Residents found dead in care facilities with a backlog of uninvestigated complaints

Last month, when state inspectors visited Promedica Skilled Nursing in West Des Moines, they had a backlog of 23 complaints to investigate at the facility – the oldest of which had been filed in September of last year.

Nineteen of those complaints were substantiated and the Iowa Department of Inspections and Appeals cited the home, which has since changed its name to Harmony West Des Moines, for the death of a female resident who was left “screaming in pan” after contracting gangrene of the genitals and going into septic shock.

The woman died March 6 – more than five months after the state fielded the first of the uninvestigated complaints against the home.

Since last June, when the Iowa Department of Inspections and Appeals reported that two dozen nursing home complaints had languished for a year or more without being investigated, the agency has made dramatic improvements in the timeliness of its investigations.

DIA attributes the previous backlog of complaints to restrictions on inspections during the COVID-19 pandemic.

But as the Promedica case shows, there still are instances where it may take several months for a nursing home complaint to be fully investigated, by which time many other complaints against the same facility may have accumulated.

In some instances, including Promedica, residents have died or been sexually abused in care facilities while complaints against the home await investigation by the state.

In February, DIA investigated the death of a U.S. Army veteran, Marvin “Pete” Jacobs, who suffocated while waiting to have his airway suctioned by the nursing staff at the Fonda Specialty Care facility in Pocahontas County,

By the time DIA inspectors visited the home to look into Jacobs’ death, there was a backlog of 10 uninvestigated complaints against the facility. Only one of the complaints was deemed substantiated, but DIA fined the home $10,000 for Jacobs’ death. That penalty was reduced to $6,500 when the home agreed not to appeal the case.

Last November, inspectors visited Lyon County’s Rock Rapids Care Centre after the home accumulated 10 separate complaints. All of the complaints were substantiated by DIA, but the agency issued no citations or financial penalties. A few months later, the home shut down due to a lack of staffing and relocated all of its residents without giving families or regulators the 60-day notice outlined in state law.

A few weeks earlier, inspectors visited the Aspire of Gowrie nursing home in central Iowa. At the time, there was a backlog of 10 complaints against the home, all of which were substantiated. The home was ultimately cited for 30 regulatory violations, including a failure to protect “multiple female residents” from sexual abuse, and federal officials fined the home $196,247.

At various times over the past several months, DIA has compiled a backlog of complaints against several other care facilities, including:

— Centerville Specialty Care: In February, when inspectors visited this southern Iowa nursing home, DIA had accumulated seven complaints against the care facility, four of which were substantiated.

— Windmill Manor: In February, when inspectors visited this eastern Iowa nursing home in Coralville, there was a backlog of 12 complaints at the home, none of which were substantiated.  The home was, however, cited for seven regulatory violations and fined $3,412.

— Aspire of Washington: Last fall, inspectors visited this eastern Iowa nursing home in response to 11 separate complaints, all of which were substantiated.

— Oakwood Specialty Care: Last October, inspectors visited this southern Iowa nursing home in Albia. At that time, there was backlog of 12 uninvestigated complaints against the home. Ten of the complaints were substantiated.

— Ravenwood Specialty Care: Last October, inspectors visited this Waterloo care facility in response to a backlog of 19 complaints, 18 of which were substantiated.

— Westwood Specialty Care: Last August, inspectors visited this Sioux City home to investigate 15 separate complaints, 11 of which were substantiated.

The latest data from DIA indicates there are now 59 uninvestigated complaints against nursing homes that are 30 to 90 days old. An additional 48 complaints are 91 days old or older. These 107 complaints represent a sharp reduction of 74% from June 2022, when there were 410 pending complaints that were at least 30 days old.

DIA spokeswoman Stefanie Bond has said the number of uninvestigated complaints last year was high due to the COVID-19 pandemic that struck in March 2020. She said after the federal Centers for Medicare and Medicaid Services, or CMS, suspended inspections at nursing homes, it developed a COVID-19 “focused infection control” process that directed state agencies like DIA to focus their inspections strictly on infection prevention.

As a result, Bond said, complaint investigations were temporarily limited to those involving infection issues and those involving allegations of immediate jeopardy to residents’ health and safety. That, in turn, led to a growing nationwide backlog of uninvestigated complaints and the inspections that are needed to recertify care facilities, she said.

“Although CMS suspended or reprioritized most complaint survey activity during the pandemic, which caused a backlog of complaints, DIA surveyors continue to work diligently to address Iowans’ concerns at health care facilities in a timely manner,” Bond said.

She added that with regard to complaints alleging residents have been placed in immediate jeopardy due to violations likely to cause serious injury, impairment, or death, DIA has investigated 100% of those complaints within the timeframe specified by CMS.