Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 St Luke Lutheran Nursing Home during CMS and state inspections, most recent first.
A resident dependent on a mechanical lift was transferred while staff adjusted a kinked sling with the resident already suspended, causing the sling to slip and the resident to fall to the floor with sacral fractures. Staff also reported inconsistent sling sizing practices and use of locked lift wheels during transfers. In a separate event, a cognitively impaired resident with a care plan directing staff not to leave her unattended in the bathroom fell again after staff left her alone at the sink to get her wheelchair.
The facility failed to ensure required Dependent Adult Abuse Mandatory Reporter Training remained current for staff. A CNA worked shifts without current certification, and an LPN also worked with residents while certification had expired. Staff interviews showed uncertainty about the process for tracking training status, and the DON acknowledged the lapse.
Failure to maintain resident dignity during care and services. Residents with dementia and other conditions were subjected to disrespectful interactions, including staff entering without knocking, failing to introduce themselves, rough handling during care, crude comments after incontinence, talking about why staff did not like a resident in the resident’s presence, and stating that a resident would pass away soon. Staff also removed a resident’s shirt rapidly, causing the resident to elevate her voice, and did not ask if she was okay.
Improper Use of a Positioning Device as a Restraint: A resident with Alzheimer’s disease, HF, and anemia had a positioning device placed behind her left side under the fitted sheet after CNAs assisted her into bed. Surveyors observed the device under the sheet, and the facility policy stated that if a resident cannot remove the device in the same manner it was applied, it is considered a restraint. The DON stated the wedge should not have been under the sheet.
Bed-Hold Notices Lacked Required Signatures and Documentation: The facility failed to document signed bed-hold notices or the resident representative’s decision for two residents who transferred to the hospital. One resident had repeated hospital transfers with missing signatures and no bed-hold form for one transfer, while another resident with severe cognitive impairment had a bed-hold form that did not show whether the representative wanted to hold the bed. Progress notes also lacked documentation of family notification and receipt of notice, despite facility policy requiring written bed-hold information and documentation of multiple contact attempts.
The facility failed to accurately code MDS assessments for two residents. One resident with anxiety, depression, schizophrenia, and a Level II PASRR was incorrectly coded as not Level II, and staff confirmed it should have been coded as Level II. Another resident with right-sided weakness, bed confinement status, and a transfer assist rail was coded as having a bed rail restraint, although the Unit Manager stated the bedrail was not a restraint and the RAI Manual describes when bed rails do not meet the definition of a physical restraint.
An LPN failed to use EBP and did not perform hand hygiene between glove changes while assisting a resident with catheter care. The LPN emptied the catheter bag, handled the urine graduate and catheter supplies with soiled gloves, placed the graduate on the floor, and then reapplied clean gloves without hand hygiene before finishing care. The facility’s policies identified urinary catheters as devices requiring EBP and required hand hygiene before donning gloves and after removing soiled gloves.
Failure to provide privacy during resident transfers. Two residents were assisted into bed by CNAs using a mechanical lift, but the curtains were not closed during the transfers. Facility policy required privacy curtains to be drawn during cares, and the DON stated staff should have closed the curtains during transfers.
Failure to report allegations of abuse within the required timeframe. Staff reported multiple incidents involving a CNA speaking to or handling residents in a rude, rough, or demeaning manner, including comments made in residents’ presence and one instance where a resident’s shirt was rapidly removed and the resident voiced discomfort. The affected residents had dementia or severe cognitive impairment and required assistance with ADLs. Staff said the concerns were submitted to the Administrator, DON, and ADON, but the allegations were not reported to DIAL within the required 2 hours per policy.
A resident with moderate cognitive deficit exited the facility undetected due to inactive door alarms, resulting in a fall and injuries. Additionally, another resident was improperly transferred using a sit-to-stand lift, as the safety strap was not tightened, posing a risk to her safety.
The facility failed to obtain complete Authorization for Withholding CPR forms for four residents. One resident's form had a scribbled-out note and lacked a date and witness signature. Another resident's form was undated despite being signed by the resident and a witness. Two other residents' forms were missing physician and witness signatures, with one form having a date written in the wrong space. The facility's policy for obtaining and documenting CPR directives was not followed.
