Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windmill Manor during CMS and state inspections, most recent first.
Unsafe Laundry Handling and PPE Use: Laundry staff transported clean laundry in an uncovered cart, with clothing hanging outside the cart and touching a hallway handrail, then mixed dirty clothing with clean clothing during delivery to resident rooms. Staff also handled laundry from a room under EBP and left the cart uncovered during the observation. In the laundry room, staff sorted soiled laundry wearing gloves but no gown, despite the supervisor stating gloves and gowns were required.
Food service was inconsistent, with hot items observed at varying temperatures and a test tray showing pork entrees and pureed pork below the facility’s stated hot-holding range. A resident with intact cognition reported lunch arrived after 1:00 PM and was cold, while another resident with dysphagia and severe vascular dementia reported pureed food was overcooked, flavorless, and cold. The DM also stated the meal service was too slow and unorganized and that temperature logging was not being completed.
Kitchen sanitation, food dating, and log completion failures. Surveyors found sticky floors, crumbs, debris on shelving, food particles in the microwave and on the grill, a dirty heat cart, and multiple opened food items in the pantry and refrigerator with no dates or expired dates. The Dietary Manager stated the kitchen had been without a manager for about a month and a half, and the cleaning schedule and temperature/sanitizer logs were not completed.
An unlocked medication cart was left accessible during med pass near the dining room. A CMA walked away from the cart multiple times while administering meds, leaving all drawers unlocked, including the narcotics lock. The CMA said she left it unlocked because the cart stayed in sight and she did not want to keep locking and unlocking it between residents. An LPN, the DON, and the Administrator stated the cart should be locked at all times, and facility policy required meds to be stored in locked mobile med carts.
Failure to Report and Investigate Alleged Visitor Abuse: A resident with dementia and a BIMS score of 8/15 was involved in two incidents where a visitor stepped on his foot and told him to shut up, and later a family member became aggressive during care. An RN did not intervene during the first event, and the facility could not provide evidence of an investigation or APS report for either allegation, despite staff stating that abuse involving a visitor would be reported and investigated.
Failure to revise a resident’s care plan to address safety with a visitor after allegations of abuse were identified. The resident had dementia, weakness, and a BIMS score of 8/15. The record showed two incidents in which the same visitor acted aggressively toward the resident, including stepping on the resident’s foot and yelling at him, and later becoming aggressive during care. The care plan did not include a problem area for visitor-related safety, and the SW was unsure what interventions had been implemented.
A resident with dysphagia and severe vascular dementia was ordered a regular diet when supervised and a pureed diet when unsupervised, but was served a mixed/soft and pureed lunch while being supervised in her room. The resident said she usually ate in her room and did not want pureed food, while the Speech Therapist said dietary provided pureed food even though she requested regular texture. The DON stated the resident coughed with regular consistency food and would only accept supervision from the Speech Therapist.
A resident with a lung transplant missed four doses of essential antirejection medications when Azathioprine and Tacrolimus were not available in the facility. Medication administration records showed missed doses due to unavailability, and staff interviews revealed delays in reordering, lack of timely follow-up with the pharmacy, and insufficient documentation or physician notification regarding the missed doses.
A CNA failed to use a gait belt while assisting a resident with moderate cognitive impairment and mobility deficits during a bathroom transfer. The resident fell and sustained a left arm and wrist fracture. Facility policy required gait belt use for all transfers, and the CNA had received training on this procedure. The incident occurred because the CNA did not see a gait belt available in the room and did not use one, leading to the resident's injury.
A resident with multiple mental health diagnoses remained in the facility beyond the 60-day limit specified in their PASARR approval, but the required resubmission was not completed. The Social Services Director was unaware of the need to update time-limited PASARRs, and facility policy requiring resubmission for extended stays was not followed.
The facility failed to implement care plans for two residents, resulting in medication errors. A resident with depression and anxiety did not receive Clonazepam as prescribed, leading to increased anxiety and an ER visit. Another resident with chronic pain received an incorrect dosage of Lyrica. The facility's care plan policy was not followed.
