Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Lutheran Living Senior Campus during CMS and state inspections, most recent first.
The facility failed to fully inform two residents and/or their representatives about the risks and benefits of psychotropic medications before starting or changing the drugs. One resident with intact cognition had orders for clonazepam, trazodone, Lamictal, and buspirone, but the record lacked documentation of informed discussion, and the POA said staff did not explain what the meds were for or their risks and benefits. Another resident with intact cognition had aripiprazole, buspirone, and escitalopram ordered after admission, but the chart lacked a current psychotropic consent form; the DON acknowledged the only consent on file was from a prior admission.
Damaged room surfaces and housekeeping lapses were observed for two residents. One resident with dementia had a dented, cracked wall above the bed that had reportedly been present for over a year, while another resident who required a Hoyer lift had a gouged floor, missing trim, wall marks, a board left on the floor for about 2 months, and an empty cleaner spray bottle left under the bed after housekeeping said the room had already been cleaned.
An LPN and RN failed to follow hand hygiene and EBP during resident care involving trach and PEG tube care, wound care, and dressing changes. An LPN provided device and wound-related care without consistently wearing a gown or performing hand hygiene between glove changes, despite EBP signage and care plans calling for gown and glove use. An RN also handled wound care supplies on a dirty surface, touched the resident and equipment during treatment, and continued wound care without proper hand hygiene and glove changes.
Daily Staffing posting was incomplete and not posted every day. The posted form at the main entrance did not include the resident census or actual hours worked for RN, LPN, or CNA staff, and review of prior postings showed the same blanks. Staff stated the Scheduling and Staffing Manager completed the forms on weekdays, filled in weekend forms on Monday, and the information was not posted on Saturdays or Sundays.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
The facility failed to provide enough staff with the required competencies and skills to meet the behavioral health needs of residents, resulting in unmet behavioral health care requirements.
A resident with multiple chronic conditions and impaired cognition did not receive quarterly Care Conferences as required, with documentation missing for several quarters. Family and staff interviews confirmed the conferences were not consistently held, and facility policy mandating quarterly interdisciplinary reviews with resident and family input was not followed.
A resident with severe cognitive impairment and multiple chronic conditions developed a new open wound on the lower extremity, but the facility did not notify the physician or family as required. Documentation and staff interviews confirmed that the expected notifications and documentation did not occur, despite facility policy and physician orders mandating prompt communication of such changes.
A resident with severe cognitive impairment and multiple chronic conditions developed a new open wound on the left shin. Despite care plan directives and physician orders to report new skin issues, staff did not document any intervention or notify the provider or family. Interviews with an LPN and the DON confirmed that required notifications and interventions were not completed.
A resident with intact cognition and multiple diagnoses received an involuntary discharge notice that cited the wrong Iowa Administrative Code chapter, referencing regulations for Resident Care Facilities instead of those for LTC facilities. The error was confirmed through record review and interviews, with the long-term care ombudsman stating the notice should have referenced the correct chapter.
A resident with severe cognitive impairment fell and sustained fractures, requiring hospital transfer. The facility failed to promptly notify the resident's legal guardian, as the message was left on an office phone instead of the provided after-hours number. Staff interviews revealed a lapse in following the correct notification process.
The facility failed to serve meals at a palatable temperature during a dinner meal, affecting residents on the 600 Hall. Food temperatures were checked before serving, but by the time the last meal tray was delivered, temperatures had dropped significantly. The Culinary Director acknowledged the issue, noting that the facility was running behind schedule, which may have contributed to the deficiency.
A resident with moderate cognitive impairment and a history of false statements accused a CNA of abuse. The facility conducted an investigation, finding no physical evidence of harm, but failed to report the incident to authorities as required by policy. The Administrator deemed it a behavioral issue, not abuse, leading to a deficiency in handling the incident.
The facility failed to notify the Ombudsman of hospital transfers for two residents, despite having a policy requiring such notification within 24 hours. One resident, with intact cognition, was transferred via non-emergency ambulance, while another was transferred twice to the emergency room. The DON and Administrator confirmed the lack of documentation for these notifications.
A facility failed to obtain a hemoglobin A1c test for a resident with Type II diabetes mellitus, despite an order being placed. The resident, who had severely impaired cognition and received daily insulin injections, did not have the test completed as there was no documentation of the results. Interviews with staff revealed that the order was missed, and the facility lacked adequate checks to ensure lab orders were completed.
