Inspection Reports for The Vinton Lutheran Home
1301 Second Avenue, IA, 523491699
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 6, 2026 identified a deficiency related to the facility’s failure to update a resident’s care plan for falls after multiple incidents. Earlier inspections showed a pattern of deficiencies primarily involving medication management, infection control, food safety, and timely reporting of abuse allegations. Complaint investigations were mostly unsubstantiated or resulted in minor citations, except for a substantiated complaint in 2024 related to failure to report abuse timely and care plan issues. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated some improvement over time, with previous deficiencies corrected by follow-up inspections, though some issues with documentation and care planning have recurred.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
47 residents
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Jan 6, 2026
Visit Reason
A complaint investigation for complaint #2651674-C and facility reported incident #2697304-I was conducted from 2026-01-05 to 2026-01-06. The facility reported incident #2697304-I resulted in a deficiency.
Findings
The facility failed to keep a resident's care plan updated for falls for 1 of 3 residents reviewed. Resident #1 experienced multiple falls in November 2025, including a re-fracture of the right pelvis, but the care plan did not include interventions for the falls on 11/15/25 and 11/17/25 as required by facility policy.
Complaint Details
Complaint #2651674-C and facility reported incident #2697304-I were investigated. The facility reported incident #2697304-I resulted in a deficiency.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep a resident's care plan updated for falls after multiple incidents. | SS = D |
Report Facts
Resident census: 47
Fall risk score: 5
Dates of falls: Falls occurred on 2025-11-15, 2025-11-17, and 2025-11-20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A-RN | Registered Nurse/Care Plan Coordinator | Interviewed regarding failure to update care plan after resident falls |
Inspection Report
Follow-Up
Deficiencies: 1
Nov 13, 2025
Visit Reason
A revisit of the survey ending October 21, 2025 was conducted from November 12, 2025 to November 13, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 22, 2025.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding correction of deficiencies from previous survey |
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was certified in compliance effective May 10, 2025, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 3
Apr 7, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from April 7, 2025 to April 10, 2025.
Findings
The facility was found deficient in ensuring proper gradual dose reductions (GDR) for psychotropic medications for residents, proper food safety and sanitation practices in the kitchen, and infection prevention and control measures including proper documentation and maintenance of oxygen tubing. Multiple deficiencies were noted related to medication management, food handling, and infection control.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure psychotropic medication gradual dose reduction (GDR) was attempted or declined with physician rationale for 2 of 4 residents reviewed. | SS=D |
| Failure to ensure proper food handling practices and cleanliness of kitchen equipment, including uncovered food trays and dirty equipment. | SS=E |
| Failure to establish and maintain an infection prevention and control program, including failure to document oxygen tubing changes and properly date oxygen tubing. | SS=D |
Report Facts
Residents reviewed for psychotropic medication GDR: 4
Facility census: 47
Date range of inspection: April 7, 2025 to April 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding rationale for continued dose of Sertraline for Resident #19 |
| Director of Nursing | DON | Interviewed regarding rationale for GDR recommendations and oxygen tubing documentation |
| Dietary Director | Made aware of kitchen sanitation concerns and reviewed cleaning policies with staff | |
| Maintenance Director | Provided Ice Machine Cleaning Log and reported cleaning frequency |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 8, 2025
Visit Reason
A revisit of the survey ending December 4, 2024 was conducted on January 7, 2025 to January 8, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 3, 2025.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2024
Visit Reason
A complaint investigation for complaint #122238-C was conducted on August 16, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #122238-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2024
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective May 22, 2024, based on acceptance of the Plan of Correction and substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 13, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction 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 October 13, 2023.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Sep 12, 2023
Visit Reason
The inspection was conducted due to an investigation of a facility reported incident #112061-I and a Focused Infection Control Survey conducted on 9/12-9/13/2023.
Findings
The incident #112061-I was not substantiated but a deficient practice was identified related to the facility's failure to report an allegation of abuse timely. The Focused Infection Control Survey did not result in a deficiency.
Complaint Details
Incident #112061-I was not substantiated but a deficient practice was identified due to failure to report an allegation of abuse timely. The incident was reported on 04-03-2023. Staff involved were educated on the need to immediately report abuse allegations. The QA Committee will monitor monthly or as needed regarding resident abuse allegations and follow up as needed.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to report an allegation of abuse within 24 hours or the next business day for 1 of 3 residents reviewed (Resident #1). | SS=D |
Report Facts
Residents reviewed: 3
Census: 50
Mental Status score: 11
Date range: 2023-09-12 to 2023-09-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Charge Nurse | Educated on 04-03-2023 regarding immediate reporting of abuse allegations |
| Staff C | Certified Nurses Aide (C.N.A.) | Involved with the abuse allegation and separated from employment on 04-03-2023 |
| Staff A | Certified Nurses Aide (C.N.A.) | Reported the incident to Staff B-LPN/Charge Nurse on 03/24/23 |
| Staff D | Director of Nursing | Interviewed and stated she was not informed of the incident until 04/03/23 and started investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 21, 2023
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was certified in compliance with the regulatory requirements effective March 14, 2023, and no discretionary denial of payment was effectuated.