The facility failed to follow physician orders for three residents, resulting in medication errors. A resident with anxiety and depression did not receive Clonazepam as prescribed, leading to increased anxiety and an ER transfer. Another resident received an incorrect dosage of Lyrica, and a third resident was given medications meant for someone else. Interviews confirmed the expectation for staff to adhere to physician orders.
A resident with a history of pulmonary embolism and on anticoagulant medication reported blood in her stool and requested a hospital transfer, which was denied by an LPN. Despite clear communication and distress, the resident's request was dismissed, and her family was not informed. The resident was eventually transported to the hospital the next morning for possible gastrointestinal bleeding.
A resident on anti-coagulants experienced diarrhea and rectal bleeding, expressing a desire to go to the hospital. Despite clear symptoms and requests, the LPN did not act promptly, leading to a delay in care. CNAs observed the resident's condition worsening and eventually insisted on calling an ambulance. The resident was later found to have a significant blood clot and decreased hemoglobin levels at the hospital.
A resident with severely impaired cognition experienced multiple falls resulting in serious injuries, including fractures, due to the facility's failure to implement and modify safety interventions. The resident's care plan did not adequately address cognitive status, and there was a lack of documentation for incident reports. The facility's emergency care procedures were not effectively followed, contributing to the deficiency.
The facility was cited for deficiencies in kitchen cleanliness and food handling, including soiled surfaces, improper food storage, and inadequate hand hygiene. Flies were present in the kitchen, and staff failed to follow proper glove use and food handling protocols. Refrigerators were found at incorrect temperatures, and facility policies on sanitation and fly prevention were not followed.
The facility failed to maintain correct temperatures for food and drink during meal service. Observations showed milk, chocolate milk, fortified milk, half-and-half creamer, and potato salad were above the required cold temperature of 41°F. Drinks were not served on ice, and post-meal checks confirmed the temperature issues. The Food Service Supervisor expected cold items to be at 34-35°F, as per the facility's policy.
A resident with severe cognitive impairments was not kept in clean clothes or with a clean face after meals, despite requiring assistance. Observations showed the resident repeatedly left in soiled clothing without staff intervention. Interviews revealed inconsistencies in care, with staff sometimes avoiding attempts to clean the resident due to resistance. The facility's policy on resident rights was not upheld.
The facility failed to provide adequate incontinent care for three residents, as observed during a survey. A resident with severe cognitive impairment did not have a care plan intervention for incontinent care, and a CNA failed to cleanse all necessary areas. Another resident with mild cognitive impairment received care that did not include cleansing the hips. A third resident with intact cognition had a care plan lacking direction for post-incontinence care, and CNAs failed to wash the front peri area. The DON confirmed that expected procedures were not followed.
The facility failed to effectively implement its QAPI process, resulting in repeated deficiencies related to Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. Despite having a QAPI Plan that included monitoring and root cause analysis, the same issues were identified in both current and previous surveys, indicating ineffective resolution of these problems.
Unsafe Laundry Handling and PPE Use
Penalty
Summary
The facility failed to ensure laundry was processed and transported in a safe and sanitary manner in a hallway serving 31 residents and in the laundry room. During a continuous observation starting at 1:30 PM on 04/07/2026, Laundry staff delivered clean laundry in Hall 100 using a cart covered with a bed sheet, but three pieces of clothing hung outside the cart and touched the handrail in the hallway. The staff removed the cover sheet, bundled it up, and placed it on top of the cart. While carrying clean clothes on hangers into a resident's room, the staff brushed against her scrub top. At 1:37 PM and again at 1:39 PM, the staff removed dirty clothing from a resident room and placed it in the cart with the clean clothing. At 1:42 PM, the staff removed dirty clothing from a room under Enhanced Barrier Precautions and placed it on top of clean clothing in the cart. The clean clothing cart remained uncovered during the observation, which ended at 2:05 PM. The facility also failed to ensure appropriate PPE was worn when soiled laundry was sorted. During an observation on 4/8/2026 at 9:25 AM, Laundry staff sorted laundry wearing gloves but no gown. The Housekeeping and Laundry Supervisor stated staff should wear gloves and gowns when sorting laundry, and the Laundry staff later stated she should have been wearing a gown and gloves. Facility policy titled Laundry and Linens Department Policy, dated 03/2024, directed the Laundry Supervisor to ensure the department complied with established standards, and the Infection Control policy dated 12/17/2019 directed the facility to follow standard precautions including hand hygiene, proper use of PPE, and care of laundry.