A medication cart was found unlocked and accessible in a facility hallway, contrary to policy requiring it to be locked when not in use. Staff members passed by without securing it, and the DON confirmed the expectation for carts to be locked when not in use or out of sight.
A resident with severe cognitive impairment and exit-seeking behavior managed to leave the facility undetected due to a failure in the Wanderguard alarm system. Despite being identified as high risk for elopement and equipped with a Wanderguard bracelet, the alarm did not activate when the resident exited the building. The resident remained outside unsupervised for nearly 11 minutes before staff were alerted by a visitor. Staff had previously noted issues with the alarm system's functionality, which contributed to the deficiency.
The facility failed to provide adequate incontinence care during the night shift, as staff were observed socializing instead of attending to residents' needs. Two residents reported dissatisfaction with the care received, noting that they were not checked on until late at night or left saturated until morning. This indicates a failure to adhere to professional standards of practice for incontinence care.
The facility failed to properly identify residents before administering medications, leading to a medication error where a resident received another's medications. Additionally, incorrect transcription and administration of Hydrocodone/Acetaminophen and Lasix orders for another resident resulted in improper dosing. These errors were not identified or corrected by the staff, indicating lapses in medication management.
A resident with marginally impaired cognitive status and renal insufficiency tested positive for COVID-19, but the facility failed to notify the physician promptly. The PA learned of the positive result only when a request for cough syrup was made, and the on-call physician was not informed. The DON and ADON were later made aware of the notification delay.
A resident with severe cognitive impairment called for help but staff were unable to respond for up to 10 minutes due to significant staffing shortages. The resident was found unresponsive and later confirmed deceased. The facility's on-call ADON was contacted for assistance but did not provide support, instructing staff to manage the situation themselves. The resident's care plan included safety measures, but these were insufficient without adequate staffing.
Failure to Inform Residents and Representatives About Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents and/or their representatives were fully informed of the risks and benefits of psychotropic medications before the medications were started or changed for 2 of 5 residents reviewed for unnecessary medications. Resident #3 had intact cognition with a BIMS score of 15 and diagnoses including depression, anxiety, bipolar disorder, and an intellectual disability. The resident’s record showed orders for clonazepam, trazodone, Lamictal, and buspirone, including new starts and dose changes, but the clinical record lacked documentation that staff explained the risks and benefits of these medications to the resident and/or the resident’s representative before the medications began or were changed. Resident #3’s POA reported that facility staff frequently called to report medication changes but did not explain what the medications were for or discuss the risks and benefits. Resident #3 stated he took medications for diabetes, could identify that he took medications for mood, but denied having mood problems and did not know what medications he took or the risks and benefits of taking them. Staff interviews showed nursing staff believed they were notifying residents and families and completing psychotropic medication consent forms, but the DON stated Lamictal was not considered a psychotropic medication and said staff should obtain consent for new antidepressant, antianxiety, or antipsychotic medications. The DON also stated the facility had only recently learned that a new consent was needed for any dose or medication change. Resident #47 also had intact cognition with a BIMS score of 15 and diagnoses including depression and diabetes mellitus. The resident’s care plan addressed high-risk medications and included review of medication side effects with the resident and/or the person in charge of healthcare decisions for informed consents. Physician orders showed aripiprazole, buspirone, and escitalopram started after admission, but the record lacked a consent form for those psychotropic medications. The only consent form in the record was dated before the current admission, and the DON acknowledged that the prior consent was from a previous admission and that a new consent should have been reviewed with the resident and/or representative upon readmission.
Damaged Room Surfaces and Unremoved Cleaning Bottle
Penalty
Summary
Failure to maintain a safe, clean, comfortable, and homelike environment was identified for two residents whose rooms had damaged surfaces and, in one room, an empty cleaning bottle left on the floor. Resident #53 had a BIMS score of 8 out of 15 and a diagnosis of dementia, with the MDS showing substantial to maximal assistance needed for transfers and repositioning. In the resident’s room, surveyors observed a fist-sized dent and crack in the wall above the bed and a previously patched area behind the recliner. A family member stated the damage above the bed had been present since the resident moved into the room over a year earlier, and that the facility had only repaired a larger hole behind the recliner after it was requested. Resident #81 had a BIMS score of 15 out of 15 and required a Hoyer lift for transfers, bed mobility, lower body dressing, showering, and toilet hygiene. Surveyors observed a gouge in the floor beside the bed, missing trim near the bathroom entrance, black marks on the lower wall by the bathroom, and a board lying on the floor between the bed and wall. The resident stated the board had been on the floor for about 2 months and had been attached to the wall by the bed, and that the floor had been damaged for about the same amount of time. Later, an empty spray bottle labeled cleaner was observed on the floor under the bed frame near the head of the bed and remained there during a later observation, while housekeeping staff stated the room had already been cleaned and confirmed she had cleaned it.
