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 The Vinton Lutheran Home during CMS and state inspections, most recent first.
A resident with multiple comorbidities, moderate cognitive impairment, and a history of falls experienced several documented falls, including incidents from bed and from a commode, one of which resulted in a skin tear and another in a re-fracture of the pelvis. Although an initial care plan identified a low fall risk and included general fall precautions, the comprehensive care plan was not updated with new, resident-specific fall interventions after the subsequent falls. An RN care plan coordinator acknowledged that no new interventions were added to the care plan following these events, despite facility policy requiring that post-fall safety measures and individualized interventions be promptly communicated and incorporated into the care planning process.
A resident with severe cognitive and physical impairments suffered a head injury and brain hemorrhage after falling from a mechanical lift during a transfer. Staff used a lift with a defective spreader bar and an inappropriate sling, did not clear the resident over a bed wedge, and lacked clear guidance on sling selection. Multiple staff had previously reported issues with sling straps detaching, but no corrective action was taken, and maintenance staff were not properly trained to inspect the equipment.
A resident with severe cognitive impairment fell and sustained facial injuries when her foot got caught while being transported in a wheelchair without foot pedals. The facility's policy required foot pedals during transport, but this was not followed, leading to the incident.
A resident with pneumonia and septicemia missed a dose of antibiotics due to improper management of a leaking PICC line. A nurse applied glue to the line, contrary to facility policy, and failed to notify the physician promptly. The resident was sent to the ER for a new PICC line.
The facility failed to take a resident to the restroom timely, resulting in soiled clothing, and did not sanitize the chair he sat in. Another resident's fingernails were not cleaned or trimmed, despite severe cognitive impairment and the need for assistance with personal hygiene. Facility policies on furniture cleaning and resident rights were not followed.
The facility failed to complete a PASRR for a resident with a history of mental disorders, including Anxiety Disorder, Depression, and Bipolar Disorder. The resident had a PASRR Level II Summary of Finding report dated 4/30/19, but no follow-up PASRR was documented since then. The DON confirmed the oversight.
A resident with moderate cognitive impairment and multiple medical conditions experienced several falls, but the facility failed to reassess and update the care plan with specific interventions to prevent future falls. The care plan did not document all falls, and mini care plans used by staff were often undated and illegible, leading to confusion about current interventions. The facility's fall assessment and management policy was not consistently followed.
The facility failed to notify the pharmacist of a resident's admission in a timely manner, resulting in a delayed drug regimen review (DRR) for a resident with anxiety disorder, depression, and diabetes mellitus II. The DRR was conducted nearly a month after admission, contrary to the facility's policy requiring a DRR within one week of a new admission.
The facility failed to ensure they were not serving expired food items, which could reduce the risk of contamination and food-borne illness. During an initial tour of the facility kitchen, several expired food items were found, including unopened boxes of fudge cream icing mix, cinnamon streusel topping mix, cans of evaporated milk, boxes of grape nuts cereal, quart containers of half and half, and containers of whipping cream. The Dining Services Director (DSM) stated that staff were expected to check for expired food items each day, with new delivery orders, and at a minimum of twice a week. However, the facility's policy on Date Marking/Leftovers/Discarding Food lacked direction for monitoring expired food items.
Failure to Update Fall Care Plan After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s fall care plan updated following multiple falls, as required by regulation and facility policy. The resident was admitted with diagnoses including a fractured right pubis, diabetes, obesity, and kidney failure, and required substantial assistance with ADLs such as showering, standing, and toileting, using a walker or wheelchair for mobility. The MDS identified moderate cognitive impairment and a fall in the month prior to admission. The initial care plan, dated 11/3/25, documented a fall risk score of 5 (low risk) and included general interventions such as encouraging slow transitions from lying to sitting and sitting to standing, keeping the call light within reach, allowing use of half upper side rails, and directing staff to provide first aid, assess for causes, remedy as needed, and report to the primary care physician in the event of a fall. Progress notes documented three separate falls: the resident was found sitting on the floor next to the bed early in the morning on one date, found on his knees in front of the commode with a skin tear to the left elbow on another date, and later found on the floor again, after which he experienced pain and inability to stand as usual, leading to an x-ray order and transfer to the emergency room where a re-fracture of the right pelvis was identified and the resident did not return. Despite these falls, the comprehensive care plan was not updated to include new, resident-specific fall interventions related to the incidents on 11/15/25 and 11/17/25. A mini care plan noted use of a low bed and an intervention that the resident should not be left on the commode alone, but the dates were unclear and these measures were not incorporated into the main care plan. The RN care plan coordinator confirmed that no new interventions were added to the care plan after the falls, which was inconsistent with the facility’s Fall Assessment and Management Policy requiring that interventions and safety measures be communicated to staff and added to the mini care plan immediately following a fall and that fall-reduction interventions be resident-specific and based on the fall.