The facility failed to provide adequate respiratory care for four residents requiring oxygen. A resident with chronic obstructive pulmonary disease had tubing dated over two months prior, while another had undated tubing. A third resident with heart failure had tubing dated five months prior, and a fourth resident with coronary artery disease had outdated tubing. Staff interviews revealed that weekly tubing changes were expected but not consistently followed.
The facility failed to implement proper infection control and hand hygiene practices, particularly during care for a resident with a catheter and another resident with COVID-19. Staff did not perform hand hygiene after glove removal and were observed not wearing masks during a COVID-19 outbreak, contrary to facility policies.
The facility did not consistently knock on residents' doors before entering, violating their right to privacy and dignity. A resident reported feeling disrespected as staff entered without knocking or announcing themselves. Observations confirmed that CNAs and a CMA entered rooms without knocking, contrary to the facility's policy as acknowledged by the DHS.
A facility failed to update a care plan for a resident with severe cognitive impairment and pressure ulcers. The care plan and TAR were inconsistent, as the resident was observed with a boot on one foot and a regular shoe on the other, contrary to the care plan's directive. Staff interviews revealed the resident's heel wounds and treatment practices, but the care plan did not reflect these, leading to the deficiency.
The facility failed to follow prescribed interventions for pressure ulcer care for two residents. One resident with a chronic heel ulcer did not receive the required treatment, and the heel protector boot was not applied. Another resident with severe cognitive impairment had orders for inflatable boots on both heels, but only one boot was applied. Documentation inconsistencies and staff's failure to adhere to treatment plans were observed.
The facility failed to answer call lights within the mandated 15 minutes for four residents, leading to extended wait times and inadequate care. One resident waited over 2 hours, resulting in incontinence and wet clothing due to an unemptied catheter bag. The Device Activity Report confirmed multiple instances of prolonged call light activation.
The facility failed to ensure that food items were covered before being transported from the dining area to residents' rooms. Multiple CNAs transported meal trays with uncovered items such as cake, drinks, juice, coffee, and ranch dressing to the rooms of five different residents, contrary to the facility's policy.
A facility failed to report an abuse allegation to the Iowa Department of Inspections & Appeals within 24 hours. A resident with no cognitive impairment reported a physical altercation with an aide, but later denied any hitting. The facility's policy requires such allegations to be reported within 2 hours, but the administrator did not report it, believing it was unnecessary.
The facility failed to investigate allegations of abuse and separate a resident from the staff member alleged of abuse. Despite the resident's initial accusation, the CNA was not suspended or disciplined, and the resident was not separated from the CNA during the investigation. Interviews revealed inconsistencies and a lack of immediate action, and the facility's policy on abuse prevention and investigation was not followed.
Unsafe mechanical lift transfer and repeated unattended bathroom falls
Penalty
Summary
The facility failed to ensure safe and appropriate mechanical lift transfers for a resident who was dependent on staff for all ADLs and required a mechanical lift for transfers. The resident had diagnoses including Alzheimer’s disease, heart failure, and anemia. During the transfer, staff observed a kink in the sling and attempted to adjust it while the resident was already suspended in the lift. The sling loop shifted and folded, the resident slid out of the lift, and she fell to the floor. She was sent to the ED and later found to have bilateral sacral body fractures and severe osteopenic disease. Staff interviews and the facility investigation described that the resident fell when the sling came loose during the transfer. The report also documented that staff did not follow the lift manufacturer’s instructions and the facility’s own lifting practices during the transfer. The mechanical lift manual stated the wheels should never be locked when lifting or lowering a patient, yet staff observed and reported that the lift wheels were locked during transfers. Staff also described uncertainty about the correct sling size to use for the resident, with one staff member stating that staff just pick a sling that fits and another stating there was no assigned size or chart available to guide selection. The DON stated there was nothing in writing for staff to refer to regarding the appropriate sling size. The facility also failed to prevent further falls for another resident with severely impaired cognition, dementia, Parkinson’s disease, and anxiety disorder. That resident’s care plan directed staff not to leave her unattended in the bathroom, and a prior fall investigation documented that she had been left unattended in the bathroom and later fell. A subsequent fall investigation documented that staff again left her unattended at the bathroom sink to retrieve her wheelchair, and she fell while washing her hands. The facility’s fall protocol identified interventions to prevent subsequent falls, but the report stated it lacked documentation of follow-up to ensure the interventions were being done.
