The Aase Haugen Home in Decorah. (Photo via Google Earth)
Several state-licensed care facilities have been cited recently for resident abuse, injuries or neglect, with one home cited for a resident’s death due to dehydration.
In the case involving a death, the Iowa Department of Inspections, Appeals and Licensing cited the Aase Haugen Home in Decorah for failing to provide residents with the required nursing services.
According to state inspectors, the home failed to promptly identify an acute change in a male resident’s condition and then failed to intervene and provide the necessary care.
The inspectors allege that in mid-October 2024, the man showed signs of increased blood pressure, an elevated pulse and a fever, and then become largely unresponsive without the staff completing an assessment of his condition.
On Oct. 22, the man was seen by a psychiatric provider via video conferencing. The provider noticed the man was “was slumped over and not responding to her questions,” inspectors later reported, and so she immediately halted the consultation and told the nurse at the Aase Haugen Home the man appeared to be in urgent need of a medical evaluation.
The resident was rushed to a hospital emergency room where the emergency room staff allegedly wrote in their reports the man appeared to be suffering from sepsis, which can be a life-threatening infection, and that the man was “profoundly dehydrated” and verbally nonresponsive. The man was admitted to the hospital with what the staff described as “a seven-liter water deficit.”
He died on Nov. 7, 2024, with the immediate cause of death listed as dehydration due to, or as a consequence of, sepsis.
DIAL proposed a state fine of $9,750 but held that fine in suspension so that federal regulators could determine whether a federal penalty is warranted.
In February 2024, the Aase Haugen Home was fined $7,000 by the state after a resident fell to the floor, striking her head and breaking her hip, while being helped to the bathroom by a worker. The resident was taken to a hospital and died four weeks later.
Five months later, in July 2024, the home was cited again for safety violations after a resident fell from a mechanical lift at the home, resulting in physical injuries, “intense pain” and a gradual loss of consciousness. The state proposed a fine of $4,500, which was tripled to $13,500 due to the repeat nature of the safety violation, and then held in suspension.
Federal records indicate the last time the federal government fined Aase Haugen home was in July 2023 when a civil penalty of $59,839 was imposed. That fine was tied to a citation for failure to intervene when a resident showed signs of high blood sugar and then died en route to a hospital.
Some of the other Iowa care facilities recently cited include:
Aspire, Perry – This nursing home was fined $500 for failing to ensure that background checks were completed on workers before they had contact with residents. According to inspectors, a nurse aide whose state certification was suspended due to findings of abuse was allowed to work three shifts in the home as a CNA. In addition, the same worker was allowed to work one shift as a certified medication aide although there was no indication she had ever been certified as a medication aide.
The situation was uncovered when a state inspector observed the worker “fumbling” through medications and needing assistance finding certain drugs. The worker allegedly told the inspector she had not been trained and was simply given the keys to the medication cart and “left to figure it out on her own.” When asked where she had received her medication aide certification, the worker allegedly told the inspector, “I didn’t get it around here.”
The home’s director of nursing allegedly told inspectors that the day the aide worked, the medication cart had been “horrible” in that she appeared to have never administered medications before. The director of nursing also indicated the staffing agency used by the home was responsible for performing staff background checks and Aspire had to trust they were doing the job because the home didn’t have time to do it.
Inspectors then determined the home’s director of nursing had also started working for Aspire without a full background check. The staff allegedly told inspectors the administrator had put the director of nursing to work in the home while advising her to “stay away from residents” until a background check could be completed.
Woodward Resource Center, Woodward – This state-run facility for disabled individuals was fined $500 for failure to report suspected resident abuse. According to state inspectors, video surveillance in the home shows that on the afternoon of Oct. 20, 2024, a resident was seated in a living room recliner, rocking back and forth, when a residential treatment worker crossed the room and tried to push the recliner forward. The worker then “gave the back of the recliner a hard shove to the ground (and the resident) somersaulted out backwards,” inspectors reported. Two workers witnessed the incident but allegedly failed to report it.
One Vision-Pine House, Fort Dodge –This care facility was fined $500 for failing to report suspected abuse. The fine was then tripled to $1,500 due the repeat nature of the violation. According to inspectors, the home failed to report in a timely fashion a large, unexplained bruise on a 62-year-old man with severe intellectual disabilities.
Colonial Manor, Perry – This nursing home was fined $2,750 after the assistant director of nursing admitted attempting to cover up the fact that a male resident had fallen and broken his hip. The assistant director of nursing admitted allegedly told inspectors that Colonial Manor’s new owners had recently discontinued the use of alarms that alert workers to a resident’s fall, and the man’s family had been unhappy with the change, telling her they’d be waiting for a phone call to inform them the man had sustained a broken hip “and that would be the end of him.”
The assistant director of nursing allegedly stated that due to that conversation, she panicked and was “petrified” when, days later, the man fell and sustained a broken hip. She said she helped the man off the floor but performed no range-of-motion tests and didn’t check his vital signs or perform any further assessments. She later admitted what she had done, inspectors reported, but also told management she regretted confessing, saying, “Am I going to get fired? … I should not have told you guys and kept my mouth shut.” She was fired a few days later, according to state inspectors.