MUSCATINE, Iowa — A Muscatine nursing home with a long history of safety violations is facing renewed scrutiny after a resident died under its care. The Iowa Department of Inspections, Appeals, and Licensing reported that staffing shortages at Lutheran Living Senior Campus played a key role in the incident.
Incident Overview
This Article Includes
On July 24, 2025, staff at Lutheran Living ended one-on-one supervision for a male paraplegic resident due to a lack of available personnel. Just hours before his scheduled involuntary discharge, the man was later found dead in his room.
The resident had been diagnosed with major depressive disorder and was involved in an assault case on June 30, where a female resident sustained bruises. A police report was filed, and the facility issued him a forced discharge notice on the same day.
Warning Signs Ignored
On July 24, the day before his planned discharge, the man spoke with the facility’s social services director, thanking her for supporting him during his failed appeal and assuring her she had done all she could.
Later that day, a certified nurse aide overheard him making several phone calls, including one to a bank, where he reportedly requested that his funds be transferred to his nephew “if anything happens.”
He also sent a text message to a relative saying, “It’s check out time.” Alarmed, the relative immediately called the facility, urging staff to monitor him closely. However, the phone went unanswered, and her message was left on voicemail.
Staffing Shortage and Discovery
At 10 p.m., two certified nurse aides failed to report for their night shifts, forcing the home to discontinue one-on-one supervision.
By 5:30 a.m. on July 25, a nurse heard a CNA screaming and rushed to the man’s room, where he was found unresponsive. Emergency responders confirmed his death.
A family member later told inspectors that the resident was supposed to receive 24-hour monitoring and believed understaffing contributed to the tragedy, saying:
“If they had just checked the voicemail, things could have been different.”
State Findings and Citations
An August 7 inspection revealed multiple failures in the man’s care plan, including missing updates about his assault, discharge order, and supervision needs. Regulators cited Lutheran Living for:
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Inadequate staffing to meet behavioral and mental health needs
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Failing to protect residents from environmental hazards
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Violations involving resident rights, care planning, and quality of care
During the investigation, officials also discovered a backlog of seven unresolved complaints, three of which led to additional citations.
History of Safety Violations
The facility has repeatedly faced fines for resident-safety failures:
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October 2023 → $8,500 state fine (suspended) + $26,711 federal fine after residents suffered injuries from improper transfers. Inspectors documented 26 additional violations.
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July 2024 → $10,000 state fine (tripled to $30,000) + $134,971 federal fine after staff failed to assist a resident calling for help, who was later found deceased.
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October 2024 → $6,750 state fine (tripled to $20,250) when a resident wandered out of the facility without alarms triggering.
Currently, regulators have proposed a $10,000 fine for failing to recognize self-harm risks, along with a $30,000 fine for repeated safety violations. Both remain under federal review.
Facility’s Rating and Response
Lutheran Living Senior Campus, operated by the nonprofit Lutheran Homes Society, currently holds a one-star rating — the lowest possible — from the Centers for Medicare & Medicaid Services.
Facility administrator Andrew Harris declined to comment on the incident or the state’s findings.
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