Inspection Reports for St Luke Lutheran Nursing Home
1301 St Luke Drive, IA, 513016043
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 28, 2025 found the facility in substantial compliance with all previously cited deficiencies corrected, and the related complaint was not substantiated. Earlier inspections showed a pattern of deficiencies related primarily to resident care issues such as timely reporting and investigation of abuse allegations, response to call lights, infection prevention, and food safety. Complaint investigations included some substantiated cases involving abuse reporting and inadequate care, but most complaints were found unsubstantiated. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility appears to have improved over time, correcting prior deficiencies and maintaining compliance in the most recent inspections.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a April 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 28, 2025
Visit Reason
A revisit of the survey ending September 04, 2025 and investigation of incident #2631743-I was conducted from October 23, 2025 to October 28, 2025.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 17, 2025. Incident #2631743 allegation was not cited.
Complaint Details
Investigation of incident #2631743-I was conducted; allegation was not cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 14, 2024
Visit Reason
A revisit of the survey ending August 22, 2024 and investigation of complaint #123908-C was conducted on October 14, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 12, 2024. Complaint #123908-C was not substantiated.
Complaint Details
Complaint #123908-C was investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
May 25, 2024
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 certified in compliance effective May 25, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 4
Apr 25, 2024
Visit Reason
The inspection was conducted as a result of complaints #119922-C and #120153-C alleging abuse at the facility. The investigation focused on verifying these allegations and the facility's compliance with reporting and investigation requirements.
Findings
The facility failed to report an allegation of abuse within the required timeframe and failed to investigate allegations of abuse thoroughly. The facility also failed to ensure call lights were answered timely and failed to maintain food safety standards. Staff education and monitoring plans were implemented to address these issues.
Complaint Details
Complaints #119922-C and #120153-C were substantiated. The facility failed to report an allegation of abuse timely and failed to investigate abuse allegations properly. Resident #5 denied abuse occurred during interviews, but the facility did not meet reporting requirements.
Severity Breakdown
Level D: 2
Level E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 24 hours for 1 resident (Resident #5). | Level D |
| Failure to investigate allegations of abuse thoroughly for Resident #5. | Level D |
| Failure to ensure call lights were answered within 15 minutes for 4 residents (Residents #2, #5, #6, and #7). | Level E |
| Failure to ensure food was covered before leaving the dining area and served to residents in their rooms, violating food safety requirements. | Level E |
Report Facts
Resident census: 75
Total capacity: 75
Call lights not answered timely: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant | Named in abuse allegation involving Resident #5 |
| Staff H | Registered Nurse | Interviewed regarding abuse allegations and staff reports |
| Staff I | Licensed Practical Nurse | Interviewed regarding abuse allegations and staff reports |
| Staff J | Registered Nurse | Involved in investigation and reporting of abuse allegations |
| Staff A | Assistant Director of Nursing | Conducted investigation and interviewed staff and resident |
| Staff D | Certified Nursing Assistant | Involved in food service and meal tray delivery |
| Staff B | Dietary Manager | Interviewed regarding food safety and meal service |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 17, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on September 17, 2023, related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective September 17, 2023.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 4
Aug 17, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of incident #114811-1 from August 14, 2023 to August 17, 2023.
Findings
The facility was found to have deficiencies in meeting professional standards of care, including failure to follow physician orders for bowel protocols, inadequate care to prevent infections related to urinary catheters, insufficient nursing staff to timely respond to call lights, and failure to maintain proper food and beverage temperatures. Plans of correction were provided for all deficiencies.
Complaint Details
Investigation of facility self-report incident #114811-1 was conducted and was not substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to follow a physician's order for bowel protocol for Resident #2. |
| Failure to provide care to assure cleanliness and prevent infections for Resident #112 with a urinary catheter. |
| Failure to ensure staff answered resident call lights and responded in a timely manner for Residents #13, #5, and #37. |
| Failure to maintain food and beverage temperatures within safe ranges. |
Report Facts
Residents reviewed: 12
Census: 62
Residents interviewed: 20
Residents with call light delays: 3
Correction dates: Multiple correction dates set for 9/8/2023 and 9/17/2023.
Inspection Report
Plan of Correction
Deficiencies: 0
May 28, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on May 28, 2023, related to facility certification compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective May 28, 2023. No specific deficiencies or severity levels are detailed in the document.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
May 10, 2023
Visit Reason
Investigation of complaints #107571-C, #108812-C, #109531-C and facility self-reported incidents #108730-I, #110067-I and #110958-I completed May 3-10, 2023.
Findings
The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall with serious injury.
Complaint Details
Investigation was complaint-related involving multiple complaints and self-reported incidents. The fall was identified as accidental and not likely preventable by the resident's physician.
Deficiencies (1)
| Description |
|---|
| The facility failed to provide necessary nursing supervision for 1 of 3 residents who fell and sustained a serious injury. |
Report Facts
Resident census: 59
Brief Interview for Mental Status (BIMS) score: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 16, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction indicating acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective September 16, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Aug 16, 2022
Visit Reason
The inspection was conducted as a complaint survey from 8/9/22 through 8/16/22, triggered by Complaint #104063-C which was substantiated.
