Windmill Manor
Inspection Findings
F-Tag F0760
F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
on 12/30/25 at 2:50 PM, the Director of Nursing (DON), stated that she was notified on 11/21/25 that Resident #3 had missed 2 doses of her Tacrolimus and then the ADON called the lung transplant clinic to report this. The DON reported that she called the pharmacy to determine why Resident #3's medication was not delivered on 11/14/25 and was informed that there had been a mistake with the courier service.
The DON revealed an expectation of facility nurses to keep calling the pharmacy or notify leadership nurses if a medication was not delivered. The DON stated that an inservice education was provided to all nurses and medication aides on medication ordering and delivery. The DON reported that omission of medication at scheduled times would be considered a medication error and the expectation for a medication error would be for nurses to notify the physician, the resident's responsible party, and document the incident.
Review of the facility provided medication error report, completed by DON, dated 11/21/25, revealed that Resident #3 had an order for Tacrolimus 2mg every AM and 2.5mg every PM and described the error as medication not delivered by back up, missed 2 doses, and 11/14/25 PM dose was late. The report noted that the pharmacy did not order medication pick up in their system. The corrective action taken included education to nurses and measures taken to prevent in the future listed education and monitoring.Review of
the facility in-service education for the nursing department related to medications, dated 11/21/25, instructed for nurses to follow: Unavailable Medications: When medication is unavailable, CMAs are to alert
the nurse, never mark unavailable. The nurse is to go to the Stat Safe and try to pull the medication. If the medication is not in the Stat Safe the nurse is to call the pharmacy. The pharmacy can send it from a backup pharmacy. If the pharmacy sends it from back up and it does not come within 2 hours, call the pharmacy again. Notify the provider of missed doses and the POA/residents. CMAs, if you give the last dose of a medication, let the nurse know so that the nurse can call the pharmacy and get it sent before the next dose is due. Try to call after hours to see if they can still arrange for a back up pharmacy delivery.
Review of the facility policy titled, Medication Administration, revised February 2004, revealed the Objective Statement is to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. The Section: Procedures listed: #7. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the Medication Administration Record (MAR), and the time frame circled on the MAR.
Event ID:
Facility ID:
If continuation sheet
Windmill Manor in Coralville, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Coralville, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Windmill Manor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.