Lutheran Living Senior Campus
2421 Lutheran Drive, Muscatine, IA 52761 · Muscatine County · 155 certified beds · avg 121 residents/day · certified since Jan 1, 2001
Part of chain: HEALTH DIMENSIONS GROUP (10 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 7, 2025 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 7, 2025 · F-0741 · triggered by a complaint
The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression.
Why it matters: Residents with dementia or other behavioral health needs may be mishandled, overmedicated, or left in distress.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 30, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 31, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 5, 2023 · F-0603 · triggered by a complaint
The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment.
Why it matters: Forced isolation is emotionally harmful and can hide neglect or abuse from view.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 30, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 5, 2023 · F-0610
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 30, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Oct 5, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 30, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (43)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 13, 2026 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Aug 7, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Aug 7, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 7, 2025 | B · Minimal risk, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Dec 12, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 30, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 30, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 30, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 30, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 31, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 5, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint |
| Oct 5, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 5, 2023 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility employed staff who were not licensed, certified, or registered as required by state law. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Oct 5, 2023 | C · Minimal risk, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 22 | 3 | J ▲ |
| 2024 | 10 | 2 | J ▲ |
| 2025 | 7 | 2 | J ▲ |
| 2026 | 4 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $253,886, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Aug 7, 2025 | Fine | $92,203 |
| Jul 31, 2024 | Fine | $134,971 |
| Jul 31, 2024 | Payment Denial | 46 days from Sep 4, 2024 |
| Oct 5, 2023 | Fine | $26,712 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.42 | 4.37 | 3.95 | top 43% in Iowa; top 25% in the U.S. |
| Registered Nurse hours | 0.51 | 0.85 | 0.69 | bottom 12% in Iowa; bottom 38% in the U.S. |
| Weekend total nurse staffing | 3.93 | 3.86 | 3.50 | top 42% in Iowa; top 25% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.51 | 0.48 | bottom 21% in Iowa; bottom 36% in the U.S. |
| Total nursing staff turnover (%) | 42.9 | 44.0 | 45.8 | bottom 49% in Iowa; top 44% in the U.S. |
| RN turnover (%) | 65.2 | 42.1 | 42.9 | bottom 18% in Iowa; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.85, RN 0.44, weekend 3.43. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Baars, Tyler | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2024 |
| Baars, Tyler | Individual | Corporate Director | NOT APPLICABLE | 10/01/2024 |
| Baars, Tyler | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2024 |
| Beckey, Vicki | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2022 |
| Beckey, Vicki | Individual | Corporate Director | NOT APPLICABLE | 10/01/2022 |
| Beckey, Vicki | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| Briscoe, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2013 |
| Briscoe, Patricia | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2013 |
| Burzlaff, Susan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2013 |
| Burzlaff, Susan | Individual | Corporate Director | NOT APPLICABLE | 10/01/2013 |
| Burzlaff, Susan | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2013 |
| Eversmeyer, Susan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2020 |
| Eversmeyer, Susan | Individual | Corporate Director | NOT APPLICABLE | 11/01/2020 |
| Eversmeyer, Susan | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2020 |
| Francis, Megan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2021 |
| Francis, Megan | Individual | Corporate Director | NOT APPLICABLE | 10/01/2021 |
| Francis, Megan | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2021 |
| Harris, Andrew | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2024 |
| Harris, Andrew | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Health Dimensions Consulting INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2013 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What mental health services do you provide on-site, and who delivers them?"
- "What training does your staff have in dementia and behavioral health, and how many residents with these needs do you serve?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Accura Healthcare of Muscatine | 2.2 mi | Muscatine, IA | ★★☆☆☆ | 3/5 | |
| Wilton Retirement Community | 13.2 mi | Wilton, IA | ★★★★★ | 5/5 | |
| Simpson Memorial Home | 13.9 mi | West Liberty, IA | ★★★☆☆ | 4/5 | |
| Lone Tree Health Care Center INC | 17.3 mi | Lone Tree, IA | ★★★★★ | 4/5 | |
| Colonial Manors of Columbus Community | 17.4 mi | Columbus Junction, IA | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165432.