Inspection Reports for Lamoni Specialty Care
215 South Oak Street, IA, 501400460
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 7, 2025, found the facility to be in substantial compliance with no deficiencies. Earlier inspections showed some deficiencies primarily related to medication management, including issues with transcription errors and controlled substance documentation, as well as nutritional care and fall prevention. Complaint investigations were mostly unsubstantiated, though some substantiated complaints led to citations for medication transcription errors, failure to report missing narcotics, and inadequate fall risk interventions. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections demonstrating compliance following corrective actions.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
31 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 7, 2025
Visit Reason
A complaint investigation for complaints #2660583 was conducted from November 6, 2025 to November 7, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2660583 was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
May 15, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective May 15, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Apr 30, 2025
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints (#126612-C, #126638-C, #126741-C, #127372-C, and #127398-C) from April 23, 2025 to April 30, 2025. Complaints #126741-C and #127372-C resulted in deficiencies.
Findings
The facility failed to report missing morphine from a resident's supply and failed to ensure accurate reconciliation and documentation of controlled medications and narcotic counts. Staff did not complete required narcotic counts at shift changes, and there was evidence of coercion of a nurse to falsely admit to spilling morphine. The Director of Nursing did not report the missing narcotics to the State Agency, believing the discrepancy was explained by spillage and manufacturer variance.
Complaint Details
The visit was complaint-related, investigating complaints #126612-C, #126638-C, #126741-C, #127372-C, and #127398-C. Complaints #126741-C and #127372-C were substantiated resulting in deficiencies related to narcotic reporting and documentation.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report 4 milliliters of morphine missing from a resident's supply in a timely manner. | SS=D |
| Failure to ensure accurate reconciliation of all controlled medications. | SS=D |
| Failure to maintain accurate and complete medical records, including Individual Narcotic Records and Controlled Drugs-Count Records. | SS=D |
Report Facts
Missing morphine volume: 4
Facility census: 31
Audits planned: 4
Audits planned: 2
Shift change narcotic counts reviewed: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Carr | Administrator | Signed plan of correction |
| Staff D | Registered Nurse | Involved in narcotic count and reporting deficiencies |
| Staff I | Licensed Practical Nurse | Involved in narcotic count, discovered missing morphine, and reported discrepancy |
| Staff H | Registered Nurse | Reported missing morphine to Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Investigated missing morphine, did not report to State Agency, pressured nurse to admit spilling morphine |
| Staff M | Registered Nurse | Received report of missing morphine and nurse's concerns about coercion |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 13, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective February 13, 2025.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 1
Feb 12, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from February 10, 2025 to February 12, 2025.
Findings
The facility failed to meet professional standards of quality related to accurate transcription of a physician order for Resident #14, resulting in incomplete administration of ear drops. The facility implemented corrective actions including separate orders for Debrox drops and flush, staff education, and audits to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Facility failed to accurately transcribe a physician order for Resident #14, resulting in incomplete administration of ear drops. |
Report Facts
Census: 35
Deficiency correction date: Correction date set as 2025-02-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Nurse who transcribed the order incorrectly and later flushed Resident #14's ears |
| Director of Nursing | Spoke to Nurse Practitioner regarding the order issue |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 4, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective April 4, 2024.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 1
Mar 20, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #114376-C, 114409-C, and facility reported incidents #114672-I and 117584-I.
Findings
The facility failed to accurately transcribe and implement physician orders for one resident, resulting in a medication transcription error that contributed to hospitalization. Corrective actions included education of nursing staff, risk management, and implementation of double notation procedures for orders.
Complaint Details
Complaint #114409-C and Facility Reported Incident #117584-I were substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to accurately transcribe and implement physician orders for Resident #4, resulting in a medication transcription error. |
Report Facts
Residents present: 29
Complaints investigated: 3
Audits planned: 4
Medication dosage: 300
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Noted the order on 11/30/23 and involved in transcription error |
| Director of Nursing | DON | Notified ARNP of order review and stated expectations for double notation |
| Advanced Registered Nurse Practitioner | ARNP | Notified by DON and reviewed medication orders for Resident #4 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 14, 2023
Visit Reason
A complaint investigation for Complaint #113372-C was conducted from June 7, 2023 to June 14, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #113372-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 23, 2023
Visit Reason
A Recertification Survey was conducted from March 20, 2023 to March 23, 2023.
Findings
The facility was found in substantial compliance.
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Jan 31, 2023
Visit Reason
Investigation of facility-reported incident #108615-I and complaints #109210-C, #109532-C, and #110170-C was conducted from January 17 to January 31, 2023.
Findings
The facility failed to ensure full implementation of nutritional assessments and interventions for one of three residents reviewed (Resident #5), resulting in significant weight loss and inadequate nutritional intake despite dietary recommendations and interventions.
Complaint Details
Complaint #109210-C was substantiated. Complaint #109532-C was substantiated without facility deficiency. Complaint #110170-C was not substantiated. Facility-reported incident #108615-I was not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to fully implement nutritional assessments and interventions for Resident #5, including missed weight measurements and incomplete administration of recommended nutritional supplements. | SS=D |
Report Facts
Resident census: 23
Weight loss percentage: 11
Weight measurements: 109
Weight measurements: 97
House Supplement dosage: 4
House Supplement dosage recommended: 6
Meal intake percentages: 25
Meal refusals: 26
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Jan 31, 2023
Visit Reason
Investigation of a facility-reported incident and complaints #108615-I, #109210-C, #109532-C, and #110170-C was conducted from January 17 to January 31, 2023.