Inspection Report
Renewal
Census: 35
Deficiencies: 7
Jan 17, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from January 17, 2023 to January 20, 2023 to assess compliance with federal regulations for the facility.
Findings
The facility was found deficient in multiple areas including quality of care related to bowel management, bedrail use and education, psychotropic medication management, infection control, dietary staffing and food safety, and bed safety. Deficiencies were documented with specific resident cases and policy reviews.
Severity Breakdown
Level D: 3
Level E: 1
Level F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure bowel movement procedure was followed for one resident who had no bowel movement for four days and did not receive ordered treatments. | Level D |
| Facility failed to document education and consent for bed rail use for five residents and failed to assess alternatives and risks properly. | Level E |
| Facility failed to ensure two of five residents receiving antipsychotic medications had correct diagnoses and targeted behaviors documented. | Level D |
| Facility failed to employ sufficient qualified dietary staff and ensure completion of required training. | Level F |
| Facility failed to ensure food safety including proper thaw dates and labeling of nutrition shakes. | Level F |
| Facility failed to ensure infection prevention and control program was fully implemented including proper disinfection of glucometers and laundry area barriers. | Level D |
| Facility failed to conduct regular inspection and maintenance of beds and bed rails, affecting 29 of 35 residents. | Level F |
Report Facts
Survey Census: 35
Residents affected by bed rail deficiency: 5
Residents affected by antipsychotic medication deficiency: 2
Residents affected by bed maintenance deficiency: 29
Residents affected by food safety deficiency: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay D. Wilson | Administrator | Signed the initial comments and plan of correction |
| Director of Nursing | DON | Named in multiple findings related to bowel management, bed rail use, medication management, infection control, and dietary monitoring |
| Assistant Director of Nursing | ADON | Named in findings related to bowel management and bed rail use education |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding bowel management procedures |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding bowel management and glucometer disinfection |
| Medical Director | MD | Interviewed regarding bowel management and resident behaviors |
| Dining Services Director | Interviewed regarding dietary staffing and food safety | |
| Dietary Manager | Named in dietary staffing and training deficiencies | |
| Consultant Pharmacist | CRPh | Interviewed regarding medication monitoring and diagnoses |
| Housekeeping/Laundry Director | Named in infection control and laundry area barrier deficiencies |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 10
Aug 26, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of a complaint at The Vinton Lutheran Home. The complaint #96840-C was substantiated.
Findings
The facility was found not in compliance with deficiencies related to notification of changes, reporting of alleged violations, transfer and discharge requirements, comprehensive care plans, quality of care, free of medication errors, labeling and storage of drugs, qualified dietary staff, food procurement and safety, and infection prevention and control. The facility failed to document family notification of a resident's fracture, failed to report a resident-to-resident incident, and failed to ensure timely assessment and intervention after a fall.
Complaint Details
Complaint #96840-C was substantiated. The facility was found not in compliance with multiple regulatory requirements including failure to notify family of resident's fracture, failure to report resident-to-resident abuse, and failure to provide adequate care and documentation.
Deficiencies (10)
| Description |
|---|
| Failed to document family notification of resident's fractured shoulder. |
| Failed to report a resident-to-resident abuse incident to the State Agency. |
| Failed to provide adequate discharge and transfer documentation and notification. |
| Failed to develop and implement comprehensive care plans for residents. |
| Failed to ensure quality of care related to fall assessment and intervention. |
| Medication error rate exceeded 5 percent. |
| Failed to properly label and store drugs and biologicals. |
| Facility dietary staff lacked required qualifications and training. |
| Failed to maintain food safety and sanitation standards in kitchen. |
| Failed to maintain effective infection prevention and control program. |
Report Facts
Total residents: 45
Census: 45
Medication error rate: 10.71
Medication errors: 3
Medication error threshold: 5
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Dec 14, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey and an investigation of Complaint #93827 and a Mandatory #94031 were conducted by the Department of Inspections and Appeals on 12/7-14/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. However, the facility failed to ensure staff responded to an allegation of abuse and reported the allegation within the required timeframe, as evidenced by a resident with bruising and staff interviews.
Complaint Details
The complaint investigation was triggered by allegations of abuse, neglect, exploitation, or mistreatment involving Resident #1. The facility failed to report the allegation within the required timeframe and failed to ensure appropriate corrective action. The investigation included record review, staff interviews, and resident observations. The resident had bruising and reported being hurt by staff. The facility developed an educational document for staff on reporting abuse and implemented Quality Assurance monitoring.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staff responded to an allegation of abuse and reported the allegation within the required timeframe. |
Report Facts
Census: 44
Date Survey Completed: Dec 14, 2020
Inspection Report
Routine
Census: 46
Deficiencies: 0
Nov 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 11/16/2020 and 11/17/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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.
Report Facts
Total residents: 55
Report
Nov 10, 2025
File
ScannedReport_833_2025-11-10_083242.pdf
Report
Dec 31, 2024
File
ScannedReport_833_2024-12-31_011009.pdf
Report
May 22, 2024
File
ScannedReport_833_2024-05-22_124723.pdf
Loading inspection reports...
