Opportunity Living No. 2 in Lake City, Iowa. (Photo via Google Earth)
A Lake City care facility where a resident died after choking on food one day after his admission has been fined $10,000 by the state.
State records indicate the 45-year-old resident of Lake City’s Opportunity Living No. 2, a 16-bed care facility for people with intellectual disabilities, died of cardiac arrest last month after inhaling food into his airway.
According to state inspectors, the man moved to Opportunity Living No. 2 on Nov. 26, 2024, after living the previous six months at another facility. The man, who had a severe intellectual disability, was riding in a van on Nov. 27, 2024, one day after his admission to the Lake City home, when a staffer allegedly fed him pieces of a McDonald’s cheeseburger while the van was in motion.
The resident apparently choked, which led to a trip to a hospital emergency room where, according to inspectors, the staff listed their clinical impressions as “cardiac arrest, aspiration into the airway.” The man died five days later on Dec. 2.
Inspectors spoke to the staff at the facility where the man had previously been living and learned that he had been on a restricted diet that required his food to be cut into tiny, soft pieces. Workers at that facility had allegedly conducted outreach training for the Opportunity Living No. 2 staff, instructing them on the man’s diet and mealtime procedures.
According to inspectors, the director of community living at Opportunity Living No. 2 confirmed for them that she had failed to obtain from the other facility the man’s assessments and individual program plan.
During their investigation of the death, state inspectors concluded on Dec. 12 that residents of Opportunity Living No. 2 were in immediate jeopardy. Within two and a half hours, that designation was removed after the facility revised its admission process to include meetings with staff at facilities from which new residents were transferred.
In addition, Opportunity Living No. 2 outlined plans to require two workers inside vehicles when traveling outside the city, and to avoid serving meals in moving vehicles. The home also indicated it would retrain the staff on the use of first aid kits in company vehicles.
Previous violations
The facility was fined twice in 2023 in separate cases.
In October 2023, Opportunity Living No. 2 was fined $3,250 for failing to ensure its staff followed established policies and procedures for transporting residents.
In July 2023, the home was cited for failing to report a suspected case of abuse involving a resident who sustained a fractured clavicle. A nurse in the home reportedly told inspectors that while she had asked a colleague to provide a written statement surrounding the incident, she couldn’t recall what the statement said, what she did with it or whether she ever shared it with the director of nursing.
The director of nursing allegedly told inspectors that when a worker relayed her suspicions that the resident’s injuries were the result of abuse, she quickly told the worker to “stop spreading rumors” since she didn’t actually see any abuse.