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Two Iowa care facilities cited for resident deaths [1]

['Clark Kauffman', 'More From Author', '- February']

Date: 2024-02-26

Two Iowa nursing homes have been cited by the state for contributing to the deaths of residents injured in falls at the facilities.

The Iowa Department of Inspections, Appeals and Licensing says that Perry Lutheran Home in Dallas County failed to provide adequate nursing supervision to prevent injuries sustained by two residents late last year, one of whom later died.

Separately, DIAL inspectors allege that Stacyville Community Nursing Home in Mitchell County failed to provide a safe environment for its residents. On Oct. 12, 2023, a female resident of the home was found on the floor near her bathroom, bleeding from the head. She was taken to a hospital, lapsed into a coma, and died two days after the fall. A physician reportedly told state inspectors the woman suffered a brain bleed that was either caused by her fall or was the reason for her fall. A state fine of $5,000 was imposed.

The Stacyville home has a three-star overall rating from the federal Centers for Medicare and Medicaid Services, but a one-star rating — CMS’ lowest possible score — for staffing levels. Since January 2022, the non-profit home has been fined nine times by CMS, according to the agency.

In the Perry Lutheran Home case, DIAL inspectors allege that a female resident of the home, known to be at a high risk for falling, fell nine times at the facility over an eight-week period in late 2023. After the ninth fall, the home allegedly failed to provide consistent neurological checks to rule out a brain injury. Eventually, the woman was taken to a hospital and diagnosed with brain damage that led to her death days later. According to the state inspectors, the official cause of death was a subdural hematoma related to a fall at the nursing home.

Around the same time, another resident of Perry Lutheran Home sustained her fourth fall, which resulted in a broken leg and hospitalization. In that case, state inspectors allege the home failed to complete a thorough and in-depth analysis of the cause the fall and failed to implement effective interventions to prevent additional incidents.

A proposed state fine of $9,250 for failing to provide residents with a safe environment was tripled to $27,750, but was then suspended pending a determination of whether a federal fine would be imposed.

In addition, proposed state fines of $500 for failing to inform the state of a major injury sustained by a resident was held in suspension, as was a $9,750 proposed state fine for failing to provide residents with the required level of nursing services.

In November 2023, the state proposed and then held in suspension a fine of $17,050 for resident abuse and failure to provide residents with a safe environment.

Inspectors alleged that the staff at Perry Lutheran Home had failed to notify the home’s administration of incidents of a sexual nature between a male resident who was seen attempting to kiss, hug and grope a female resident’s breast. The female resident was deemed incapable of consenting to sexual contact. “Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need to be reported,” inspectors alleged.

Inspectors noted that months before that incident, the same male resident was found in the bed of a different female resident. When the woman began yelling for the man to get out of her bed, he allegedly became angry and grabbed the woman by her neck before the two were separated by a worker.

Currently, Perry Lutheran Home has an overall rating of one star from CMS. The most recent federal fine that was imposed against the facility was a $994 penalty imposed in 2022, according to CMS records.

The facility, located at 2323 E. Willis Ave., is operated by the non-profit Lutheran Home for the Aged Association. It is a physically separate facility from the Perry Lutheran Home Eden Acres campus, formerly known as Rowley Memorial Masonic Home.

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