Inspection Reports for Lutheran Living Senior Campus
2421 Lutheran Drive, IA, 527619392
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 4, 2025 found the facility in substantial compliance following a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to resident care, including failure to provide adequate supervision, timely notifications to physicians and families, and behavioral health assessments. Prior reports also noted issues with staffing levels, medication management, and safety protocols, some of which were linked to substantiated complaints and incidents involving resident harm. Enforcement actions such as immediate jeopardy were identified in 2024 related to staffing and supervision failures, but these were resolved with corrective actions and no fines or license suspensions are listed in the available reports. The facility appears to have improved over time, with recent re-inspections confirming correction of prior deficiencies and no new citations in the latest investigations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
124 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2025
Visit Reason
A complaint investigation was conducted for complaints #2680414-C, #2673228-C, and #2680633-C from December 1, 2025 to December 4, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #2680414-C, #2673228-C, and #2680633-C; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 17, 2025
Visit Reason
A complaint investigation for complaints #2630889-C and 2634007-C was conducted from November 12, 2025 to November 17, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaints #2630889-C and 2634007-C; the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 28, 2025
Visit Reason
An on-site revisit of the survey ending August 7, 2025 was conducted on October 27-28, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 2, 2025.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 8, 2025
Visit Reason
An investigation for facility reported incident #2633285-I was conducted from October 1, 2025 to October 8, 2025. Additionally, an on-site revisit was required to complete the survey ending on August 7, 2025.
Findings
The facility reported incident #2633285-I did not result in a deficiency. However, the facility is not in substantial compliance as an on-site revisit needs to be completed for the prior survey.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 6
Aug 7, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#1746939-C, #1746946-C, #1746954-C, #1746956-C, #1746958-C, #1746960-C, #2574374-C) and facility reported incidents (#2573332-I) between July 30, 2025 and August 7, 2025.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly Care Conferences for residents, failure to provide timely physician and family notifications for significant changes or incidents, failure to provide proper discharge notices, failure to perform behavioral health assessments, and inadequate supervision and care leading to a resident's suicide. The facility also failed to follow proper staffing and notification protocols.
Complaint Details
The visit was complaint-related, investigating multiple complaints and facility reported incidents. Complaints #1746946-C, #1746954-C, and #2574374-C resulted in deficiencies. The facility reported incident #2573332-I also resulted in a deficiency.
Severity Breakdown
D: 3
B: 1
J: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to conduct quarterly Care Conferences for 1 of 3 residents reviewed. | D |
| Failure to provide timely physician and family notification for 1 of 3 residents who experienced a newly documented open wound. | D |
| Failure to provide proper discharge notice consistent with state regulations for 1 of 1 residents reviewed. | B |
| Failure to perform behavioral health assessments for Resident #1 after a 30 day involuntary discharge notice following an alleged assault on another resident. | J |
| Failure to provide sufficient/competent staff to meet behavioral health needs of Resident #1. | J |
| Failure to provide adequate supervision and care resulting in Resident #1's suicide. | J |
Report Facts
Resident census: 124
Residents reviewed for Care Conferences: 3
Residents reviewed for discharge notice: 1
Residents with behavioral health assessments missed: 1
Resident #1 supervision hours: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2025
Visit Reason
The document is a Plan of Correction related to a survey ending on March 6, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective March 13, 2025.
Report Facts
Survey end date: Mar 6, 2025
Certification effective date: Mar 13, 2025
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Mar 6, 2025
Visit Reason
The inspection was conducted as a result of investigation of complaints #126730-C, #126977-C, #127004-C and a facility self-report from March 4, 2025 to March 6, 2025.
Findings
The complaint #126730-C was substantiated. The facility failed to notify the resident's guardian in a timely manner after a fall resulting in injury and transfer to the hospital for one of three residents reviewed. The facility has developed and implemented a plan of correction to ensure compliance with notification requirements and prevent future similar incidents.
Complaint Details
Complaint #126730-C was substantiated based on clinical record review, legal guardian interview, and staff interviews indicating failure to notify the resident's guardian promptly after a fall on 2/13/25.
