Nursing home cited for COVID-19 death, abuse, staffing levels and ‘disgusting’ food

By: - July 29, 2022 1:58 pm

An Iowa nursing home where a resident died after being denied COVID-19 treatment has been fined $19,250. (Photo courtesy of the Iowa Department of Inspections and Appeals)

An Iowa nursing home resident died of COVID-19 in March after the facility failed to provide any of the doctor-prescribed treatments for the virus.

State records indicate that a resident of Centerville Specialty Care in Appanoose County was admitted to the home in late January with a goal of being able to transition back into the community. According to state inspectors, the resident tested positive for COVID-19 four weeks later, on the evening of Feb. 26, but the resident’s physician was not notified.

Three days later, on March 1, after the resident’s oxygen saturation levels had dipped to 86%, the resident’s doctor became aware of the COVID-19 test and ordered an antibiotic, a steroid medication and other drugs for the resident. The doctor also ordered that the resident be given oxygen, a chest x-ray, a laboratory test to detect anemia or infection, and a blood test and a test to check for blood clots, all to be completed that same day.

Nineteen hours later, with none of the treatments provided or tests conducted, the resident died due to COVID-related pneumonia, according to the state.

Inspectors found that the physician’s orders were only entered into the facility’s computer after the resident had died. They reported their review of medical records “revealed no documentation of the circumstances surrounding the death.”


Inspectors tried to speak to the staff nurse who was caring for the resident when the physician orders were written, but the worker didn’t answer the phone or return messages. The inspectors also called the staff nurse who inputted the physician orders after the resident’s death, but she, too, did not answer the phone or return messages.

The home’s director of nursing told inspectors she did not recall any details of the resident’s death, and the administrator was unable to explain the home’s failure to notify the physician or implement the physician’s orders.

Administrator: Job is ‘overwhelming’

A sample review of the home’s COVID-19 testing logs indicated that some workers in the home were not being tested weekly as required, inspectors reported. One worker who wasn’t tested had been granted an exemption from the COVID-19 vaccine.

The administrator of the home told inspectors she was responsible for monitoring the COVID-19 tests but was taking the staff’s word that they were being tested as needed, adding that she did not follow up to verify the claims. The administrator acknowledged she needed to establish a new process “because she was doing everything herself and it was too overwhelming,” the inspectors reported.

In reviewing the medical records of the resident who died, inspectors found that the resident was diabetic, and the home had failed to comply with physician orders regarding blood-sugar levels on 53 occasions in March.

In addition, the resident did not receive various physician-ordered medications on 24 occasions in February, due to the drugs not being available from the pharmacy. The resident’s physician was not notified of any of those failures, inspectors alleged.

Abuse, flies and ‘disgusting’ food

The inspectors reported similar issues with another resident’s care. On 20 separate occasions in May and June, the staff at the home had failed to notify doctors of that resident’s low blood-sugar levels, despite orders that they do so. The home also failed to administer glucagon to correct the levels and failed to do “any follow-up assessments or checks of the resident’s blood sugar.”

During their recent visit, state inspectors reviewed records indicating two nurse aides had complained to the administration that one or two of their colleagues had placed a resident in bed and then “folded her up like a pretzel” in the bed, with both the foot and the head of the bed elevated. The complaining workers felt their colleagues were “were being mean” and were intentionally hurting the resident. The resident complained of being “roughed up” by the accused workers. The home’s administrator told inspectors one of the accused workers was fired, and the other was allowed to remain employed after being cleared of wrongdoing.

Inspectors also cited the home for repeatedly failing to respond to the Resident Council’s formal grievances about the staff’s response to call lights. On some occasions, residents said, they had to wait 40 minutes to an hour for someone to respond to their call light.

A registered nurse at the home told inspectors that recently the facility had only two workers — herself and one nurse aide — on duty to care for 43 residents during an overnight shift. The nurse said she complained to the director of nursing who “just shrugged her shoulders.” The administrator reportedly told inspectors that the home “recently had a COVID-19 outbreak and a bunch of staff quit on the same day.”

During their July 7 visit, inspectors fielded complaints from several residents about flies in their rooms, in the hallways and in the dining area, which the inspectors themselves had observed. Some the residents had taken to carrying fly swatters with them.

The home was also cited for failing to serve palatable food to residents. Inspectors watched as a worker served microwaved pork – the meat was supposed to have been grilled or deep fried — while acknowledging that the pork looked “’nasty” and “not cooked.” Two residents refused the meal, with one saying, “I’m not going to eat this.” Speaking to inspectors, the director of nursing acknowledged that “if two staff members said the pork looked disgusting, it should not be served to the residents.”

In all, the home was cited for violating 21 federal standards of care and two state standards of care, with the issues including medication and treatment, quality of care, staffing levels, dietary needs, COVID-19 testing and pest control.

The home’s current administrator, Natasha Blackburn, could not be reached for comment Friday.

The state has fined the home $19,250. That fine will be reduced by 35% if the owner, Care Initiatives of West Des Moines, chooses not to appeal the penalty.


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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.