Meals Served at Improper Temperature and Poor Quality
Penalty
Summary
Food and drink were not consistently served at a safe, appetizing temperature and were not always palatable. During the noon meal observation, staff took temperatures of the pork entree and pureed pork at 171 F and 166 F, respectively. Later, a test tray for the State Agency showed the pureed pork at 113 F and the pork entree at 135 F, and the pork entree was described as lukewarm upon taste test. The Dietary Manager stated that hot foods should be served between 145 F and 165 F, and also reported that no food temperature had been entered in the April 2026 log book and that the service was too slow and unorganized. Resident interviews reflected concerns with meal timing, temperature, and quality. A resident with intact cognition reported lunch was not served until after 1:00 PM and was cold. Another resident with dysphagia and severe vascular dementia with psychotic disturbances reported the pureed food was overcooked, had no flavor, and was cold; the resident usually ate in the room. During observation, that resident received lunch at 1:08 PM. The Dietary Manager also stated the process for logging food temperatures and dishwasher temperatures needed to change, and identified cleanliness, staff training, and consistency as areas needing improvement.
Kitchen sanitation, food dating, and log completion failures
Penalty
Summary
The facility failed to maintain kitchen equipment and floors in a clean and sanitary manner and failed to ensure food items were properly dated and expired items discarded. During a continuous observation of the kitchen, surveyors found a wet brown substance on the dry pantry floor, a sticky floor, visible crumbs on the kitchen floor, dry food and debris on shelving, food particles and a brown substance inside the microwave, a crusty and sticky heat cart, and a grill that still had particles from breakfast with a dirty grill scraper stored above it. In the dry pantry, opened items including a low-calorie punch drink, a container of unidentified white powder, and a bag of crispy fried onions had no open dates. In the refrigerator, the temperature log was blank for several days, a container of soy sauce was opened without an open date, and an outdated pureed dessert dated 3/29/26 was present. The dishwasher temperature and sanitizer logs and the April food temperature logs were also not completed. During interview, the Dietary Manager stated it was her first day and that the kitchen had not had a manager for about a month and a half. While reviewing the kitchen, she acknowledged an expired open container of bread crumbs and an open bag of pasta with no date, and removed and discarded both items. She also acknowledged the current cleaning schedule, which showed none of the cleaning tasks had been signed off for the month. Review of the facility policy titled Sanitation and Safety stated that its purpose was to prevent food contamination and food poisoning and that all daily and scheduled cleaning would be maintained.
Unlocked Medication Cart During Medication Pass
Penalty
Summary
The facility failed to properly store and secure resident safety and accessibility of a medication cart during medication pass near the main dining room. During a continuous observation on 04/06/2026, Staff J, CMA positioned the medication cart in the living room about 20 feet from the dining room. At 4:18 PM, Staff J walked away from the cart to administer medication and left all eight drawers unlocked, including the first lock to the narcotics. At 4:40 PM and again at 4:50 PM, Staff J again walked away from the cart to administer medication to a resident in the dining room, and the cart remained unlocked. During interview, Staff J stated she typically locked the medication cart when she walked away, but because she was going from the living room across to the dining room and the cart remained in her sight, she did not lock it. She also stated that when administering medications to residents in the dining room she would have to constantly lock and unlock the cart, so she did not lock it between residents. Staff K, LPN, stated the medication cart should be locked at all times, even if a nurse administered medications without leaving the room, and said that if she positioned the cart in the living room and administered medications to residents in the dining room, the cart would be locked. The DON and Administrator also stated that medication carts must be locked at all times and staff should never walk away and leave a cart unlocked. Facility policy required resident medications to be stored in one or more locked mobile medication carts.
