Man found dead in pool of blood at troubled Iowa care facility

A Muscatine nursing home that has been repeatedly cited for resident-safety violations and short-staffing is now being cited for staffing issues that contributed to a resident’s death.

According to the Iowa Department of Inspections, Appeals and Licensing, which inspects and oversees the state’s nursing homes, on July 24, 2025, the staff at the Lutheran Living Senior Campus discontinued one-on-one supervision of a male paraplegic resident who had been involved in an assault a few weeks earlier.

The move was made, according to inspectors, “to address a staffing shortage.” Shortly after the one-on-one supervision was dropped, and just hours before his forced discharge from the facility, the resident apparently killed himself.

The resident, who had previously been diagnosed with major depressive disorder, was alleged to have assaulted a female resident on June 30, leaving her with black and blue bruising on her leg that was consistent with the victim’s account of the incident. The Muscatine County Sheriff’s Office was contacted and a police report was filed, according to inspectors.

The facility then initiated an emergency discharge of the male resident and hand-delivered him a notice of involuntary discharge on June 30.

On July 24, the eve of his planned discharge, the resident spoke to the home’s social services director, who had assisted him in his unsuccessful appeal of the discharge. He allegedly told her he did not want her to feel guilty about anything that happened, and that she had done all she could to help him.

Later that same day, a certified nurse aide overheard the man “making a lot of phone calls” — one of which she believed was to a bank. In that call, she later told inspectors, the man informed bank officials that he wanted his money to go to his nephew “if anything were to happen to me.”

At some point that evening, the man contacted a relative and texted her, “It’s check out time.” Concerned the man was contemplating suicide, the woman called Lutheran Living Senior Campus but the phone at the home had been left unattended and so her call was routed to voicemail.

According to inspectors, the woman left a voicemail message asking the staff to keep an eye on the man.

At 10 p.m. that evening, two CNAs failed to report for their overnight shifts so the home discontinued the one-on-one supervision of the resident, allowing the CNA in that area of the building to handle other residents’ needs.

At about 5:30 a.m. on July 25, a registered nurse who was working in another area of the building heard one of the CNAs screaming. Following the sound, she entered the male resident’s room and found the man lying on the floor in a large pool of blood with no pulse and no signs of respiration. Paramedics were summoned, reported there was blood “all over the room,” and pronounced the man dead.

A nurse at the facility later determined the man had used a piece of glass from a broken picture frame and a set of scissors to cut himself, severing an artery in his left arm, according to the inspectors’ report.

The family member who called the facility during the night later told inspectors her relative was supposed to be under 24-hour surveillance and that from what she had gathered, the facility was short-staffed. “If they had just listened to the voicemail, that could have saved his life,” the woman reportedly told inspectors.

Resident-safety violations repeatedly cited

When the inspectors reviewed the man’s care plan on Aug. 7, they allegedly found no status updates regarding the assault, the involuntary discharge, or the one-on-one supervision.

The inspections department cited the home for a failure to have sufficient, competent staff to meet residents’ behavioral health needs, failure to protect residents from hazards in the environment, and violations related to resident rights, care planning, the discharge process and overall quality of care.

State records show that when the inspectors arrived at the home to investigate the death, there was a backlog of seven complaints to be investigated, three of which resulted in citations for deficiencies.

Andrew Harris, the facility’s administrator, declined to comment on the death or the state’s findings when contacted by the Iowa Capital Dispatch.

A $10,000 state fine related to the home’s failure to recognize and address behaviors that suggested self-harm has been proposed but held in suspension so that federal regulators can determine whether a federal fine is warranted.

In addition, a $30,000 state fine for lack of resident safety has been proposed and held in suspension. That proposed fine would have been $10,000 but was tripled due to it being the latest in a series of repeat violations tied to resident safety.

The other incidents were:

— October 2023: The state held in suspension an $8,500 fine related to resident safety, and a $26,711 federal fine was imposed. That action stemmed from incidents in which the home improperly transferred several residents from wheelchairs or mechanical lifts, resulting in hospital visits, increased pain, staples to the back of the head, surgical repair of a hip, a new wound and bruising. At that time, 26 other violations were noted by inspectors.

— July 2024: The state held in suspension a $10,000 fine related to resident safety, and a $134,971 federal fine was imposed. Because that incident represented a repeat violation, the proposed state fine was tripled to $30,000. The action stemmed from an incident in which the staff was unable to respond to a resident who was calling out for help. The resident was later found dead, face down in the bed with their feet on the floor. Workers later told inspectors the home was short-staffed at the time.

— October 2024: The state proposed and held in suspension a $6,750 fine related to resident safety. Because that represented a repeat violation, the proposed fine was tripled to $20,250. That action stemmed from an incident in which a resident wandered from the building without an alarm sounding.

Lutheran Living Senior Campus currently has a one-star rating on the five-star scale used by the Centers for Medicare and Medicaid Services to measure overall quality of care. The facility is owned and operated by the nonprofit Lutheran Homes Society.