Findings
The facility was found deficient in providing adequate ADL care, specifically bathing for dependent residents, quality of care related to wound assessment and treatment, and ensuring a safe environment free of accident hazards. Deficiencies were documented with detailed resident case reviews and staff interviews.
Complaint Details
Complaint #104063-C was substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to ensure baths were provided for 4 of 4 residents observed, with documentation showing only 1 bath provided in several weeks. |
| Failure to ensure appropriate assessments and documentation of wounds for 2 of 2 residents with wounds. |
| Failure to ensure the resident environment remained free of accident hazards for 1 of 4 residents reviewed. |
Report Facts
Census: 64
Dates of baths provided: 1
Correction Date: All deficiencies to be corrected by 9/16/2022
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 17, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective April 17, 2022.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Mar 17, 2022
Visit Reason
The inspection was conducted as a recertification survey and investigation of incident #99017 completed March 14-17, 2022. Incident #99017 was not substantiated.
Findings
The facility was found deficient in care plan timing and revision, bowel/bladder incontinence care, catheter and UTI prevention, and infection prevention and control. Deficiencies included failure to create individualized care plans, improper incontinence care, failure to perform hand hygiene, and inadequate infection control practices.
Complaint Details
The visit was triggered by investigation of incident #99017, which was not substantiated.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to create an individualized care plan to ensure a resident's diet orders were followed for 1 out of 14 residents reviewed. | SS=D |
| Failure to ensure proper bowel/bladder incontinence care and catheter management for 1 out of 2 residents reviewed. | SS=D |
| Failure to establish and maintain an infection prevention and control program including hand hygiene and proper handling of linens and personal laundry. | SS=E |
Report Facts
Residents reviewed: 14
Residents reviewed: 2
Residents reviewed: 56
Residents reviewed: 1
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in infection control and medication administration deficiencies |
| Staff B | Certified Nurse Assistant (CNA) | Named in incontinence care deficiency |
| Staff C | Certified Nurse Assistant (CNA) | Named in incontinence care deficiency |
| Staff D | Dietary Staff | Named in infection control and hand hygiene deficiencies |
| Staff E | Dietary Staff | Named in infection control and hand hygiene deficiencies |
| Staff F | Laundry Supervisor | Named in laundry handling deficiency |
| Staff G | Certified Nurse's Aide (CNA) | Named in infection control and hand hygiene deficiencies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plan expectations and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 26, 2021
Visit Reason
An investigation of complaint #94994-C and incident #95192-I was completed from 1/19/21 to 1/26/21 to determine compliance with quality of care regulations.
Findings
The investigation found that complaint #94994-C and incident #95192-I were not substantiated. The facility provided care ensuring residents received treatment and services according to professional standards and person-centered care plans. Staff were educated on recognizing and reporting changes in resident conditions, and monitoring protocols were implemented for continued compliance.
Complaint Details
Complaint #94994-C and Incident #95192-I were investigated and found not substantiated.
Report Facts
Dates of investigation: Investigation conducted from 1/19/21 to 1/26/21
Date of correction plan: Correction date set for 2/12/21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Greg Metzger | Interim Admin | Signed the plan of correction on 2/10/21 |
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 0
Jan 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 1/6/21 to 1/7/21 to assess the facility's 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
Abbreviated Survey
Census: 68
Deficiencies: 0
Nov 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 16-17, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 74
Deficiencies: 0
Jun 8, 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.
Report Facts
Total residents: 74
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 7
Feb 27, 2020
Visit Reason
A re-certification survey was conducted from 2/24/20 to 2/27/20 to assess compliance with federal regulations and identify any deficiencies at St Luke Lutheran Nursing Home.
Findings
The facility was found deficient in multiple areas including resident rights, abuse prevention policies, comprehensive care plans, provision of ADL care, nurse aide registry verification, in-service training, and infection prevention and control. Specific issues included failure to assure dignity for one resident, incomplete training for staff, missing physician orders, inadequate incontinent care, and lapses in infection control practices.
Deficiencies (7)
| Description |
|---|
| Failure to assure dignity for 1 of 18 residents reviewed related to resident rights. |
| Facility failed to ensure 1 of 6 staff completed required 2 hour mandatory adult abuse training within 6 months of hire. |
| Facility failed to obtain physician orders for diets for 5 of 18 residents reviewed and failed to follow a physician order for 1 resident. |
| Facility failed to provide complete incontinent care for 4 of 6 residents reviewed. |
| Facility failed to assure registry verification for 1 of 3 Certified Nursing Assistants prior to hire. |
| Facility failed to assure Certified Nursing Assistants received required 12 hours of in-service education annually. |
| Facility failed to establish and maintain an infection prevention and control program that provides a safe, sanitary, and comfortable environment. |
Report Facts
Residents reviewed: 18
Staff reviewed: 6
Residents reviewed: 78
Residents reviewed: 4
Certified Nursing Assistants reviewed: 3
Staff reviewed: 3
Report
Sep 22, 2025
File
ScannedReport_818_2025-09-22_125617.pdf
Report
Sep 17, 2024
File
ScannedReport_818_2024-09-17_114008.pdf
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