Expired Abuse Reporter Training for CNA and LPN
Penalty
Summary
The facility failed to meet requirements for Dependent Adult Abuse Mandatory Reporter Training for 1 of 5 employees reviewed, Staff H, a CNA. Review of Staff H’s personnel file showed a Dependent Adult Abuse Mandatory Reporter Training certificate dated [DATE]/22 and another training completion dated [DATE], but timecard review showed Staff H worked on [DATE]/[DATE]/25 without being certified in Adult Abuse Mandatory Reporter Training. The facility’s policy required employees to receive abuse-related training upon initial employment and to complete the initial 2-hour Iowa Department of Human Services training within 6 months of hire, with recertification every 3 years. During interview, Staff E, an LPN, stated staff are required to be certified in Dependent Adult Abuse Mandatory Reporter Training and did not know if there was a process to ensure staff stayed current in training. In a later interview, the DON acknowledged that Staff E worked with residents while certification in Dependent Adult Abuse Mandatory Reporter Training had expired and stated Staff E should have taken the class sooner. She worked a couple of shifts but is now certified.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to respect residents’ dignity during care and services for multiple residents with significant cognitive impairment and dependence for personal care. Resident #5 had diagnoses of dementia, vision impairment, and anxiety disorder, with a BIMS score of 00 and need for partial/moderate assistance with hygiene, bathing, and toileting. A CNA reported witnessing another CNA enter the resident’s room without knocking, turn on the light, fail to introduce herself, and then fling the resident’s feet back into bed while telling her to stay in bed. Resident #44 had diagnoses of Alzheimer’s disease, anxiety disorder, and pain, with an unable-to-complete BIMS and dependence for toilet hygiene, bathing, and dressing. While transferring the resident, she became incontinent of bowel movement and a CNA commented in the resident’s presence, “Are you fucking kidding me?” Resident #54 had heart failure, dementia, and seizure disorder, with a BIMS score of 6 and dependence for toilet hygiene and lower body dressing; a CNA reported that while helping the resident get up for supper, another CNA talked about why staff did not like the resident in the resident’s presence. Resident #80 had heart failure, dementia, and malnutrition, with a BIMS score of 4 and substantial/maximal assistance needs for hygiene and dressing; a CNA reported another CNA said the resident would pass away soon, rapidly removed the resident’s shirt causing the resident to elevate her voice, and then told the resident, “you’re fine,” without asking if she was okay.
Improper Use of a Positioning Device as a Restraint
Penalty
Summary
The facility failed to protect Resident #54 from the use of a physical restraint that the resident could not remove on her own. Resident #54’s MDS documented diagnoses of Alzheimer’s Disease, heart failure, and anemia, and the BIMS was not completed because the resident was rarely or never understood. During observation on 8/25/2025, a positioning device was seen behind the resident’s left side of her back under the fitted sheet. During a later observation on 8/27/2025, two CNAs assisted the resident into bed, and after she was lying down, one CNA removed a positioning device from the closet and placed it under the fitted sheet and pressure relieving device behind the resident’s left side of her back before leaving the room. The facility’s restraint policy stated that if a resident cannot remove a device in the same manner it was applied and it restricts the resident’s typical ability to change position or place, the device is considered a restraint. The DON stated that the wedge should not have been under the sheet.
Bed-Hold Notices Lacked Required Signatures and Documentation
Penalty
Summary
The facility failed to ensure bed hold notices were signed by residents or their responsible persons when residents transferred out of the facility, and the chart lacked documentation of notification and the resident or responsible person's decision to enact a bed hold for 2 of 2 residents reviewed. For Resident #3, the record showed multiple hospital transfers and readmissions, including discharge to acute care hospital on 4/28/25 and again on 8/15/25, with readmissions on 4/29/25 and 8/19/25. The bed hold form for the 4/28/25 transfer lacked a signature from the resident or responsible person, and no bed hold form was found for the 8/15/25 transfer. The nurse's notes also lacked documentation of bed hold communication with the resident or responsible person for the 4/28/25 and 8/19/25 transfers. For Resident #23, the MDS documented coronary artery disease, hypertension, and Non-Alzheimer's Dementia, with a BIMS score of 5 indicating severe cognitive impairment. The resident was transferred to the ER on 8/24/25, admitted to the hospital shortly after, and returned to the facility on 8/26/25. The medical chart contained a bed hold form, but it did not document whether the resident representative wanted the bed hold. The progress notes lacked information about family contact regarding the bed hold and lacked signatures showing receipt of notification. Facility policy stated that all residents or representatives are to be provided written bed-hold information and that multiple attempts to notify the representative should be documented when timely contact cannot be made. During interview, the DON stated the facility sends the bed hold paperwork with the resident to the hospital, mails it to the family the next day, and scans it into the chart, but verified the chart lacked documentation of family notification and stated it was her fault that nothing was charted on the day after the resident went to the hospital.
