Lakeside Lutheran Home
Lakeside Lutheran Home in Emmetsburg, IA — inspection on February 26, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
used psychotropic medications, antipsychotic related to behavior management.
Interventions included
4/9/25.Trazadone 50 mg, give 1/2 tab at bedtime dated 4/8/25.Risperidone 0.5 mg, give 1/2 tab 3
Medication Administration Record for October 2025 showed the resident received Quetiapine 400 mg, 2 tablets in the evening initiated 4/8/25 and continued 10/29/25, after receiving Quetiapine 400 mg 1 time on 10/28/25. A letter to the Physician from the Pharmacist dated 10/31/25 documented the use of central nervous system medications was always a potential area of concern to state regulators.
The letter asked the physician to please review Resident #1's medications to determine future use. It was recommended to only make one major medication change at a time so they knew the effect of each med change.
The letter inquired about GDR for Quetiapine (antipsychotic), Trazadone (antidepressant), Divalproex (anticonvulsant), Risperidone (antipsychotic), and Perphenazine (antipsychotic).
The provider responded no changes, with no rationale given. On 2/25/26 the DON confirmed the provider did not give a rationale for no GDR on for the psychotropic medications.
165492 02/26/2026
Lakeside Lutheran Home 301 North Lawler Street Emmetsburg, IA 50536
(MDS) assessment accurately for 2 of 13 residents reviewed (Resident #19 and #31).
The facility
assessment dated [DATE], Resident #19 scored 6 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment.
The resident's diagnoses included heart failure, renal insufficiency, and chronic respiratory failure.
The MDS documented the resident had an indwelling urinary catheter.On 2/23/26 at 3:30 p.m. Resident #19 sat in her recliner and had no catheter.The Care Plan dated 2/23/26 identified Resident #19 had mixed bladder incontinence related to diuretic therapy.
Interventions included the resident used disposable briefs.The Care Plan lacked documentation the resident had a catheter.The Progress Notes dated 9/12/25 documented Resident #19 admitted skilled after right hip fracture repair, with a catheter.
The Progress Notes dated 9/15/25 at 12:37 p.m. documented receipt of an order to discontinue the urinary catheter. At 12:50 p.m. a nurse removed the resident's urinary catheter.The Progress Notes dated 9/16/25 at 3:36 p.m. documented the resident voiding without concerns after the was catheter removal.On 2/25/26 at 1 p.m. the MDS Coordinator stated she marked the MDS incorrectly (regarding the catheter). On 2/25/26 at 5 p.m. the Administrator stated the MDS should be coded accurately.
They did not have a policy for coding them accurately. 2) According to the MDS assessment dated [DATE], the facility marked no to question A1500 indicating Resident #31 was not considered by the state level 2 Preadmission Screening and Resident Review (PASRR) process to have serious mental illness. A Notice of PASRR Level 1 Screen Outcome dated 11/8/23 documented Resident #31 Level 1 positive, with no status change.
The PASRR .showed the resident had evidence of a serious mental illness.
The services identified in the previous PASRR remained appropriate.
Since the evaluation determined the resident the resident had a PASRR condition, the facility should mark yes to question A1500 on the MDS. On 2/24/26 at 1:10 p.m. the Social Services Supervisor stated they coded Resident #31's MDS incorrectly regarding PASRR.