Hand Hygiene and EBP Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure staff completed hand hygiene and used Enhanced Barrier Precautions (EBP) during resident care for residents with tracheostomy, feeding tube, wound care, and other high-contact care needs. Resident #2 had diagnoses including traumatic brain injury, seizure disorder, and quadriplegia, and used both a feeding tube and a tracheostomy. The care plan identified EBP for trach and PEG tube care, including dressing, bathing, transferring, hygiene, changing linens, changing briefs, and device care. During feeding tube care, an LPN disconnected tubing and emptied contents without gown use, changed gloves without hand hygiene, and reconnected the feeding system without completing hand hygiene or wearing a gown. During later care, the same LPN provided trach-related and feeding-related care, handled equipment and medications, and performed multiple glove changes and hand hygiene steps inconsistently, while not wearing a gown during the care activities identified for EBP. Resident #4 had diagnoses including amputation, end-stage renal disease, diabetes mellitus, morbid obesity, and a chronic right foot wound with dressing care. The care plan identified EBP for wound care, and the resident’s door had EBP signage indicating gown and glove use for wound care and other high-contact activities. During wound care, an LPN entered the room without a gown, removed and replaced gloves multiple times, and did not complete hand hygiene between some glove changes. The LPN cleansed the wound, applied betadine-soaked gauze, and completed the dressing while not following the EBP instructions posted on the door. The LPN later stated she was not aware of EBP for this resident and acknowledged not wearing a gown or completing hand hygiene between some glove changes. Resident #91 had diagnoses including stroke, diabetes mellitus, and morbid obesity, and had an order for coccyx wound care with cleansing, Triad cream, and foam dressing. During the wound treatment, an RN placed clean supplies on a chair that appeared dirty and had a white substance on the seat cushion. The RN cleaned the wound, disposed of gloves and wipes, re-gloved, and then continued treatment while touching the resident and handling supplies. The RN picked up the wound cleanser bottle from the floor, sprayed it directly onto the wound and gauze, and then applied Triad ointment and the foam dressing without completing hand hygiene and changing gloves between steps. The RN also wrote on the dressing after handling items from her pocket and then applied it to the wound.
Daily Staffing Posting Missing Required Information and Not Posted on Weekends
Penalty
Summary
The facility failed to ensure the Daily Staffing posting contained required information and was posted daily, seven days a week. The facility reported a census of 117 residents. On 2/9/26 at 1:20 PM, the Daily Staffing information posted at the receptionist desk inside the main entrance did not identify the resident census or indicate the actual hours required for each nursing staff type, including RN, LPN, or CNA. The DON stated during interview on 2/9/26 at 3:00 PM that the resident census and actual hours worked for the RN, LPN, and CNA were not completed on the 2/9/26 form. Review of the Daily Staffing postings for the prior 30 days showed the data for daily resident census and actual hours worked by each nursing category were left blank. Staff O, the Scheduling and Staffing Manager, stated she was responsible for completing and posting the Daily Staffing information, but she worked Monday through Friday and did not post the information on weekends; she completed forms for Saturdays and Sundays on Mondays and was unsure who was responsible to post them. The Director of Human Resources stated the forms did not include actual hours worked by nurses and were not posted on Saturday and Sunday. The Administrator also stated the forms were not completed with the resident census and actual hours worked for nurses, and the information had not been posted over the weekend. The facility policy titled Posting of Nurse Staffing Hours directed staff to post daily up-to-date nurse staffing information including the current date, resident census, total number of nursing staff, and actual hours worked.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents did not receive the behavioral health care and services necessary to address their individual needs, as required by regulations.