Failure to Report and Investigate Alleged Visitor Abuse
Penalty
Summary
The facility failed to implement its abuse prohibition and reporting policy for a resident with diabetes, non-Alzheimer's dementia, weakness, and a BIMS score of 8 out of 15, indicating moderately impaired cognition. Review of the electronic health record showed that during a 5/17/25 nursing note, a visitor became upset during a visit, stepped on the resident's foot, and told him to shut up, while the RN documented that he chose not to intervene at the time to avoid escalating the situation. The note stated he later wanted to formally report the visitor's inappropriate behavior toward the resident. A second nursing note dated 2/14/26 documented that a nurse observed a family member getting aggressive with the resident due to the resident refusing care and educated the person to leave the room if unable to keep composure during cares. The facility could not provide additional information regarding an investigation or report to adult protective services for either incident. Staff interviews showed the DON, Assistant Administrator, RN, and Administrator each described that physical abuse or allegations of abuse involving a visitor would be reported and investigated, but the facility was unable to show that this occurred for the incidents reviewed. The facility policy required staff who became aware of alleged abuse or neglect to immediately report it to the Administrator and required the Administrator to provide initial notice to the Iowa Department of Inspection and Appeals, but the policy did not specifically address visitor-to-resident allegations of abuse.
Failure to Update Care Plan for Visitor Safety
Penalty
Summary
The facility failed to revise Resident #72’s care plan to address safety with visitors after allegations of abuse had been identified. Resident #72’s MDS listed diagnoses of diabetes, non-Alzheimer’s dementia, and weakness, and his BIMS score was 8 out of 15, indicating moderately impaired cognition. Review of the care plan showed no problem area addressing safety with visitors related to the prior allegations. The EHR documented two incidents involving the same visitor. On 5/17/25, a nursing note stated that during a visit the resident yelled at the visitor, the visitor became upset, stepped on the resident’s foot, and told him to shut up, and the nurse did not intervene at that time but wanted to formally report the visitor’s inappropriate behavior. On 2/14/26, another nursing note stated a nurse observed the visitor becoming aggressive with the resident due to refusal of care and educated the visitor to leave the room if she could not keep her composure. During interview, the social worker stated the visitor was very involved in the resident’s care and that after one report to adult protective services there had been a care conference with the visitor, but she was not sure what interventions the facility implemented regarding the resident’s safety and the visitor. The facility policy stated the comprehensive person-centered care plan would include the resident’s mental and psychosocial needs and incorporate changes into the care plan.
Inconsistent Diet Texture Served Despite Physician Order
Penalty
Summary
The facility failed to ensure that Resident #86 received food in the consistency ordered by the physician. The resident’s MDS dated 3/10/26 identified dysphagia and severe vascular dementia with psychotic disturbances, with a BIMS score of 12 indicating moderate cognitive impairment. The physician order dated 3/30/26 directed a regular diet when supervised and a pureed diet when unsupervised, and the care plan dated 3/20/26 reflected the same approach based on whether the resident ate in the dining room or in her room. During interview, the resident stated she usually ate in her room and did not want pureed food, describing it as over-cooked and without flavor. On 4/7/26, the Speech Therapist brought the resident lunch to her room while supervising the meal, but the resident was served pot roast in a soft mixed form, mashed sweet potatoes, pureed cauliflower and broccoli, and a pureed fruit cobbler dessert. The Speech Therapist reported she had asked dietary for a regular diet but was given pureed food. The DON stated the resident coughed with regular consistency food and was not safe, and that the resident refused to eat in the dining room, near the nurse’s station, or with anyone other than the Speech Therapist supervising her meals.