Inaccurate MDS Coding for PASRR Status and Bed Rail Use
Penalty
Summary
The facility failed to accurately document and submit resident MDS assessments for 2 of 3 residents reviewed. For one resident, the MDS dated [DATE] documented a BIMS score of 13 and diagnoses of anxiety disorder, depression, and schizophrenia, but it incorrectly coded PASRR Level II as no even though the resident’s current PASRR dated 4/21/23 showed Level II approval with specialized services. Staff interviews confirmed the resident was a Level II PASRR and that this should have been coded on the MDS. The DON also stated the facility did not have a policy for MDS assessments and followed the RAI Manual, which directs coding yes when PASRR Level II screening determines the resident has serious mental illness and/or ID/DD or a related condition. For another resident, the MDS dated [DATE] documented a BIMS score of 15 and diagnoses including seizure disorder or epilepsy, bed confinement status, and malnutrition, and it coded bed rails as a physical restraint. The care plan stated the resident could not complete her own cares due to right-sided weakness and that she requested a transfer assist rail for the left side of the bed to help with transfers, mobility, care, and increased independence. The Unit Manager stated the bedrail was not a restraint and that if it is not a restraint, it should not be coded on the MDS. The RAI Manual states bed rails used with residents who are immobile do not meet the definition of a physical restraint when the resident cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present.
Failure to Use EBP and Perform Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when Staff E, an LPN, assisted Resident #41 with catheter care without using Enhanced Barrier Precautions (EBP) and did not perform hand hygiene between glove changes. During observation on 8/27/2025 at 10:11 a.m., Staff E was in the resident’s room with gloves on and a graduate in her left hand, then closed the door after the resident entered the room. With the same gloves on, Staff E opened the spout on the resident’s leg bag, emptied the contents, and set the graduate containing urine directly on the floor. Staff E then used the same soiled gloves to take alcohol swabs, clean the catheter bag opening, pick up the graduate from the floor, empty it into the toilet, add soap and water to rinse it, and dump the contents into the toilet. After removing the soiled gloves, Staff E did not perform hand hygiene before applying clean gloves to reapply the leg strap, pull the resident’s pant leg down, and apply the resident’s boots. Staff E then removed the gloves and performed hand hygiene before opening the room door. The facility’s EBP policy identified urinary catheters as indwelling medical devices requiring EBP, and the hand hygiene policy required hand hygiene before applying non-sterile gloves and after removing soiled gloves. The DON stated that staff working with a resident with a catheter are to use EBP in the room, especially when emptying a catheter bag.
Failure to Provide Privacy During Resident Transfers
Penalty
Summary
The facility failed to provide privacy of a body during personal cares for two residents during mechanical lift transfers into bed. On 8/27/2025 at 12:43 p.m., Staff C, CNA and Staff D, CNA assisted Resident #11 into bed and did not close the curtains during the transfer. On 8/27/2025 at 9:57 a.m., Staff A, CNA and Staff B, CNA assisted Resident #54 into bed and also failed to close the curtains to provide privacy during the transfer. Facility policy titled Resident Right Guidelines stated to close the door when privacy is appropriate, draw window curtains and the privacy curtain between beds, and provide privacy during cares. The DON stated staff should have the curtains closed when performing transfers.