Failure to Ensure Safe Mechanical Lift Operation and Sling Use During Resident Transfers
Penalty
Summary
The facility failed to ensure the safe operation of a full body mechanical lift and the use of appropriate slings during resident transfers, resulting in a serious incident. Staff used a mechanical lift with a spreader bar that had a gap of over 1 centimeter between the hook cradle and the rubber stopper, which was not identified prior to use. During a transfer, staff did not clear a resident's bottom over a bed wedge cushion, causing the lift sling strap to lift off the spreader bar hook. This led to the resident falling to the floor and sustaining a 3-4 centimeter gash to the back of the head, which required hospitalization for subdural and intraventricular hemorrhage. The resident involved had significant cognitive and physical impairments, including severe memory problems, inability to make daily decisions, and dependence on staff for transfers. The care plan and Kardex directed the use of a full body mechanical lift with two staff but did not specify the type or size of sling to be used. Staff interviews revealed a lack of knowledge regarding appropriate sling selection, with staff often choosing sling size by visual estimation rather than by specific guidance. There was also confusion about which slings were compatible with which lifts, and some slings in use were not recommended by the lift manufacturer. Multiple staff reported that issues with sling straps coming off the lift hooks had been observed previously and communicated to management, but no action was taken to address these concerns. Maintenance staff had not received adequate training on inspecting the lifts, and inspection logs were incomplete or lacked documentation of when equipment was removed from service. Observations also showed that staff did not consistently follow safe practices, such as ensuring the lift legs were in the wide position during transfers. The combination of equipment malfunction, lack of clear procedures, and insufficient staff training directly contributed to the incident and the resulting harm.
Failure to Use Foot Pedals During Wheelchair Transport Results in Resident Injury
Penalty
Summary
The facility failed to provide appropriate supervision while transporting a resident in a wheelchair, resulting in an injury. The resident, who had severe cognitive impairment and required substantial assistance for transfers, was being transported to the dining room table when her foot got caught, causing her to fall forward and hit her head and nose on the table. This incident led to a facial injury and fracture. The resident's care plan had identified her as a fall risk due to factors such as incontinence, impaired decision-making skills, decreased cognition, and pain. Despite these known risks, the staff did not use foot pedals while transporting the resident in her wheelchair, which was against the facility's policy. The lack of foot pedals allowed the resident's foot to become caught, leading to the fall and subsequent injuries. The facility's policy clearly stated that residents should not be pushed in wheelchairs without their feet on pedals, and any resident who self-propels should have the pedals folded to the side. However, the staff member involved in the incident did not adhere to this policy, resulting in the resident's fall and injury. The incident highlights a failure in following established safety protocols during resident transport within the facility.
Improper Management of PICC Line Leads to Missed Antibiotic Dose
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding intravenous therapy for a resident who required daily antibiotics via a PICC line. The resident, who had diagnoses including pneumonia, septicemia, and diabetes mellitus, experienced a complication when a nurse attempted to change the PICC line dressing, which was overdue by three days. During the dressing change, the nurse noted that the PICC line was leaking blood and attempted to stop the leakage by applying tape and later, glue, which was not in accordance with the facility's policy. The nurse was unable to flush the PICC line and subsequently could not administer the prescribed antibiotic. Despite the facility's policy requiring notification of the physician in such cases, the nurse did not immediately contact the physician but instead attempted to place a peripheral line, which was unsuccessful. The Director of Nurses was informed and advised the nurse to wait until the morning to contact the physician, resulting in the resident missing a dose of antibiotics. The resident was eventually sent to a local emergency room where the PICC line was replaced. The emergency room staff noted that the PICC line had been damaged and expressed concern over the use of glue to address the leakage. The resident's primary care physician also highlighted the inappropriate handling of the situation, emphasizing the need for staff to review the facility's policy on PICC line management.
Failure to Address Residents' Toileting and Personal Hygiene Needs
Penalty
Summary
The facility failed to take a resident to the restroom in a timely manner, resulting in the resident's brief soiling his clothing. The resident, who had severe cognitive impairment and required substantial assistance with toileting, was observed with a wet spot on his pants for an extended period. Despite multiple interactions with staff, the resident was not taken to the restroom promptly, and the chair he sat in was not sanitized after he sat in it with wet pants. The care plan for the resident lacked a specific check and change time frame, and staff acknowledged the need for two people to assist the resident due to combative behavior. Another deficiency involved the facility's failure to ensure a resident's fingernails were cleaned and trimmed. The resident, who had severe cognitive impairment and required assistance with personal hygiene, was observed with chipped nails and a thick brown substance under her nails. Despite documentation of the resident's refusal of a manicure, there was no record of staff re-approaching the resident or determining the root cause of her refusal. Staff interviews revealed a lack of clarity on who was responsible for nail care, and the resident's care plan did not document personal care refusal. The facility's policies on furniture cleaning and resident rights were not followed. The furniture cleaning policy required daily cleaning and sanitization of soiled furniture, which was not done. The resident rights policy emphasized the right to be treated with dignity and respect, which was compromised by the facility's failure to address the residents' toileting and personal hygiene needs adequately.
