Inspection Reports for Trinity Center at Luther Park
1555 Hull Avenue, Des Moines, IA, 503161398
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 23, 2025, identified multiple deficiencies related to documentation of psychotropic medication use, resident notifications, COVID-19 assessments, neurological evaluations after falls, use of gait belts, food handling, and infection control practices. Earlier inspections showed a pattern of similar issues including infection control, food safety, notification failures, and resident care concerns, with substantiated complaints regarding abuse investigations and emergency response. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving failure to report and investigate abuse thoroughly and inadequate emergency care resulting in serious harm or death. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in documentation, resident safety, and infection control, with no clear trend of sustained improvement over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
109 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 9
Date: Dec 23, 2025
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of complaints related to the facility.
Complaint Details
Complaint #2696701-C resulted in a deficiency related to the right to be free from chemical restraints.
Findings
The facility was found deficient in multiple areas including failure to document non-pharmacological interventions prior to administering psychotropic medications, failure to notify resident representatives in writing of hospital transfers and bed hold policies, inaccurate Minimum Data Set (MDS) coding, failure to provide consistent COVID-19 assessments and monitoring, failure to complete neurological assessments after falls, failure to use gait belts during resident transfers, failure to label and properly handle food and food storage, and failure to follow infection prevention and control protocols including PPE use and COVID-19 transmission precautions.
Deficiencies (9)
Failure to document non-pharmacological interventions prior to administration of anti-anxiety medication for Resident #39.
Failure to notify resident representative in writing of hospital transfer and bed hold policy for Resident #3.
Inaccurate MDS coding for physical restraints and mental illness for Residents #4, #9, and #21.
Failure to provide consistent and thorough COVID-19 assessments and monitoring for 17 residents.
Failure to complete neurological assessment for Resident #18 after an unwitnessed fall.
Failure to use gait belt while transferring Resident #103 who required assistance.
Failure to label food stored in refrigerator, improper thawing of meat, and failure to discard delivery boxes.
Failure to follow infection prevention and control program including PPE use, COVID-19 testing, resident cohorting, and handling contaminated linens for 20 residents.
Failure to properly handle disposable wipes during pericare for Resident #2.
Report Facts
Census: 109
Deficiencies cited: 10
COVID-19 isolation days: 5
COVID-19 monitoring days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff U | Registered Nurse | Reported documentation practices for PRN medication administration. |
| Staff G | Licensed Practical Nurse | Reported documentation practices for PRN medication administration and assisted with Resident #18 fall. |
| Staff A | Registered Nurse | Reported documentation practices for PRN medication administration. |
| Staff T | Assistant Director of Nursing | Reported expectations for documentation and infection control practices. |
| Staff F | Registered Nurse | Reported on bed hold documentation and COVID-19 assessment practices. |
| Staff K | Registered Nurse | Reported on gait belt use and resident mobility. |
| Staff I | Certified Nurse Aide | Observed assisting resident transfer without gait belt. |
| Staff P | Quality Assurance | Reported on infection control software and staff education. |
| Staff S | Licensed Practical Nurse | Reported on bed hold documentation and COVID-19 assessment practices. |
| Staff Q | Certified Nursing Assistant | Observed improper handling of disposable wipes during pericare. |
| Staff R | Certified Medication Aide | Observed improper handling of disposable wipes during pericare. |
| Staff GG | Certified Nursing Assistant | Observed improper PPE use and handling of contaminated linens. |
| Staff HH | Certified Nursing Assistant | Observed improper mask use. |
| Staff F | Registered Nurse | Observed improper mask use and reported on COVID-19 assessment practices. |
| Staff G | Licensed Practical Nurse | Observed improper mask use. |
| Staff H | Registered Occupational Therapist | Observed improper PPE use. |
| Staff L | Registered Nurse | Reported PPE requirements and infection control practices. |
| Staff JJ | Environmental Services Supervisor | Reported PPE requirements for environmental services staff. |
| DON | Director of Nursing | Reported infection control policies and COVID-19 management. |
| Facility Administrator | Reported COVID-19 testing and isolation policies. | |
| Facility Medical Director | Reported expectations for infection control and COVID-19 management. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
A complaint investigation for facility reported incidents #Incident 2625924 was conducted from October 20, 2025 to October 21, 2025.