Failure to Report Allegations of Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for 4 of 4 residents reviewed for abuse. The report identified Residents #5, #44, #54, and #80 as having allegations involving staff conduct toward residents, and the facility census was 68 residents. The facility policy stated that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation were to be reported immediately to the charge nurse and then immediately to the Administrator or designated representative, with reporting to DIAL not later than 2 hours after the allegation when serious bodily injury was involved. Resident #5 had diagnoses of dementia, vision impairment, and anxiety disorder, with a BIMS score of 00 indicating severe cognitive impairment and needed partial/moderate assistance with hygiene, bathing, and toileting. Staff I reported witnessing Staff C enter the room without knocking, turn on the light, fail to introduce herself, and fling the resident’s feet back into bed while telling her to stay in bed. Resident #44 had Alzheimer’s disease, anxiety disorder, and pain unspecified, with an unable-to-complete BIMS and dependence for toilet hygiene, bathing, and dressing. Staff I reported that while transferring Resident #44, the resident became incontinent of bowel movement and Staff C commented in the resident’s presence, “Are you fucking kidding me?” Resident #54 had heart failure, dementia, and seizure disorder, with a BIMS score of 6 indicating severe cognitive impairment and dependence for toilet hygiene and lower body dressing. Staff I reported that Resident #54 voiced concern that another CNA was upset because staff did not get her up for supper, and while staff were assisting her, Staff C talked about why staff did not like the resident in the resident’s presence. Resident #80 had heart failure, dementia, and malnutrition, with a BIMS score of 4 indicating severe cognitive impairment and required substantial/maximal assistance for hygiene and dressing. Staff I reported that Staff C stated the resident would pass away soon, rapidly removed the resident’s shirt causing the resident to elevate her voice, told the resident she was fine, and did not ask if she was okay. Staff I stated she typed a note and submitted it under the office doors of the Administrator, DON, and ADON, but no one followed up with her, and the Administrator later told her he had six days to follow up.
Failure to Monitor Resident and Ensure Safe Transfers
Penalty
Summary
The facility failed to account for the whereabouts of a resident, Resident #16, and ensure that door alarms were activated, leading to an incident where the resident exited the facility undetected. On the evening of May 7, 2024, Resident #16, who had a moderate cognitive deficit and a history of traumatic brain injury, used the handicap button to exit through the front door without triggering an alarm. The staff was unaware of his absence for over two hours until he was returned by a staff member from the assisted living facility. During his time outside, Resident #16 fell and sustained abrasions to his face, wrist, and knees. The investigation revealed that the front door alarm had been turned off earlier that evening, and staff failed to notice his absence due to inadequate supervision and monitoring. Additionally, the facility failed to correctly transfer another resident, Resident #23, using a sit-to-stand lift. Resident #23, who had intact cognitive ability but required substantial assistance with transfers, was not properly secured during a transfer from a wheelchair to a recliner. The staff member, Staff Y, did not tighten the safety strap around the resident's torso, which is a critical step in ensuring the resident's safety during the transfer. This oversight posed a risk to the resident's safety, especially given her weaker condition. The deficiencies highlight lapses in the facility's procedures for monitoring residents and ensuring their safety during transfers. The failure to maintain active door alarms and properly secure residents during transfers contributed to the incidents involving Resident #16 and Resident #23, respectively. These events underscore the need for vigilant supervision and adherence to safety protocols to prevent accidents and ensure resident well-being.
