Inspection Reports for Lamoni Specialty Care

A complaint investigation for complaints #2660583 was conducted from November 6, 2025 to November 7, 2025.

The facility was found to be in substantial compliance.

Complaint #2660583 was investigated and the facility was found to be in substantial compliance.

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.

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.

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.

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.

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.

The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.

The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective February 13, 2025.

The inspection was conducted as the facility's annual recertification survey from February 10, 2025 to February 12, 2025.

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.

The document is a Plan of Correction submitted following a survey to address deficiencies and certify compliance.

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.

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.

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 #114409-C and Facility Reported Incident #117584-I were substantiated.

A complaint investigation for Complaint #113372-C was conducted from June 7, 2023 to June 14, 2023.

The facility was found to be in substantial compliance.

Complaint #113372-C was investigated and the facility was found to be in substantial compliance.

A Recertification Survey was conducted from March 20, 2023 to March 23, 2023.

The facility was found in substantial compliance.

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.

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 #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.

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.

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 #109210-C was substantiated. Complaint #109532-C was substantiated without facility deficiency. Complaint #108615-I and #110170-C were not substantiated.

A revisit was conducted on October 4, 2022, related to the preceding investigation of complaints 100427-C, 100921-C, and 103585-C.

The facility was found in substantial compliance effective September 14, 2022.

This visit was a follow-up related to complaint investigations 100427-C, 100921-C, and 103585-C.

The inspection resulted from investigation of complaints 100427-C, 100921-C, and 103585-C conducted August 22 - 29, 2022. All complaints were substantiated.

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.

Investigation of complaints 100427-C, 100921-C, and 103585-C conducted August 22 - 29, 2022. All complaints were substantiated.

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.

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.

Complaints 99029-C and 99166-C were investigated and both were substantiated.

Complaints 90406-C and 97661-C were investigated from June 1 to June 8, 2021.

The complaints investigated were not substantiated according to the report.

Complaints 90406-C and 97661-C were investigated and found not substantiated.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.