Complaint Details
Investigation related to incident #2625924; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
An investigation for Complaints #126596-C, #129235-C and Facility Reported incidents #128235-I was conducted from July 7, 2025 to July 9, 2025.
Complaint Details
Investigation was conducted for Complaints #126596-C, #129235-C and Facility Reported incidents #128235-I.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance with health requirements.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted, resulting in certification effective November 22, 2024.
Inspection Report
Annual Inspection
Census: 111
Deficiencies: 4
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaints #123296-C, and Facility Reported Incidents #123115-I, #124404-I, conducted from October 28, 2024 to October 31, 2024.
Findings
The facility was found to have multiple deficiencies including failure to notify the Long Term Care Ombudsman of resident transfers, incomplete discharge summaries and plans, improper food handling and infection control practices. The facility provided a plan of correction and education to staff to address these issues.
Deficiencies (4)
Failure to notify the Long Term Care Ombudsman of a resident transfer as required.
Failure to complete a discharge summary and discharge plan for a resident.
Failure to ensure proper food handling procedures to prevent contamination during meal service.
Failure to establish and maintain an infection prevention and control program including proper staff training and hand hygiene.
Report Facts
Resident census: 111
Complaint numbers: 3
Dates of survey: October 28, 2024 to October 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Anderson | Administrator | Signed the initial comments page and involved in corrective actions |
| Director of Nursing | Interviewed regarding notification failures and staff retraining on catheter care | |
| Certified Dietary Manager | CDM | Provided education to dietary staff on food handling and safety |
| Staff A | Certified Nurse Aide | Observed during catheter care and infection control deficiencies |
| Staff B | Certified Nurse Aide | Observed during catheter care and infection control deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 11, 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 found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective as of September 6, 2024.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaints #122230-C and Facility Reported Incidents #119816-I and #122090-I from August 12, 2024 to August 15, 2024. The complaints and incidents were substantiated.
Complaint Details
Complaint #122230 was substantiated. Facility Reported Incident #119816-I was substantiated. The investigation was based on complaints and incidents from August 12-15, 2024. The facility failed to complete required incident reports and notifications, and did not conduct thorough investigations including staff interviews for alleged abuse.
Findings
The facility failed to complete an incident report and notify the physician and resident's emergency contact for a new bruise found on a resident. The investigation revealed inadequate staff interviews and incomplete documentation related to alleged abuse. The facility policy on notification of changes and abuse investigation protocols were not fully followed.
Deficiencies (2)
Failure to complete an incident report and notify physician and resident representative for a new bruise on a resident.
Failure to thoroughly investigate alleged abuse, neglect, exploitation, or mistreatment including lack of staff interviews.
Report Facts
Census: 115
Dates of incidents: 2024-06-28 to 2024-08-15
Dates of staff education and audits: 2024-08-07 to 2024-09-24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Woodson | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
Investigation of complaint #116176-C conducted from October 12, 2023 to October 17, 2023 at Trinity Center at Luther Park Nursing Home.
Complaint Details
Investigation of complaint #116176-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
An Annual Recertification survey and investigation of multiple complaints and facility reported incidents were conducted from September 18, 2023 to September 25, 2023.
Complaint Details
Investigation included Complaints #112147-C, #113985-C and Facility Reported Incidents #112262-I, #112902-I, #113333-I, #113650-I, #115262-I, #115542-I, #115628-I.
Findings
The facility was found to be in substantial compliance with applicable regulations as per 42 CFR Part 483, Subpart B-C.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
A revisit of the survey ending January 5, 2023 was conducted from March 17, 2023 to March 22, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 6, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
A complaint investigation was conducted for complaints #110153-C and facility reported incidents #110348-I and #111584-I from March 17, 2023 to March 22, 2023.
Complaint Details
Investigation involved complaints #110153-C and facility reported incidents #110348-I and #111584-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Date: Jan 5, 2023
Visit Reason
The inspection was conducted as a result of investigations of complaints #109327-C, #109270-C, and facility reported incidents #109344-I and #109554-I between December 5, 2022 and January 5, 2023.
Complaint Details
Complaints #109327-C and #109270-C were substantiated as stated in the initial comments on page 1.