Incomplete CPR Authorization Documentation
Penalty
Summary
The facility failed to obtain complete and properly documented Authorization for Withholding CPR forms for four residents. For Resident #3, the form was signed by the resident but included a scribbled-out note indicating a change in CPR preference, and lacked both a date and witness signature. Additionally, the facility did not include the resident's code status in a request for a physician's signature. Resident #23's form was signed by both the resident and a witness but was undated. Resident #2's form was signed only by the resident's guardian, with no date, physician signature, or witness signature. Similarly, Resident #121's form was signed by the resident's Durable Power of Attorney but lacked a witness and physician signature, although a date was written in the witness signature space. The facility's policy requires that upon admission, residents are asked about their directives, and the signed document is to be sent to the physician for signature and then placed in the resident's chart. However, these steps were not completed for the residents in question.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for four residents requiring the use of oxygen. Resident #11, with a diagnosis of chronic obstructive pulmonary disease and dyspnea, could not recall when her oxygen tubing was last changed, and it was observed to be dated over two months prior. Resident #33, who also required oxygen, was observed with undated tubing, and the resident could not remember the last change. Resident #41, diagnosed with coronary artery disease and heart failure, had oxygen tubing dated five months prior, and the Treatment Administration Record (TAR) indicated a missed change. Staff interviews revealed that oxygen tubing was expected to be changed weekly, but this was not consistently documented or followed. Resident #21, with moderate cognitive impairment and diagnoses including coronary artery disease and heart failure, had orders for oxygen administration and tubing changes that were not consistently documented. Observations showed outdated tubing, and staff interviews confirmed that the facility protocol required weekly changes, which were not adhered to. The Director of Health Services acknowledged the oversight and mentioned that the facility had taken steps to address the issue, such as ordering bright-colored stickers for easier notification of dates on the tubing.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during resident care, specifically for Resident #21, who had moderate cognitive impairment and required extensive assistance with activities of daily living. During an observation, staff members did not perform hand hygiene after removing gloves and before donning new ones while providing catheter and personal care to the resident. This was contrary to the facility's infection control guidelines, which required hand hygiene after glove removal and before handling invasive devices. The facility was also in outbreak status for COVID-19, yet staff members were observed not wearing masks in various areas of the facility, including hallways and offices. Despite the facility's policy requiring masks during an outbreak, several staff members, including the Infection Preventionist, were seen without masks in situations where they were expected to wear them. The facility had reported multiple cases of COVID-19 among residents and staff, indicating a failure to adhere to source control measures during the outbreak. Additionally, Resident #64, who had intact cognitive ability and was on hospice care, tested positive for COVID-19 and required assistance with personal care. During a bed bath provided by a CNA, the staff member did not change gloves throughout the procedure and left the room without washing hands, using only hand sanitizer in the hallway. This was inconsistent with the facility's hand hygiene policy, which required handwashing after glove removal and before moving from a contaminated to a clean body site.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' right to dignity and privacy by not consistently knocking on residents' doors before entering. This deficiency was identified through observations, interviews, and a review of facility policy. A cognitively intact resident reported that staff entered her room without knocking or announcing themselves, which made her feel disrespected. Observations confirmed that staff members, including CNAs and a CMA, entered rooms in the East Hallway without knocking or announcing their presence. The Director of Health Services acknowledged that staff are expected to knock and wait for a response before entering, as outlined in the facility's Residents' Rights document.
Failure to Revise Care Plan for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to review and revise the care plan for a resident with severe cognitive impairment, as evidenced by a discrepancy between the care plan and the treatment administration record (TAR). The resident, who had a history of pressure ulcers, was observed with a boot on the right foot and a regular shoe on the left foot, contrary to the care plan's directive to place heels in boots to prevent pressure. The TAR indicated that the resident should have inflatable boots on both heels, but staff only signed off on the treatment for 39 out of 41 opportunities. Interviews with staff revealed that the resident returned from the hospital with heel wounds, and the left heel had healed while the right heel was close to healing. Staff stated that the resident only wore the right boot during the day when sitting and wore regular shoes when ambulating with staff. The Director of Health Services acknowledged that care plans and TARs should correlate, and the facility's policy indicated that the MAR/TAR should be part of the ongoing care plan. However, the care plan did not reflect the current treatment practices, leading to the deficiency.
Failure to Follow Pressure Ulcer Care Orders
Penalty
Summary
The facility failed to adhere to prescribed interventions and physician orders for pressure ulcer care for two residents. Resident #64, who had intact cognitive ability and was under hospice care, had a chronic heel ulcer with specific treatment orders. These orders included applying waffle boots and specific wound dressings. However, observations revealed that the resident's heel was left open to air, contrary to the treatment plan, and the heel protector boot was not applied as required. Staff members were observed not following the treatment orders, and the Treatment Administration Record indicated that treatments were not consistently completed or documented. Resident #30, with severe cognitive impairment, had orders to wear inflatable boots on both heels to prevent pressure ulcers. Despite this, observations showed that only the right foot had a boot, while the left foot was in a regular shoe. The Medication Administration Record indicated inconsistencies in documentation, with staff failing to apply the boots as ordered. Staff members provided conflicting information about the resident's condition and treatment, with some stating that the left heel had healed and the right heel was close to healing. The Director of Health Services expected positioning devices to be used as documented, but this was not consistently followed.