Deficiencies (1)
| Description |
|---|
| Failure to notify the resident's guardian in a timely manner after a fall resulting in injury and hospital transfer. |
Report Facts
Resident census: 120
Resident count reviewed: 3
Brief Interview for Mental Status score: 3
Incident report date and time: Incident report dated 2/13/25 at 6:10 p.m.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant | Witnessed Resident #1 fall and reported incident |
| Staff H | Registered Nurse | Called the guardian after the fall but could not recall the number used |
| Andrew Harris | Laboratory Director or Provider/Supplier Representative | Signed the plan of correction |
Inspection Report
Renewal
Deficiencies: 0
Jan 13, 2025
Visit Reason
The visit was conducted as a recertification survey to assess compliance for renewal of the facility's certification.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction for the recertification survey ending December 12, 2024, the facility will be certified in compliance effective December 28, 2024.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 30, 2024
Visit Reason
A complaint investigation for complaint #125642-C was conducted.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #125642-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 124
Deficiencies: 5
Dec 12, 2024
Visit Reason
The inspection was conducted as an annual recertification survey from December 10, 2024 to December 12, 2024 to assess compliance with federal regulations and facility policies.
Findings
The facility was found deficient in multiple areas including failure to report an alleged abuse incident, failure to notify the Ombudsman of resident transfers, failure to meet professional standards for lab testing, failure to properly store medications, and failure to maintain proper food temperatures. The facility has plans to educate staff and implement corrective actions to address these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to report an alleged abuse incident involving Resident #52. |
| Failure to notify the Ombudsman of resident transfers for Resident #110 and Resident #37. |
| Failure to obtain a lab for hemoglobin A1c per provider's order for Resident #35. |
| Failure to ensure medication cart remained locked when not in use for 1 of 7 medication carts. |
| Failure to maintain food temperatures within regulatory standards for meals served on the 600 Hall. |
Report Facts
Residents present: 124
Residents reviewed for abuse incident: 1
Residents reviewed for professional standards lab testing: 25
Residents reviewed for Ombudsman notification: 2
Medication carts observed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing (ADON) | Interviewed regarding lab order for hemoglobin A1c and incident reporting |
| Staff B | Registered Nurse (RN) | Notified about medication cart locking issue |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding incident reporting, Ombudsman notification, and medication cart checks |
| Certified Nursing Assistant (CNA) | Certified Nursing Assistant | Involved in alleged abuse incident and interviewed |
| Culinary Director | Culinary Director | Interviewed regarding food temperature issues |
| Staff D | Dietary Aid | Interviewed regarding food temperature monitoring |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 29, 2024
Visit Reason
A revisit of the survey ending October 1, 2024 was conducted on October 28-29, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 20, 2024.
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 4
Oct 1, 2024
Visit Reason
The inspection was conducted as a result of revisiting the survey ending July 31, 2024, investigation of Complaints #123343-C, #123555-C, #123698-C and Facility Reported Incidents #122565-I, #123211-I and #123388-I. These complaints and incidents were substantiated.
Findings
The facility failed to notify a resident's physician upon discovering a positive COVID infection, failed to provide incontinence care according to professional standards, and failed to properly identify residents prior to medication administration leading to medication errors. Additionally, the facility failed to ensure adequate supervision to prevent resident elopement and maintain safety. Corrective actions and education plans were implemented with compliance audits scheduled.
Complaint Details
Complaints #123343-C, #123555-C, #123698-C and Facility Reported Incidents #122565-I, #123211-I and #123388-I were substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to notify resident's physician of positive COVID infection in a timely manner. |
| Failure to provide incontinence care in accordance with professional standards. |
| Failure to properly identify residents prior to medication administration resulting in medication errors. |
| Failure to ensure adequate supervision to prevent resident elopement and maintain safety. |
Report Facts
Facility reported census: 125
Date survey completed: Oct 1, 2024
Plan of correction completion date: Oct 20, 2024
Observation time: 1
Medication administration error date: Sep 7, 2024
Elopement observation dates: Aug 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Agency Certified Medication Aide | Named in medication error involving Resident #3. |
| Staff C | Licensed Practical Nurse | Aware of medication error and resident behaviors. |
| Staff Z | Registered Nurse | Interviewed regarding staff behavior and care. |
| Staff AA | Certified Nursing Aide | Observed during rounds and care provision. |
| Staff G | Certified Nurse Aide | Involved in resident fall incident response. |
| Staff H | Certified Nurse Aide | Assisted in resident fall incident. |
| Staff M | Licensed Practical Nurse | Alerted staff to resident fall incident. |
| Staff J | Certified Nurse Aide | Interviewed about resident elopement and wander guard. |
| Staff L | Certified Nurse Aide | Observed resident elopement and wander guard alarm issues. |
| Staff E | Certified Medication Aide | Observed resident elopement and medication administration. |
| Staff F | Nurse | Involved in medication administration and resident care. |
| Staff K | Certified Nurse Aide | Observed resident elopement and wander guard alarm. |
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 1
Jul 31, 2024
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#118707-C, #119722-C, #120233-C, #120962-C, and #121833-C) from July 15, 2024 to July 31, 2024. Complaint #120233-C was substantiated.
