Trinity Center at Luther Park

In the surveyor’s words

From the most serious findings on record at Trinity Center at Luther Park, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 23, 2025

  Based on observations, record review, staff and Iowa Department of Public Health (IDPH) interviews, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines. The facility failed to do the following; ensure staff followed proper infection control practices during resident's cares and transmission based precaution procedures to prevent the spread of COVID-19 by failing to follow facility policy and CDC guidelines, to test residents who had been exposed to other residents positive for COVID-19, separate COVID-19 positive residents from roommates, to wear proper personal protective equipment (PPE) and to properly handle contaminated linens for 20 of 20 residents reviewed (Resident #2, #6, #11, #12, #27, #32, #36, #42, #59, #68, #74, #75, #85, #91, #96, #97, #100,… […]

• Immediate jeopardy, patternF678Jan 5, 2023

  Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide basic life support to a resident requiring emergency care. Resident #1 was found unresponsive at meal time on [DATE] around 12:15 p.m., staff initiated chest compressions but failed to access the emergency cart which contained emergency equipment including a suction machine and Ambu bag to provide rescue breathing. Upon arrival of emergency medical services (EMS) after 20 minutes unresponsive, suction produced removal of a large food bolus. EMS intubated and transported to hospital where resident later expired due to asphyxiation. This failure posed an Immediate Jeopardy to the residents health and safety. […]

• Immediate jeopardy, patternF803Jan 5, 2023

  Based on clinical record review, observation, and staff interview, the facility failed to serve a resident a mechanical soft diet as ordered by the physician. During the noon meal service on [DATE], the ticket incorrectly directed staff to serve a regular diet to a resident who required a mechanical soft diet. During the process of serving the incorrect diet, this surveyor stopped the dietary staff from serving the meal. These circumstances posed an Immediate Jeopardy to the residents health and safety. (Resident #2). During closed record review the facility failed to serve the correct diets for 2 of 4 residents reviewed. (Resident #1 and Resident #3). […]

• Immediate jeopardy, isolatedF684May 10, 2021

  Based on clinical record review, staff and physician interviews, facility policy review and review of online reference sources, the facility failed to intervene following receipt of a critical Potassium laboratory value for 1 of 4 sampled (Resident #1) for assessment and intervention. On [DATE] at 8:15 p.m., Staff A (Licensed Practical Nurse) received a phone call from laboratory informing him of Resident #1's critically high potassium level. Staff A failed to document the call and failed to notify Resident #1's physician of the critical value. Staff A reported the information to Staff B (Registered Nurse) who directed staff on all floors to check for faxed receipt of the lab results. Staff B reported he did not know the lab or its value, so did not report to physician. […]

• Immediate jeopardy, isolatedF689Apr 8, 2021

  Based on clinical record review, observations, facility policy review and staff interviews, the facility failed to provide an environment free of accidents hazards and failed to provide adequate supervision for six residents. The facility failed to adequately assess and implement effective interventions for Resident #21, at risk for elopement, who removed his wander-guard device. The facility failed to respond to a sounding door alarm. Resident #21 eloped from a 2nd floor alarmed door and ambulated down 16 concrete stairs with a walker and exited the facility without staff knowledge. The facility failed to properly transfer Resident #33, #81, #90. Resident #90 sustained a laceration to the lower extremity requiring 14 sutures. Resident #81 hit her head. […]