Failure to Answer Call Lights Promptly
Penalty
Summary
The facility failed to ensure call lights were answered in under 15 minutes for four residents, leading to significant delays in care. Resident #2 reported waiting over 2 hours for her call light to be answered, resulting in incontinent episodes and wet clothing due to an unemptied catheter bag. The Device Activity Report confirmed multiple instances where Resident #2's call light was on for extended periods, including 64 minutes and 44 minutes on separate occasions. Resident #5 also experienced long wait times for her call light to be answered, expressing concerns about insufficient staffing and the risk of not making it to the bathroom in time. The Device Activity Report showed that her call light was on for 15 minutes on one occasion. Similarly, Resident #6 and Resident #7 reported long wait times, with the Device Activity Report indicating multiple instances where their call lights were on for 15 to 39 minutes. The facility's Licensed Nurse Orientation Checklist mandates that call lights should be answered within 15 minutes, a standard that was not met according to the findings.
Failure to Cover Food Items During Transport
Penalty
Summary
The facility failed to ensure that food items were covered before being transported from the dining area to residents' rooms. During an observation, it was noted that multiple CNAs transported meal trays with uncovered items such as cake, drinks, juice, coffee, and ranch dressing to the rooms of five different residents. The facility's policy, revised in November 2009, mandates that all food and beverages must be covered before transport. An interview with the Dietary Manager confirmed that the expectation was for all staff to adhere to this policy.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals (DIA) within 24 hours for a resident. The resident, who had diagnoses of diabetes mellitus, heart failure, and arthritis, had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 3/29/24, progress notes revealed that during an aide report, a nurse overheard aides discussing a physical altercation involving the resident and an aide. The resident was reported to have been swinging at the aide and claimed that the aide hit her. However, when questioned, the resident stated she did not remember the incident and denied any hitting. The incident was discussed with the nursing supervisor, who advised speaking to the aide and others present the following day. An interview with the resident on 4/2/24 concluded that no hitting took place, based on the resident's and a Certified Nursing Assistant's statements, as well as the nurse's notes from 3/29/24. The facility's policy on abuse prevention, identification, investigation, and reporting, dated October 2022, mandates that all allegations of abuse be reported to the State Agency within 2 hours. Despite this policy, the administrator did not report the incident to the DIA, as he believed it was unnecessary based on the resident's denial of being hit. This failure to report the allegation within the required timeframe constitutes a deficiency in the facility's adherence to its own policies and state regulations.
Failure to Investigate Abuse Allegations and Separate Staff
Penalty
Summary
The facility failed to investigate allegations of abuse and separate the resident from the staff member alleged of abuse during the investigation. Resident #5, who had diagnoses of diabetes mellitus, heart failure, and arthritis, and a BIMS score of 15 indicating no cognitive impairment, was involved in the incident. On 3/29/24, Resident #5 was upset with a CNA and accused the CNA of hitting her. Despite this, the CNA was not suspended or disciplined, and the resident was not separated from the CNA during the investigation. Interviews with various staff members revealed inconsistencies and a lack of immediate action. Staff G, the CNA involved, reported the incident to Staff H, an RN, who advised using two aides but did not take further action. Staff I, an LPN, overheard the accusation during a shift report and contacted the on-call nursing supervisor, Staff J, who advised speaking to the involved parties the next day. Staff J did not follow up on the investigation, assuming it was handled by the Assistant Director of Nursing (ADON). The facility's policy on abuse prevention and investigation was not followed. The policy requires immediate separation of the accused staff member from the resident and a thorough investigation, including documentation and witness statements. The Administrator believed no further action was necessary since the resident later denied being hit. However, the lack of immediate protective measures and thorough investigation led to the deficiency.
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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.
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Nursing homes near Spencer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spencer Post Acute Rehabilitation Center | 2.2 mi | ★★★★★ | 43 | 0 |
| Ruthven Community Care Center | 11.5 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Milford | 14.2 mi | ★★★★★ | 0 | 0 |
| Community Memorial Health Center | 18.5 mi | ★★★★★ | 16 | 0 |
| Accura Healthcare Of Spirit Lake | 20.6 mi | ★★★★★ | 9 | 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.