Missed Doses of Antirejection Medications Due to Unavailable Medication and Inadequate Follow-Up
Penalty
Summary
A deficiency occurred when a resident with a history of lung transplant and severe protein calorie malnutrition missed four doses of critical medications, specifically Azathioprine and Tacrolimus, due to the medications not being available in the facility. The resident was admitted after hospitalization and required ongoing antirejection medications as part of their care plan. Medication administration records showed that doses were not given on multiple occasions, with the reason documented as 'Drug/Item unavailable.' Nursing documentation and staff interviews revealed that there was a lack of timely reordering and follow-up with the pharmacy to ensure medication availability. The pharmacy confirmed that refills for certain medications were not requested by the facility in time, and when a STAT delivery was requested, there was no documentation of delivery confirmation or further follow-up when the medication did not arrive. Additionally, there was no documentation in the electronic health record of attempts to obtain the unavailable medications or of physician notification regarding the missed doses at the time they occurred. Staff interviews indicated that communication and documentation protocols were not consistently followed. Nurses and medication aides reported notifying each other about the missing medications, but did not always document their actions or notify the physician as required. The Director of Nursing stated that nurses are expected to persistently follow up with the pharmacy and notify leadership if medications are not delivered, but this did not occur in this instance, resulting in missed doses of essential antirejection medications for the resident.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while assisting a resident with a transfer in the bathroom, despite facility policy requiring its use for all transfers unless contraindicated and documented in the care plan. The resident, who had moderate cognitive impairment and required extensive assistance with transfers, was using a front-wheeled walker and was being assisted by the CNA. During the transfer, the resident tripped and fell backward after washing her hands, resulting in both the resident and the CNA landing on the floor. The CNA admitted to not using a gait belt because one was not immediately visible in the room. The incident led to the resident sustaining a closed nondisplaced fracture of the left radius, requiring emergency room evaluation and immobilization with a sling and splint. Review of the resident's care plan confirmed the need for extensive assistance and use of a walker, and facility policy mandated gait belt use for all transfers. Staff interviews and personnel records indicated the CNA had received training on gait belt use, and the expectation to use a gait belt was reiterated by the Director of Nursing. The failure to follow established policy and training directly contributed to the resident's fall and injury.
Failure to Resubmit PASARR for Resident with Extended Stay
Penalty
Summary
The facility failed to re-submit a Pre-Admission Screening and Resident Review (PASARR) for a resident with mental health diagnoses, including anxiety disorder, bipolar disorder, and delusional disorders, who remained in the facility beyond the 60-day limit specified in the original PASARR approval. Clinical record review showed that the resident's PASARR allowed for a stay of up to 60 days, after which a status change Level 1 was required if the resident was not discharged. Interviews with the Social Services Director revealed a lack of awareness regarding the need to resubmit time-limited PASARRs when the resident's stay exceeded the approved period or when there was a new mental health diagnosis. The facility's policy also directed that PASARRs for short-term approvals must be resubmitted if the resident remained after the designated timeframe, but this was not followed.
Failure to Implement Care Plans Leads to Medication Errors
Penalty
Summary
The facility failed to implement care plans for two residents, leading to medication errors and adverse outcomes. Resident #3, who had depression and anxiety, was prescribed Clonazepam 1 mg to be taken three times a day. However, the facility staff failed to administer the medication as ordered on two consecutive days, resulting in increased anxiety for the resident and necessitating a transfer to the emergency room. This oversight was confirmed by the resident during an interview. Resident #2, who suffered from acute and chronic pain due to a traumatic fracture of the T10 vertebrae, was administered an incorrect dosage of Lyrica. The staff gave 150 mg instead of the prescribed 100 mg, as noted in a medication error report. The facility's care plan policy, revised in June 2022, mandates the development and implementation of comprehensive care plans with measurable objectives and time frames to meet residents' needs, which was not adhered to in these cases.
Medication Errors and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to medication errors and adverse outcomes. Resident #3, diagnosed with anxiety, depression, bipolar disorder, delusional disorders, and alcohol dependence, did not receive the prescribed Clonazepam 1 mg three times a day on two occasions, resulting in increased anxiety and an emergency room transfer. This was confirmed by the resident during an interview. The care plan for Resident #3 indicated the need for Clonazepam to manage depression and anxiety, but the staff did not follow through with the administration as ordered. Resident #2 received an incorrect dosage of Lyrica, being administered 150 mg instead of the prescribed 100 mg, although no side effects were reported. The care plan for Resident #2 highlighted the need for pain management due to chronic back pain and a recent traumatic fracture. Additionally, Resident #1 was mistakenly given medications prescribed for another resident, including Atorvastatin, Senna, and Tamsulosin, with no documented side effects. Interviews with the interim administrator and the resident's provider confirmed the expectation that staff should follow physician orders as written, as per the facility's pharmaceutical procedures policy.