Failure to Complete PASRR for Resident with Mental Disorders
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) for a resident with a history of mental disorders, including Anxiety Disorder, Depression, and Bipolar Disorder. The resident, who had an intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, had a PASRR Level II Summary of Finding report dated 4/30/19, which approved 150 days of nursing facility care. However, the facility lacked documentation of a follow-up PASRR since 2019. The resident confirmed that she lived in the facility due to her mental illness and required assistance with self-care. The Director of Nursing (DON) acknowledged that no PASRR had been completed for the resident since 2019 and confirmed her responsibility for PASRR completion.
Failure to Update Care Plan for Fall Interventions
Penalty
Summary
The facility failed to reassess the effectiveness of fall interventions and to modify the care plan for a resident with a history of falls. The resident, who had moderate cognitive impairment and multiple medical conditions including a fractured left femur, cancer, arthritis, osteoporosis, and malnutrition, experienced several falls. Despite these incidents, the care plan did not include specific staff interventions to mitigate future falls, and some falls were not documented in the care plan at all. The care plan was not updated to reflect new interventions after each fall, and the mini care plans used by staff were often undated and illegible, leading to confusion about the most current interventions. The resident's care plan documented falls on specific dates but failed to include falls that occurred on other dates. For example, falls on 2/2/24 and 3/12/24 were not documented in the care plan. The facility's fall scene investigation reports provided brief summaries of how the falls occurred and listed interventions such as educating the resident to call for assistance and increasing visual checks. However, these interventions were not consistently added to the care plan. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that care plan interventions were not necessarily updated or documented on the resident's care plan but were instead noted on mini care plans located in the resident's room. Interviews with staff revealed that they relied on mini care plans and verbal reports during shift changes to know the most recent directives for resident care. However, the mini care plans were often handwritten, with numerous revisions and some entries highlighted, making it difficult for staff to determine the most current interventions. The DON admitted that the most current revisions were not always dated. Additionally, the facility's policy on fall assessment and management was not followed, as interventions were not consistently communicated to staff or added to the care plan immediately following a fall. The resident was placed on the Falling Star Program, but this was not adequately documented in the care plan.
Delayed Drug Regimen Review for New Admission
Penalty
Summary
The facility failed to notify the pharmacist of a resident's admission in a timely manner, resulting in a delayed drug regimen review (DRR) for a resident diagnosed with anxiety disorder, depression, and diabetes mellitus II. The resident was admitted on 11/6/23, but the DRR was not conducted until 12/5/23, nearly a month later. The resident's Medication Administration Record (MAR) documented the use of escitalopram Oxalate for depression and buspirone HCl for anxiety, with the initial admission documents signed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/6/23. Despite this, the pharmacy was not notified to perform the DRR as required by the facility's policy, which mandates a DRR within one week of a new admission. Interviews with staff revealed that the DRR and Gradual Dose Reduction (GDR) reviews were typically initiated by the pharmacy every month, with forms sent to the facility for review and then forwarded to the provider. However, in this case, the DON confirmed that the nursing staff failed to communicate with the pharmacist and provider regarding the resident's admission and medication regimen. The facility's policy, reviewed on 2/1/24, clearly indicated that Medication Regimen Reviews should be conducted within one week of new admission, upon starting an antibiotic, and monthly, but this protocol was not followed, leading to the deficiency.
Expired Food Items Found in Facility Kitchen
Penalty
Summary
The facility failed to ensure they were not serving expired food items, which could reduce the risk of contamination and food-borne illness. During an initial tour of the facility kitchen, several expired food items were found, including unopened boxes of fudge cream icing mix, cinnamon streusel topping mix, cans of evaporated milk, boxes of grape nuts cereal, quart containers of half and half, and containers of whipping cream. The Dining Services Director (DSM) stated that staff were expected to check for expired food items each day, with new delivery orders, and at a minimum of twice a week. However, the facility's policy on Date Marking/Leftovers/Discarding Food lacked direction for monitoring expired food items.
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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 Vinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Virginia Gay Nursing & Rehab, Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| Laporte City Specialty Care | 13 mi | ★★★★★ | 3 | 0 |
| Keystone Nursing Care Center Inc | 14 mi | ★★★★★ | 4 | 0 |
| Hiawatha Care Center | 18.7 mi | ★★★★★ | 7 | 0 |
| West Ridge Care Center | 20.2 mi | ★★★★★ | 3 | 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.