Findings
The facility was found to have failed to report an unusual occurrence to the state agency in a timely manner, failed to provide basic life support including CPR to a resident requiring emergency care, and failed to serve correct diets to residents as ordered by physicians. The facility also failed to prevent serious bodily injury to a resident and had deficiencies related to abuse reporting and nutritional adequacy.
Deficiencies (3)
Failure to report an unusual occurrence to the state agency in a timely manner, resulting in a resident being transferred to the hospital and later dying.
Failure to provide basic life support including CPR to a resident requiring emergency care, resulting in serious bodily injury and death.
Failure to serve correct diets to residents as ordered by physicians, including serving a regular diet to a resident requiring a mechanical soft diet.
Report Facts
Resident census: 108
Residents requesting CPR: 31
Residents on mechanical altered diet: 11
Residents reviewed for diet: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Violet Aluvisia | Director of Nursing | Named in the plan of correction letter and involved in corrective actions for deficiencies F609, F678, and F803. |
| Staff B | Registered Nurse (RN) | Confirmed involvement in CPR process during interview on 12/8/22. |
| Staff A | Licensed Practical Nurse (LPN) | Participated in CPR process and assisted with Heimlich maneuver. |
| Staff C | Certified Medication Aide (CMA) | Involved in CPR process and confirmed presence during incident. |
| Staff D | Dietary Staff | Observed serving incorrect diet and confirmed diet ticket accuracy issues. |
| Staff E | Culinary Chef | Verified diet orders and meal preparation. |
| Staff F | Speech/Language Pathologist | Explained diet texture and swallowing risks. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
An investigation of facility-reported incident #108041-I was conducted from October 25, 2022 to November 2, 2022.
Complaint Details
Investigation was related to facility-reported incident #108041-I and resulted in a finding of substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 10, 2022
Visit Reason
The document is a plan of correction related to the facility's certification based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective October 8, 2022, based on acceptance of the credible allegation of compliance and plan of correction as per Code of Federal Regulations (42 CFR) Part 483, Subpart B-C.
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 11
Date: Aug 16, 2022
Visit Reason
The inspection was an annual recertification survey combined with investigation of multiple complaints and facility reported incidents conducted from August 1, 2022 to August 16, 2022.
Complaint Details
Complaints #99662-C, #99664-C, #104834-C were substantiated. Self Report #99883-1 was substantiated.
Findings
The facility was found to have multiple deficiencies including failure to honor resident medication and treatment preferences, lack of process for unidentified personal property, failure to document rationale for emergency discharge, failure to notify residents or responsible parties of bed hold policy, failure to develop and implement interventions for edema management, failure to maintain professional standards in medication administration, failure to meet nutritional needs with correct serving sizes, failure to maintain infection control practices, failure to respond to call lights timely, failure to store drugs according to professional standards, and failure to maintain clean and labeled foods in personal refrigerators.
Deficiencies (11)
Failure to honor resident preferences for medication times unless contraindicated by physician, mealtimes and treatment times.
Failure to have a process for unidentified personal property found in the facility.
Failure to demonstrate rationale for emergency discharge and secure discharge plan.
Failure to notify resident or responsible party of bed hold policy.
Failure to develop and implement interventions for management of resident edema.
Failure to maintain professional standards by administering medications as per physician orders.
Failure to meet nutritional needs of residents by providing correct serving sizes.
Failure to maintain infection control practices during wound care, medication administration, and PPE use.
Failure to respond to resident call lights in a timely manner, at least within 15 minutes.
Failure to store drugs in accordance with currently accepted professional principles.
Failure to help residents maintain, clean and label foods for personal refrigerators.
Report Facts
Census: 110
Deficiencies cited: 11
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: May 10, 2021
Visit Reason
The inspection was conducted as an investigation of Facility Reported Incident #97074, which was substantiated.
Complaint Details
Facility Reported Incident #97074 was substantiated.
Findings
The facility failed to intervene after receiving a critical potassium laboratory value for a resident, resulting in the resident's death due to acute kidney failure caused by hyperkalemia. Staff failed to notify the resident's physician and document the critical lab results properly.
Deficiencies (1)
Failure to intervene following receipt of a critical potassium laboratory value for Resident #1, including failure to notify the physician and document the critical lab results.