Failure to Respect Resident's Right to Hospital Transfer
Penalty
Summary
The facility failed to respect a resident's right to request a transfer to the emergency room for evaluation of blood in stool. Resident #7, who had a history of pulmonary embolism and was on anticoagulant medication, reported blood in her stool and requested to go to the hospital. Despite having intact cognition and clearly communicating her request, the resident's request was dismissed by a nurse, who told her it was not important and refused to facilitate the transfer. The resident's family was not informed, and the resident experienced distress throughout the night. Multiple staff members, including CNAs, observed the resident's condition, which included multiple bowel movements with blood, weakness, and abdominal pain. They communicated the resident's request to the LPN on duty, who continued to monitor the resident but did not act on the request. The resident was eventually transported to the hospital the following morning, where she was assessed for possible gastrointestinal bleeding. The facility's failure to honor the resident's request for hospital evaluation constitutes a deficiency in respecting the resident's rights.
Failure to Timely Address Resident's Medical Concerns
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident taking anti-coagulant medication who experienced multiple episodes of diarrhea and blood in an incontinent brief. The resident, who had a history of pulmonary embolism, hypertension, and dysphagia, expressed feeling unwell and requested to be taken to the hospital. Despite the resident's clear communication of her symptoms and desire for hospital evaluation, the attending LPN did not initially act on these requests, instead administering Tylenol and taking vital signs without further intervention. Throughout the night, CNAs observed the resident's condition deteriorating, noting symptoms such as weakness, shakiness, and significant rectal bleeding. The CNAs repeatedly reported these observations to the LPN, who dismissed the severity of the situation and did not notify the resident's family or physician in a timely manner. The resident's niece later confirmed that the resident had been in pain and discomfort throughout the night, and that her requests for hospital transfer were ignored until the CNAs insisted on calling an ambulance. The resident was eventually transported to the hospital, where a CT scan revealed a defect in the urinary bladder and a large blood clot, although no acute gastrointestinal bleeding was found. The hospital's findings indicated a significant drop in hemoglobin levels, necessitating further medical intervention. The facility's policy on emergencies, which requires notifying the physician and calling for an ambulance when necessary, was not followed, leading to a delay in appropriate care for the resident.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to implement and modify interventions to ensure the safety of Resident #67, who experienced multiple falls resulting in serious injuries. Resident #67, with severely impaired cognition and dependent on staff for mobility and hygiene, suffered a right tibia fracture after being found on the bathroom floor. Despite being non-weight bearing and having a cast, the resident later fell again in the library, resulting in a left femur fracture that required surgical repair. Additionally, the resident sustained a fracture to the fifth metacarpal bone of the right hand. Interviews with facility staff revealed a lack of documentation for medical incident reports following Resident #67's falls. The Assistant Administrator acknowledged the absence of documentation to show that the falls were not considered major injuries. The MDS Coordinator noted the challenges in managing Resident #67's care due to fluctuating cognitive awareness. The resident's care plan, which included interventions such as weight-bearing as tolerated and assistance with transfers, failed to address the resident's cognitive status after each fall. The facility's Emergency Care Procedure policy outlined steps for immediate care following falls, including evaluating the resident's condition and stabilizing them if fractures were suspected. However, the facility did not adequately follow these procedures, as evidenced by the repeated falls and injuries sustained by Resident #67. The lack of appropriate interventions and documentation contributed to the deficiency in providing a safe environment for the resident.
Deficiencies in Kitchen Cleanliness and Food Handling
Penalty
Summary
The facility was found to have multiple deficiencies in its kitchen operations, including issues with cleanliness, food storage, and food handling practices. During an initial tour of the kitchen, surveyors observed soiled conditions such as food and paper particles on the floor, sticky substances, and various splatters on kitchen surfaces and equipment. Additionally, several food items were found open and undated, including lunch meat, soup, and various dry goods. The presence of flies in the kitchen was noted, with staff failing to clean surfaces after flies landed on them or to cover garbage cans properly. During meal observations, staff were seen handling glasses and food with bare hands, touching the drinking surfaces of glasses, and failing to change gloves between tasks. This improper use of gloves and lack of hand hygiene was observed multiple times, with staff touching various surfaces and food items without changing gloves. The facility's refrigerators were also found to be at incorrect temperatures, with one refrigerator measuring 46 degrees Fahrenheit and another left open with a temperature of 70 degrees Fahrenheit. Interviews with staff revealed that there were ongoing issues with a broken window allowing flies into the kitchen, and no special cleaning protocols were in place to address areas where flies had landed. The Food Service Supervisor outlined expectations for staff regarding cleanliness and food handling, but these were not being followed. Facility policies on sanitation, food storage, and fly prevention were not adhered to, contributing to the deficiencies observed during the survey.
