing training, and service plans.
Findings
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.
Deficiencies (4)
Program policies and procedures related to incident reports were not followed, affecting 2 of 3 tenants reviewed.
Failure to provide adequate care, treatment, and services to tenants, specifically Tenant #1.
Staffing deficiencies including failure to document review and ensure staff were sufficiently trained within 60 days of hire.
Failure to develop individualized service plans reflecting tenant needs, specifically Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 10
Total census: 14
Date survey completed: Mar 6, 2019
Inspection Report
Original Licensing
Census: 10
Deficiencies: 0
Date: Dec 4, 2018
Visit Reason
Initial certification inspection conducted to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
No regulatory insufficiencies were cited during the initial certification inspection.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 9
Total census: 10
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