Insufficient Competent Staff for Behavioral Health Needs
Penalty
Summary
The facility did not ensure that there were sufficient staff members with the necessary competencies and skills to meet the behavioral health needs of residents. This deficiency was identified based on observations and findings that staff were not adequately equipped to address or manage the behavioral health requirements of the resident population. The lack of appropriately skilled staff directly impacted the facility's ability to provide care tailored to the behavioral health needs of its residents.
Failure to Conduct Required Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly Care Conferences (CC) for one resident, as required by policy and regulatory standards. Clinical record review showed that the resident had multiple medical conditions, including coronary artery disease, congestive heart failure, Alzheimer's disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis. The resident's care plan indicated risks related to impaired skin integrity and lower extremity edema, with several modifications made to address these issues. Despite these needs, documentation revealed that Care Conference Summaries were only completed on two occasions, with no records for three other required quarters. Interviews with the resident's family and staff confirmed that Care Conferences were not consistently held. The Social Services designee stated that CCs are scheduled after MDS assessments and that notifications are sent to residents and their representatives, but was unaware of any previous paper documentation for missed conferences. The Director of Nursing confirmed that care plan conferences should occur quarterly or upon a change in condition. Facility policy also required quarterly interdisciplinary care plan reviews with resident and family input, which was not met in this case.
Failure to Notify Physician and Family of New Skin Wound
Penalty
Summary
The facility failed to provide timely notification to both the physician and the family for a resident who developed a newly documented open wound on the lower extremity. Clinical record review showed that the resident, who had severely impaired cognition and multiple diagnoses including coronary artery disease, congestive heart failure, Alzheimer's disease, and venous insufficiency, was assessed as not having any unhealed pressure ulcers or injuries prior to the incident. The care plan directed staff to observe and report any skin changes, and physician orders required weekly skin checks and prompt notification of new lesions or changes. Despite these directives, documentation revealed that a new open area was identified on the resident's left shin, but there was no evidence in the records that the physician or family were notified of this change. Interviews with staff confirmed that the expectation was to notify the physician, family, and appropriate facility leadership of newly identified wounds, and to document these notifications in the nurse progress notes. However, the responsible LPN could not recall if notifications were made, and the nurse progress notes did not reflect any such communication. The Director of Nursing also acknowledged that both the physician and family should have been contacted. Facility policy required notification of significant changes in a resident's condition, including changes in skin integrity, but this was not followed in this instance.
Failure to Provide Timely Intervention for New Skin Wound
Penalty
Summary
A deficiency occurred when the facility failed to provide timely interventions for a resident who developed a newly documented open wound on the left shin. The resident had a history of severe cognitive impairment, coronary artery disease, congestive heart failure, Alzheimer's disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis. The care plan directed staff to observe the resident's skin during care and report any concerns, including open areas, to the medical team. A physician's order was in place to notify the provider of any new lesions. Despite these directives, a weekly skin assessment identified a new open area on the resident's left shin, but there was no documented intervention or evidence that the physician or family were notified. Further review of nurse progress notes and staff interviews confirmed that the required notifications and interventions were not completed. The LPN involved could not recall if the physician or family had been contacted, and the DON stated that staff should have called the physician, obtained an order, started the order, documented it, and notified the family. The lack of timely notification and intervention for the new wound constituted a failure to follow established care protocols for residents with impaired skin integrity.
Incorrect Regulatory Citation on Involuntary Discharge Notice
Penalty
Summary
The facility failed to cite the correct chapter of the Iowa Legislature State Regulations when issuing an involuntary discharge notice to a resident. The notice referenced Iowa Administrative Code 481-57.14(2), which applies to Resident Care Facilities, instead of the appropriate Chapter 58 for Long Term Care Facilities. This error was identified during a review of the clinical record, interviews with the long-term care ombudsman, and staff. The resident involved had an intact cognitive status, as indicated by a BIMS score of 15, and was dependent on staff for transfers. Diagnoses included paraplegia, anxiety, depression, and alcohol abuse with an alcohol-induced mood disorder. The involuntary discharge notice was hand-delivered to the resident, advising of discharge due to behavior posing a threat to the health and safety of others. The long-term care ombudsman confirmed that the incorrect code was cited and stated that the notice should have referenced the correct chapter. The ombudsman also noted that the error would typically render the notice inapplicable and require the process to be restarted. The deficiency was identified through the facility's documentation and interviews, which confirmed the use of the incorrect regulatory citation in the discharge process.