Deficiency in Maintaining Correct Food and Drink Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at the correct temperatures, resulting in a deficiency. During the noon meal preparation and serving, several items did not meet the required cold temperature of 41 degrees Fahrenheit or less. Specifically, milk, chocolate milk, fortified milk, half-and-half creamer, and potato salad were observed at temperatures above the acceptable limit. Additionally, drinks were not served on ice during the meal. Post-meal temperature checks revealed that these items still did not meet the correct holding temperature. The Food Service Supervisor stated that cold items should be maintained at 34-35 degrees Fahrenheit throughout service, as per the facility's Meal Service Procedure policy, which instructs staff to return food items to the kitchen if cold food is above 41 degrees Fahrenheit.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring they were kept in clean clothes and with a clean face after meals. The resident, who has severe cognitive impairments due to conditions such as Alzheimer's disease and progressive neurological conditions, requires assistance with dressing and personal hygiene. Observations over several days revealed that the resident was repeatedly left in soiled clothing with food stains and drool, without staff intervention to clean or change them. Despite the care plan indicating the need for assistance and the potential for the resident to reject care, staff did not consistently attempt to address the resident's hygiene needs. Interviews with facility staff, including the Memory Lane Coordinator and the Director of Nursing, highlighted inconsistencies in care. The Memory Lane Coordinator noted that the resident is on a behavior plan due to resistance to care and that staff sometimes do not attempt to clean the resident due to fear of physical resistance. The Director of Nursing expressed an expectation that staff should clean residents if they have food matter on them, but this was not consistently practiced. The facility's policy on resident rights emphasizes treating residents with respect and dignity, which was not upheld in this case.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for three residents, as observed during a survey. Resident #74, with severe cognitive impairment and frequent incontinence, did not have a care plan intervention directing staff on providing incontinent care. During an observation, a CNA provided care but failed to cleanse all necessary areas, leaving a strong urine odor in the room. The Director of Nursing (DON) confirmed that the expected procedure was not followed, as the CNA did not wash the front of the perineal area, abdominal folds, buttocks, or hips. Resident #49, with mild cognitive impairment and total dependence on toileting hygiene, received care from two CNAs who failed to cleanse the left or right hip after removing a wet brief. Similarly, Resident #71, with intact cognition and always incontinent of bladder, had a care plan lacking direction for post-incontinence care. During care, CNAs failed to wash the resident's front peri area after an incontinence episode. The Assistant Director of Nursing (ADON) and the DON both confirmed that the expected care procedures were not followed, as the facility's policy required washing all soiled skin areas.
Repeated Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in repeated deficiencies cited during the current survey, which were also noted in previous surveys. The deficiencies identified included issues related to Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. The facility had a census of 94 residents at the time of the survey. The QAPI Plan provided by the facility, dated 6/28/2023, outlined a process for monitoring care and utilizing data from various sources. It included tracking, investigating, and monitoring adverse events using the Plan, Do, Study, Act (PDSA) cycle of improvement. However, despite these measures, the facility continued to experience the same deficiencies, indicating that the QAPI process was not effectively addressing the issues. The plan also mentioned the use of structured root cause analysis approaches to identify and address problems, but the recurrence of deficiencies suggests that these methods were not successfully implemented.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Coralville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lantern Park Specialty Care | 1.4 mi | ★★★★★ | 0 | 0 |
| Oaknoll Retirement Residence | 4.8 mi | ★★★★★ | 5 | 0 |
| Briarwood Healthcare Center | 5 mi | ★★★★★ | 1 | 0 |
| Iowa City Rehab & Health Care | 7.5 mi | ★★★★★ | 27 | 0 |
| Solon Nursing Care Center | 9.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.