Lutheran Retirement Home
Lutheran Retirement Home in Northwood, IA — inspection on February 26, 2026.
Found 4 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
right heel with wound cleanser to area on shower days, paint with Betadine solution, and cover with a
expected the staff to follow the physician orders as written or notify the physician of the need to
documentation for a pressure sore will be initially in the interdisciplinary notes as well as weekly pressure sore progress report sheet.
The form needed completed weekly until the area is resolved.
The facility would notify the physician sooner than weekly with any decline in the wound.
The TAR will direct the treatments and initiated when completed.
165485 02/26/2026
Lutheran Retirement Home 701 9th Street North Northwood, IA 50459
prevent accidents.
clinical record review and staff interviews the facility failed to provide adequate supervision for a
reviewed (Resident #13).
The facility reported a census of 36 residents.
Findings include:Resident #13's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment.
The MDS indicated Resident #13 needed substantial/maximal assistance (Helper does more than half the effort.
Helper lifts or holds the trunk or limbs and provides more than half the effort) for transfers and toileting.
The MDS further documented the resident had diagnoses of Alzheimer Disease, anxiety, history of falling and unsteady on feet. Resident #13's undated Care Plan documented they had limited physical mobility, unsteadiness on their feet and had a risk for falls.
The Care Plan included the following Interventions in place prior to the fall to have a pressure alarm at all times, is dependent on staff for transfers and toileting and documented he fell four times prior to the fall in the shower room.
Review of the facility's Incident Report for Resident #13 on 1/24/26 documented they had an unwitnessed fall in the shower room.
Prior to the fall the staff saw him in the sitting room in his wheelchair and somewhat anxious. It documented as Resident #13 was in the shower room, the Certified Nurses' Aide (CNA) left the resident unattended to retrieve the lift for assistance. On 2/24/26 at 3:05 PM Staff E, CNA, reported on the day Resident #13 fell in the shower room, he needed to use the bathroom, so she took him to the shower room to change him because the standing mechanical lift is usually in the shower room.
She reported when she took him in the shower room there was no standing mechanical lift, so she left him in the shower room to go get the equipment.
Staff E reported when she came back, she heard the alarm in his wheelchair going off with Resident #13 on the floor. In addition, she saw Staff F, Licensed Practical Nurse (LPN), and Staff G, CNA, in the room assessing Resident #13.
Staff E reported she didn't know what she was thinking leaving him by himself in the shower room.
Staff E reported she knew better but was in a hurry. On 2/24/26 at 3:18 PM Staff F, LPN, reported as she talked with Staff G in the hallway, they heard an alarm going off.
Once they figured out the alarm was in the shower room, they went to go see what was going on.
When they entered the shower room, they found Resident #13 on the floor in front of his wheelchair and yelling for help. Resident #13 had no injuries from the fall.
Staff F reported Staff E didn't receive education following the fall.
They added, it is just common knowledge to not leave a fall risk resident alone in the shower room. On 2/24/26 at 3:49 PM Staff G, reported she was working the day Resident #13 fell.
Staff G reported she was not far from the shower room talking to the nurse after coming out of a room.
Staff G heard an alarm going off and once she figured out it was the shower room she told Staff F, that she was going to check the alarm.
When Staff F and Staff G entered the shower room, they found no staff present and Resident #13 on the floor in front of his wheelchair.
Staff G reported the staff should know residents with alarms should not be left in the shower room unattended.
Staff G reported they didn't receive education on leaving residents in the shower room she is aware of after the incident. On 2/25/26 at 1:40 PM the Director of Nursing (DON) reported staff are not to leave residents unattended in the shower room at any time.
165485 02/26/2026
Lutheran Retirement Home 701 9th Street North Northwood, IA 50459
serve food in accordance with professional standards.
Drug Administration the facility failed to prevent the risk of cross contamination to potential bacterial
facility reported a census of 36 residents.
Findings include: On initial walk through of the kitchen on 2/23/26 at 10:20 AM observed Staff D, Cook, with multiple rings on 8 of her fingers. On both wrists she wore bracelets while working in the kitchen prepping the meal. On 2/23/26 at 12:20 PM observed Staff D serving the noon meal.
She continued to wear the rings on 8 of her fingers and bracelets on both wrists. On 2/24/26 at 11:00 AM observed Staff D pureed pork chops, sweet potatoes, and broccoli for the noon meal.
The observation revealed Staff D still wore rings on 8 fingers, with some of her fingers having multiple rings on them.
She wore a bracelet on both wrists. On 2/24/26 at 12:00 PM watched Staff D serve the noon meal wearing all the jewelry from the previous observations. On 2/24/26 at 12:30 PM Staff D reported she knew she wore more jewelry than she should based on the regulations and policy. On 2/24/26 at 1:00 PM the Dietary Manager reported the staff can't wear jewelry, except a plain wedding band when working in the kitchen.
The facility policy titled Employee Sanitary Practices dated 2005 directed to keep jewelry to a minimum of wedding rings, plain watches, and no dangle earrings.
The Food Code Manual January 18, 2023, Version documented jewelry is prohibited except for a plain ring such as a wedding band; while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
165485 02/26/2026
Lutheran Retirement Home 701 9th Street North Northwood, IA 50459
quarterly
minimum required members necessary at the Quality Assessment and Assurance (QAA) meetings to
reported a census of 36 residents.
Findings include:
Review of the facility QAA sign in sheets revealed the July and October 2025 quarterly meetings didn't have the Director of Nursing (DON) present.On 2/26/26 at 11:05 AM the Administrator reported the DON didn't attend the quarterly meetings for July and October because they were gone that day.
She reported she didn't try to reschedule the meeting so the DON could attend.
The undated facility policy titled Quality Assurance Program documented all staff members of the quality assurance team will meet quarterly with the Medical Director.
The policy failed to define the quality assurance team members.