Failure to Timely Notify Guardian After Resident's Fall
Penalty
Summary
The facility failed to notify the legal guardian of a resident in a timely manner following a fall that resulted in injury and subsequent transfer to the hospital. The resident, who had a severely impaired cognitive status due to Alzheimer's and other health conditions, fell in her bedroom while being assisted by a Certified Nursing Assistant. The fall resulted in facial and knee fractures, necessitating hospital care. Despite the severity of the incident, the guardian was not informed until the following day, as the message was left on an office phone rather than the provided after-hours on-call number. Interviews with staff revealed that the Registered Nurse responsible for notifying the guardian did not recall using the correct contact number, and the Assistant Director of Nursing had instructed the nurse to use the on-call number. The guardian expressed ongoing concerns about communication issues and emphasized the importance of prompt notification. The ADON acknowledged the oversight and noted that the correct contact information and process were available at the nurse's station, but were not utilized in this instance.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable temperature during a dinner meal observed, affecting several residents who received room trays on the 600 Hall. Staff D, a Dietary Aid, mentioned that food temperatures are taken once the food is placed in the steam table and before the first resident is served. However, the plates and food covers are not heated prior to plating, and there have been random complaints about the food not being hot enough. During an observation, the temperatures of the food items before leaving the main kitchen were within acceptable ranges, but by the time the last meal tray was delivered, the temperatures had significantly dropped, with the turkey burger and sweet potato fries being notably below the desired temperature. The Culinary Director acknowledged that the food temperatures were not satisfactory and expressed surprise at the low temperature of the turkey burgers, which were in juice. The Director also noted that the facility was running behind schedule, which may have contributed to the issue. A CNA mentioned that while food temperatures are checked before serving, she was unsure of the specific temperature requirements. The facility's policy emphasizes providing meals at a safe and appetizing temperature, but the observed deficiency indicates a failure to adhere to this standard.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident with moderate cognitive impairment, anxiety disorder, and depression. The resident, who required assistance with daily activities and was frequently incontinent, accused a CNA of hitting her and using derogatory language. The incident was reported to the nurse on call, who conducted an investigation, including a head-to-toe assessment of the resident, which revealed no physical signs of abuse. Despite the resident's history of making false statements, the facility's policy required immediate reporting of all abuse allegations, which was not followed in this case. The incident occurred when the resident was found crying and reported the alleged abuse to another CNA. The resident was then taken to a dining room, given a snack, and had her clothing changed. The accused CNA stated that the resident was unhappy about being woken up due to her bedding being saturated with urine. The CNA assisted the resident with personal care and noted that the resident was not crying at that time. The facility's investigation included interviews with staff and a review of the resident's condition, but the incident was not reported to the appropriate authorities as required by the facility's abuse prevention policy. The facility's Administrator and DON were informed of the incident, and the accused CNA was removed from duty pending the investigation. However, the Administrator decided not to report the incident, believing it to be a behavioral issue rather than abuse. This decision was based on the resident's history of false accusations and the lack of physical evidence of harm. The facility's policy mandates reporting all abuse allegations within specific timeframes, which was not adhered to, resulting in a deficiency in the facility's handling of the incident.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding the transfer of two residents to the hospital. Resident #110, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) exam, was transferred to the hospital via non-emergency ambulance. However, the facility's records did not include any notification to the Ombudsman about this transfer. Similarly, Resident #37, who also had intact cognition with a BIMS score of 13, was transferred to the emergency room twice, once in September and once in October, without any documented notification to the Ombudsman. During interviews, the Director of Nursing (DON) and the Administrator acknowledged the lack of documentation for Ombudsman notification for both residents. The facility's policy requires the Social Services Director or designee to notify the Iowa Long-Term Care Ombudsman within 24 hours of issuing a written notice to the resident, including details such as the resident's name, reason for discharge/transfer, and a copy of the notice. Despite this policy, the facility did not adhere to the notification requirements for the transfers of Resident #37 and Resident #110.
