Twelve care facilities fined $500 each for resident abuse, lack of background checks

A dozen Iowa care facilities were recently fined $500 each for violating regulations related to resident abuse and worker-background checks.

The $500 state fines were imposed by the Iowa Department of Inspections Appeals and Licensing, and are tied to allegations of failing to conduct background checks of workers, failing to investigate cases of suspected abuse and failing to inform the state of potential resident abuse.

While many other types of nursing home violations trigger federal fines that can lead to penalties of up to $10,000 or more, resident abuse violations are often subject to a state fine of $500. In some cases, the facilities haven’t appealed the $500 penalties, so they’ve been automatically reduced to $325.

The recent cases include:

Fleur Heights Center for Wellness and Rehabilitation, a skilled nursing facility in Des Moines. State inspectors alleged the facility failed to ensure a staff member completed the two-hour training on dependent-adult abuse within six months of being hired in June 2022, and also failed to complete a background check prior to one individual working in the home.

The worker who had not been trained in dependent-adult abuse during the previous 16 months of employment completed the training during the state’s inspection. Similarly, the worker who had not undergone a complete background check during their six months of employment at the home underwent such a check during the inspection.

In late 2019, the Fleur Heights Care Center was cited for failing to immediately respond to and report the suspected abuse of three dementia patients by one of its long-time caregivers. The worker allegedly twisted and pulled off one resident’s briefs with enough force to tear the garment; told another resident to “shut up;” and placed her hand over a third resident’s mouth to stifle the woman’s screams. Another caregiver told inspectors the worker handled one of the residents “like a piece of meat.”

Prestige Care Center, a skilled nursing facility in Fairfield. Inspectors alleged the home failed to report an allegation of resident-to-resident sexual abuse in a timely manner, and also failed to report facial bruising of an unknown origin. The sexual abuse matter was related to a male resident who was seen with one hand inside the briefs of another resident.

In the case of the resident bruising, the director of nursing had attributed a purple bruise on a resident’s jawbone, under her chin, to coughing, suggesting the resident had coughed and struck her chin on her shoulder – but in discussions with inspectors, she acknowledged having never seen a bruise caused in that manner.

Morning Star at Jordan Creek, an assisted living center in West Des Moines. The state alleged the facility failed to complete a child- and dependent-adult abuse background check prior to employing one of the seven workers whose files were reviewed by the state. The worker in question had been hired in April 2021 with only a criminal background check, and no abuse check, completed before hiring.

Another worker at the home had some unspecified criminal history that should have led to the Iowa Department of Health and Human Services reviewing the history to determine whether the worker was employable in a care setting. Instead, the individual was put to work in the center in October 2022.

Azria Health Park Place, a skilled nursing facility in Des Moines. The state alleged the home failed to implement its own abuse-and-neglect policy by failing to complete background checks prior to staff employment. Inspectors found that a worker at the home had undergone a background check in 2011, but had left the facility and been rehired on three occasions since then, most recently in August 2023, with no additional background checks being completed.

REM Iowa-Terry Avenue in Hiawatha, an intermediate care facility for people with disabilities. State inspectors alleged the facility failed to ensure the staff immediately reported all allegations of abuse, neglect or mistreatment of residents.

According to inspectors, a facility investigation concluded in September 2023 that for “about a month or two,” during the overnight shift, an employee used a stack of chairs to prevent a resident from leaving his bedroom and locked the door to the resident’s bathroom.

Cherokee Specialty Care, a skilled nursing facility in Cherokee. Inspectors alleged the home failed to obtain approval from the Iowa Department of Health and Human Services for the newly hired activities director to work in the facility.

Inspectors alleged that a background check conducted shortly after the director was hired indicated a criminal history that required evaluation by DHHS. The home had no record of DHHS approving the hire. The administrator told inspectors the facility’s corporate office, Care Initiatives, informed her the director had been cleared to work.

Linn Manor Care Center, a skilled nursing facility in Marion. Inspectors alleged that in three cases, the home failed to identify incidents of potential abuse and failed to report them within 24 hours.

In one case, a resident touched and patted another resident on the breast on Jan. 12, 2023 in a common area of the facility. The director of nursing was aware of the incident and concluded there was no intentional inappropriate contact. A worker who witnessed the incident reported the alleged abuser “knew what he was doing when he touched” the other resident and that he had become more aggressive.

In a separate incident, a resident had screamed in distress while the staff cared for her, which led to a nursing assistant grabbing the woman’s hand and telling her to “shut up.” The worker continued to hold the woman’s wrists and then forced the woman’s arms through her clothes to get her ready for bed.

Cedar Ridge Village, a skilled nursing facility in West Des Moines. State inspectors alleged the home failed to complete the required background record check evaluation process for a new employee, prior to the worker’s employment. The home had hired an individual in May 2023 without completing the necessary form requesting a state evaluation of the individual’s background to determine their eligibility to work in a nursing home.

Grandview Health Care Center, a skilled nursing facility in Oelwein. State inspectors alleged the facility failed to make a timely report of an allegation of resident abuse within 24 hours and failed to separate a resident from her alleged abuser.

The incident involved a worker who alleged that a colleague had tied a resident down in a wheelchair and parked the chair at the nurses’ station. The worker who reported the matter said that while her colleague appeared to be in a panic while trying to prevent her from entering the nurses’ station, she could “clearly see” that a belt had been used to tie the woman to the chair.

Tripoli Nursing and Rehabilitation, a skilled nursing facility in Tripoli. State inspectors alleged the home failed to separate residents and failed to provide timely interventions to assure residents’ safety, after an altercation between two residents.

Records indicated a resident reported that a fellow resident had hit him in the ribs, so he retaliated by kicking the other resident “in the butt, under his wheelchair, four times.” The complaining resident told inspectors he had told the administrator of the attack and she told him he had to put up with it, adding that he wanted something done or he would be calling the state. Both residents complained of lingering pain from the altercation.

The facility did not have a policy on resident-to-resident abuse at the time of the incident, the administrator told inspectors.

Southern Hills Specialty Care, a skilled nursing facility in Osceola. Inspectors alleged the facility failed to identify and assess a resident injury that consisted of a large bruise that partially wrapped around the resident’s upper arm. Facility records indicate the bruise wasn’t assessed for roughly two weeks by which time it was yellow and in the final stages of healing.

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