(Muscatine, IA) -- Iowa Department of Inspections, Appeals, and Licensing (DIA) inspectors say Lutheran Living Senior Campus, a one-star rated facility, removed one-to-one supervision from a high-risk, paraplegic resident on July 24 to cover an overnight staffing shortage; the resident was found deceased in his room the next morning.
According to the inspection file, two certified nursing assistants did not report for duty that night. The on-duty supervisor and the on-call nurse reassigned the 1:1 aide without authorization from the director of nursing. Staff documented two-hour checks until the resident was discovered around 5:30 a.m. on July 25. A nurse reported the resident used a piece of glass from a broken picture frame and a pair of scissors to inflict fatal injuries.
Investigators noted a relative called the facility hours earlier after receiving a concerning message from the resident; the call went to an unattended voicemail. The facility, owned by the nonprofit Lutheran Homes Society, reported implementing a new phone-answering policy after the incident.
Regulators cited the home under federal behavioral-health requirements and declared Immediate Jeopardy beginning July 24; the condition was removed Aug. 7 following corrective actions that included suicide-prevention training and policy changes.
Related History
- July 2024: Inspectors cited the facility after a resident was found deceased with her head between the mattress and a bed rail, after her calls for help went unanswered for up to 10 minutes due to short staffing.
- October 2023: Inspectors cited unsafe transfer practices that injured residents, leading to federal penalties.
- January 2017: A resident suffered severe burns requiring a skin graft after a nurse used a disposable ice pack filled with 180-degree water from a coffee maker as a heating pad, a violation of facility policy.
Missed Warnings
The most recent state report also details missed or unreported warning signs. Multiple staff members told inspectors they observed potential indicators of worsening depression in the days before the death but did not elevate those concerns to leadership.
A relative told inspectors she tried to warn the facility after receiving a text message that read, "It's check out time." "If they had just listened to the voicemail," she told inspectors, "that could have saved his life".
Photo: Photo: Iowa Department of Inspections, Appeals, & Licensing