Failure to Complete Ordered Lab Test for Diabetic Resident
Penalty
Summary
The facility failed to obtain a lab test for hemoglobin A1c as ordered by the provider for a resident with a diagnosis of Type II diabetes mellitus. The resident, who had severely impaired cognition and was receiving insulin injections daily, had an order for an Hgb A1c test to be completed on a specific date. However, the facility lacked documentation of the test results, indicating that the test was not completed as ordered. Interviews with facility staff revealed that the order for the Hgb A1c test was placed by an agency nurse, but the test was missed and not completed. The Assistant Director of Nursing (ADON) acknowledged the oversight and stated that she could not find the test results. The Director of Nursing (DON) confirmed that the order was missed and explained that the facility did not have adequate checks in place to ensure the completion of lab orders at the time of the survey.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that a medication cart remained locked when not in use, as observed on the 400 hall across from the nursing station. On the specified date, a staff member walked past the medication cart without ensuring the lock was engaged, leaving the cart unlocked and medications accessible. Another staff member also passed by without securing the cart. At approximately 2:13 PM, a Registered Nurse (RN) was notified of the unlocked cart while present in the office off the nursing station. The Director of Nursing (DON) later confirmed that staff should lock the cart when not in use or within their sight. The facility's policy on medication labeling and storage, revised in November 2024, mandates that all medications be stored in a locked cart or medication room.
Resident Elopement Due to Wanderguard System Failure
Penalty
Summary
The facility failed to prevent a resident with exit-seeking behavior from leaving the premises without staff knowledge. The resident, who had a severely impaired cognitive status and required significant assistance with daily activities, was able to exit the facility in his wheelchair. The resident's care plan identified him as high risk for elopement, and he was equipped with a Wanderguard bracelet intended to prevent such incidents. However, the alarm system did not activate when the resident exited the building, allowing him to remain outside unsupervised for nearly 11 minutes before staff were alerted by a visitor. On the day of the incident, multiple staff members reported that the resident was actively trying to leave and required frequent redirection. Despite these behaviors, the Wanderguard system failed to sound an alarm when the resident exited the facility. Staff interviews and video footage confirmed that the alarm did not activate until the resident was brought back inside. Additionally, a staff member had previously questioned the functionality of the Wanderguard system, noting that it did not activate when the resident was near the elevator, which should have triggered the alarm. The incident was further complicated by the fact that the resident was able to exit the facility by following a visitor who had coded the door open. This suggests a potential vulnerability in the facility's security measures, as the resident was able to leave undetected. The failure of the alarm system to activate, combined with the resident's known exit-seeking behavior, contributed to the deficiency in ensuring a safe environment for residents at risk of elopement.
Removal Plan
- Resident placed on 1:1 observation until he was moved to the locked Memory Care Unit.
- Neuro checks initiated, witness statement obtained, and notifications made.
- Elopement assessment and care plan updated.
- Staff education on elopement and documentation began.
- Residents wander guard immediately checked for functionality.
- Staffing was reviewed for time of incident and determined not to be a contributing factor.
- All residents with wander guards were reviewed, tested and ensured orders were put in place for monitoring.
- Elopement drills were conducted.
- Elopement Risk Assessments were reviewed on all residents and revised, if necessary.
- All elopement care plans were reviewed and revised as necessary.
- Elopement Book at front desk was reviewed and updated as necessary.
- All Maintenance logs were reviewed and found in compliance with alarm monitoring.
- TARS reviewed and physician orders updated to include what functionality of the alarm looks like.
- Ideacom, our wander guard service vendor, sent a technician to recalibrate the Wanderguard after the system passed all tests. The technician was unable to duplicate the issue and felt it was a technology glitch. Technician increased the sensitivity of the wander guard zones for optimal coverage.
- Main entrance was monitored by staff, until Ideacom technician arrived to evaluate system and increase sensitivity.
- Implementation of a Weekend Manager on Duty to ensure we have coverage at the front entrance every day of the week.
- Wanderguard alarm on doors will continue to be monitored ongoing.
- Wanderguard bracelets on residents will continue to be monitored ongoing.
- Negative findings will be corrected immediately and reported at Quality Assurance and Performance Improvement Meeting and conduct education training as needed.
- Ongoing random reviews of this system will be incorporated into the monthly Quality Assurance Performance Improvement Program.