Findings
The facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner, resulting in the resident being found unresponsive and deceased. The investigation revealed severe staffing shortages on the night of the incident, inadequate response to staffing calls, and failure of the Assistant Director of Nursing to fulfill on-call responsibilities.
Complaint Details
The investigation was triggered by complaints #118707-C, #119722-C, #120233-C, #120962-C, and #121833-C. Complaint #120233-C was substantiated. The Immediate Jeopardy began on February 11, 2024, when Resident #1 was found unresponsive and deceased. The facility removed the Immediate Jeopardy on July 26, 2024 after implementing corrective actions.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner, resulting in resident found unresponsive and deceased. | SS=J |
Report Facts
Resident census: 129
Date of incident: Feb 11, 2024
Immediate Jeopardy removal date: Jul 26, 2024
Number of complaints investigated: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Nurse assigned to Resident #1 on the night of the incident; verified resident's death and called 911 |
| Staff L | Licensed Practical Nurse (LPN) | Nurse on duty during incident; involved in resident assessment and response |
| Staff H | Certified Nursing Assistant (CNA) | CNA who heard resident call for help and participated in finding resident unresponsive |
| Staff I | Certified Nursing Assistant (CNA) | CNA who assisted in rounds and finding resident unresponsive |
| Staff M | Certified Nursing Assistant (CNA) | Scheduled to work night shift until 2 a.m. but left early; reported staffing concerns |
| Staff O | Certified Nursing Assistant (CNA) | Assigned to CCDI Unit; left shift early due to medical emergency |
| Staff S | Assistant Director of Nursing (ADON) | On-call manager who refused to come to facility during staffing shortage and was reprimanded |
| Director of Nursing (DON) | Director of Nursing | Facility DON involved in education and staffing oversight |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 12, 2023
Visit Reason
A revisit of the survey ending October 5, 2023 was conducted from December 6, 2023 to December 12, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 13, 2023.
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 21
Oct 5, 2023
Visit Reason
The complaint investigation was conducted based on allegations of resident abuse, dignity violations, inconsistent documentation of code status, failure to notify family and physician of incidents, and inadequate staffing and care practices at Lutheran Living Senior Campus.
Findings
The facility was found deficient in multiple areas including failure to protect residents' dignity and privacy, inconsistent documentation and communication of advance directives, failure to notify family and physicians of incidents, resident-to-resident abuse, inadequate investigation of abuse allegations, insufficient staffing, incomplete care plans, failure to prevent catheter bags from touching the floor, and failure to maintain a functioning call light system. Several residents experienced falls, injuries, and inadequate care due to these deficiencies.
Complaint Details
The complaint investigation was initiated due to multiple allegations including resident abuse by staff, failure to protect resident dignity, inconsistent documentation of advance directives, failure to notify family and physicians of incidents, inadequate staffing, and failure to prevent accidents and injuries. The investigation revealed substantiated abuse and neglect, failure to report and investigate allegations timely, and multiple care and safety deficiencies.
