State inspectors find no violations in Iowa nursing homes with major outbreaks

By: - December 9, 2020 4:00 pm

Drawing of coronavirus cells. (Image via National Foundation for Infectious Diseases)

With COVID-19 outbreaks growing in Iowa’s nursing homes, state inspectors report finding no infection-control violations in many of the facilities with the biggest current, active outbreaks.

As of Wednesday afternoon, there were 141 current, active outbreaks in Iowa nursing homes, according to the Iowa Department of Public Health. There are 5,725 infections associated with those outbreaks. That’s an increase of 236 from the 5,489 nursing home infections reported just 24 hours earlier.

The current number of nursing home outbreaks is also more than five times the number of infections reported in late September when there were 1,030 infections tied to 50 active outbreaks in Iowa nursing homes.

The Iowa Department of Inspections and Appeals, which is the state agency that inspects nursing homes for compliance with the federal regulations on infection control, continues to find very few homes out of compliance with those regulations. And when violations are found, even at homes with major outbreaks, fines and penalties are rarely imposed.

In the past, the department has pointed out that inspections are only “a snapshot” and represent the violations that inspectors observe, or can document, at that point in time. Workers are likely to be more diligent in observing infection-control protocols with state inspectors on site, and inspectors are unlikely to visit nursing homes in the midst of a major outbreak.

For example, one of the worst current, active outbreaks is at the Ravenwood Specialty Care Center in Waterloo. Although the facility houses about 125 residents, 140 staffers and residents have been infected as part of this particular outbreak, according to state public health officials.

The state inspectors’ last published report of a visit to Ravenwood dates back to August, which was shortly after a highly publicized search for a resident who had wandered away. According to DIA records, the resident, later identified as Mike Jensen, left Ravenwood and was found four days later in a ditch, submerged in water up to his chest. The former Wartburg College music instructor was admitted to a local hospital for treatment of sepsis, hypothermia and potential heart damage, and Ravenwood was fined $8,750. The inspectors found no violations of infection-control regulations during their August visit.

Inspectors have visited the Good Shepherd Health Center in Mason City three times since the COVID-19 pandemic began, most recently four weeks ago. Good Shepheard is home to 160 residents but is now the site of a major outbreak involving 215 residents and workers. State inspectors, however,  report finding no infection-control violations at Good Shepherd during visits there in June, July and November.

At the Risen Son Christian Village in Council Bluffs, there is an active outbreak involving 142 residents and workers — more than double the home’s current census estimate of 68 residents. In June, the home was cited for numerous infection-control issues but no fines or penalties were imposed by the state. Since then, infection-control inspections have taken place in July, August, September and November. Each time, state inspectors reported no infection-control violations.

Here’s a look at the Iowa nursing homes with active outbreaks involving more than 50 infections. This list notes the number of COVID-19 cases associated with these outbreaks, and each home’s history of inspections for infection-control issues. The information is from the Iowa Department of Public Health and the Iowa Department of Inspections and Appeals:

Appanoose County

Centerville Specialty Care, 64 cases: Cited for one violation on June 17, with no penalty imposed. No violations found during July and September inspections.

Black Hawk County

Ravenwood Specialty Care, 140 cases: No violations found during a June inspection. In mid-August, the home was cited for resident-safety violations and fined $8,750 after a resident wandered away and was found days later outdoors, in about 2 feet of water, submerged up to his chest. The resident was admitted to the ICU of a local hospital for treatment of sepsis, hypothermia, potential skeletal or heart-muscle damage, and an altered mental status. No violations were found during subsequent inspection a week later.

Cedar Falls Health Care Center, 55 cases: No violations found during infection-control inspections in June and November.

Pillar of Cedar Valley, 89 cases: No violations found during infection-control inspections in July and November. In June, the home was cited for failing to use personal protective equipment in caring for residents. No fines or penalties were imposed.

Bremer County

Bartel’s Lutheran Retirement Home (aka Bartel’s Skilled Nursing & Rehabilitation Center), 85 cases: No state inspection data available.

Cass County

Heritage House, 83 cases: No violations found during infection-control inspections in June, September and November.

Atlantic Specialty Care, 81 cases: No violations found during the home’s one infection-control inspection in June.

Cerro Gordo County

Good Shepherd Health Center, 215 cases: No violations found during infection-control inspections in June, July and November.

Crawford County

Eventide Lutheran Home, 52 cases: No violations found during infection-control inspections in June, October and November.

