Resident deaths, gangrene and amputations tied to poor quality care
Four Iowa nursing homes have been added to the federal list of the nation’s worst care facilities.
Over the past four months, the homes have all been deemed eligible for inclusion on the Centers for Medicare and Medicaid Services’ national list of Special-Focus Facilities. They join six other Iowa care facilities already deemed eligible for inclusion on the periodic list of nursing homes that have recurring quality-of-care problems.
The four Iowa homes added to the list since July are: Embassy Rehab and Care Center in Sergeant Bluff; Harmony West Des Moines; the Ivy at Davenport; and Westwood Specialty Care in Sioux City.
The four join six other Iowa facilities long considered eligible for special-focus status and increased oversight by regulators: Aspire of Gowrie, which has been eligible for seven months; Dunlap Specialty Care, which has been eligible for six months; Genesis Senior Living in Des Moines, which has been eligible for 17 months; Griswold Rehabilitation & Health Care Center, which has been eligible for 13 months; Iowa City Rehabilitation and Health Care Center, which has been eligible for seven months; and New London Specialty Care, which has been eligible for 10 months.
Iowa has two care facilities that are officially designated as special-focus facilities and, as a result, are operating under additional scrutiny and oversight by the government: Aspire of Gowrie and Arbor Court of Mount Pleasant. It’s not clear why CMS has designated Aspire of Gowrie as both a special-focus facility and a candidate for designation as a special-focus facility. CMS officials were unable to address that question Wednesday.
The four Iowa homes recently deemed eligible for inclusion on the federal list have a history of regulatory issues:
— Westwood Specialty Care in Sioux City: This 85-bed facility has a one-star rating from CMS for both overall quality and its inspection results. So far this year, it has been cited for 48 regulatory violations.
Among the issues: In May, state inspectors alleged the home failed to complete a timely assessment and interventions for five of 18 residents whose care was reviewed. That failure, the inspectors said, “resulted in a death and several hospitalizations and visits to an emergency room for treatment.” The home was also cited for failing to adequately respond to a resident’s worsening foot injury that stemmed from an ingrown toenail. The lack of care allegedly led to an infection and the amputation of the resident’s toes.
Westwood Specialty Care is owned and managed by Iowa’s largest nursing home chain, the tax-exempt nonprofit Care Initiatives, based in West Des Moines. According to tax records, CEO Michael Beal collected a total of $608,638 in compensation from Care Initiatives and its affiliates in 2021. Board members of the nonprofit were paid $134 an hour for their services.
She was screaming, and you could hear her down the hall. She was saying her butt is on fire.
– Nurse at Harmony West Des Moines, as quoted by state officials investigating a woman’s death
— Harmony West Des Moines: This 120-bed facility has a one-star rating from CMS for overall quality, and has been cited for 53 violations over the course of five inspections this year.
Among the issues: The home was alleged to have neglected, over a period of several days, a resident’s complaints related to an apparent bowel obstruction that eventually led to fissures and to feces being discharged through her vagina.
A nurse told inspectors the woman had complained of extreme pain. “She was screaming, and you could hear her down the hall,” the nurse told inspectors. “She was saying her butt is on fire … It took an hour and a half before I got the order to send her to the ER.”
At the hospital, the woman was diagnosed with septic shock, a life-threatening infection, and gangrene in the area surrounding her genitals. After two surgeries, the resident died.
CMS reports that it has no ownership information available on Harmony West. Real estate records indicate the property is currently owned by Manor Care Health Services.
— The Ivy at Davenport: This 75-bed facility has a one-star rating from CMS for both overall quality and its inspection results. So far this year, it has been cited for 38 regulatory violations.
Among the issues: Earlier this year, state inspectors published a 220-page report documenting 35 state and federal violations, including rodents, medication errors, illicit drug use and other problems. A nurse who was on the home’s payroll told inspectors staffing levels were “absolutely horrible” and that she could not express how bad it was.
The home had “failed to maintain clean floors, empty trash (and) clean resident equipment,” inspectors said, leaving some areas of the facility “with strong odors smelling of urine, body odor and garbage.”
The home also failed to provide bed sheets or pillowcases to some of the residents, leaving them in beds that had no sheets. One resident had no nightstand, so their food was being placed directly on the floor. A nurse told inspectors rodents were seen recently “throughout the hallways and in resident rooms.”
The Ivy at Davenport is managed by Ivy Healthcare of Surfside, Florida. The company’s president and CEO, Ryan Coane, is part owner of the facility and told the Iowa Capital Dispatch last year that his “top priority is our resident’s health and well-being.” He said the Davenport facility’s workers, “and the love they have for every resident at the center, is unsurpassable.”
— Embassy Rehab and Care Center: This 60-bed facility has a one-star rating from CMS for both inspection results and for quality measures. In May, state inspectors visited the facility in response to four complaints, all of which were substantiated, and cited the facility for 40 state and federal violations, an unusually high number.
Among the violations: A resident complained that when he told a male aide the water in the shower was too hot, the aide turned the water to ice cold. The resident responded by telling the Filipino aide to “go back to the jungle,” at which point the aide allegedly placed his hand over the resident’s mouth and nose while pressing the resident’s neck down until the water from the shower went up the resident’s nose. The resident said he tried to yell for help but could not.
The business is owned by a for-profit entity called Kismet Sux LLC, and an affiliate, Lantis Enterprises. The individuals who have a significant ownership stake in the business include Cammy, Mary and Travis Lantis.
Homes ‘eligible’ for added oversight don’t receive it
The federal Special-Focus Facilities list is updated monthly by CMS and includes homes deemed by the agency to have “a history of serious quality issues.”
Nationally, there are 88 nursing facilities on the list, with one or two slots filled by each state. Those homes are enrolled in a special program intended to stimulate improvements in their quality of care through increased regulatory oversight.
Because the number of Special-Focus Facilities is capped, new facilities – even those that have earned CMS’ lowest ratings for quality — can’t be named a special-focus facility until other homes in that same state shut down or improve and “graduate” from the program.
That’s a process that can take four years or more. As a result, there are several homes in each state that are designated as eligible for special-focus status due to their ongoing quality-of-care issues, but they are unable to benefit from actual enrollment in the program. Iowa generally has 10 nursing homes on the list of eligible facilities.
Currently, the only Iowa home listed as having graduated from the program after a sustained period of improving care is Touchstone Healthcare Community in Sioux City. However, Touchstone’s graduation appears to coincide with the home’s closing in July 2022 amid ongoing quality-of-care issues.
In fact, Touchstone was only added to CMS’ special-focus list six days after it closed and the last of its residents was moved out. Prior to that, Touchstone has been on the list for almost four years before graduating.
Typically, all of the homes that are deemed eligible for special-focus designation have about twice the average number of violations cited by state inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents, and they have established a pattern of serious problems that has persisted over a long period of time.
Source : Lowa Capital Dispatch