Severity Breakdown
F 550: 1
F 578: 1
F 580: 1
F 600: 1
F 603: 1
F 609: 1
F 610: 1
F 622: 1
F 644: 1
F 645: 1
F 655: 1
F 657: 1
F 677: 1
F 684: 1
F 689: 1
F 690: 1
F 725: 1
F 732: 1
F 758: 1
F 839: 1
F 865: 1
F 919: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to protect residents' dignity and privacy, including staff entering rooms without knocking and catheter bags not covered or kept off the floor. | F 550 |
| Inconsistent documentation and communication of advance directives and code status for multiple residents. | F 578 |
| Failure to notify family and physician of significant changes or incidents involving residents. | F 580 |
| Failure to protect residents from abuse and neglect, including resident-to-resident physical aggression and staff-to-resident abuse. | F 600 |
| Failure to prevent involuntary seclusion of a resident by staff verbal threats. | F 603 |
| Failure to report allegations of abuse within required regulatory timeframes. | F 609 |
| Failure to thoroughly investigate allegations of abuse and to prevent further abuse during investigations. | F 610 |
| Failure to ensure thorough documentation and communication during resident transfers to hospitals. | F 622 |
| Failure to resubmit PASARR screening following change in medical diagnoses for residents. | F 644 |
| Failure to complete baseline care plans within 48 hours of admission for residents. | F 655 |
| Failure to complete and revise comprehensive care plans timely and to conduct care plan conferences quarterly. | F 657 |
| Failure to provide showers twice weekly as scheduled for dependent residents. | F 677 |
| Failure to assess and document pain and injuries following resident falls and incidents. | F 684 |
| Failure to provide adequate supervision and assistance devices to prevent accidents and falls, resulting in multiple resident injuries and hospitalizations. | F 689 |
| Failure to prevent catheter bags from touching the floor and lack of dignity covers for catheter bags. | F 690 |
| Failure to ensure sufficient nursing staff to meet resident needs and provide quality care. | F 725 |
| Failure to post required nurse staffing information daily in a location accessible to residents and visitors. | F 732 |
| Failure to document non-pharmacological interventions prior to administration of PRN psychotropic medications. | F 758 |
| Failure to ensure staff held required certification and licensure to administer medications. | F 839 |
| Failure to maintain an effective QAPI program to address previously identified quality deficiencies, resulting in multiple repeat deficiencies. | F 865 |
| Failure to provide residents with accessible and functioning call system devices at bedside and bathroom. | F 919 |
Report Facts
Resident census: 140
Deficiencies cited: 22
Severity counts: 1
Resident #124 BIMS score: 15
Resident #26 BIMS score: 0
Resident #60 BIMS score: 15
Resident #84 BIMS score: 8
Resident #99 BIMS score: 4
Resident #7 BIMS score: 15
Resident #48 BIMS score: 15
Resident #52 BIMS score: 12
Resident #385 BIMS score: 8
Resident #101 BIMS score: 15
Resident #56 BIMS score: 15
Resident #118 BIMS score: 8
Resident #128 BIMS score: 15
Resident #438 BIMS score: 15
Resident #64 BIMS score: 8
Resident #385 BIMS score: 15
Resident #99 fall incidents: 3
Staff training dates: 6
Staffing ratio: 2
Staffing ratio: 1
Shower frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff V | Certified Nursing Assistant | Named in resident abuse and neglect allegation involving Resident #385 |
| Staff JJ | Medication Aide | Worked without current CNA certification |
| Staff X | Activities Assistant | Witnessed resident involuntary seclusion incident |
| Staff II | Activities Assistant | Witnessed resident involuntary seclusion incident |
| Staff HH | Director of People and Culture | Reported resident involuntary seclusion incident |
| Staff D | Nurse | Reported staffing shortages and resident care delays |
| Staff J | Assistant Director of Nursing | Interviewed about incident reporting and care plan completion |
| Staff K | Assistant Director of Nursing | Interviewed about incident reporting and care plan completion |
| Staff P | Licensed Practical Nurse | Interviewed about catheter care and incident reporting |
| Staff M | Certified Nurse Aide | Interviewed about staffing and shower completion |
| Staff EE | Registered Nurse | Reported staffing shortages and resident care issues |
| Staff R | Licensed Practical Nurse | Witnessed resident fall and injury |
| Staff Z | Registered Nurse | Witnessed resident fall and injury |
| Staff O | Licensed Practical Nurse | Interviewed about incident reporting and catheter care |
| Staff Q | Certified Nurse Aide | Witnessed resident to resident abuse |
| Staff L | Certified Nurse Aide | Interviewed about catheter care and resident abuse |
| Staff N | Certified Nurse Aide | Interviewed about catheter care |
| Staff B | Staff | Interviewed about code status documentation |
| Staff A | Assistant Director of Nursing | Interviewed about code status documentation |
| Staff G | Registered Nurse | Interviewed about resident to resident incidents |
| Staff F | Registered Nurse | Interviewed about staffing and resident care |
| Staff T | Registered Nurse | Interviewed about staffing and resident care |
| Staff BB | Certified Nurse Assistant | Interviewed about resident mobility |
| Staff DD | Certified Nurse Assistant | Interviewed about resident mobility |
| Staff FF | Certified Nurse Assistant | Interviewed about resident mobility |
| Staff E | Certified Nurse Assistant | Interviewed about resident mobility |
| Staff HH | Director of People and Culture | Interviewed about staff certification and abuse training |
| Staff T | Registered Nurse | Interviewed about staffing and workload |
| Staff U | Certified Nurse Assistant | Interviewed about staffing and workload |
| Staff F | Registered Nurse | Interviewed about staffing and workload |
| Staff M | Certified Nurse Assistant | Interviewed about staffing and workload |
| Staff S | Certified Medication Aide | Interviewed about staffing and workload |
| Staff J | Assistant Director of Nursing | Interviewed about incident reporting and staffing |
| Staff EE | Registered Nurse | Interviewed about staffing and resident supervision |
| Staff CC | Certified Nurse Assistant | Interviewed about resident mobility and falls |
Inspection Report
Plan of Correction
Deficiencies: 0
May 23, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Lutheran Living Senior Campus, certifying compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective May 23, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 2
Apr 26, 2023
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#108012-C, #109452-C, #112427-C) and facility reported incidents (#105513-I, #108639-I, #112190-I, #112547-I) from April 12, 2023 to April 26, 2023. Complaint #112427-C and incidents #105513-I and #112547-I were substantiated.
