Care facility cited a third time for failure to protect residents from harm

A western Iowa nursing home with a history of regulatory violations could be fined more than $30,000 after being cited three times for failure to protect residents from harm.

The most recent incident at Correctionville Specialty Care involves a male resident of the home who was found in his wheelchair, at night, near a busy state highway, with the staff unaware of his absence.

According to the Iowa Department of Inspections, Appeals and Licensing, the home failed to maintain a working door-alarm system, allowing three of the home’s 38 residents, as well as various visitors, to enter and exit the home unnoticed by the staff.

In mid-August, one resident of the home was found in his wheelchair, in the driveway of the facility, at about 8:15 p.m. and was wheeled backed inside. An hour later, the staff found the man outside again, this time by the parking lot entrance, just 20 feet from U.S. 20.

According to state inspectors, the man had “left the facility in his wheelchair, at night, unattended, and was found by an off-duty staff member near a busy highway.”

The inspectors’ report indicates the home’s administrator later felt the man was capable of making his own decisions as to when he could safely leave the building, adding that she didn’t believe the man was ever in any danger. She reportedly told inspectors the man couldn’t have reached the highway due to his wheelchair being unable to navigate the many potholes in the facility’s driveway.

While inspectors were at the home investigating that incident, they watched as a female resident with Alzheimer’s disease passed through an exit door without an alarm sounding. An inspector also observed a male resident of the home as he passed through an exit door, resulting in a door alarm that stopped after just five beeps. “No staff came out to the area to investigate,” the inspector reported.

Later, visitors entered and exited the building and the door-alarm sounded but “no one came out to investigate,” the inspector added.

The state proposed a $10,000 fine for failure to provide adequate supervision to protect residents, and tripled the potential penalty to $30,000 due to it being the third high-level, Class 1 violation of that type during the past 13 months. An additional $500 penalty was proposed for failing to report the incident involving the man found near the highway.

Both state fines have been held in suspension while federal regulators determine what action, if any, they will take in the matter.

Home cited for failure to adequately care for incontinent residents 

Separately, the home was also cited for failing to provide adequate care for incontinent residents, with one employee telling inspectors that on several occasions she had arrived for work in the morning and found residents who “were soaked with urine.”

According to inspectors, one worker reported finding a male resident with “a very red and sore groin.” The man appeared to be “very wet with dried feces all over his groin,” according to the inspectors’ report.

Another worker reportedly told state officials that a few weeks before the inspectors’ on-site visit, “almost all the residents” in the hallways where she worked “were completely soaked to the bed.”  The worker allegedly told inspectors she reported the situation to the director of nursing, who dismissed her concerns.

A third employee reportedly told inspectors that she came into work one morning the previous week and found six residents’ beds were “completely soaked through to the mattress.” On a previous occasion, the employee said, there were eight beds that had to be stripped and two aides ended up quitting that same day.

Another employee of the home told inspectors the condition of the residents had been “very bad” earlier in the morning on the day of the state inspection, with only two aides working the floor and the director of nursing not reporting for work. Some of the residents’ beds, the worker alleged, “were soaked through” the morning of the inspection, and one resident had feces all over her floor, her bed, and her hands.

No fine was proposed for the cited violation of failing to provide adequate incontinence care.

Home has history of fines

Some of the home’s problems date back to July 2022, when the state proposed, and collected, an $8,500 fine for failure to provide adequate supervision to protect residents. At that time, the facility was cited for 15 federal regulatory violations – an unusually high number – and three state violations.

In March of this year, the state proposed, and suspended, a $9,250 fine for failure to provide adequate supervision to protect residents. The suspended fine was tripled to $27,750 due to the July 2022 citation for the same violation. At the time, inspectors were investigating five complaints against the facility, three of which were substantiated.

In May, the state proposed, and suspended, an $8,250 fine for failing to prevent the abuse of a resident by state-certified nurse aide.

The federal Centers for Medicare and Medicaid Services says Correctionville Specialty Care has a one-star rating for overall quality and for its state-inspection results. According to CMS’ Care Compare website, the federal agency has fined the facility three times in the past three years – most recently in November 2022 for $9,750.

Correctionville Specialty Care is owned and operated by Care Initiatives, a nonprofit corporation based in West Des Moines. According to tax records, Care Initiatives ended the 2020 fiscal year with $5.8 million in net income after payment of $207 million in expenses. Former president and CEO Miles King collected $605,487 in compensation that year from Care Initiatives, the tax records show.

Correctionville Specialty Care’s administrator, Amanda Nobles, could not be reached Wednesday, and Care Initiatives did not respond to a request for comment.

The family of Elizabeth Eickholt sued Correctionville Specialty Care in April 2020. In 2018, Eickholt was living at the facility when she was admitted to the hospital with a number of medical conditions, then released back to the home with orders the home allegedly failed to follow, leading to her death. In October, a judge agreed to the company’s request that the matter be settled largely through arbitration.