Findings
Complaint #109210-C and #109532-C were substantiated, with #109532-C substantiated without facility deficiency. Complaint #108615-I and #110170-C were not substantiated. The facility failed to ensure full implementation of nutritional assessments and interventions for one resident, resulting in weight loss and malnutrition risk.
Complaint Details
Complaint #109210-C was substantiated. Complaint #109532-C was substantiated without facility deficiency. Complaint #108615-I and #110170-C were not substantiated.
Deficiencies (1)
| Description |
|---|
| F692 Nutrition/Hydration Status Maintenance: Facility failed to maintain acceptable nutritional status and ensure full implementation of nutritional assessments and interventions for Resident #5. |
Report Facts
Resident census: 23
Weight loss percentage: 11
Dates of weight measurements: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding weight measurement procedures and implementation of RD recommendations. |
| Registered Dietitian | Registered Dietitian | Provided nutritional assessments, recommendations, and progress notes for Resident #5. |
| Advanced Registered Nurse Practitioner | ARNP | Provided clinical observations and comments on Resident #5's condition and weight loss. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 4, 2022
Visit Reason
A revisit was conducted on October 4, 2022, related to the preceding investigation of complaints 100427-C, 100921-C, and 103585-C.
Findings
The facility was found in substantial compliance effective September 14, 2022.
Complaint Details
This visit was a follow-up related to complaint investigations 100427-C, 100921-C, and 103585-C.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Aug 29, 2022
Visit Reason
The inspection resulted from investigation of complaints 100427-C, 100921-C, and 103585-C conducted August 22 - 29, 2022. All complaints were substantiated.
Findings
The facility failed to provide adequate nursing supervision and assistance devices to prevent accidents, resulting in a resident falling and sustaining a right lower leg fracture. The investigation detailed multiple incidents involving Resident #4 and Resident #9, including falls and inadequate fall risk interventions.
Complaint Details
Investigation of complaints 100427-C, 100921-C, and 103585-C conducted August 22 - 29, 2022. All complaints were substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. | SS=G |
Report Facts
Census: 30
Deficiency count: 1
Audit frequency: 4
Audit duration: 4
Follow-up audits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Reported Resident #4 required Hoyer lift and assist of 2 staff for all transfers |
| Staff D | Certified Nursing Assistant (CNA) | Reported Resident #4 transferred with Hoyer lift, sling, and assist of 2 staff |
| Staff E | Certified Medication Aide (CMA) | Reported Resident #4 transferred with assist of 2 staff and Hoyer lift |
| Staff F | Certified Nursing Assistant (CNA) | Reported Resident #4 transferred with Hoyer lift and 2 person assist |
| Staff G | Certified Nursing Assistant (CNA) | Assisted with transfer of Resident #4 and reported shower chair was soapy and slick |
| Staff J | Certified Nursing Assistant (CNA) | Assisted with transfer of Resident #4 and reported uncertainty about sling removal |
| Director of Nursing | Director of Nursing (DON) | Reported no fall risk care plan prior to fall and confirmed bed position after review |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 3
Aug 19, 2021
Visit Reason
The inspection was conducted as an annual health survey and investigation of complaints 99029-C and 99166-C during August 16-19, 2021. Both complaints were substantiated.
Findings
The facility failed to meet professional standards for safe medication administration for 2 of 5 residents reviewed, failed to properly label and store food items increasing risk of contamination, and did not ensure proper COVID-19 screening and PPE use by staff. Staff education and corrective actions were planned to address these deficiencies.
Complaint Details
Complaints 99029-C and 99166-C were investigated and both were substantiated.
Severity Breakdown
Severity Level: E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| F 658 Services Provided Meet Professional Standards: Facility failed to follow professional standards for safe medication administration practices for 2 of 5 residents reviewed. | — |
| F 812 Food Procurement, Store, Prepare, Serve - Sanitary: Facility failed to label and store food items appropriately to reduce risk of contamination and food-borne illness. | — |
| F 880 Infection Prevention & Control: Facility failed to provide COVID-19 screening for visitors and staff, and ensure proper use of face coverings (masks) by staff. | Severity Level: E |
Report Facts
Census: 34
BIMS score: 11
BIMS score: 14
Insulin injections: 7
Incident report date: May 13, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and incident with Resident #5 |
| Staff C | Certified Medication Aide (CMA) | Verified medication handling and storage in Resident #5's room |
| Staff D | Registered Nurse (RN) | Acknowledged medication error with Resident #7 and described identification issues |
| Director of Nursing (DON) | Director of Nursing | Reviewed medication administration records and interviewed about medication errors |
| Administrator | Administrator | Interviewed regarding food storage and COVID-19 mask policy enforcement |
| Staff A | Dietary Aide | Observed wearing face covering improperly during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2021
Visit Reason
Complaints 90406-C and 97661-C were investigated from June 1 to June 8, 2021.
Findings
The complaints investigated were not substantiated according to the report.
Complaint Details
Complaints 90406-C and 97661-C were investigated and found not substantiated.
Inspection Report
Routine
Census: 29
Deficiencies: 0
Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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