Windmill Manor: Transfer Safety Violation Causes Harm - IA
Federal inspectors who visited the facility on September 17, 2025, cited the home for actual harm under the fall and accident prevention standard, one of the more serious harm categories in the federal inspection system. The violation stemmed from a single aide, identified in inspection records as Staff A, who failed to use a gait belt when transferring or walking residents who needed assistance.
The gait belt requirement at Windmill Manor is not new. The facility adopted its policy in December 2003, more than two decades ago. The policy is direct: all direct care staff shall use a gait belt when transferring or ambulating residents, no exceptions unless a resident's care plan specifically says otherwise.
Staff A had been trained on exactly this.
When she was hired in September 2024, the new employee checklist she completed included gait belt use. A month later, on September 30, 2024, she attended a facility in-service training session on the topic and signed her name to confirm she was there. Less than a year after that, on July 16, 2025, she attended a second gait belt training session. She signed that one too.
The Director of Nursing told inspectors on the morning of the visit that using a gait belt for residents who need transfer assistance is an expectation, full stop.
Staff A knew the policy. She had signed off on it twice. She did not follow it.
Gait belts are wide fabric or leather belts fastened around a resident's waist before a transfer or a walking assist. They give the aide a stable grip and help prevent a resident from pitching forward or sideways if their balance fails. Without one, a caregiver grabbing at a falling resident is left reaching for an arm, a shoulder, clothing — anything — which can mean the resident hits the floor anyway, or the aide wrenches their own back trying to catch them.
The inspection report does not describe the specific incident or incidents that triggered the complaint, and it does not name the residents who were affected. It records the outcome plainly: actual harm, a few residents.
What the record does show is a gap between what a facility says it requires and what happens in a room when a door closes. Windmill Manor had a policy old enough to vote. It had a Director of Nursing who could articulate the expectation without hesitation. It had training sessions, attendance sheets, signatures. None of it was enough.
The inspection was a complaint survey, meaning someone reported a concern before inspectors arrived. The facility's own documentation became the evidence against it: the training logs showing Staff A had been educated on the requirement, the policy showing the requirement had existed for decades, the DON's interview confirming the standard was understood.
The residents who needed a gait belt to be moved safely through their own hallways did not get one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windmill Manor from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 18, 2026 · Our methodology
Windmill Manor in Coralville, IA was cited for violations during a health inspection on September 17, 2025.
The gait belt requirement at Windmill Manor is not new.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.