Inspection Reports for
The Vinton Lutheran Home

The complaint investigation found that the facility did not update the care plan for Resident #1 after falls on 11/15/25 and 11/17/25, despite the resident sustaining injuries including a skin tear and a re-fracture of the right pelvis. The facility reported a census of 47 residents.

The facility failed to update the care plan with new interventions after multiple falls of Resident #1, resulting in a re-fracture of the resident's right pelvis. The care plan did not include interventions for falls occurring on 11/15/25 and 11/17/25, and staff admitted to not documenting new interventions despite implementing some safety measures.

Complaint #2651674-C and facility reported incident #2697304-I were investigated. The facility reported incident #2697304-I resulted in a deficiency.

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.

All deficiencies were corrected and the facility is in substantial compliance effective October 22, 2025.

The visit was complaint-related due to a fall incident on 9/26/25 where Resident #1 fell from a full body mechanical lift due to a sling strap detaching from the lift's spreader bar, resulting in a 3-4 cm head laceration and subsequent hospitalization with subdural and intraventricular hemorrhages. The immediate jeopardy was identified on 10/16/25 and removed on 10/17/25 after corrective actions.

The facility failed to properly operate a full body mechanical lift and use appropriate slings for 3 of 5 residents reviewed, resulting in an immediate jeopardy when a resident fell due to a sling strap detaching from the lift, causing a serious head injury. The facility took corrective actions including staff education, removal of defective slings, and implementation of a monthly lift inspection program.

The facility was found deficient in ensuring proper gradual dose reductions for psychotropic medications without documented physician rationale, maintaining proper food handling and kitchen cleanliness, and documenting oxygen tubing changes as ordered to prevent infections. All deficiencies were cited with minimal harm potential and affected a few or some residents.

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.

Complaint #123810-C was not substantiated. Self-reported incident #124606-I and Complaint #124598-C were substantiated with deficiencies.

The facility was found to have deficiencies related to failure to meet professional standards in comprehensive care plans for intravenous therapy and failure to provide adequate supervision to prevent accidents during wheelchair transport, resulting in injuries to residents.

The complaint investigation revealed that Resident #2's PICC line was improperly managed by Staff E-RN who applied glue to stop bleeding from a leaking PICC line, contrary to policy, resulting in missed antibiotic dose and emergency room visit. Resident #1 was injured due to inadequate supervision during wheelchair transport when foot pedals were not used, causing a fall and facial fracture. Staff G received disciplinary action including suspension.

The facility failed to follow intravenous therapy protocols for one resident, resulting in improper handling of a leaking PICC line, and failed to provide adequate supervision during wheelchair transport for another resident, resulting in a fall and injury. Both incidents involved minimal to actual harm to residents.

The facility was found deficient in multiple areas including failure to timely assist a resident to the restroom, inadequate nail care for a resident, incomplete PASRR screening, failure to update care plans after falls, delayed pharmacist drug regimen review, and serving expired food items. Deficiencies were generally assessed as minimal harm with few residents affected.

The complaint involved an allegation by Resident #1 that a staff member purposefully stepped on his toes on or about 3/17/23. The allegation was reported to a Licensed Practical Nurse on 3/24/23 but was not reported to administration until 4/3/23. The Director of Nursing was unaware of the incident until 4/3/23 when she began an investigation and reported it to the State Agency.

The facility failed to report an allegation of abuse within 24 hours or the next business day for 1 of 3 residents reviewed. Resident #1 reported that a staff member purposefully stepped on his toes, but the incident was not reported to administration promptly. The Director of Nursing was not informed until weeks later, and an investigation was subsequently initiated.

The complaint involved an allegation by Resident #1 that a staff member purposefully stepped on his toes on or about 3/17/23. The allegation was reported to a Licensed Practical Nurse on 3/24/23 but was not reported to administration or the State Agency until 4/3/23. The Director of Nursing was unaware of the incident until 4/3/23 and then initiated an investigation and reported it as required.

The facility failed to report an allegation of abuse within 24 hours or the next business day for one resident. Staff interviews and record reviews confirmed that a staff member purposefully stepped on Resident #1's toes on or about 3/17/23, but the incident was not reported to administration until 4/3/23.

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.

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.

The facility was found deficient in multiple areas including failure to follow bowel management procedures for a resident, inadequate documentation and consent for bed rail use, improper use of antipsychotic medications without specific targeted behaviors, insufficient qualifications of the Dietary Services Director, lack of meal choices for residents on pureed diets, improper food storage and ice machine sanitation, failure to use manufacturer-recommended disinfectants for glucometers, lack of barrier between clean and dirty laundry areas, failure to notify residents about COVID-19 cases timely, and inadequate inspection and maintenance of bed frames and rails.

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.

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.

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.

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.

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.