The Iowa Dispatch reported the disturbing “care” provided to residents at Rowley Memorial Masonic Home. The nursing home cut staffing to compensate for financial losses and landed on the federal watch list after inspectors cited the facility for contributing to a resident death, hiring an unlicensed caregiver, failing to protect residents from sexual abuse and allowing a kitchen worker to supervise its dementia ward.
The home is now on the Centers for Medicare and Medicaid Services’ Special Focus Facilities list. The national list was created to identify those homes that have an established pattern of numerous, serious violations related to resident care. The home is still allowed to operate on a conditional license from the state.
The home is owned by the Herman L. Rowley Memorial Trust and is part of the Rowley Masonic Community complex, which includes assisted living units and independent living apartments. The facility is run by Health Dimensions Group, a Minnesota company that manages nursing homes in Iowa, Colorado, Wisconsin, Illinois and other states.
In May 2019, the home was cited for failing to have on hand any portable liquid oxygen tanks for the residents who had been prescribed continuous oxygen. Inspectors determined the facility’s oxygen-tank supplier had stopped making deliveries of oxygen due to non-payment of past-due bills.
The inspectors then discovered there were 31 vendors – including suppliers of medical equipment – that were owed almost $600,000 by the Rowley Memorial Masonic Home. Seven vendors that provided essential resident-care services told inspectors they would no longer do business with the home. In addition to that, the facility was $600,000 behind on its mortgage, inspectors said.
At the time, the facility was also cited for a 16% medication-error rate. One resident had to be taken by ambulance to a hospital after being found unresponsive in bed after a staff-induced drug overdose.
Inspectors also cited the home for failing to have a functional call-light system that would allow residents to summon the staff for assistance. Residents reported soiling themselves as they waited 40 minutes for someone to come to their aid. An audit of the call-light system revealed 472 instances, over a seven-week period, in which residents waited 15 minutes or more for a response.
In the wake of that inspection, federal officials fined the home more than $106,000.
Two months later, in July 2019, inspectors returned to the home and cited it for failing to protect a male resident of the home’s dementia unit from sexual abuse at the hands of another male resident. In one instance, a worker saw the alleged perpetrator pin the victim against the wall and put his hand in the other man’s pants. The facility was also cited for medication errors, insufficient staff, and inadequate training for the staff. Residents were waiting up to 62 minutes for a response to their call lights, inspectors alleged.
In October 2019, inspectors returned to the home and issued a 111-page report detailing 21 additional violations, including failure to complete background checks on workers; failure to report physical altercations among the residents; medication errors; improper use of psychotropic drugs; and employing as a nurse aide an individual who had failed the skills test three times and wasn’t state certified as required by law.
The home was also cited for having insufficient bedside medical equipment for a tracheostomy patient who was found in bed, not breathing, three days after admission. With no equipment readily available to suction the resident’s airway, a nurse aide tried to breathe air into the man’s lungs using only her mouth on the surgical hole in his neck. The man was rushed to a nearby hospital where he died two hours later.
The home’s nurse manager and director of operations each told inspectors the man should never have been admitted to the home given the level of skilled care he required.
On at least nine occasions in the month leading up to the October inspection, the only person working a shift in the home’s dementia unit was a kitchen worker who told inspectors he had been “sitting shifts” in the nursing department for about two months, although he had no medical certification of any kind. He told inspectors that while he couldn’t legally provide resident care, he supervised the unit and could shut off residents’ call lights and inform them someone else would eventually come to assist them.
Other workers told inspectors the facility was often short-staffed and residents were falling and being injured as a result. They acknowledged their practice was to answer call lights by shutting them off with a promise to return later and provide whatever assistance the residents needed.
Even with state inspectors on site, there were times when the dementia unit was either entirely unstaffed or had only one nurse aide present. An inspector observed one resident near a doorway repeatedly yelling, “Help me,” with no workers responding.
Additional state inspections were conducted at the home in November, December and January, but the Iowa Department of Inspections and Appeals has yet to publish the findings from those inspections on its web site.
In November, the agency suspended all Medicaid and Medicare payments for new admissions to the home. About damn time!