State inspectors cited the Fleur Heights Care Center in Des Moines in November for failing to respond swiftly to resident mistreatment by one of its caregivers. The worker allegedly tugged a resident’s briefs off with such force that the garment was torn, instructed another resident to “shut up,” and put her palm over a third resident’s mouth to muffle her screams.
A dozen Iowa nursing homes were recently penalized $500 each for breaking standards concerning resident abuse and background checks.
The state fines of $500 were imposed by the Iowa Department of Inspections, Appeals, and Licensing in response to charges of failing to do worker background checks, failing to investigate suspected abuse instances, and failing to notify the state of probable resident abuse.
While many other types of nursing home crimes result in federal fines of up to $10,000 or more, resident abuse violations are frequently subject to a state charge of $500. Because the institutions in certain circumstances did not fight the $500 penalties, they were automatically reduced to $325.
Recent examples include:
Fleur Heights Center for Wellness and Rehabilitation is a Des Moines skilled care facility. According to state inspectors, the institution failed to guarantee that a staff member completed the two-hour training on dependent-adult abuse within six months of being employed in June 2022, and it also failed to conduct a background check on one individual who worked in the home.
During the state’s inspection, the worker who had not been taught about dependent-adult abuse during the previous 16 months of employment completed the training. Similarly, the worker who had not been subjected to a thorough background check during their six months of working at the house was subjected to one during the inspection.
The Fleur Heights Care Center was cited in late 2019 for failing to respond to and report the alleged mistreatment of three dementia patients by one of its long-term caregivers. The worker allegedly twisted and yanked one person’s briefs off with such force that the garment was torn; urged another resident to “shut up;” and placed her palm over a third resident’s mouth to muffle the woman’s screams. Inspectors were told by another caregiver that the worker treated one of the residents “like a piece of meat.”
Prestige Care Center is a Fairfield skilled care facility. Inspectors claimed the institution failed to report an accusation of resident-to-resident sexual assault in a timely manner, as well as unidentified facial bruising. The sexual assault case involved a male resident who was seen with one hand inside another patient’s underpants.
In the case of the resident bruising, the director of nursing attributed a purple bruise on a resident’s jawbone, under her chin, to coughing, implying the resident coughed and hit her chin on her shoulder – but in discussions with inspectors, she admitted she had never seen a bruise caused in that manner.
Morning Star at Jordan Creek is a West Des Moines assisted living facility. The state claimed that the facility neglected to do a child and dependent adult abuse background check before hiring one of the seven workers whose files were reviewed by the state. The employee in question was hired in April 2021 with simply a criminal background check and no abuse check conducted.
Another worker at the facility had an unspecified criminal past, which should have prompted the Iowa Department of Health and Human Services to investigate whether the person was suitable for employment in a care setting. Instead, the person was assigned to work in the facility in October 2022.
Azria Health Park Place is a Des Moines skilled care facility. The state claimed the home failed to follow its own abuse-and-neglect policy by neglecting to conduct background checks prior to hiring staff. Inspectors discovered that a worker at the residence had undergone a background check in 2011, but had since quit and been rehired three times, most recently in August 2023, with no additional background checks done.
Hiawatha’s REM Iowa-Terry Avenue is an intermediate care facility for people with disabilities. According to state inspectors, the institution failed to ensure that any claims of abuse, neglect, or mistreatment of residents were quickly reported by the staff.
A facility investigation revealed in September 2023 that for “about a month or two,” during the overnight shift, a staff utilized a stack of chairs to prevent a resident from exiting his bedroom and closed the door to the resident’s restroom, according to inspectors.
Cherokee Specialty Care is a Cherokee skilled nursing facility. The home allegedly neglected to secure approval from the Iowa Department of Health and Human Services for the newly hired activities director to work in the institution, according to inspectors.
Inspectors claimed that a background check completed shortly after the director’s hiring revealed a criminal history that merited the DHHS investigation. There was no record of DHHS approving the hire at the residence. Inspectors were advised by the administrator that the director had been cleared to work by the facility’s corporate office, Care Initiatives.
Linn Manor Care Center is a Marion skilled care facility. Inspectors said that the home failed to detect occurrences of suspected abuse and failed to report them within 24 hours on three occasions.
On Jan. 12, 2023, a resident touched and patted another resident on the breast in the facility’s common space. The incident was reported to the director of nursing, who found that there was no intentional inappropriate contact. According to a witness, the alleged abuser “knew what he was doing when he touched” the other occupant and had become more forceful.
In a separate incident, a resident yelled in pain while being cared for, prompting a nursing assistant to seize the woman’s hand and instruct her to “shut up.” The worker continued to grip the woman’s wrists before forcing her arms through her garments to prepare her for bed.
Cedar Ridge Village is a West Des Moines skilled care facility. The house allegedly failed to complete the required background record check review process for a new employee prior to the worker’s employment, according to state inspectors. In May 2023, the home recruited an individual without completing the required form requesting a state examination of the individual’s past to determine eligibility to work in a nursing home.
Grandview Health Care Center is an Oelwein skilled care facility. According to state inspectors, the institution failed to disclose an accusation of resident abuse within 24 hours and neglected to separate a resident from her accused abuser.
A worker claimed that a colleague had tied down a resident in a wheelchair and parked the chair at the nurses’ station. According to the employee who reported the incident, while her colleague appeared to be in a panic while attempting to prevent the woman from accessing the nurses’ station, she could “clearly see” that a belt had been used to bind the woman to the chair.
Tripoli Nursing and Rehabilitation is a Tripoli skilled nursing facility. Following a fight between two residents, state inspectors claimed the home failed to segregate people and failed to give prompt interventions to ensure residents’ safety.
According to the records, a person said that another resident hit him in the ribs, so he reacted by hitting the other resident “in the butt, under his wheelchair, four times.” The aggrieved tenant told inspectors that he had informed the administrator about the attack, and she had told him that he would have to put up with it or call the state. Both residents said that the confrontation left them in agony.
The administrator told inspectors that the institution did not have a policy on resident-to-resident abuse at the time of the occurrence.
Southern Hills Specialty Care is an Osceola skilled care facility. The institution allegedly neglected to recognize and assess a resident’s injury, which comprised a huge bruise that partially wrapped around the resident’s upper arm, according to inspectors. According to facility records, the bruise was not inspected for around two weeks, by which time it was yellow and in the last stages of healing.