Findings
The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified including failure to notify the physician of a resident's change in condition (Resident #8) and failure to ensure resident safety to prevent undetected elopement of a cognitively impaired resident (Resident #1) from a locked unit.
Complaint Details
The investigation was triggered by complaints #108012-C, #109452-C, #112427-C and facility reported incidents #105513-I, #108639-I, #112190-I, and #112547-I. Complaint #112427-C and incidents #105513-I and #112547-I were substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician of a change in resident condition and failed to make appropriate assessments for Resident #8 with orthostatic hypotension and increased fall risk. | SS=D |
| Failed to ensure resident safety and prevent undetected elopement of Resident #1 from a locked CCDI unit due to malfunctioning door alarms and inadequate supervision. | SS=D |
Report Facts
Total Residents: 133
Blood Pressure Readings: Multiple BP readings for Resident #8 from 4/12/23 to 4/20/23 recorded in mmHg
Staff on CCDI Unit Shift: 3
Temperature: 88
Wind Speed: 18
Humidity: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse (RN) | Named in failure to notify physician of Resident #8's orthostatic hypotension |
| Staff K | Internal Medicine Physician | Resident #8's physician who was not notified timely of orthostatic hypotension |
| Staff H | Therapy Director | Interviewed regarding therapy services for Resident #8 |
| Staff I | Physical Therapist (PT) | Provided therapy services and noted BP drops for Resident #8 |
| Staff J | Assistant Director of Nursing (ADON) | Notified physician of Resident #8's orthostatic hypotension on 4/19/23 |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed Resident #1 elopement and provided statement |
| Staff C | Certified Nursing Assistant (CNA) | Witnessed Resident #1 elopement and provided statement |
| Staff D | Maintenance Director | Found Resident #1 outside after elopement and reported malfunctioning door alarms |
| Staff A | Licensed Practical Nurse (LPN) | On duty during Resident #1 elopement, did not hear door alarms |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for orthostatic BP checks and reported Resident #1 elopement |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 23, 2022
Visit Reason
The document is a plan of correction submitted following a prior deficiency statement, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective July 20, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 129
Deficiencies: 10
Jun 15, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of multiple complaints and a facility-reported incident.
Findings
The survey identified multiple deficiencies including failure to report injuries of unknown origin, failure to notify the Ombudsman of hospital transfers, failure to provide bed hold policy upon hospital transfer, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, failure to assess skin under splints, unsafe resident transfers, improper catheter care, incorrect diet portioning, and infection control violations related to COVID-19 positive staff working and inadequate PPE use during tracheostomy care.
Complaint Details
Complaints #100894-C and #103891-C were substantiated. Complaints #102289-C and #103938-C were not substantiated. Facility-reported incident #104410-I was substantiated.