Report Facts
Census: 97
Potassium level: 8.7
Potassium reference range: 3.5 - 5.1
CPR duration: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Failed to document and notify physician of critical potassium lab value |
| Staff B | Registered Nurse | Directed staff to check for faxed lab results but did not know lab value |
| Staff C | Registered Nurse | Worked evening and night shifts on 4/21/21; did not call physician due to lack of lab value |
| Assistant Director of Nursing | ADON | Documented resident's condition and interviewed regarding incident |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 5
Date: Apr 8, 2021
Visit Reason
A recertification survey and complaint investigation were conducted from March 29, 2021 to April 22, 2021, including review of facility reported incidents and complaints related to alleged abuse, neglect, and medication administration.
Complaint Details
Complaint #96938-C and #96496-C were substantiated. Facility Reported Incident #93593-I was not substantiated. Facility Reported Incidents #96380-I and #96670-I were substantiated.
Findings
The facility was found to have failed to report an allegation of abuse within 24 hours, failed to administer medications as ordered for one resident, failed to provide adequate supervision to prevent accidents for six residents, and failed to ensure residents were free from significant medication errors and food safety violations.
Deficiencies (5)
Failure to report an allegation of abuse to the Department of Inspections & Appeals within 24 hours for one resident.
Failure to administer medications as ordered by physician for one of 18 sampled residents.
Failure to provide an environment free of accident hazards and adequate supervision for six residents at risk of elopement and injury.
Failure to ensure residents are free from significant medication errors.
Failure to procure, store, prepare, and serve food in accordance with professional food service safety standards.
Report Facts
Census: 100
Deficiencies cited: 5
Resident sample size: 18
Medication doses missed: 6
Medication doses administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Rieck | CEO/Administrator | Signed the statement of deficiencies and plan of correction |
| Staff Q | Certified Nursing Assistant | Reported missing belongings and completed investigation forms |
| Staff P | Certified Nurse Aide | Reported night shift activities and missing belongings procedures |
| Staff R | Registered Nurse | Worked on unit with Resident #94 and reported missing rings |
| Director of Nursing | DON | Reported missing rings, medication administration issues, and policy revisions |
| Staff K | Licensed Practical Nurse | Interviewed regarding medication administration errors |
| Staff N | Registered Nurse | Reported on Resident #21 elopement and door alarm issues |
| Staff L | Clinical Administrative Assistant | Notified Staff N of elopement and reviewed surveillance footage |
| Staff U | Maintenance | Reported on door alarm functionality |
| Staff G | Registered Nurse | Observed insulin administration and medication errors |
| Staff D | Certified Nurse Aide | Provided care to Resident #95 and reported oxygen use |
| Staff E | Certified Nurse Aide | Assisted Resident #81 with transfers and reported fall |
| Staff B | Certified Nurse Aide | Reported skin tear and assisted with transfers for Resident #90 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
An investigation of complaints #89769-C and facility reported incidents #95193-I and #94084-I was conducted from 2021-01-19 to 2021-01-25.
Complaint Details
Complaint #89769-C was not substantiated. Incident #94084-I was not substantiated. Incident #95193-I was not substantiated.
Findings
Complaint #89769-C and incidents #94084-I and #95193-I were all found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
Investigation of complaints #90474-C, #90664-C, and #90843-C, including a COVID-19 Focused Infection Control Survey conducted in conjunction with the complaint investigations.
Complaint Details
Complaints #90474-C, #90664-C, and #90843-C were investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the Code of Federal Regulations and in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 85
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Date: Jan 29, 2020
Visit Reason
The investigation was conducted related to facility reported incidents #87555 and #87943, with incident #87943 substantiated. The visit focused on assessing the facility's compliance with supervision and accident prevention requirements.
Complaint Details
The visit was complaint-related, investigating incidents #87555 and #87943. Incident #87943 was substantiated based on clinical record review, staff and resident interviews, and observations.
Findings
The facility failed to provide adequate supervision for Resident #1, resulting in a fall and fracture due to being left unattended on the toilet despite alarms. The investigation revealed staff did not follow protocols to prevent falls and left the resident unattended, leading to injury.
Deficiencies (1)
Facility failed to provide adequate supervision and assistance devices to prevent accidents for Resident #1, resulting in a fall and fracture.
Report Facts
Resident census: 118
Incident report dates: Jan 7, 2020
Care Plan date: Feb 16, 2019
Correction completion date: Feb 13, 2020
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