Lutheran Living Senior Campus

In the surveyor’s words

From the most serious findings on record at Lutheran Living Senior Campus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Aug 7, 2025

  Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, and staff interviews, the facility failed to perform behavioral health assessments for Resident #1 after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. On [DATE] the 1:1 supervision was discontinued to address a staffing shortage without Resident #1 being assessed. During the early morning hours of [DATE], with no 1:1 supervision, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. […]

• Immediate jeopardy, isolatedF741Aug 7, 2025

  Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, staff and family interviews, and facility policy review, the facility failed to recognize and address potential statements and behaviors that indicated Resident #1's self harm risk after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. […]

• Immediate jeopardy, isolatedF689Sep 30, 2024

  Based on clinical record review, observations, facility video and staff interviews, the facility failed to ensure a resident with exit seeking behavior did not exit the facility without staff knowledge. (Resident #4) The facility reported census was 125. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/17/24 at 3:30 pm. The IJ began on August 4, 2024. Facility staff removed the Immediate Jeopardy on 9/24/24 through the following actions: - Resident placed on 1:1 observation on 8/4/24 until he was moved to the locked Memory Care Unit on 8/5/24. - Neuro checks initiated, witness statement obtained, and notifications made on 8/4/24. - Elopement assessment and care plan updated 8/5/24. - Staff education on elopement and documentation began 8/4/24. […]

• Immediate jeopardy, isolatedF689Jul 31, 2024

  Based on clinical record review, personnel records, medical examiner interview and staff interviews, the facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner for 1 of 5 residents (Resident #1) reviewed for safety. Per staff interview, Resident #1 called out for help on [DATE] at approximately 4:30 AM, and staff were unable to respond for up to 10 minutes. The resident subsequently found face down in bed, feet on the floor, unresponsive. The facility reported a census of 129 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 5:35 p.m. The IJ began on February 11, 2024, when Resident #1 found unresponsive. […]

• Immediate jeopardy, isolatedF603Oct 5, 2023

  Based on interviews, clinical record review, facility policy review and facility investigation review, the facility failed to ensure a resident was not subjected to involuntary seclusion when a staff member had used verbal threats to impose the understanding to a resident that she was not allowed to leave her room. This deficient practice resulted in Resident #385 displaying behaviors of anxiety, tearfulness, and fear of the staff member that imposed the involuntary seclusion to the residents room for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 140 residents. […]