Severity Breakdown
SS=D: 6
SS=C: 1
SS=E: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin to the State Agency for Resident #56. | SS=D |
| Failure to notify the State Long-Term Care Ombudsman office of hospitalization transfers for 6 of 10 residents reviewed. | SS=C |
| Failure to provide the resident or representative the facility's bed-hold policy upon hospital transfer for 6 of 10 residents reviewed. | SS=E |
| Failure to complete a Minimum Data Set assessment accurately for Resident #85 regarding dialysis status. | SS=D |
| Failure to implement a comprehensive care plan including orthopedic care items for Resident #129 and indwelling catheter for Resident #179. | SS=D |
| Failure to assess and document skin beneath an arm splint following fracture for Resident #129. | SS=D |
| Failure to provide safe transfers to prevent injury from a fall for Resident #33. | SS=D |
| Failure to ensure catheter bags and tubing remained off the floor to prevent urinary tract infections for Residents #10, #59, and #179. | SS=D |
| Failure to ensure residents on pureed and soft mashable diets received proper portion sizes and correct food textures. | SS=E |
| Failure to restrict staff members who tested positive and/or had symptoms consistent with COVID-19 from work and failure to wear proper PPE during tracheostomy care for Resident #44. | SS=F |
Report Facts
Deficiencies cited: 10
Residents reviewed for hospitalizations: 10
Residents on pureed diet: 3
Residents on soft mashable diet: 6
Residents with indwelling catheters reviewed: 4
Residents reviewed for safe transfers: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Culinary Staff | Tested positive for COVID, worked while symptomatic and was not tested before returning. |
| Staff Q | Culinary Staff | Tested positive for COVID, worked while positive with N95 mask. |
| Staff S | Certified Nursing Assistant | Tested positive for COVID, worked while positive with N95 mask. |
| Staff A | Assistant Director of Nursing | Responsible for COVID testing and notification of positive staff. |
| Staff O | Licensed Practical Nurse / MDS Coordinator | Reported MDS error for Resident #85 and described splint care. |
| Staff T | Registered Nurse | Described splint care and skin assessment expectations. |
| Staff BB | Certified Nursing Assistant | Provided catheter care and described cleaning procedures. |
| Staff FF | Registered Nurse | Described catheter care and expectations for staff reporting tubing on floor. |
| Staff KK | Licensed Practical Nurse | Described PPE use for tracheostomy care. |
| Staff N | Certified Nursing Assistant | Involved in fall incident with Resident #33. |
| Staff M | Licensed Practical Nurse | Provided education to Staff N after fall incident. |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Feb 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #89930, #95317, #95320 and a Facility Self-Reported Incident #95321 were conducted due to allegations of verbal abuse and failure to treat a resident with dignity and respect.
Findings
The facility was found compliant with COVID-19 infection control practices. However, complaints and a self-reported incident were substantiated involving Staff A verbally abusing Resident #1 during medication administration, failing to treat the resident with dignity and respect. Multiple staff and family member statements confirmed the verbal abuse incident.
Complaint Details
Complaints #95320, #95317 and Facility Self-Reported Incident #95321 were substantiated. The incident involved Staff A verbally abusing Resident #1 on 1/15/21, witnessed by another CNA and the resident's family member. Staff A was found to have a history of complaints regarding disrespectful behavior.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to treat a resident with dignity and respect, including verbal abuse by Staff A during medication administration. | SS=D |
Report Facts
Facility Census: 128
Resident Records Reviewed: 10
BIMS Cognitive Assessment Score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) and Certified Medication Aide (CMA) | Named in verbal abuse and dignity violation incident involving Resident #1 |
| Staff B | Certified Nursing Assistant (CNA) | Witness to the verbal abuse incident |
| Staff C | Licensed Practical Nurse (LPN) | Received family complaint and directed investigation |
| Staff D | Certified Nursing Assistant (CNA) | Provided statements about Staff A's behavior |
| Staff E | Licensed Practical Nurse (LPN) | Provided statements about Staff A's behavior |
Inspection Report
Routine
Census: 129
Deficiencies: 0
Dec 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 11/22/20 to 12/01/20 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.
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #91477 were conducted by the Department of Inspections and Appeals on 6/15/20 - 6/16/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint was not substantiated.
Complaint Details
Complaint #91477 was investigated and found not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 16, 2020
Visit Reason
The inspection was conducted to investigate two reported incidents (#87720 and #87630) at the facility between 1/13/2020 and 1/16/2020.
Findings
Incident #87720 was not substantiated, and incident #87630 was substantiated but resulted in no deficiency.
Complaint Details
Two incidents were investigated; incident #87720 was not substantiated, and incident #87630 was substantiated with no deficiency.
Report Facts
Incident number: 87720
Incident number: 87630
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