Delaware County

Good Neighbor Home, 85 cases: No violations found during infection-control inspections in June and October.

Dubuque County

Dubuque Specialty Care, 73 cases: No violations found during infection-control inspections in July and November. In June, the home was cited by the state for  allowing three staff members to work with symptoms of COVID-19, and for the failure of the staff to wear personal protective equipment during two days of the four-day inspection. A $10,000 fine was proposed by the state, but suspended.

Hamilton County

Crestview Nursing & Rehab, 68 cases: Since June, the home has undergone five separate inspections for infection control issues. No violations found during infection-control inspections in October and July. In June, the home was cited for failing to use proper infection-control techniques, but no fine or penalty was imposed. In November, the home was again cited for failing to use proper infection-control techniques, but no fine or penalty was imposed. (In September, the home was fined $9,000 for a resident’s death resulting from a fall, but no infection-control issues were cited.)

Southfield Wellness Community, 67 cases: Since June, the home has undergone five separate inspections for infection control issues. No violations found during infection-control inspections in July, October and November. In June, the home was cited for failing to use proper infection-control techniques. (At the time, the home was also cited for unrelated resident-safety issues.) In September, no infection-control issues were found but the home was cited for an incident involving a registered nurse who was reportedly seen holding a pair of scissors and telling a resident she intended to cut off his penis.

Hancock County

Westview Care Center, 74 cases: No violations found during infection-control inspections in June, October and November.

Humboldt County

Good Samaritan Home-Holstein, 54 cases: No violations found during infection-control inspections in June and November.

Willow Dale Wellness Village, 64 cases: No infection-control violations were found during inspections in June, August and September.

Jones County

Monticello Nursing & Rehab, 72 cases: No violations found during infection-control inspections in June, July, October and November.

Anamosa Care Center, 75 cases: No violations found during infection-control inspections in June, September and November.

Keokuk County

Manor House Care Center, 52 cases: No violations found during infection-control inspections in June and November.

Kossuth County

Good Samaritan Home-Algona, 73 cases: No violations found during infection-control inspections in June and October.

Linn County

Willow Gardens Care Center, 72 cases: No violations found during infection-control inspections in June, July, October and November.

Louisa County

Wapello Specialty Care, 61 cases: No violations found during an infection-control inspection in June.

Marshall County

Iowa Veterans’ Home, 136 cases: No violations found during infection-control inspections in June, July and August.

Pottawattamie County

Risen Son Christian Village, 142 cases: In June, the home was cited for numerous infection-control issues but no fines or penalties were imposed. No infection-control violations were found during inspections in July, August, September and November.

Ringgold County

Clearview Home-Mt. Ayr, 58 cases: In June, the home was cited for infection-control issues but no fines or penalties were imposed. No infection-control violations were found during a subsequent inspection in July.

Scott County

Ivy at Davenport, 54 cases: No infection-control violations were found during two inspections in June. In September, inspectors saw staffers working with face masks pulled down around their chin, were not wearing protective gloves or gowns when necessary and were not washing their hands. No fines or penalties were imposed as a result of those violations.

Good Samaritan Home-Davenport, 82 cases: No infection-control violations were found during inspections in June and December.

Davenport Lutheran Home, 67 cases: No infection-control violations were found during inspections in June, November and December.

Shelby County

Elm Crest Retirement Community, 83 cases: No infection-control violations were found during inspections in June, October and November.

Story County

Rolling Green Village, 59 cases: No infection-control violations were found during inspections in June, September and December.

Tama County

Premier Estates of Toledo, 53 cases: In August, the home was cited for failing to have a written, implemented infection-control program with policies and procedures based on the guidelines issued by the Center for Disease Control and Prevention. A $4,000 state fine was proposed but held in suspension. During a September inspection, no infection-control violations were found.

Union County

Creston Specialty Care, 55 cases: No infection-control violations were found during inspections in June and November.

Wapello County

Ridgewood Specialty Care, 53 cases: No infection-control violations were found during inspections in June and November.

Warren County

Carlisle Center for Wellness, 57 cases: No infection-control violations were found during an inspection in June.

Webster County

Marian Home, 73 cases: No infection-control violations were found during inspections in June, September, October and November. In August, the home was cited for failing to implement adequate infection-control interventions during a COVID outbreak in the facility. Workers were observed wearing goggles on top of their heads while talking to residents who were not properly masked. No fines or penalties were imposed.

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Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.

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