Failure to Provide Adequate Incontinence Care During Night Shift
Penalty
Summary
The facility failed to provide incontinence care in accordance with professional standards of practice for residents who required assistance. Observations made during the night shift revealed that staff members were not actively attending to residents' needs. Instead, three staff members were observed socializing in the lounge area, with two sitting in recliners and one standing, while the television was on. They were seen leaving the lounge area only briefly and did not consistently check on residents, particularly those identified as needing incontinence care. This lack of attention was corroborated by a registered nurse who mentioned that some aides have been known to take naps during their shifts. Two residents, one with moderately impaired cognitive status and another with intact cognitive status, reported dissatisfaction with the care they received at night. The first resident, who required moderate assistance with various activities of daily living and was frequently incontinent, stated that staff did not check on him until 4:00 a.m. The second resident, who required independent to moderate assistance and was occasionally incontinent, reported being left saturated until morning. These accounts highlight the facility's failure to ensure timely and adequate incontinence care for residents, as required by professional standards.
Medication Administration Errors and Mismanagement
Penalty
Summary
The facility failed to properly identify residents prior to administering medications, leading to a medication error involving Resident #3. Resident #3, who had an intact cognitive status and was independent in daily activities, was mistakenly given another resident's medications by an agency Certified Medication Aide, Staff Q. The error occurred when Staff Q, while in the dining room, asked Resident #3 if he was another resident, and despite Resident #3 indicating he had already taken his medications, Staff Q administered the wrong medications. The error was realized when the actual resident arrived, and the incident was reported to the Director of Nursing. Resident #3 was sent to the emergency department for evaluation but remained stable with no adverse effects. Another deficiency involved Resident #7, who had a cognitive status indicating intact mental faculties and required assistance with daily activities. The facility failed to clarify and correctly transcribe a medication order for Hydrocodone/Acetaminophen, resulting in the administration of incorrect doses. The order was initially unclear, and the agency nurse did not verify it with the Physician Assistant, leading to the use of a prn bubble pack for scheduled doses. This resulted in variations in doses administered, which were not clarified or corrected by the staff. Additionally, the facility failed to initiate and adjust Lasix medication orders for Resident #7 in a timely manner. The August Medication Administration Record showed that the staff did not start the additional Lasix doses as ordered and continued incorrect dosing beyond the specified dates. These errors were not identified by the staff, indicating a lapse in medication management and adherence to professional standards of practice.
Failure to Notify Physician of COVID-19 Positive Result
Penalty
Summary
The facility failed to notify a resident's physician upon discovering a positive COVID-19 infection. Resident #8, who had a marginally impaired cognitive status with a BIMS score of 12, was independent in most activities but required moderate assistance with dressing. The resident's medical history included renal insufficiency. On 8/25/24, a progress note indicated that Resident #8 tested positive for COVID-19, but there was no documentation that the primary care physician was informed of this result. The following day, a Physician Assistant (PA) noted that they were made aware of the positive COVID-19 status only when a request for cough syrup was submitted. The PA also noted that the on-call physician had not been notified, and the Director of Nursing and Assistant Director of Nursing were informed of the delay in notification, emphasizing the importance of immediate notification for medical orders and consideration of Paxlovid treatment.
Inadequate Staffing and Supervision Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner. On the night in question, the resident, who had severe cognitive impairment and required substantial assistance for mobility, called out for help at approximately 4:30 AM. Staff were unable to respond for up to 10 minutes, and the resident was subsequently found unresponsive, face down in bed with her feet on the floor. The resident was later confirmed deceased. The facility was experiencing significant staffing shortages on the night of the incident. Multiple staff members were required to cover additional halls due to the absence of scheduled staff. This led to delays in responding to the resident's call for help. Interviews with staff revealed that the facility's on-call Assistant Director of Nursing (ADON) was contacted for assistance due to the short staffing but did not provide the necessary support, instructing staff to manage the situation themselves. The resident's care plan included interventions for safety and fall prevention, such as the use of a body pillow, a fall mat, and ensuring the bed was in a low position. However, these measures were insufficient without adequate staffing to respond to the resident's needs. The lack of timely response and supervision contributed to the resident's death, highlighting a critical deficiency in the facility's ability to ensure resident safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muscatine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Of Muscatine | 2.1 mi | — | 2 | 0 |
| Accura Healthcare Of Muscatine | 2.2 mi | ★★★★★ | 1 | 0 |
| Wilton Retirement Community | 13.1 mi | ★★★★★ | 2 | 0 |
| Simpson Memorial Home | 13.9 mi | ★★★★★ | 6 | 0 |
| Lone Tree Health Care Center Inc | 17.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lutheran Living Senior Campus.
100% money-back within 48 hours.
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.