Recent inspection brings local nursing home issues to light

WELLMAN — A damning report from the Iowa Department of Inspections and Appeals in January raised numerous red flags for Parkview Manor in Wellman, drawing statewide attention to the retirement community.

While some Washington County nursing homes have stellar reviews and inspection reports from the Centers for Medicare and Medicaid Services, Parkview is the latest in a string of area retirement facilities accused of resident abuse, medication errors, and other failures to provide adequate care.

Wellman’s Parkview faces numerous citations

Parkview Manor was cited with 24 state and federal infractions after an inspection in January, where officials from the Iowa Department of Inspections and Appeals said the 62-bed facility failed to prevent resident abuse, prevent pressure sores, or assess condition changes for most of the residents reviewed.

One resident at the home died in October from “complications of blunt force trauma injuries” after a fall in September which left her with a “goose egg” bump on the head, according to staff statements. The CMS report alleges the resident received a partial neurological assessment immediately after the fall — which staff described as causing a “loud thunk” — but then went 16 hours without a follow-up, before she was found unconscious by the day shift and sent to an emergency room.

The inspector’s report said the patient’s son was notified of the fall, but that he claimed it was “down played” by the facility, adding that when he met his mother at the hospital, he “could not recognize her.”

For eight out of nine residents reviewed, the state said Parkview failed to prevent abuse, including a handful of cases where one male resident kicked and punched others.

“There were female residents who were afraid of (the man) and male residents who did not know what to do when he approached,” said one nurse note cited in the CMS report.

The report also noted a Certified Medication Aide, identified as “Staff X,” who “was verbally and physically aggressive with a resident.” Another employee said the aide was “hateful,” leaving bruises after grabbing a resident, as well as swearing at them and telling them that they “stunk,” according to the report.

Other citations found that the nursing home failed to treat worsening pressure ulcers for two residents, failed to implement preventive measures for patients at risk of the sores, and sometimes neglected to document treatments for the wounds. At one point during the latest review, an employee told inspectors there was “a big gap in the knowledge of the nurses here.”

Another part of the report said staff failed to adequately respond when a resident aspirated something, leading to their hospitalization with, “a high probability of imminent life deterioration due to acute respiratory failure,” although it didn’t indicate whether the resident survived.

The Iowa Capital Dispatch reported earlier this month that Parkview Manor is owned by MGM Healthcare, a company that also owns Des Moines’ Genesis Senior Living Center, which has been cited over maggot-infested wounds and failures to provide pain medication.

Parkview Manor’s administrator did not reply to repeated voicemails from The Union requesting comments.

UP Home had one rough year, few issues since

In Washington, United Presbyterian Home was hit with 19 citations in 2022, including alleged failures to prevent abuse by a resident who frequently made sexual gestures, intruded on the privacy of others, and was involved in some physical altercations.

One woman living at the facility said she and others were “really scared of him,” with reports that the man put his hands down a female resident’s shirt, and wandered into women’s rooms at night, sometimes naked.

“I’m sick and tired of this,” said one woman at the facility after the resident attempted to enter her room in December of 2021, according to a CMS report. “This has been an ongoing situation, and something needs to be done about it!”

UP Home CEO Erin Drahota said the facility was between a rock and a hard place when it came to providing care for the man, who was discharged from the community in June of 2022 and moved to another home in the area, according to the facilities Plan of Corrections.

The resident in question had advanced dementia, according to Drahota, who said several behavioral interventions failed, but that no beds were available in the state at psychiatric facilities he could otherwise have moved to. Other retirement communities were also unlikely to accept the resident’s transfer, given the reported behaviors.

“Even as we saw that our interventions weren’t working and we couldn’t find ways to redirect and prevent him from wandering into other residents’ rooms, we had a hard time finding somewhere to put him,” she said. “You’re trying to do the right thing according to regulations and by your residents, but a lot of times there’s not really a good solution … I think if you asked the family of this particular resident, they would be grateful that we exhausted all our options to keep him home.”

The 2022 report also highlighted an alleged medication error, a case where a medication cart was left unlocked and unattended by nurses, and staff who did not pass word of a resident’s seizures and falls to the Director of Nursing or resident’s doctor.

Subsequent inspections showed no repeats of those issues, but did make another citation for failing to prevent environmental hazards after a resident wandered onto an elevator, traveled to the building’s basement, and was inadvertently found 15 minutes later. That citation was revealed in a November 2023 report, but a recertification visit in December concluded the home’s correction plan was sufficient.

Despite the relative lack of issues since 2022, UP Home maintains a 1-star rating from Medicare.gov, which flags the facility with an icon to indicate that it was cited for an abuse-related issue in the last three years. That’s a stark contrast from the 5-star rating it had held in several previous years.

Drahota said that was frustrating for the home. While she agreed the extensive regulations on nursing homes were important, the CEO said inspection reports often failed to grasp, or at least convey, all the context surrounding a given incident.

“Doing the plan of corrections doesn’t always necessarily mean that we agree with their findings,” she said. “It’s a snapshot in time … every situation is so nuanced, and there are things surrounding it that surveyors don’t always take into consideration, or don’t know.”

The retirement community remains well-regarded by its residents, according to Drahota, who said the facility continued to operate with the utmost care.

“We’ve asked ourselves this question a lot in this last year or so, because regardless of the weight we put in our rating … how do we measure quality?” she said. “To me, quality isn’t numbers on a page, quality is satisfaction of our residents, satisfaction of our families, satisfaction of our staff members, and those are all things that we have.”

Aspire of Washington shows mixed history

Aspire of Washington has a 1-star rating from the Centers for Medicare and Medicaid Services as well. Although the most recent inspection, a revisit in August of 2023 — issued no citations to the facility — it’s received a total of 65 since the start of 2022.

An inspection last summer said a staff member at the retirement community improperly mixed two different versions of insulin into one syringe. It went on to allege that the home also failed to inform residents’ families of adverse events, including a case of shingles, an incident of physical unresponsiveness, and a medication change; it also said the facility at one time ran out of clean linens, and failed to note some residents’ eligibility for Veterans Affairs services.

Older reports include allegations of failures to assess condition changes, drugs and food items stored in the same fridge, and nine cases where staff failed to treat “residents with respect and dignity,” in October of 2022. Another citation claimed the facility failed to adequately report alleged cases of abuse in January of 2023.

The nursing home has several other years with few incidents, however, including complaint inspections in 2019-2021 that did not end in citations, and consistent jumps from double-digit citation counts to zero by the next revisit from CMS.

Aspire of Washington Nursing Home Administrator Kayleen Martin said she was not authorized by the facility’s corporate office, Beacon Health Management LLC, to comment. A request for comments from The Union was forwarded to a company representative, who did not immediately reply.

It’s not all bad news

Medicare inspections in Washington County aren’t all bleak. Washington’s Halcyon House and Kalona’s Pleasantview Homes are both at 5-star Medicare ratings, with one and two regulatory citations issued, respectively, in the last three years.

At Halcyon, a February 2023 inspection did lead to a citation for insufficient nursing staff, after reports of residents who waited an unusually long time for assistance to use the bathroom, clean up a spilled beverage, and receive food at the dining room.

While a copy of Halcyon’s Plan of Corrections for the citations was not immediately available, CMS found the facility in compliance after a revisit in March of 2023.

Pleasantview, meanwhile was cited in March of 2023, when a nurse failed to monitor a resident as they took medications, who would normally do so only while supervised. In 2021, the facility was cited for an alleged failure to coordinate information in a PASARR form, which nursing homes must complete under federal law. Both infractions were resolved by the next CMS revisit, according to subsequent reports.

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